N.J. Admin. Code § 11:4-23.8A

Current through Register Vol. 56, No. 21, November 4, 2024

Section 11:4-23.8A - Minimum benefit standards for 2010 Standardized Medicare supplement benefit plan policies or certificates issued for delivery with an effective date for coverage on or after June 1, 2010

(a) No policy or certificate shall be advertised, solicited, delivered or issued for delivery in this State as a Medicare supplement policy or certificate with an effective date for coverage on or after June 1, 2010 unless it complies with the standards of 11:4-23.6 and the benefit standards set forth in this section. No carrier may offer any 1990 Standardized Medicare supplement benefit plan for sale on or after June 1, 2010.

(b) Medicare supplement policies shall be guaranteed renewable.

(c) A Medicare supplement policy or certificate shall provide that benefits and premiums under the policy or certificate shall be suspended at the request of the policyholder or certificateholder for the period (not to exceed 24 months) in which the policyholder or certificateholder has applied for and is determined to be entitled to medical assistance under Title XIX of the Social Security Act ( 42 U.S.C. § 1396v through end), but only if the policyholder or certificateholder notifies the issuer of the policy or certificate within 90 days after the date that the individual becomes entitled to that assistance.

1. If suspension occurs and if the policyholder or certificateholder loses entitlement to Title XIX medical assistance, the policy or certificate shall be automatically reinstituted (effective as of the date of the termination of the entitlement) if the policyholder or certificateholder provides notice of their loss of the entitlement to the Title XIX assistance within 90 days after the date of that loss and the policyholder or certificateholder pays the premium attributable to the period subsequent to the date of the termination of the entitlement.

2. Each Medicare supplement policy shall provide that benefits and premiums under the policy shall be suspended for any period that may be provided by Federal regulation at the request of the policyholder if the policyholder is entitled to benefits under Section 226(b) of the Social Security Act, 42 U.S.C. § 426(b), and is covered under a group health plan (as defined in Section 1862(b)(1)(A)(v) of the Social Security Act, 42 U.S.C. § 1395y(b)(1)(A)(v)) . If suspension occurs and if the policyholder or certificateholder loses coverage under the group health plan, the policy shall be automatically reinstituted (effective as of the date of loss of coverage) if the policyholder provides notice of loss of coverage within 90 days after the date of the loss and pays the premium attributable to the period from the date of the termination of their enrollment in the group health plan.

3. Reinstitution of coverage as described in (c)1 and 2 above shall:

i. Not impose any waiting period with respect to treatment of preexisting conditions;

ii. Provide for resumption of coverage that is substantially equivalent to the coverage that was in effect before the date of the suspension. If the suspended Medicare supplement policy provided coverage for outpatient prescription drugs, reinstitution of the policy for Medicare Part D enrollees shall be without coverage for outpatient prescription drugs and shall otherwise provide substantially equivalent coverage to the coverage in effect before the date of suspension; and

iii. Provide for classification of premiums on terms at least as favorable to the policyholder or certificateholder as the premium classification terms that would have applied to the policyholder or certificateholder had the coverage not been suspended.

(d) All carriers delivering or issuing for delivery in this State Medicare supplement policies or certificates of group Medicare supplement policies shall offer to all applicants a policy or certificate providing only the basic (core) benefits defined at (g) below. A policy or certificate providing only basic (core) benefits shall be designated as standardized Medicare supplement benefit plan A.

1. If a carrier makes available any additional benefits as described in (g)3 through 7 below or offers standardized benefit Plans K or L (as described in (e)7 and 8 below), then the carrier shall make available to each prospective policyholder and certificateholder, in addition to a policy form or certificate form with only the basic (core) benefits (as described in (g)1 below), a policy form or certificate form containing the standardized benefit Plan C (as described in (e)2 below) or standardized benefit Plan F (as described in (e)4 below).

