N.M. Admin. Code § 13.10.25.23

Current through Register Vol. 35, No. 23, December 10, 2024

Section 13.10.25.23 - REQUIRED DISCLOSURE PROVISIONS

A.General rules.

(1)Renewal or continuation. Medicare Supplement policies and certificates shall include a renewal or continuation provision. The language or specifications of the provision shall be consistent with the type of contract issued. The provision shall be appropriately captioned and shall appear on the first page of the policy, and shall include any reservation by the issuer of the right to change premiums and any automatic renewal premium increases based on the policyholder's age.

(2) Riders or endorsements. Except for riders or endorsements by which the issuer effectuates a request made in writing by the insured, exercises a specifically reserved right under a Medicare Supplement policy, or is required to reduce or eliminate benefits to avoid duplication of Medicare benefits, all riders or endorsements added to a Medicare Supplement policy after date of issue or at reinstatement or renewal which reduce or eliminate benefits or coverage in the policy shall require a signed acceptance by the insured. After the date of policy or certificate issue, any rider or endorsement which increases benefits or coverage with a concomitant increase in premium during the policy term shall be agreed to in writing signed by the insured, unless the benefits are required by the minimum standards for Medicare Supplement policies, or if the increased benefits or coverage is required by law. Where a separate additional premium is charged for benefits provided in connection with riders or endorsements, the premium charge shall be set forth in the policy.

(3)Payment standards. Medicare Supplement policies or certificates issued or delivered after July 1, 1992 shall not provide for the payment of benefits based on standards described as "usual and customary," "reasonable and customary" or words of similar import.

(4)Disclosure of preexisting condition limitations. If a Medicare Supplement policy or certificate contains any limitations with respect to preexisting conditions, such limitations shall appear as a separate paragraph of the policy and be labeled as "Preexisting Condition Limitations."

(5)Return and refund period. Medicare Supplement policies and certificates shall have a notice prominently printed on the first page of the policy or certificate or attached thereto stating in substance that the policyholder or certificate holder shall have the right to return the policy or certificate within 30 days of its delivery and to have the premium refunded within 30 days after its return if, after examination of the policy or certificate, the insured person is not satisfied for any reason.

(6)Delivery of guide.

(a) Issuers of accident and sickness policies or certificates which provide hospital or medical expense coverage on an expense incurred or indemnity basis to persons eligible for Medicare shall provide to those applicants a Guide to Health Insurance for People with Medicare in the form developed jointly by the NAIC and Center for Medicare and Medicaid Services (CMS) and in a type size no smaller than 12 point type. Delivery of the guide shall be made whether or not the policies or certificates are advertised, solicited or issued as Medicare Supplement policies or certificates as defined in this regulation. Except in the case of direct response issuers, delivery of the guide shall be made to the applicant at the time of application and acknowledgement of receipt of the guide shall be obtained by the issuer. Direct response issuers shall deliver the guide to the applicant upon request but not later than at the time the policy is delivered.

(b) For the purposes of this section, "form" means the language, format, type size, type proportional spacing, bold character, and line spacing.

B.Notice requirements.

(1)Benefit changes. As soon as practicable, but no later than 30 days prior to the annual effective date of any Medicare benefit changes, an issuer shall notify its policyholders and certificate holders of modifications it has made to Medicare Supplement insurance policies or certificates in a format acceptable to the superintendent. The notice shall:

(a) include a description of revisions to the Medicare program and a description of each modification made to the coverage provided under the Medicare Supplement policy or certificate, and

(b) inform each policyholder or certificate holder as to when any premium adjustment is to be made due to changes in Medicare.

(2)Required format. The notice of benefit modifications and any premium adjustments shall be in outline form and in clear and simple terms so as to facilitate comprehension.

(3)No solicitation. The notices shall not contain or be accompanied by any solicitation.

C.MMA notice requirements. Issuers shall comply with any notice requirements of the Medicare Prescription Drug, Improvement and Modernization Act of 2003.

D.Outline of coverage requirements.

