(1) An insurance policy or subscriber contract may not be advertised, solicited, or issued for delivery in this state as a Medicare supplement policy unless it meets the minimum standards adopted under this section. The minimum standards do not preclude other provisions or benefits which are not inconsistent with the minimum standards.
(2)(a) The commission must adopt rules establishing minimum standards for Medicare supplement policies that, taken together with the requirements of this part, are no less comprehensive or beneficial to persons insured or covered under Medicare supplement policies issued, delivered, or issued for delivery in this state, including certificates under group or blanket policies issued, delivered, or issued for delivery in this state, than the standards provided in 42 U.S.C. s. 1395ss, or the most recent version of the NAIC Model Regulation To Implement the NAIC Medicare Supplement Insurance Minimum Standards Model Act adopted by the National Association of Insurance Commissioners.
Terms Used In Florida Statutes 627.674
- Beneficiary: A person who is entitled to receive the benefits or proceeds of a will, trust, insurance policy, retirement plan, annuity, or other contract. Source: OCC
- Contract: A legal written agreement that becomes binding when signed.
- person: includes individuals, children, firms, associations, joint adventures, partnerships, estates, trusts, business trusts, syndicates, fiduciaries, corporations, and all other groups or combinations. See Florida Statutes 1.01
- Statute: A law passed by a legislature.
(b) The rules must establish specific standards, including standards of full and fair disclosure, that set forth the manner, content, and required disclosure for the sale of group, blanket, franchise, and individual Medicare supplement policies and Medicare supplement subscriber contracts of dental service plans and nonprofit health care services plans. The standards may cover, but not be limited to:
1. Terms of renewability.
2. Initial and subsequent conditions of eligibility.
3. Nonduplication of coverage.
4. Probationary periods.
5. Benefit limitations, exceptions, and reductions.
6. Elimination periods.
7. Requirements for replacement coverage.
8. Recurrent conditions.
9. Definitions of terms.
10. Application forms.
(c) The commission may adopt rules that specify prohibited policies or policy provisions, not otherwise specifically authorized by statute, which in the opinion of the office are unjust, unfair, or unfairly discriminatory to the policyholder, the person insured under the policy, or the beneficiary.
(d) For policies issued on or after January 1, 1991, the commission may adopt rules to establish minimum policy standards to authorize the types of policies specified by 42 U.S.C. s. 1395ss(p)(2)(C) and any optional benefits to facilitate policy comparisons.
(3) A policy may not be filed with the office as a Medicare supplement policy unless the policy meets or exceeds the requirements of 42 U.S.C. s. 1395ss, or the most recent version of the NAIC Medicare Supplement Insurance Minimum Standards Model Act, adopted by the National Association of Insurance Commissioners.
(4) A policy filed with the office as a Medicare supplement policy must:
(a) Have a definition of “Medicare eligible expense” that is not more restrictive than health care expenses of the kinds covered by Medicare or to the extent recognized as reasonable by Medicare. Payment of benefits by insurers for Medicare eligible expenses may be conditioned upon the same or less restrictive payment conditions, including determinations of medical necessity, as apply to Medicare claims.
(b) Provide that benefits designed to cover cost-sharing amounts under Medicare will be changed automatically to coincide with any changes in the applicable Medicare deductible amount and copayment percentage factor. Premiums may be modified to correspond with such changes, subject to prior approval by the office.
(c) Be written in simplified language, be easily understood by purchasers, and otherwise comply with s. 627.602.
(d) Contain a prominently displayed no-loss cancellation clause enabling the applicant to return the policy within 30 days after receiving the policy, or the certificate issued thereunder, with return in full of any premium paid. The insurer must, in a timely manner, pay a refund under this paragraph directly to the individual who paid the premium.
(e) Contain a prominently displayed notice of any coordination-of-benefits clause which might in any way restrict payment under the policy.
(f)1. Be accompanied by a copy of the Medicare Supplement Buyer’s Guide developed jointly by the National Association of Insurance Commissioners and the Health Care Financing Administration of the United States Department of Health and Human Services.
2. A policy referred to in subparagraph (g)4. that does not qualify as a Medicare supplement policy under this part must also be accompanied by the buyer’s guide pursuant to this paragraph.
3. Except in the case of a direct response insurer, delivery of the buyer’s guide shall be made at the time of application, and acknowledgment of receipt or certification of delivery of the buyer’s guide shall be provided to the insurer. Direct response insurers shall deliver the buyer’s guide upon request, but not later than at the time the policy is delivered.
(g)1. Be accompanied by an outline of coverage in the form prescribed by the National Association of Insurance Commissioners in the NAIC Model Regulation To Implement the NAIC Medicare Supplement Insurance Minimum Standards Model Act, adopted by the National Association of Insurance Commissioners on July 31, 1991, and as prescribed in s. 627.6743.
2. The outline shall be delivered to the applicant at the time application is made, and, except for the direct response policy, acknowledgment of receipt or certification of delivery of the outline of coverage shall be provided to the insurer.
3. If the policy is issued on a basis which would require revision of the outline, a substitute outline of coverage properly describing the policy, contract, or group certificate must accompany the policy, when it is delivered, and contain the following statement, in no less than 12-point type, immediately above the company name: “NOTICE: Read this outline of coverage carefully. It is not identical to the outline of coverage provided upon application, and the coverage originally applied for has not been issued.”
4. The following language must be printed on or attached to the first page of the outline of coverage delivered in conjunction with an individual policy of hospital confinement insurance, indemnity insurance, specified disease insurance, specified accident insurance, supplemental health insurance other than Medicare supplement insurance, or nonconventional health insurance coverage, as defined by law in this state, to a person eligible for Medicare: “This policy IS NOT A MEDICARE SUPPLEMENT policy. If you are eligible for Medicare, review the Medicare Supplement Buyer’s Guide available from the company.”
(5) A Medicare supplement policy may not contain benefits which duplicate benefits provided by Medicare.