Section 45-06-01.1-07.1 - 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, 2010The 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 with an effective date for coverage before June 1, 2010, remain subject to the requirements of sections 45-06-01.1-06 and 45-06-01.1-07.
1.a. An issuer shall make available to each prospective policyholder and certificate holder a policy form or certificate form containing only the basic benefits, as defined in subsection 2 of section 45-06-01.1-06.1.b. If an issuer makes available any of the additional benefits described in subsection 3 of section 45-06-01.1-06.1, or offers standardized benefit plans K or L as described in subdivisions h and i of subsection 5, then the issuer shall make available to each prospective policyholder and certificate holder, in addition to a policy form or certificate form with only the basic benefits as described in subdivision a, a policy form or certificate form containing either standardized benefit plan C as described in subdivision c of subsection 5 or standardized benefit plan F as described in subdivision e of subsection 5. 2. No groups, packages, or combinations of Medicare supplement benefits other than those listed in this section shall be offered for sale in this state, except as may be permitted in subsection 6 and section 45-06-01.1-08.3. Benefit plans shall be uniform in structure, language, designation, and format to the standard benefit plans listed in this subsection and conform to the definitions in section 45-06-01.1-02. Each benefit shall be structured in accordance with the format provided in subsections 2 and 3 of section 45-06-01.1-06.1; or, in the case of plans K or L, in subdivisions h and i of subsection 5 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 3, an issuer may use other designations to the extent permitted by law.5. Makeup of 2010 standardized benefit plans: a. Standardized Medicare supplement benefit plan A shall include only the following: the basic benefits as defined in subsection 2 of section 45-06-01.1-06.1.b. Standardized Medicare supplement benefit plan B shall include only the following: the basic benefit as defined in subsection 2 of section 45-06-01.1-06.1, plus one hundred percent of the Medicare part A deductible as defined in subdivision a of subsection 3 of section 45-06-01.1-06.1.c. Standardized Medicare supplement benefit plan C shall include only the following: the basic benefit as defined in subsection 2 of section 45-06-01.1-06.1, plus one hundred percent of the Medicare part A deductible, skilled nursing facility care, one hundred percent of the Medicare part B deductible, and medically necessary emergency care in a foreign country as defined in subdivisions a, c, d, and f of subsection 3 of section 45-06-01.1-06.1, respectively.d. Standardized Medicare supplement benefit plan D shall include only the following: the basic benefit as defined in subsection 2 of section 45-06-01.1-06.1, plus one hundred percent of the Medicare part A deductible, skilled nursing facility care, and medically necessary emergency care in a foreign country as defined in subdivisions a, c, and f of subsection 3 of section 45-06-01.1-06.1, respectively.e. Standardized Medicare supplement plan F shall include only the following: the basic benefit as defined in subsection 2 of section 45-06-01.1-06.1, plus one hundred percent of the Medicare part A deductible, the skilled nursing facility care, one hundred percent of the Medicare part B deductible, one hundred percent of the Medicare part B excess charges, and medically necessary emergency care in a foreign country as defined in subdivisions a, c, d, e, and f of subsection 3 of section 45-06-01.1-06.1, respectively.f. Standardized Medicare supplement plan F with high deductible shall include only the following: one hundred percent of covered expenses following the payment of the annual deductible set forth in paragraph 2. (1) The basic benefit as defined in subsection 2 of section 45-06-01.1-06.1, plus one hundred percent of the Medicare part A deductible, skilled nursing facility care, one hundred percent of the Medicare part B deductible, one hundred percent of the Medicare part B excess charges, and medically necessary emergency care in a foreign country as defined in subdivisions a, c, d, e, and f of subsection 3 of section 45-06-01.1-06.1, 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 one thousand five hundred dollars and shall be adjusted annually from 1999 by the secretary of the United States 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.g. Standardized Medicare supplement benefit plan G shall include only the following: the basic benefit as defined in subsection 2 of section 45-06-01.1-06.1, plus one hundred percent of the Medicare part A deductible, skilled nursing facility care, one hundred percent of the Medicare part B excess charges, and medically necessary emergency care in a foreign country as defined in subdivisions a, c, e, and f of subsection 3 of section 45-06-01.1-06.1, respectively. Effective January 1, 2020, the standardized benefit plans described in subdivision d of subsection 1 of section 45-06-01.1-07.2 of this regulation (Redesignated plan G high deductible) may be offered to any individual who was eligible for Medicare prior to January 1, 2010.