Florida Regulations 69O-156.0085: Standard Medicare Supplement Benefit Plans 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.
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The following standards are applicable to all Medicare supplement policies or certificates delivered or issued for delivery in this state with an effective date for coverage on or after June 1, 2010. No policy or certificate may be advertised, solicited, delivered or issued for delivery in this state as a Medicare supplement policy or certificate unless it complies with these benefit plan standards. Benefit plan standards applicable to Medicare supplement policies and certificates issued with an effective date for coverage before June 1, 2010, remain subject to the requirements of Rules 69O-156.006, 69O-156.007, and 69O-156.008, F.A.C.
(1)(a) An issuer shall make available to each prospective policyholder and certificateholder a policy form or certificate form containing only the basic (core) benefits, as defined in subsection 69O-156.0075(2), F.A.C.
(b) If an issuer makes available any of the additional benefits described in subsection 69O-156.0075(3), F.A.C., or offers standardized benefit Plans K or L as described in paragraphs 69O-156.0085(5)(h) and (i), F.A.C., then the issuer 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 paragraph (1)(a) above, a policy form or certificate form containing either standardized benefit Plan C as described in Fl. Admin. Code R. 69O-156.0085(5)(c), or standardized benefit Plan F as described in Fl. Admin. Code R. 69O-156.0085(5)(e)
(2) No groups, packages or combinations of Medicare supplement benefits other than those listed in this rule shall be offered for sale in this state, except as may be permitted in subsection 69O-156.0085(6) and Fl. Admin. Code R. 69O-156.030
(3)(a) Benefit plans shall be uniform in structure, language, designation and format to the standard benefit plans listed in this subsection and as provided in Form OIR-B2-MSC2 (05/09), “”Outline of Coverage, Benefit Plans, Benefit Chart of Medicare Supplement Plans Sold on or After June 1, 2010″”, and shall conform to the definitions in Fl. Admin. Code R. 69O-156.003
(b) Form OIR-B2-MSC2 (05/09), “”Outline of Coverage, Benefit Plans, Benefit Chart of Medicare Supplement Plans Sold on or After June 1, 2010″”, is hereby adopted and incorporated by reference, and is available and may be printed from the Office’s website: http://www.floir.com/iportal.
(c) Each benefit shall be structured in accordance with the format provided in subsections 69O-156.0075(2) and 69O-156.0075(3), F.A.C.; or, in the case of plans K or L, in paragraph 69O-156.0085(5)(h) or 69O-156.0085(5)(i), F.A.C. and list the benefits in the order shown. For purposes of this Section, “”structure, language, and format”” means style, arrangement and overall content of a benefit.
(4) In addition to the benefit plan designations required in subsection 69O-156.0085(3), F.A.C., an issuer may use other designations to the extent permitted by law.
(5) Make-up of 2010 Standardized Benefit Plans:
(a) Standardized Medicare supplement benefit Plan A shall include only the following: The basic (core) benefits as defined in subsection 69O-156.0075(2), F.A.C.
(b) Standardized Medicare supplement benefit Plan B shall include only the following: The basic (core) benefit as defined in subsection 69O-156.0075(2), F.A.C., plus one hundred percent (100%) of the Medicare Part A deductible as defined in Fl. Admin. Code R. 69O-156.0075(3)(a)
(c) Standardized Medicare supplement benefit Plan C shall include only the following: The basic (core) benefit as defined in subsection 69O-156.0075(2), F.A.C., plus one hundred percent (100%) of the Medicare Part A deductible, skilled nursing facility care, one hundred percent (100%) of the Medicare Part B deductible, and medically necessary emergency care in a foreign country as defined in paragraphs 69O-156.0075(3)(a), (c), (d), and (f), F.A.C., respectively.
(d) Standardized Medicare supplement benefit Plan D shall include only the following: The basic (core) benefit, as defined in subsection 69O-156.0075(2), F.A.C., plus one hundred percent (100%) of the Medicare Part A deductible, skilled nursing facility care, and medically necessary emergency care in a foreign country as defined in paragraphs 69O-156.0075(3)(a), (c), and (f), F.A.C., respectively.
