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«Model Regulation Service —April 1995 MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS MODEL ACT Table of Contents Section 1. Definitions Section 2. ...»

Model Regulation Service —April 1995



Table of Contents

Section 1. Definitions

Section 2. Applicability and Scope

Section 3. Standards for Policy Provisions and Authority

to Promulgate Regulations

Section 4. Loss Ratio Standards

Section 5. Disclosure Standards

Section 6. Notice of Free Examination Section 7.

Filing Requirements for Advertising Section 8. Administrative Procedures Section 9. Penalties Section 10. Separability Section 11. Effective Date Section 1. Definitions

A. “Applicant” means:

(1) In the case of an individual Medicare supplement policy, the person who seeks to contract for insurance benefits, and (2) In the case of a group Medicare supplement policy, the proposed certificateholder.

B. “Certificate” means, for the purposes of this Act, any certificate delivered or issued for delivery in this state under a group Medicare supplement policy.

C. “Certificate form” means the form on which the certificate is delivered or issued for delivery by the issuer.

D. “Issuer” includes insurance companies, fraternal benefit societies, health care service plans, health maintenance organizations, and any other entity delivering or issuing for delivery in this state Medicare supplement policies or certificates.

Drafting Note: It is intended that nonprofit hospital and medical service associations be subject to this model act. In those states where such associations are prohibited from issuing subscriber contracts that include all of the benefits required by Section 3 of this Act, they shall include so much of those benefits as are permitted and they shall be issued in conjunction with another contract including at least the remainder of the minimum benefits required. In such event, the combination of contracts will be considered to have been issued in compliance with Section 3 of this Act.

E. “Medicare” means the “Health Insurance for the Aged Act,” Title XVIII of the Social Security Amendments of 1965, as then constituted or later amended.

F. “Medicare supplement policy” means a group or individual policy of [accident and sickness] insurance or a subscriber contract [of hospital and medical service associations or health maintenance organizations], other than a policy issued pursuant to a contract under Section 1876 of the federal Social Security Act (42 U.S.C. Section 1395 et. seq.), or an issue

–  –  –

Drafting Note: OBRA 1990 contained an exception from this definition for policies issued pursuant to an agreement under Section 1833 (42 U.S.C. 1395l) of the federal Social Security Act. The Social Security Act Amendments of 1994 eliminated the exemption for Section 1833 plans effective December 31, 1995. These plans, commonly know as health care prepayment plans (HCPPs), arrange for certain Part B services on a pre-paid basis. The federal law continues to authorize HCPP agreements.

However, since they are now included in the federal definition of a Medicare supplement policy, HCPPs are subject to the requirements of this model, unless they are exempt under Section 2B. In states authorized for the Medicare Select program, these plans may be able to comply with Medicare supplement requirements.

–  –  –

Editor’s Note: Wherever the term “commissioner” appears, the title of the chief insurance regulatory official of the state should be inserted.

–  –  –

E. The commissioner may adopt from time to time reasonable regulations necessary to conform Medicare supplement policies and certificates to the requirements of federal

law and regulations promulgated thereunder, including but not limited to:

–  –  –

F. The commissioner may adopt reasonable regulations that specify prohibited policy provisions not otherwise specifically authorized by statute which, in the opinion of the commissioner, are unjust, unfair or unfairly discriminatory to any person insured or proposed to be insured under a Medicare supplement policy or certificate.

Drafting Note: Each state should examine its statutory authority to promulgate regulations and revise this section accordingly so that sufficient rulemaking authority is present and that unnecessary duplication of unfair practice provisions does not occur.

–  –  –

Section 4. Loss Ratio Standards Medicare supplement policies shall return to policyholders’ benefits which are reasonable in relation to the premium charged.

The commissioner shall issue reasonable regulations to establish minimum standards for loss ratios of Medicare supplement policies on the basis of incurred claims experience, or incurred health care expenses where coverage is provided by a health maintenance organization on a service rather than reimbursement basis, and earned premiums in accordance with accepted actuarial principles and practices.

Section 5. Disclosure Standards

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B. The commissioner shall prescribe the format and content of the outline of coverage required by Subsection A. For purposes of this section, “format” means style, arrangements and overall appearance, including such items as the size, color and prominence of type and arrangement of text and captions. The outline of coverage

shall include:

–  –  –

C. The commissioner may prescribe by regulation a standard form and the contents of an informational brochure for persons eligible for Medicare, which is intended to improve the buyer’s ability to select the most appropriate coverage and improve the buyer’s understanding of Medicare. Except in the case of direct response insurance policies, the commissioner may require by regulation that the informational brochure be provided to any prospective insureds eligible for Medicare concurrently with delivery of the outline of coverage. With respect to direct response insurance policies, the commissioner may require by regulation that the prescribed brochure be provided upon request to any prospective insureds eligible for Medicare, but in no event later than the time of policy delivery.

D. The commissioner may adopt regulations for captions or notice requirements, determined to be in the public interest and designed to inform prospective insureds that particular insurance coverages are not Medicare supplement coverages, for all accident and sickness insurance policies sold to persons eligible for Medicare, other


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E. The commissioner may adopt reasonable regulations to govern the full and fair disclosure of the information in connection with the replacement of accident and sickness policies, subscriber contracts or certificates by persons eligible for Medicare.

Section 6. Notice of Free Examination Medicare supplement policies and certificates shall have a notice prominently printed on the first page of the policy or certificate or attached thereto stating in substance that the applicant shall have the right to return the policy or certificate within thirty (30) days of its delivery and to have the premium refunded if, after examination of the policy or certificate, the applicant is not satisfied for any reason.

A refund made pursuant to this section shall be paid directly to the applicant by the issuer in a timely manner.

Section 7. Filing Requirements for Advertising

Every issuer of Medicare supplement insurance policies or certificates in this state shall provide a copy of any Medicare supplement advertisement intended for use in this state whether through written, radio or television medium to the Commissioner of Insurance of this state for review or approval by the commissioner to the extent it may be required under state law.

Drafting Note: States should examine their existing laws regarding the filing of advertisements to determine the extent to which review or approval is required.

Section 8. Administrative Procedures Regulations adopted pursuant to this Act shall be subject to the provisions of [cite section of state insurance code relating to the adoption and promulgation of rules and regulations or cite the state’s administrative procedures act, if applicable].

–  –  –

In addition to any other applicable penalties for violations of the Insurance Code, the commissioner may require issuers violating any provision of this Act or regulations promulgated pursuant to this Act to cease marketing any Medicare supplement policy or certificate in this state which is related directly or indirectly to a violation or may require the issuer to take actions necessary to comply with the provisions of this Act, or both.

Section 10. Separability If any provision of this Act or the application of it to any person or circumstances is for any reason held to be invalid, the remainder of the Act and the application of the provision to other persons or circumstances shall not be affected.

Section 11. Effective Date The Act shall be effective on [insert date].

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1980 Proc. II 22, 26, 588, 591, 593, 603-605 (adopted).

1981 Proc. I 47, 51, 420, 424, 446, 453-456 (amended and reprinted).

1988 Proc. I 9, 20-21, 629-630, 652-654, 665-668 (amended and reprinted).

1988 Proc. II 5, 13, 568, 601, 604, 624-626 (amended and reprinted).

1989 Proc. I 14, 813-814, 836.1-836.4 (amended at special plenary session September 1988).

1990 Proc. I 6, 27-28, 477, 574-575, 577-580 (amended and reprinted).

1992 Proc. I 12, 12-16, 1085 (amended at special plenary in July 1991).

1995 Proc. 1st Quarter 7, 12, 501, 575, 586, 588-591 (amended and reprinted).

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