(1) Issuers shall provide an outline of coverage to all applicants at the time application is presented to the prospective applicant and, except for direct response policies, shall obtain an acknowledgement of receipt of the outline from the applicant; and

(2) If an outline of coverage is provided at the time of application and the Medicare Supplement policy or certificate is issued on a basis which would require revision of the outline, a substitute outline of coverage properly describing the policy or certificate shall accompany the policy or certificate 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."

(3) The outline of coverage provided to applicants pursuant to this section consists of four parts: a cover page, premium information, disclosure pages, and charts displaying the features of each benefit plan offered by the issuer. The outline of coverage shall be in the language and format prescribed below in no less than 12 point type. All plans shall be shown on the cover page, and the plans that are offered by the issuer shall be prominently identified. Premium information for plans that are offered shall be shown on the cover page or immediately following the cover page and shall be prominently displayed. The premium and mode shall be stated for all plans that are offered to the prospective applicant. All possible premiums for the prospective applicant shall be illustrated.

(4) The following items shall be included in the outline of coverage in the order prescribed below.

Benefit Chart of Medicare Supplement Plans Sold on or After June 1, 2010

[Insert "Benefit Chart of Medicare Supplement Plans Sold on or After June 1, 2010" provided in the Model Regulation To Implement the NAIC Medicare Supplement Insurance Minimum Standards Model Act - NAIC Model #651, as adopted in 2017.]

PREMIUM INFORMATION

We [insert issuer's name] can only raise your premium if we raise the premium for all policies like yours in this State. [If the premium is based on the increasing age of the insured, include information specifying when premiums will change.]

READ YOUR POLICY VERY CAREFULLY

This is only an outline describing your policy's most important features. The policy is your insurance contract. You must read the policy itself to understand all of the rights and duties of both you and your insurance company.

RIGHT TO RETURN POLICY

If you find that you are not satisfied with your policy, you may return it to. If you send the policy back to us within 30 days after you receive it, we will treat the policy as if it had never been issued and will return all of your payments.

POLICY REPLACEMENT

If you are replacing another health insurance policy, do NOT cancel it until you have actually received your new policy and are sure you want to keep it.

NOTICE

This policy may not fully cover all of your medical costs.

[for agents:] - Neither [insert company's name] nor its agents are connected with Medicare

[for direct response:] [insert company's name] is not connected with Medicare.

This outline of coverage does not give all the details of Medicare coverage. Contact your local Social Security Office or consult Medicare and You for more details.

COMPLETE ANSWERS ARE VERY IMPORTANT

When you fill out the application for the new policy, be sure to answer truthfully and completely all questions about your medical and health history. The company may cancel your policy and refuse to pay any claims if you leave out or falsify important medical information. [If the policy or certificate is guaranteed issue, this paragraph must not appear.]

Review the application carefully before you sign it. Be certain that all information has been properly recorded.

[Include for each plan prominently identified in the cover page, a chart showing the services, Medicare payments, plan payments and insured payments for each plan, using the same language, in the same order, using uniform layout and format as listed below. No more than four plans may be shown on one chart. For purposes of illustration, charts for each plan are included in Model Regulation to Implement the NAIC Medicare Supplement Insurance Minimum Standards Model Act - NAIC Model #651, as adopted in 2017. An issuer may use additional benefit plan designations on these charts pursuant to Subsection D of 13.10.25.14 NMAC.]

[Include an explanation of any innovative benefits on the cover page and in the chart, in a manner approved by the superintendent.]

Benefit Chart of Medicare Supplement Plans Sold on or after January 1, 2020

This chart shows the benefits included in each of the standard Medicare Supplement plans. Some plans may not be available. Only applicants first eligible for Medicare before 2020 may purchase Plans C, F, and high deductile F.

[Use the Benefit Chart of Medicare Supplement Plans Sold on or After June 1, 2020 provided in the Model Regulation To Implement the NAIC Medicare Supplement Insurance Minimum Standards Model Act - NAIC Model #651, as adopted in 2017.]