(e) Standardized Medicare supplement [regular] Plan F shall include only the following: The basic (core) benefit as defined in subsection 69O-156.0075(2), F.A.C., plus one hundred percent (100%) of the Medicare Part A deductible, the skilled nursing facility care, one hundred percent (100%) of the Medicare Part B deductible, one hundred percent (100%) of the Medicare Part B excess charges, and medically necessary emergency care in a foreign country as defined in paragraphs 69O-156.0075(3)(a), (c), (d), (e), and (f), F.A.C., respectively.
(f) Standardized Medicare supplement Plan F With High Deductible shall include only the following: one hundred percent (100%) of covered expenses following the payment of the annual deductible set forth in subparagraph 2. below.
1. The basic (core) benefit as defined in subsection 69O-156.0075(2), F.A.C., plus one hundred percent (100%) of the Medicare Part A deductible, skilled nursing facility care, one hundred percent (100%) of the Medicare Part B deductible, one hundred percent (100%) of the Medicare Part B excess charges, and medically necessary emergency care in a foreign country as defined in paragraphs 69O-156.0075(3)(a), (c), (d), (e), and (f), F.A.C., respectively.
2. The annual deductible in Plan F With High Deductible shall consist of out-of-pocket expenses, other than premiums, for services covered by Plan F, 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 twelve-month period ending with August of the preceding year, and rounded to the nearest multiple of ten dollars ($10).
(g) Standardized Medicare supplement benefit Plan G shall include only the following: The basic (core) benefit as defined in subsection 69O-156.0075(2), F.A.C., plus one hundred percent (100%) of the Medicare Part A deductible, skilled nursing facility care, one hundred percent (100%) of the Medicare Part B excess charges, and medically necessary emergency care in a foreign country as defined in paragraphs 69O-156.0075(3)(a), (c), (e), and (f), F.A.C., respectively.
(h) Standardized Medicare supplement Plan K is mandated by The Medicare Prescription Drug, Improvement and Modernization Act of 2003, and shall include only the following:
1. Part A Hospital Coinsurance 61st through 90th days: Coverage of one hundred percent (100%) of the Part A hospital coinsurance amount for each day used from the 61st through the 90th day in any Medicare benefit period;
2. Part A Hospital Coinsurance, 91st through 150th days: Coverage of one hundred percent (100%) of the Part A hospital coinsurance amount for each Medicare lifetime inpatient reserve day used from the 91st through the 150th day in any Medicare benefit period;
3. Part A Hospitalization After 150 Days: Upon exhaustion of the Medicare hospital inpatient coverage, including the lifetime reserve days, coverage of one hundred percent (100%) 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 issuer’s payment as payment in full and may not bill the insured for any balance;
4. Medicare Part A Deductible: Coverage for fifty percent (50%) of the Medicare Part A inpatient hospital deductible amount per benefit period until the out-of-pocket limitation is met as described in subparagraph 10.;
5. Skilled Nursing Facility Care: Coverage for fifty percent (50%) of the coinsurance amount for each day used 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 subparagraph 10.;
6. Hospice Care: Coverage for fifty percent (50%) of cost sharing for all Part A Medicare eligible expenses and respite care until the out-of-pocket limitation is met as described in subparagraph 10.;
7. Blood: Coverage for fifty percent (50%), under Medicare Part A or B, of the reasonable cost of the first three (3) 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 subparagraph 10.;
8. Part B Cost Sharing: Except for coverage provided in subparagraph (i), coverage for fifty percent (50%) 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 subparagraph 10.;
9. Part B Preventive Services: Coverage of one hundred percent (100%) of the cost sharing for Medicare Part B preventive services after the policyholder pays the Part B deductible; and
10. Cost Sharing After Out-of-Pocket Limits: Coverage of one hundred percent (100%) 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 $4000 in 2006, indexed each year by the appropriate inflation adjustment specified by the Secretary of the U.S. Department of Health and Human Services.