(e) Carriers may offer to all applicants policies or certificates providing the basic (core) benefits and additional benefits defined at (g) below. Only those additional benefits defined at (g) below may be included in 2010 Standardized Medicare plan supplement policies or certificates delivered or issued for delivery in this State. Policies or certificates providing additional benefits shall be structured and designated as follows:

1. Standardized Medicare supplement benefit plan B shall provide:

i. The Basic (Core) Benefit; and

ii. One hundred percent of the Medicare Part A Deductible benefit:

2. Standardized Medicare supplement benefit plan C shall provide:

i. The Basic (Core) Benefit;

ii. One hundred percent of the Medicare Part A Deductible benefit;

iii. The Skilled Nursing Facility Care benefit;

iv. The Coverage of one hundred percent of the Medicare Part B Deductible; and

v. The Medically Necessary Emergency Care in a Foreign Country benefit.

3. Standardized Medicare supplement benefit plan D shall provide:

i. The Basic (Core) Benefit;

ii. One hundred percent of the Medicare Part A Deductible benefit;

iii. The Skilled Nursing Facility Care benefit; and

iv. The Medically Necessary Emergency Care in a Foreign Country benefit.

4. Standardized Medicare supplement benefit Plan F shall provide:

i. The Basic (Core) Benefit;

ii. One hundred percent of the Medicare Part A Deductible benefit;

iii. The Skilled Nursing Facility Care benefit;

iv. One hundred percent of the Medicare Part B Deductible benefit;

v. One hundred percent of the Medicare Part B Excess Charges Benefit; and

vi. The Medically Necessary Emergency Care in a Foreign Country benefit.

5. Standardized Medicare supplement benefit high deductible plan F shall include 100 percent of covered expenses following the payment of the annual high deductible plan "F" deductible, and shall provide: the Basic (Core) Benefit; 100 percent of the Medicare Part A Deductible benefit; the Skilled Nursing Facility Care benefit; 100 percent of the Medicare Part B Deductible benefit; the 100 percent of Medicare Part B Excess Charges benefit; and the Medically Necessary Emergency Care in a Foreign Country benefit. The annual high deductible plan F deductible shall consist of out-of-pocket expenses, other than premiums, for services covered by the Medicare supplement plan F policy, and shall be in addition to any other specific benefit deductibles. The basis for the deductible shall be $ 1,500, and shall be adjusted annually from 1999 by the Secretary of the U.S. Department of Health and Human Services to reflect the change in the Consumer Price Index for all urban consumers for the 12-month period ending with August of the preceding year, and rounded to the nearest multiple of $ 10.00.

6. Standardized Medicare supplement benefit plan G shall provide:

i. The Basic (Core) Benefit;

ii. One hundred percent of the Medicare Part A Deductible benefit;

iii. The Skilled Nursing Facility Care benefit;

iv. One hundred percent of the Medicare Part B Excess Charges benefit; and

v. The Medically Necessary Emergency Care in a Foreign Country benefit.

7. Standardized Medicare supplement benefit plan K shall provide:

i. Coverage of 100 percent of the Part A hospital coinsurance amount for each day used from the 61st through the 90th day in any Medicare benefit period;

ii. Coverage of 100 percent of the Part A hospital coinsurance for each Medicare lifetime inpatient reserve day used from the 91st through the 150th day in any Medicare benefit period;

iii. Upon exhaustion of the Medicare hospital inpatient coverage, including the lifetime reserve days, coverage of 100 percent of the Medicare Part A eligible expenses for hospitalization paid at the applicable prospective payment system (PPS) rate, or other appropriate Medicare standard of payment, subject to a lifetime maximum benefit of an additional 365 days. The provider shall accept the carrier's payment as payment in full and may not bill the insured for the balance;

iv. Coverage of 50 percent of the Medicare Part A Deductible until the out-of-pocket limitation is met as described in (e)7x below;

v. Coverage for 50 percent of the coinsurance amount for each day from the 21st day through the 100th day in a Medicare benefit period for post-hospital skilled nursing facility care eligible under Medicare Part A until the out-of-pocket limitation is met as described in (e)7x below;

vi. Coverage for 50 percent of cost sharing for all Part A Medicare eligible expenses for hospice and respite care until the out-of-pocket limitation is met as described in (e)7x below;