PLAN A

MEDICARE (PART A)-HOSPITAL SERVICES-PER BENEFIT PERIOD

[Use the Plan A (Part A) chart, chart notes and associated values provided in the Model Regulation To Implement the NAIC Medicare Supplement Insurance Minimum Standards Model Act - NAIC Model #651, as adopted in 2017.]

MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR

[Use the Plan A (Part B) chart, chart notes and associated values provided in the Model Regulation To Implement the NAIC Medicare Supplement Insurance Minimum Standards Model Act - NAIC Model #651, as adopted in 2017.]

PARTS A & B

[Use the Plan A (Parts A& B) chart, chart notes and associated values provided in the Model Regulation To Implement the NAIC Medicare Supplement Insurance Minimum Standards Model Act - NAIC Model #651, as adopted in 2017.] PLAN B

PLAN B

MEDICARE (PART A)-HOSPITAL SERVICES-PER BENEFIT PERIOD

[Use the Plan B (Part A) charts, chart notes and associated values provided in the Model Regulation To Implement the NAIC Medicare Supplement Insurance Minimum Standards Model Act - NAIC Model #651, as adopted in 2017.]

MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR

[Use the Plan B (Part B) charts, chart notes and associated values provided in the Model Regulation To Implement the NAIC Medicare Supplement Insurance Minimum Standards Model Act - NAIC Model #651, as adopted in 2017.]

PARTS A & B

[Use the Plan B (Parts A& B) chart, chart notes and associated values provided in the Model Regulation To Implement the NAIC Medicare Supplement Insurance Minimum Standards Model Act - NAIC Model #651, as adopted in 2017.]

PLAN C

MEDICARE (PART A)-HOSPITAL SERVICES-PER BENEFIT PERIOD

[Use the Plan C (Part A) charts, chart notes and associated values provided in the Model Regulation To Implement the NAIC Medicare Supplement Insurance Minimum Standards Model Act - NAIC Model #651, as adopted in 2017.]

MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR

[Use the Plan C (Part B) charts, chart notes and associated values provided in the Model Regulation To Implement the NAIC Medicare Supplement Insurance Minimum Standards Model Act - NAIC Model #651, as adopted in 2017.]

PARTS A & B

[Use the Plan C (Parts A& B) chart, chart notes and associated values provided in the Model Regulation To Implement the NAIC Medicare Supplement Insurance Minimum Standards Model Act - NAIC Model #651, as adopted in 2017.]

OTHER BENEFITS-NOT COVERED BY MEDICARE

[Use the Plan C chart, chart notes and associated values for Other Benefits - Not Covered by Medicare provided in the Model Regulation To Implement the NAIC Medicare Supplement Insurance Minimum Standards Model Act - NAIC Model #651, as adopted in 2017.]

PLAN D

MEDICARE (PART A)-HOSPITAL SERVICES-PER BENEFIT PERIOD

[Use the Plan D (Part A) chart, chart notes, and associated values provided in the Model Regulation To Implement the NAIC Medicare Supplement Insurance Minimum Standards Model Act - NAIC Model #651, as adopted in 2017.]

MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR

[Use the Plan D (Part B) chart, chart notes and associated values provided in the Model Regulation To Implement the NAIC Medicare Supplement Insurance Minimum Standards Model Act - NAIC Model #651, as adopted in 2017.]

PARTS A & B

[Use the Plan D (Parts A& B) chart, chart notes and associated values provided in the Model Regulation To Implement the NAIC Medicare Supplement Insurance Minimum Standards Model Act - NAIC Model #651, as adopted in 2017.]

OTHER BENEFITS-NOT COVERED BY MEDICARE

[Use the Plan D chart, chart notes and associated values for Other Benefits - Not Covered by Medicare provided in the Model Regulation To Implement the NAIC Medicare Supplement Insurance Minimum Standards Model Act - NAIC Model #651, as adopted in 2017.]