(i) Standardized Medicare supplement Plan L is mandated by The Medicare Prescription Drug, Improvement and Modernization Act of 2003, and shall include only the following:
1. The benefits described in subparagraphs 69O-156.0085(5)(h)1., 2., 3., and 9., F.A.C.;
2. The benefit described in subparagraphs 69O-156.0085(5)(h)4., 5., 6., 7., and 8., F.A.C., but substituting seventy-five percent (75%) for fifty percent (50%); and
3. The benefit described in subFl. Admin. Code R. 69O-156.0085(5)(h)10., but substituting $2000 for $4000.
(j) Standardized Medicare supplement Plan M shall include only the following: The basic (core) benefit as defined in subsection 69O-156.0075(2), F.A.C., plus fifty percent (50%) of the Medicare Part A deductible, skilled nursing facility care, and medically necessary emergency care in a foreign country as defined in paragraphs 69O-156.0075(3)(b), (c), and (f), F.A.C., respectively.
(k) Standardized Medicare supplement Plan N shall include only the following: The basic (core) benefit as defined in subsection 69O-156.0075(2), F.A.C., plus one hundred percent (100%) of the Medicare Part A deductible, skilled nursing facility care, and medically necessary emergency care in a foreign country as defined in paragraphs 69O-156.0075(3)(a), (c) and (f), F.A.C., respectively, with co-payments in the following amounts:
1. The lesser of twenty dollars ($20) or the Medicare Part B coinsurance or co-payment for each covered health care provider office visit (including visits to medical specialists); and
2. The lesser of fifty dollars ($50) or the Medicare Part B coinsurance or co-payment for each covered emergency room visit, however, this co-payment shall be waived if the insured is admitted to any hospital and the emergency visit is subsequently covered as a Medicare Part A expense.
(6) New or Innovative Benefits: An issuer may, with the prior approval of the Office, offer policies or certificates with new or innovative benefits, in addition to the standardized benefits provided in a policy or certificate that otherwise complies with the applicable standards. The new or innovative benefits shall include only benefits that are appropriate to Medicare supplement insurance, are new or innovative, are not otherwise available, and are cost-effective. Approval of new or innovative benefits must not adversely impact the goal of Medicare supplement simplification. New or innovative benefits shall not include an outpatient prescription drug benefit. New or innovative benefits shall not be used to change or reduce benefits, including a change of any cost-sharing provision, in any standardized plan.
Rulemaking Authority 624.308, 627.674(2) FS. Law Implemented 624.307(1), 627.674, 627.6741 FS. History-New 1-4-10.
(1)(a) An issuer shall make available to each prospective policyholder and certificateholder a policy form or certificate form containing only the basic (core) benefits, as defined in subsection 69O-156.0075(2), F.A.C.
(b) If an issuer makes available any of the additional benefits described in subsection 69O-156.0075(3), F.A.C., or offers standardized benefit Plans K or L as described in paragraphs 69O-156.0085(5)(h) and (i), F.A.C., then the issuer 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 paragraph (1)(a) above, a policy form or certificate form containing either standardized benefit Plan C as described in Fl. Admin. Code R. 69O-156.0085(5)(c), or standardized benefit Plan F as described in Fl. Admin. Code R. 69O-156.0085(5)(e)
(2) No groups, packages or combinations of Medicare supplement benefits other than those listed in this rule shall be offered for sale in this state, except as may be permitted in subsection 69O-156.0085(6) and Fl. Admin. Code R. 69O-156.030
(3)(a) Benefit plans shall be uniform in structure, language, designation and format to the standard benefit plans listed in this subsection and as provided in Form OIR-B2-MSC2 (05/09), “”Outline of Coverage, Benefit Plans, Benefit Chart of Medicare Supplement Plans Sold on or After June 1, 2010″”, and shall conform to the definitions in Fl. Admin. Code R. 69O-156.003
(b) Form OIR-B2-MSC2 (05/09), “”Outline of Coverage, Benefit Plans, Benefit Chart of Medicare Supplement Plans Sold on or After June 1, 2010″”, is hereby adopted and incorporated by reference, and is available and may be printed from the Office’s website: http://www.floir.com/iportal.
