Ins 3.39(34)(d)3. 3. For purposes of par. (b) 5. and 6., no enrollment of an individual with an organization or provider described in par. (b) 5. a., or with a plan or in a program described in par. (b) 6., may be deemed to be an initial enrollment under this paragraph after the 2-year period beginning on the date on which the individual first enrolled with such an organization, provider, plan or program.
Ins 3.39(34)(e) (e) Products to which eligible persons are entitled prior to June 1, 2010. The Medicare supplement or Medicare cost policy to which eligible persons are entitled under:
Ins 3.39(34)(e)1. 1. Paragraph (b) 1., 1m., 1r., 2., 3., and 4., is a Medicare supplement policy as defined in sub. (5) along with any riders available or a Medicare select policy as defined in sub. (30). except the Outpatient Prescription Drug Rider defined in sub. (5) (i) 7.
Ins 3.39(34)(e)2. 2. Paragraph (b) 5. is the same Medicare supplement policy in which the individual was most recently previously enrolled, if available from the same issuer, or, if not so available, a policy as described in subd. 1.
Ins 3.39(34)(e)3. 3. Paragraph (b) 6. and 8. is a Medicare supplement policy as described in sub. (5) along with any riders available or a Medicare select policy as defined in sub. (30).
Ins 3.39(34)(e)4. 4. Paragraph (b) 7., is a Medicare supplement policy as described in sub. (5) along with any riders available or a Medicare select policy as defined in sub. (30), that is offered and is available for issuance to new enrollees by the same issuer that issued the individual's Medicare supplement policy with the outpatient prescription drug coverage.
Ins 3.39(34)(e)5. 5. Paragraph (b) 3., is a Medicare cost policy as described in sub. (7) along with any enhancements and riders, that is offered and is available for issuance to new enrollees by the same issuer that issued the individual's Medicare cost policy.
Ins 3.39(34)(e)6. 6. The Outpatient Prescription Drug Rider referenced in sub. (5) (i) 7. may only be issued through December 31, 2005.
Ins 3.39(34)(ez) (ez) Products to which eligible persons are entitled on or after June 1, 2010. The Medicare supplement or Medicare cost policy or certificate to which eligible persons are entitled under:
Ins 3.39(34)(ez)1. 1. Paragraph (b) 1., 1m., 1r., 1s., 2., 3. and 4., is a Medicare supplement policy or certificate as defined in sub. (5m) along with any riders available or a Medicare select policy or certificate as defined in sub. (30m).
Ins 3.39(34)(ez)2. 2. Paragraph (b) 5. is the same Medicare supplement policy or certificate in which the individual was most recently previously enrolled, if available from the same issuer, or, if not so available, a policy or certificate as described in subd. 1.
Ins 3.39(34)(ez)3. 3. Paragraph (b) 6. and 8. is a Medicare supplement policy or certificate as described in sub. (5m) along with any riders available or a Medicare select policy or certificate as defined in sub. (30m).
Ins 3.39(34)(ez)4. 4. Paragraph (b) 7., is a Medicare supplement policy or certificate as described in sub. (5m) along with any riders available or a Medicare select policy or certificate as defined in sub. (30m), that is offered and is available for issuance to new enrollees by the same issuer that issued the individual's Medicare supplement policy or certificate with the outpatient prescription drug coverage.
Ins 3.39(34)(f) (f) Notification provisions.
Ins 3.39(34)(f)1.1. At the time of an event described in par. (b) because of which an individual loses coverage or benefits due to the termination of a contract or agreement, policy, or plan, the organization that terminates the contract or agreement, the issuer terminating the policy, or the administrator of the plan being terminated, respectively, shall notify the individual of his or her rights under this section, and of the obligations of issuers of Medicare supplement or Medicare cost policies under par. (a). The notice shall be communicated contemporaneously with the notification of termination.
Ins 3.39(34)(f)2. 2. At the time of an event described in par. (b) because of which an individual ceases enrollment under a contract or agreement, policy, or plan, the organization that offers the contract or agreement, regardless of the basis for the cessation of enrollment, the issuer offering the policy, or the administrator of the plan, respectively, shall notify the individual of his or her rights under this section, and of the obligations of issuers of Medicare supplement or Medicare cost policies under par. (a). Such notice shall be communicated within 10 working days of the issuer receiving notification of disenrollment.
Ins 3.39(34)(f)3. 3. At the time of an event described in par. (b) because of which a hospital in a Medicare select network leaves the network the issuer shall notify the insured of his or her rights under this section, and of the obligations of issuers of Medicare supplement or Medicare cost policies under par. (a). The notice to insureds shall be communicated within 10 business days of the issuer receiving notification of the hospital's notice of leaving the network.
Ins 3.39(35) (35)Exchange of Medicare supplement policy. An issuer that submits and receives approval to offer a Medicare supplement insurance policy that is effective or issued on or after June 1, 2010, may offer an exchange subject to the following requirements:
Ins 3.39(35)(a) (a) By or before May 31, 2011, on a one-time basis in writing, an issuer may offer to all of its existing Medicare supplement policyholders or certificateholders covered by a policy with an effective prior to June 1, 2010, the option to exchange the existing policy to a different policy that complies with subs. (4s), (5m) and (30m), as applicable.
