Title 27
Insurance

Chapter 18.2
Medicare Supplement Insurance Policies

§ 27-18.2-3. Standards for policy provisions.

(a) No Medicare supplement insurance policy or certificate in force in the state shall contain benefits that duplicate benefits provided by Medicare.

(b) Notwithstanding any other provision of law of this state, a Medicare supplement policy or certificate shall not exclude or limit benefits for loss incurred more than six (6) months from the effective date of coverage because it involved a preexisting condition. The policy or certificate shall not define a preexisting condition more restrictively than a condition for which medical advice was given or treatment was recommended by or received from a physician within six (6) months before the effective date of coverage.

(c) The commissioner shall adopt reasonable regulations to establish specific standards for policy provisions of Medicare supplement policies and certificates. Those standards shall be in addition to and in accordance with the applicable laws of this state, including but not limited to §§ 27-18-3(a) and 42-62-12 and regulations promulgated pursuant to those sections. No requirement of this title or chapter 62 of title 42 relating to minimum required policy benefits, other than the minimum standards contained in this chapter, shall apply to Medicare supplement policies and certificates. 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;

(8) Recurrent conditions; and

(9) Definitions of terms.

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

(e) The commissioner shall adopt reasonable regulations to establish minimum standards for premium rates, benefits, claims payment, marketing practices, and compensation arrangements and reporting practices for Medicare supplement policies and certificates.

(f) The commissioner may adopt any reasonable regulations necessary to conform Medicare supplement policies and certificates to the requirements of federal law and regulations promulgated pursuant to federal law, including but not limited to:

(1) Requiring refunds or credits if the policies or certificates do not meet loss ratio requirements;

(2) Establishing a uniform methodology for calculating and reporting loss ratios;

(3) Assuring public access to policies, premiums, and loss ratio information of issuers of Medicare supplement insurance;

(4) Establishing a process for approving or disapproving policy forms and certificate forms and proposed premium increases;

(5) Establishing a policy for holding public hearings prior to approval of premium increases that may include the applicant’s provision of notice of the proposed premium increase to all subscribers subject to the proposed increase, at least ten (10) days prior to the hearing; and

(6) Establishing standards for Medicare select policies and certificates.

(g) Each Medicare supplement Plan A policy or applicable certificate that an issuer currently, or at any time hereafter, makes available in this state shall be made available to any applicant under the age of sixty-five (65) who is eligible for Medicare due to a disability or end-stage renal disease, provided that the applicant submits their application during the first six (6) months immediately following the applicant’s initial eligibility for Medicare Part B, or alternate enrollment period as determined by the commissioner. The issuance or coverage of any Medicare supplement policy pursuant to this section shall not be conditioned on the medical or health status or receipt of health care by the applicant; and no insurer shall perform individual medical underwriting on any applicant in connection with the issuance of a policy pursuant to this subsection.

(1) Any individual under the age of sixty-five (65) enrolled in a Medicare supplement Plan A by reason of disability or end-stage renal disease pursuant to subsection (g) of this section, shall receive a six-month (6) open enrollment period for any policy or applicable certificate that an issuer currently makes available in this state beginning on the first day of the month in which the individual both attains the age of sixty-five (65) and remains enrolled in Medicare Parts A & B.

(h) Each year, for the duration of the Medicare Annual Enrollment Period (AEP) for coverage with an effective date of January 1 of the following year, an individual enrolled in a Medicare supplement policy or Medicare Advantage plan who has been covered by any Medicare supplement policy(s) or Medicare Advantage plan(s) with no gap in coverage greater than ninety (90) days beginning from that individual’s Medicare Initial Enrollment Period (IEP), shall be afforded guaranteed issue rights for any available Medicare supplement policy or applicable certificate that an issuer currently makes available in this state.

(1) The issuance or coverage of any Medicare supplement policy pursuant to subsection (h) of this section shall not be conditioned on the medical or health status or receipt of health care by the applicant and no issuer shall perform individual medical underwriting on any applicant in connection with the issuance of a policy pursuant to this subsection.

(2) For those individuals under the age of sixty-five (65) enrolled in a Medicare Advantage or Medicare supplement Plan A due to a disability, pursuant to subsection (g) of this section the individual shall be afforded guaranteed issue rights for every Medicare supplement Plan A policy or applicable certificate that an issuer makes available in this state. Coverage shall be afforded pursuant to subsection (h)(1) of this section.