(c) Each benefit shall be structured in accordance with the format provided in subsections 69O-156.0075(2) and 69O-156.0075(3), F.A.C.; or, in the case of plans K or L, in paragraph 69O-156.0085(5)(h) or 69O-156.0085(5)(i), F.A.C. and list the benefits in the order shown. For purposes of this Section, “”structure, language, and format”” means style, arrangement and overall content of a benefit.
(4) In addition to the benefit plan designations required in subsection 69O-156.0085(3), F.A.C., an issuer may use other designations to the extent permitted by law.
(5) Make-up of 2010 Standardized Benefit Plans:
(a) Standardized Medicare supplement benefit Plan A shall include only the following: The basic (core) benefits as defined in subsection 69O-156.0075(2), F.A.C.
(b) Standardized Medicare supplement benefit Plan B shall include only the following: The basic (core) benefit as defined in subsection 69O-156.0075(2), F.A.C., plus one hundred percent (100%) of the Medicare Part A deductible as defined in Fl. Admin. Code R. 69O-156.0075(3)(a)
(c) Standardized Medicare supplement benefit Plan C shall include only the following: The basic (core) benefit as defined in subsection 69O-156.0075(2), F.A.C., plus one hundred percent (100%) of the Medicare Part A deductible, skilled nursing facility care, one hundred percent (100%) of the Medicare Part B deductible, and medically necessary emergency care in a foreign country as defined in paragraphs 69O-156.0075(3)(a), (c), (d), and (f), F.A.C., respectively.
(d) Standardized Medicare supplement benefit Plan D shall include only the following: The basic (core) benefit, as defined in subsection 69O-156.0075(2), F.A.C., plus one hundred percent (100%) of the Medicare Part A deductible, skilled nursing facility care, and medically necessary emergency care in a foreign country as defined in paragraphs 69O-156.0075(3)(a), (c), and (f), F.A.C., respectively.
(e) Standardized Medicare supplement [regular] Plan F shall include only the following: The basic (core) benefit as defined in subsection 69O-156.0075(2), F.A.C., plus one hundred percent (100%) of the Medicare Part A deductible, the skilled nursing facility care, one hundred percent (100%) of the Medicare Part B deductible, one hundred percent (100%) of the Medicare Part B excess charges, and medically necessary emergency care in a foreign country as defined in paragraphs 69O-156.0075(3)(a), (c), (d), (e), and (f), F.A.C., respectively.
(f) Standardized Medicare supplement Plan F With High Deductible shall include only the following: one hundred percent (100%) of covered expenses following the payment of the annual deductible set forth in subparagraph 2. below.
1. The basic (core) benefit as defined in subsection 69O-156.0075(2), F.A.C., plus one hundred percent (100%) of the Medicare Part A deductible, skilled nursing facility care, one hundred percent (100%) of the Medicare Part B deductible, one hundred percent (100%) of the Medicare Part B excess charges, and medically necessary emergency care in a foreign country as defined in paragraphs 69O-156.0075(3)(a), (c), (d), (e), and (f), F.A.C., respectively.
2. The annual deductible in Plan F With High Deductible shall consist of out-of-pocket expenses, other than premiums, for services covered by Plan F, 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 twelve-month period ending with August of the preceding year, and rounded to the nearest multiple of ten dollars ($10).
(g) Standardized Medicare supplement benefit Plan G shall include only the following: The basic (core) benefit as defined in subsection 69O-156.0075(2), F.A.C., plus one hundred percent (100%) of the Medicare Part A deductible, skilled nursing facility care, one hundred percent (100%) of the Medicare Part B excess charges, and medically necessary emergency care in a foreign country as defined in paragraphs 69O-156.0075(3)(a), (c), (e), and (f), F.A.C., respectively.
