NAC687B.319. Standardized Benefit Plan J or High Deductible Benefit Plan J.

     1. A 1990 standardized benefit plan to supplement Medicare which is designated as Standardized Benefit Plan J or High Deductible Benefit Plan J must provide the following benefits:

     (a) The benefits required by NAC 687B.290.

     (b) Coverage for all of the Medicare Part A inpatient hospital deductible amount per benefit period.

     (c) For Medicare Part A eligible expenses for posthospital care received at a skilled nursing facility, coverage for the actual billed charges up to the coinsurance amount from the 21st day through the 100th day in any Medicare benefit period.

     (d) Coverage for all of the Medicare Part B deductible amount per calendar year, regardless of whether the insured has been confined in a hospital.

     (e) Coverage for 100 percent of the Medicare Part B excess charge calculated by determining the difference between the actual Medicare Part B charge as billed, not to exceed any limitation on that charge established by the Medicare program or state law, and the Medicare Part B charge that has been approved.

     (f) For plans sold or issued before January 1, 2006, as an extended benefit, coverage is provided for 50 percent of the charges for prescription drugs received as an outpatient, after payment of a deductible of $250 per calendar year, not to exceed $3,000 in benefits received by the insured per calendar year, to the extent not covered by Medicare. This paragraph only applies to those persons currently covered by Plan J and who do not apply for Medicare Part D.

     (g) Coverage of Medicare eligible expenses for 80 percent of the billed charges for medically necessary emergency care received in a foreign country to the extent not covered by Medicare, if such care would have been covered by Medicare if provided in the United States and the care began during the first 60 consecutive days of the trip outside the United States. The benefit is subject to the payment of a deductible of $250 per calendar year and a lifetime maximum benefit of $50,000. As used in this paragraph, “emergency care” means medical care needed immediately because of a sudden and unexpected injury or illness.

     (h) Coverage for the following preventative health services for the actual amount charged for each service not to exceed 100 percent of the amount approved by Medicare for that service, as identified in the American Medical Association’s Current Procedural Terminology (AMA CPT) codes, not to exceed $120 per year, to the extent not covered by Medicare:

          (1) An annual clinical medical history and physical examination that may include the tests and services set forth in subparagraph (2) and educational services that address measures to be taken for preventative health care.

          (2) Preventive screening tests or preventive services, the selection and frequency of which is determined to be medically appropriate by the attending physician.

     (i) Coverage for short-term services that provide to a person recovering from an illness, injury or surgery in his or her home, assistance with daily activities such as bathing, dressing, personal hygiene, eating, ambulating, administering prescription drugs and changing bandages and other dressings. The coverage must comply with the requirements of NAC 687B.325.

     2. In addition to the requirements of subsection 1, a 1990 standardized benefit plan to supplement Medicare which is designated as High Deductible Benefit Plan J must require the insured to pay an annual deductible. The annual deductible for High Deductible Benefit Plan J is subject to change. For the current deductible, please consult the most current version of the Guide to Health Insurance for People with Medicare, which must be provided by an issuer to an applicant pursuant to NAC 687B.240. The cover page of the outline of coverage which must be provided to an applicant by an issuer pursuant to NAC 687B.250 must specify the current amount of the deductible. The annual deductible for High Deductible Benefit Plans F and J may be adjusted annually by the Secretary of Health and Human Services to reflect the change in the Consumer Price Index for All Urban Consumers published by the United States Department of Labor for the calendar year ending on July 31 of the immediately preceding year, and rounded to the nearest multiple of $10. The deductible must be paid in addition to the premium and in addition to any other deductibles relating to a specific benefit.

     (Added to NAC by Comm’r of Insurance, 7-16-92, eff. 7-30-92; A 5-13-96; R110-98, 2-23-99; R075-02, 9-20-2002; R027-04, 8-2-2004; A by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit; A by Comm’r of Insurance by R049-09, 10-27-2009)