Ins 3.39(35)(b) (b) The offer shall be made on a nondiscriminatory basis without regard to the age or health status of the insured unless such offer or issue would be in violation of state or federal law.
Ins 3.39(35)(c) (c) The offer shall remain open for a minimum of 120 days from the date of the mailing by the issuer.
Ins 3.39(35)(d) (d) In the event of an exchange, if the replaced policy is priced on an issue age rate schedule, the rate charged to the insured for the newly exchanged policy shall recognize the policy reserve buildup, due to the pre-funding inherent in the use of an issue age rate basis, for the benefit of the insured.
Ins 3.39(35)(e) (e) The rating class of the new policy or certificate shall be the class closest to the insured's class of the replaced coverage.
Ins 3.39(35)(f) (f) The issuer may not apply new preexisting condition limitations or a new incontestability period to the newly issued policy for those benefits that were contained in the exchanged policy or certificate of the insured but may apply a preexisting condition limitation of no more than 6 months to any added benefits contained in the newly issued policy or certificate that were not present in the exchanged policy or certificate.
Ins 3.39(36) (36)Genetic information. In addition to compliance with ss. 631.89 and 632.748, Stats., beginning on May 21, 2009, an issuer of a Medicare supplement policy or certificate may not deny or condition the issuance or effectiveness of the policy or certificate, including the imposition of any exclusion of benefits under the policy based on a preexisting condition, on the basis of the genetic information with respect to such individual. The issuer may not discriminate in the pricing of the policy or certificate, including the adjustment of rates of an individual on the basis of the genetic information with respect to such individual.
Ins 3.39(36)(a) (a) In this subsection and for use in policies or certificates:
Ins 3.39(36)(a)1. 1. "Family member" means, with respect to an individual, any other individual who is a first through fourth degree relative of the individual.
Ins 3.39(36)(a)2. 2. "Genetic information" means, with respect to any individual, information about such individual's genetic tests, the genetic tests of family members of such individual, and the manifestation of a disease or disorder in family members of such individual. Such term includes, with respect to any individual, any request for, or receipt of, genetic services, or participation in clinical research that includes genetic services, by such individual or any family member of such individual. Any reference to genetic information concerning an individual or family member of an individual who is a pregnant woman includes genetic information of any fetus carried by such pregnant woman, or with respect to an individual or family member utilizing reproductive technology, includes genetic information of any embryo legally held by an individual or family member. The term "genetic information" does not include information about the sex or age of any individual.
Ins 3.39(36)(a)3. 3. "Genetic services" means a genetic test, genetic counseling including, obtaining, interpreting, or assessing genetic information, or genetic education.
Ins 3.39(36)(a)4. 4. "Genetic test" means an analysis of human deoxyribonucleic acid, ribonucleic acid or chromosomes, proteins, or metabolites that detect genotypes, mutations, or chromosomal changes. The term "genetic test" does not mean an analysis of proteins or metabolites that does not detect genotypes, mutation, or chromosomal changes; or an analysis of proteins or metabolites that is directly related to a manifested disease, disorder, or pathological condition that could reasonably be detected by a health care professional with appropriate training and expertise in the field of medicine involved.
Ins 3.39(36)(a)5. 5. "Issuer of a Medicare supplement policy or certificate" includes third-party administrators, or other person acting for or on behalf of such issuer.
Ins 3.39(36)(a)6. 6. "Underwriting purposes," means all of the following:
Ins 3.39(36)(a)6.a. a. Rules for, or determinations of, eligibility including enrollment and continued eligibility for benefits under the policy.
Ins 3.39(36)(a)6.b. b. The computation of premium or contribution amounts under the policy.
Ins 3.39(36)(a)6.c. c. The application of any preexisting condition exclusions under the policy.
Ins 3.39(36)(a)6.d. d. Other activities related to the creation, renewal, or replacement of a contract of health insurance or health benefits.
Ins 3.39(36)(b) (b) An issuer of a Medicare supplement policy or certificate may not request or require an individual or a family member of such individual to undergo a genetic test. An issuer may not request, require or purchase genetic information for use in underwriting. An issuer may not request, require or purchase genetic information with respect to any individual prior to such individual's enrollment under the policy in connection with such enrollment.
Ins 3.39(36)(c) (c) Nothing in par. (b) shall be construed to limit the ability of an issuer, to the extent otherwise permitted by law, from any of the following;
Ins 3.39(36)(c)1. 1. Denying or conditioning the issuance or effectiveness of a policy or certificate or increasing the premium for a group based on the manifestation of a disease or disorder of an insured or applicant.
Ins 3.39(36)(c)2. 2. Increasing the premium for any policy issued to an individual based on the manifestation of a disease or disorder of an individual who is covered under the policy.
Ins 3.39(36)(d) (d) Notwithstanding par. (b), the manifestation of a disease or disorder in one individual cannot also be used as genetic information about other group members to further increase the premium for the group.