PLAN F or HIGH DEDUCTIBLE PLAN F

MEDICARE (PART A)-HOSPITAL SERVICES-PER BENEFIT PERIOD

[Use the Plan F or High Deductible Plan F (Part A) chart, chart notes and associated values provided in the Model Regulation To Implement the NAIC Medicare Supplement Insurance Minimum Standards Model Act - NAIC Model #651, as adopted in 2017.]

MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR

[Use the Plan F or High Deductible Plan F (Part B) chart, chart notes and associated values provided in the Model Regulation To Implement the NAIC Medicare Supplement Insurance Minimum Standards Model Act - NAIC Model #651, as adopted in 2017.]

PARTS A & B

[Use the Plan F or High Deductible Plan F (Parts A& B) chart, chart notes and associated values provided in the Model Regulation To Implement the NAIC Medicare Supplement Insurance Minimum Standards Model Act - NAIC Model #651, as adopted in 2017.]

OTHER BENEFITS-NOT COVERED BY MEDICARE [Use the Plan F or High Deductible Plan F chart and associated values for Other Benefits - not covered by Medicare provided in the Model Regulation To Implement the NAIC Medicare Supplement Insurance Minimum Standards Model Act - NAIC Model #651, as adopted in 2017.]

PLAN G or HIGH DEDUCTIBLE PLAN G

MEDICARE (PART A)-HOSPITAL SERVICES-PER BENEFIT PERIOD

[Use the Plan G or High Deductible Plan G (Part A) chart, chart notes and associated values provided in the Model Regulation To Implement the NAIC Medicare Supplement Insurance Minimum Standards Model Act - NAIC Model #651, as adopted in 2017.]

MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR

[Use the Plan G or High Deductible Plan G (Part B) chart, chart notes and associated values provided in the Model Regulation To Implement the NAIC Medicare Supplement Insurance Minimum Standards Model Act - NAIC Model #651, as adopted in 2017.]

PARTS A & B

[Use the Plan G or High Deductible Plan G (Parts A& B) chart, chart notes and associated values provided in the Model Regulation To Implement the NAIC Medicare Supplement Insurance Minimum Standards Model Act - NAIC Model #651, as adopted in 2017.]

OTHER BENEFITS-NOT COVERED BY MEDICARE [Use the Plan G or High Deductible Plan G chart, chart notes and associated values for Other Benefits - not covered by Medicare provided in the Model Regulation To Implement the NAIC Medicare Supplement Insurance Minimum Standards Model Act - NAIC Model #651, as adopted in 2017.]

PLAN K

MEDICARE (PART A)-HOSPITAL SERVICES-PER BENEFIT PERIOD

[Use the Plan K (Part A) chart, chart notes and associated values provided in the Model Regulation To Implement the NAIC Medicare Supplement Insurance Minimum Standards Model Act - NAIC Model #651, as adopted in 2017.]

MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR

[Use the Plan K (Part B) chart, chart notes and associated values provided in the Model Regulation To Implement the NAIC Medicare Supplement Insurance Minimum Standards Model Act - NAIC Model #651, as adopted in 2017.]

PARTS A & B

[Use the Plan K (Parts A& B) chart, chart notes and associated values provided in the Model Regulation To Implement the NAIC Medicare Supplement Insurance Minimum Standards Model Act - NAIC Model #651, as adopted in 2017.]

PLAN L

MEDICARE (PART A)-HOSPITAL SERVICES-PER BENEFIT PERIOD

[Use the Plan L (Part A) chart, chart notes and associated values provided in the Model Regulation To Implement the NAIC Medicare Supplement Insurance Minimum Standards Model Act - NAIC Model #651, as adopted in 2017.

MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR

[Use the Plan L (Part B) chart. chart notes and associated values provided in the Model Regulation To Implement the NAIC Medicare Supplement Insurance Minimum Standards Model Act - NAIC Model #651, as adopted in 2017.

PARTS A & B

[Use the Plan L (Parts A& B) chart, chart notes and associated values provided in the Model Regulation To Implement the NAIC Medicare Supplement Insurance Minimum Standards Model Act - NAIC Model #651, as adopted in 2017.]