vii. Coverage for 50 percent, under Medicare A or B, of the reasonable cost of the first three pints of blood (or equivalent quantities of packed red blood cells, as defined under Federal regulations) unless replaced in accordance with Federal regulations until the out-of-pocket limitation is met as described in (e)7x below;

viii. Except for coverage provided in (e)7ix below, coverage for 50 percent of the cost sharing otherwise applicable under Medicare Part B after the policyholder pays the Part B deductible until the out-of-pocket limitation is met as described in (e)7x below;

ix. Coverage of 100 percent of the cost sharing for Medicare Part B preventive services after the policyholder pays the Part B deductible; and

x. Coverage of 100 percent of all cost sharing under Medicare Parts A and B for the balance of the calendar year after the individual has reached the out-of-pocket limitation on annual expenditures under Medicare Parts A and B of $ 4,000 in 2006, indexed each year by the appropriate inflation adjustment specified by the Secretary of the U.S. Department of Health and Human Services.

8. Standardized Medicare supplement benefit plan L shall provide:

i. Coverage of 100 percent of the Part A hospital coinsurance amount for each day used from the 61st through the 90th day in any Medicare benefit period;

ii. Coverage of 100 percent of the Part A hospital coinsurance for each Medicare lifetime inpatient reserve day used from the 91st through the 150th day in any Medicare benefit period;

iv. Coverage of 75 percent of the Medicare Part A Deductible until the out-of-pocket limitation is met as described in (e)8x below;

v. Coverage for 75 percent of the coinsurance amount for each day from the 21st day through the 100th day in a Medicare benefit period for post-hospital skilled nursing facility care eligible under Medicare Part A until the out-of-pocket limitation is met as described in (e)8x below;

vi. Coverage for 75 percent of cost sharing for all Part A Medicare eligible expenses for hospice and respite care until the out-of-pocket limitation is met as described in (e)8x below;

vii. Coverage for 75 percent, under Medicare Part A or B, of the reasonable cost of the first three pints of blood (or equivalent quantities of packed red blood cells, as defined under Federal regulations) unless replaced in accordance with Federal regulations until the out-of-pocket limitation is met as described in (e)8x below;

viii. Except for coverage provided in (e)8ix below, coverage for 75 percent of the cost sharing otherwise applicable under Medicare Part B after the policyholder pays the Part B deductible until the out-of-pocket limitation is met as described in (e)8x below;

ix. Coverage of 100 percent of the cost sharing for Medicare Part B preventive services after the policyholder pays the Part B deductible; and

x. Coverage of 100 percent of all cost sharing under Medicare Parts A and B for the balance of the calendar year after the individual has reached the out-of-pocket limitation on annual expenditures under Medicare Parts A and B of $ 2,000 in 2006, indexed each year by the appropriate inflation adjustment specified by the Secretary of the U.S. Department of Health and Human Services.

9. Standardized Medicare supplement benefit plan M shall provide:

i. The Basic (Core) Benefit;

ii. Coverage of 50 percent of the Medicare Part A Deductible benefit;

iii. The Skilled Nursing Facility Care benefit; and

iv. The Medically Necessary Emergency Care in a Foreign Country benefit.

10. Standardized Medicare supplement benefit plan N shall provide:

i. The Basic (Core) Benefit;

ii. One hundred percent of the Medicare Part A Deductible benefit subject to the copayment in (e)10v below;

iii. The Skilled Nursing Facility Care benefit subject to the copayment in (e)10v below;

iv. The Medically Necessary Emergency Care in a Foreign Country benefit subject to the copayment in (e)10v below; and

v. A copayment in the following amounts will apply to Part B benefits as described in (g)1v below:

(1) The lesser of $ 20.00 or the Medicare Part B coinsurance or copayment for each covered health care provider office visit (including visits to medical specialists); and

(2) The lesser of $ 50.00 or the Medicare Part B coinsurance or copayment for each covered emergency room visit; however, this copayment shall be waived if the insured is admitted to any hospital and the emergency room visit is subsequently covered as a Medicare Part A expense.