(h) Standardized Medicare supplement Plan K is mandated by The Medicare Prescription Drug, Improvement and Modernization Act of 2003, and shall include only the following:
1. Part A Hospital Coinsurance 61st through 90th days: Coverage of one hundred percent (100%) of the Part A hospital coinsurance amount for each day used from the 61st through the 90th day in any Medicare benefit period;
2. Part A Hospital Coinsurance, 91st through 150th days: Coverage of one hundred percent (100%) of the Part A hospital coinsurance amount for each Medicare lifetime inpatient reserve day used from the 91st through the 150th day in any Medicare benefit period;
3. Part A Hospitalization After 150 Days: Upon exhaustion of the Medicare hospital inpatient coverage, including the lifetime reserve days, coverage of one hundred percent (100%) 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 issuer’s payment as payment in full and may not bill the insured for any balance;
4. Medicare Part A Deductible: Coverage for fifty percent (50%) of the Medicare Part A inpatient hospital deductible amount per benefit period until the out-of-pocket limitation is met as described in subparagraph 10.;
5. Skilled Nursing Facility Care: Coverage for fifty percent (50%) of the coinsurance amount for each day used 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 subparagraph 10.;
6. Hospice Care: Coverage for fifty percent (50%) of cost sharing for all Part A Medicare eligible expenses and respite care until the out-of-pocket limitation is met as described in subparagraph 10.;
7. Blood: Coverage for fifty percent (50%), under Medicare Part A or B, of the reasonable cost of the first three (3) 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 subparagraph 10.;
8. Part B Cost Sharing: Except for coverage provided in subparagraph (i), coverage for fifty percent (50%) 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 subparagraph 10.;
9. Part B Preventive Services: Coverage of one hundred percent (100%) of the cost sharing for Medicare Part B preventive services after the policyholder pays the Part B deductible; and
10. Cost Sharing After Out-of-Pocket Limits: Coverage of one hundred percent (100%) 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 $4000 in 2006, indexed each year by the appropriate inflation adjustment specified by the Secretary of the U.S. Department of Health and Human Services.
(i) Standardized Medicare supplement Plan L is mandated by The Medicare Prescription Drug, Improvement and Modernization Act of 2003, and shall include only the following:
1. The benefits described in subparagraphs 69O-156.0085(5)(h)1., 2., 3., and 9., F.A.C.;
2. The benefit described in subparagraphs 69O-156.0085(5)(h)4., 5., 6., 7., and 8., F.A.C., but substituting seventy-five percent (75%) for fifty percent (50%); and
3. The benefit described in subFl. Admin. Code R. 69O-156.0085(5)(h)10., but substituting $2000 for $4000.
(j) Standardized Medicare supplement Plan M shall include only the following: The basic (core) benefit as defined in subsection 69O-156.0075(2), F.A.C., plus fifty percent (50%) of the Medicare Part A deductible, skilled nursing facility care, and medically necessary emergency care in a foreign country as defined in paragraphs 69O-156.0075(3)(b), (c), and (f), F.A.C., respectively.
(k) Standardized Medicare supplement Plan N shall include only the following: The basic (core) benefit as defined in subsection 69O-156.0075(2), F.A.C., plus one hundred percent (100%) of the Medicare Part A deductible, skilled nursing facility care, and medically necessary emergency care in a foreign country as defined in paragraphs 69O-156.0075(3)(a), (c) and (f), F.A.C., respectively, with co-payments in the following amounts:
1. The lesser of twenty dollars ($20) or the Medicare Part B coinsurance or co-payment for each covered health care provider office visit (including visits to medical specialists); and
2. The lesser of fifty dollars ($50) or the Medicare Part B coinsurance or co-payment for each covered emergency room visit, however, this co-payment shall be waived if the insured is admitted to any hospital and the emergency visit is subsequently covered as a Medicare Part A expense.
(6) New or Innovative Benefits: An issuer may, with the prior approval of the Office, offer policies or certificates with new or innovative benefits, in addition to the standardized benefits provided in a policy or certificate that otherwise complies with the applicable standards. The new or innovative benefits shall include only benefits that are appropriate to Medicare supplement insurance, are new or innovative, are not otherwise available, and are cost-effective. Approval of new or innovative benefits must not adversely impact the goal of Medicare supplement simplification. New or innovative benefits shall not include an outpatient prescription drug benefit. New or innovative benefits shall not be used to change or reduce benefits, including a change of any cost-sharing provision, in any standardized plan.
Rulemaking Authority 624.308, 627.674(2) FS. Law Implemented 624.307(1), 627.674, 627.6741 FS. History-New 1-4-10.