PLAN M

MEDICARE (PART A)-HOSPITAL SERVICES-PER BENEFIT PERIOD

[Use the Plan M (Part A) chart, chart notes and associated values provided in the Model Regulation To Implement the NAIC Medicare Supplement Insurance Minimum Standards Model Act - NAIC Model #651, as adopted in 2017.

MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR

[Use the Plan L (Part B) chart, chart notes and associated values provided in the Model Regulation To Implement the NAIC Medicare Supplement Insurance Minimum Standards Model Act - NAIC Model #651, as adopted in 2017.

PARTS A & B

[Use the Plan M (Parts A& B) chart, chart notes and associated values provided in the Model Regulation To Implement the NAIC Medicare Supplement Insurance Minimum Standards Model Act - NAIC Model #651, as adopted in 2017.]

OTHER BENEFITS-NOT COVERED BY MEDICARE

[Use the Plan M chart, chart notes and associated values for Other Benefits - not covered by Medicare provided in the Model Regulation To Implement the NAIC Medicare Supplement Insurance Minimum Standards Model Act - NAIC Model #651, as adopted in 2017.

PLAN N

MEDICARE (PART A)-HOSPITAL SERVICES-PER BENEFIT PERIOD [Use the Plan N (Part A) chart, chart notes and associated values provided in the Model Regulation To Implement the NAIC Medicare Supplement Insurance Minimum Standards Model Act - NAIC Model #651, as adopted in 2017.]

MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR

[Use the Plan N (Part B) chart, chart notes and associated values provided in the Model Regulation To Implement the NAIC Medicare Supplement Insurance Minimum Standards Model Act - NAIC Model #651, as adopted in 2017.]

PARTS A & B

[Use the Plan N (Parts A& B) chart, chart notes and associated values provided in the Model Regulation To Implement the NAIC Medicare Supplement Insurance Minimum Standards Model Act - NAIC Model #651, as adopted in 2017.]

OTHER BENEFITS-NOT COVERED BY MEDICARE [Use the Plan N chart, chart notes and associated values for Other Benefits - not covered by Medicare provided in the Model Regulation To Implement the NAIC Medicare Supplement Insurance Minimum Standards Model Act - NAIC Model #651, as adopted in 2017.

E. Notice Regarding Policies or Certificates Which are not Medicare Supplement Policies.

(1) Any accident and sickness insurance policy or certificate, other than a Medicare Supplement policy, a policy issued pursuant to a contract under Section 1876 of the Federal Social Security Act (42 U.S.C. § 1395 et seq.), disability income policy; or other policy identified in Subsection B of 13.10.25.3 NMAC, issued for delivery in this state to persons eligible for Medicare shall notify insureds under the policy that the policy is not a Medicare Supplement policy or certificate. The notice shall either be printed or attached to the first page of the outline of coverage delivered to insureds under the policy, or if no outline of coverage is delivered, to the first page of the policy, or certificate delivered to insureds. The notice shall be in no less than 12 point type and shall contain the following language:

"THIS [POLICY OR CERTIFICATE] IS NOT A MEDICARE SUPPLEMENT [POLICY OR CONTRACT]. If you are eligible for Medicare, review the Guide to Health Insurance for People with Medicare available from the company."

(2) Pursuant to Subsection B of 13.10.25.31 NMAC, applications provided to persons eligible for Medicare for the health insurance policies or certificates described in Paragraph (1) of Subsection D of this section shall be disclosed, using the applicable statement in Appendix C as provided in the Model Regulation To Implement the NAIC Medicare Supplement Insurance Minimum Standards Model Act - NAIC Model #651, as adopted in 2017, the extent to which the policy duplicates Medicare. The disclosure statement shall be provided as a part of, or together with, the application for the policy or certificate.

N.M. Admin. Code § 13.10.25.23

13.10.25.23 NMAC - N, 08/31/09, Adopted by New Mexico Register, Volume XXIX, Issue 24, December 27, 2018, eff. 1/1/2019