(f) No groupings, packages or combinations of Medicare supplement benefits shall be offered which differ from the standardized Medicare supplement benefit plans specified in (d) and (e) above, except as an Innovative Benefit which may be approved by the Commissioner. Benefit plans shall be uniform in structure, language, designation and format to the standardized Medicare supplement benefit plans A, B, C, D, F, G, K, L, M and N as set forth in (d) and (e) above. For purposes of this section, "structure," "language," and "format" means style, arrangement and overall content of a benefit.

(g) The following terms and phrases, as used in this section, shall have the following meanings:

1. "Basic (Core) Benefit" means coverage of:

i. Medicare Part A eligible expenses for hospitalization from the 61st day through the 90th day in any Medicare benefit period, to the extent not covered by Medicare;

ii. Medicare Part A eligible expenses for hospitalization for each Medicare lifetime inpatient reserve day used, to the extent not covered by Medicare;

iii. One hundred percent of Medicare Part A eligible expenses for hospitalization upon exhaustion of Medicare hospital inpatient coverage, including lifetime reserve days, up to a maximum lifetime benefit of 365 days, to be paid at the applicable prospective payment system (PPS) rate, or other appropriate Medicare standard of payment. The provider shall accept the carrier's payment as payment in full and may not bill the insured for any balance;

iv. The reasonable cost of the first three pints of blood (or equivalent quantities of packed red blood cells, as defined by Federal regulations) under Medicare Parts A and B, unless replaced in accordance with Federal regulation;

v. The coinsurance amount or, in the case of hospital outpatient department services paid under a prospective payment system, the copayment amount of Medicare Part B eligible expenses (generally 20 percent of the approved amount; 50 percent of the approved charges for outpatient psychiatric services), regardless of hospital confinement, subject to the Medicare Part B deductible; and

vi. Coverage of cost sharing for all Part A Medicare eligible hospice care and respite care expenses.

2. "Innovative Benefits" means benefits that a carrier may, with the prior approval of the Commissioner pursuant to 17B:26A-6, offer in addition to the standardized benefits provided in a policy or certificate that otherwise complies with the applicable standards. The innovative benefits shall include only benefits that are appropriate to Medicare supplement insurance, are new or innovative, are not otherwise available, are cost-effective, and do not adversely impact the goal of Medicare supplement simplification. Innovative benefits shall not include an outpatient prescription drug benefit. Innovative benefits shall not be used to change or reduce benefits, including a change of any cost-sharing provision, in any standardized plan.

3. "Medically Necessary Emergency Care in a Foreign Country" means coverage to the extent not covered by Medicare of 80 percent of the billed charges for Medicare-eligible expenses for medically necessary emergency hospital, physician and medical care received in a foreign country, which care would have been covered by Medicare if received in the United States, and which care began during the first 60 consecutive days of each trip outside the United States, to the extent billed charges are not covered by Medicare, and subject to a calendar year deductible of $ 250.00 and a lifetime maximum benefit of $ 50,000. For purposes of this benefit, "emergency care" shall mean care needed immediately because of an injury or an illness of sudden and unexpected onset.

4. "Medicare Part A Deductible" means coverage of 100 percent of the Medicare Part A inpatient hospital deductible amount per benefit period.

5. "Medicare Part B Deductible" means coverage of 100 percent of the Medicare Part B deductible amount per calendar year regardless of hospital confinement.

6. "One hundred percent of the Medicare Part B Excess Charges" means coverage for all of the difference between the Medicare Part B approved charge and the actual Medicare Part B billed charge, up to but not exceeding any charge limitation established by the Medicare program or this State's law, if any.

7. "Skilled Nursing Facility Care" means coverage for the actual billed charges up to the Medicare coinsurance amount from the 21st day through the 100th day in a Medicare benefit period, for post-hospital skilled nursing facility care eligible under Medicare Part A.

N.J. Admin. Code § 11:4-23.8A

New Rule, R.2009 d.239, effective 8/3/2009.
See: 41 N.J.R. 956(a), 41 N.J.R. 2928(a).