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, sixty-first through ninetieth days. Coverage of one hundred percent of the part A hospital coinsurance amount for each day used from the sixty-first through the ninetieth day in any Medicare benefit period;(2) Part A hospital coinsurance, ninety-first through one hundred fiftieth days. Coverage of one hundred percent of the part A hospital coinsurance amount for each Medicare lifetime inpatient reserve day used from the ninety-first through the one hundred fiftieth day in any Medicare benefit period;(3) Part A hospitalization after one hundred fifty days. Upon exhaustion of the Medicare hospital inpatient coverage, including the lifetime reserve days, coverage of one hundred percent of the Medicare part A eligible expenses for hospitalization paid at the applicable prospective payment system rate, or other appropriate Medicare standard of payment, subject to a lifetime maximum benefit of an additional three hundred sixty-five 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 of the Medicare part A inpatient hospital deductible amount per benefit period until the out-of-pocket limitation is met as described in paragraph 10;(5) Skilled nursing facility care. Coverage for fifty percent of the coinsurance amount for each day used from the twenty-first day through the one hundredth day in a Medicare benefit period for posthospital skilled nursing facility care eligible under Medicare part A until the out-of-pocket limitation is met as described in paragraph 10;(6) Hospice care. Coverage for fifty percent of cost-sharing for all part A Medicare eligible expenses and respite care until the out-of-pocket limitation is met as described in paragraph 10;(7) Blood. Coverage for fifty 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 paragraph 10; (8) Part B cost-sharing. Except for coverage provided in paragraph 9, coverage for fifty 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 paragraph 10;(9) Part B preventive services. Coverage of one hundred percent 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 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 four thousand dollars in 2006, indexed each year by the appropriate inflation adjustment specified by the secretary of the United States 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 paragraphs 1, 2, 3, and 9 of subdivision h of subsection 5 of section 45-06-01.1-07.1;(2) The benefit described in paragraphs 4, 5, 6, 7, and 8 of subdivision h of subsection 5 of section 45-06-01.1-07.1, but substituting seventy-five percent for fifty percent; and(3) The benefit described in paragraph 10 of subdivision h of subsection 5 of section 45-06-01.1-07.1, but substituting two thousand dollars for four thousand dollars.j. Standardized Medicare supplement plan M shall include only the following: the basic benefit as defined in subsection 2 of section 45-06-01.1-06.1, plus fifty percent of the Medicare part A deductible, skilled nursing facility care, and medically necessary emergency care in a foreign country as defined in subdivisions b, c, and f of subsection 3 of section 45-06-01.1-06.1, respectively.k. Standardized Medicare supplement plan N shall include only the following: the basic benefit as defined in subsection 2 of section 45-06-01.1-06.1, plus one hundred percent of the Medicare part A deductible, skilled nursing facility care, and medically necessary emergency care in a foreign country as defined in subdivisions a, c, and f of subsection 3 of section 45-06-01.1-06.1, respectively, with copayments in the following amounts: (1) The lesser of twenty dollars 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 fifty dollars 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 visit is subsequently covered as a Medicare part A expense.6. New or innovative benefits. An issuer may, with the prior approval of the commissioner, 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. N.D. Admin Code 45-06-01.1-07.1
Amended by Administrative Rules Supplement 374, October 2019, effective 10/1/2019.General Authority: NDCC 26.1-36.1-02(1)(2), 26.1-36.1-03
Law Implemented: NDCC 26.1-36.1-02