Ins 3.39(36)(e) (e) An issuer of a Medicare supplement policy or certificate may not request or require an individual or a family member of such individual to undergo a genetic test. Nothing in this paragraph shall be construed to preclude an issuer of a Medicare supplement policy or certificate from obtaining and using the results of a genetic test in making a payment determination when consistent with the requirements of par. (b). If genetic information is obtained, the request may only include the minimum amount necessary to accomplish the intended purpose.
Ins 3.39(36)(f) (f) If an issuer of a Medicare supplement policy or certificate obtains genetic information incidental to the requesting, requiring or purchasing of other information concerning any individual, such request, requirement or purchase may not be considered a violation of this section.
Ins 3.39 Note Note: This rule requires the use of a rate change transmittal form which may be obtained from the Office of the Commissioner of Insurance, P.O. Box 7873, Madison, WI 53707-7873.
Ins 3.39 Note Note: The rule revisions published in June, 1994 first apply to any policy issued, renewed or solicited on or after September 1, 1994.
Ins 3.39 Note Note: For a complete history of s. Ins 3.39 from July 1977 to October 31, 2001, see the History note following s. Ins 3.39 as published in Register October 2001 No. 550.
Ins 3.39 History History: CR 00-133: am (2) (a) (intro.), (3) (cm), (4) (intro.), (a), (b) 2., (34) (b) 5. a., 6., (c) 1. and Appendix 1, cr. (4) (a) 18p., (34) (b) 2. b., 2. f. and (c) 3., r. (7) (b),(c), (7) (g), (21) (f), r. and recr. (7) (d), (13) and (34) (b) 2.a., renum (7) (e) to be (7) (c) and am., renum. (7) (f) to be (7) (d), (34) (b) 2. b. to be 2. c., 2. c. to be 2. d and 2. d. to be 2. e.,Register October 2001 No. 550, eff. 11-1-01; corrections in (34) (b) 2. and 3., made under s. 13.93 (2m) (b) 1., Stats., Register October 2001 No. 550; emerg. am. eff. 12-16-02; corrections in (2) (a), (4), (7) (b) and (c), (13) and (33) made under s. 13.93 (2m) (b) 7., Stats., Register December 2002 No. 564; CR 02-118: am. (4) (a) 18p., (5) (c) 4., (34) (a) 1. and 2., (b) (intro.), 2. (intro.), a., b., 3. (intro.), a. and c., 4. (intro.), 5. a. and 6., r. (34) (b) 2. f. and fm., renum. (34) (c) and (d) to be (34) (e) and (f), cr. (34) (c) and (d) Register April 2003 No. 568, eff. 5-1-03; CR 04-121: am. (1) (c), (4) (intro.), (a) 1. to 3., 6., 12., 18m. and 18r. b., (4m) (a), (b) and (d), (5) (c) 6., 12. to 15., (i) (intro.) and 7., (j), (k) (intro.), (m) (intro.), (14) (a), (c) 6., (j), (m), (15), (16) (a), (c) (intro.), 1., 3. and (e), (21) (a) and (e), (22) (a), (b), (d), (e), (f) (intro.) and 1., (23) (a) (intro.), 1., 3., 4. and (c), (25) (a) to (c), (26) (a) (intro.), (27), (29), (30) (a), (b) 1. to 7., (c), (d), (e) (intro.) and 1. e., (f) 1., (g) (intro.), (h), (i) (intro.), 1. (intro.) and b., 3., 7., and 9., (j), (k) (intro.), (L) to (o), (p) (intro.) and 8., (34) (a), (b) 1., 1m., 2. (intro.) and a., 3. d., 4. (intro.), 5. a., 6., (c) 1. (intro.) and a., 2., 4., (e) and (f), and Appendices 5 and 8, cr. (2) (f), (4) (a) 20., 21., (5) (n), (o), (23) (a) 5., (30) (q), (r), (34) (b) 1r., 7., 8., and (c) 5., r. and recr. (3), (7), (22) (i) and Appendices 1, 3, 4, and 6, renum. (23) (a) 5., (30) (q) and (r) and (34) (c) 5. to be (23) (a) 6, (30) (s) and (t) and (34) (c) 6. and am. (23) (a) 6., (30) (s) and (t), r. (33) Register June 2005 No. 594, eff. 7-1-05; CR 08-112: am. (1) (a), (b), (3) (q), (v), (w), (4) (intro.), (a) 3., 8., 17., (5) (title), (intro.), (6) (intro.), (7) (a), (d), (8) (c), (9) (b), (14) (title), (a), (d) 3., (15), (23) (d), (24) (g), (26) (b), (30) (a) 1., 2., (b) (intro.), (31) (a) and (34) (e) (title), renum. (1) (c) to be (1) (d), cr. (1) (c), (3) (ce), (cs), (4s), (5m), (14m), (17), (18), (30m), (34) (ez), (35) and (36) Register June 2009 No. 642, eff. 7-1-09; CR 09-076: am. (5m) (e) (intro.), 5., (6) (intro.), (7) (a) (intro.), (8) (a) (intro.), (14m) (d) (intro.), (34) (b) 1., (c) 1., (ez) 1. and Appendix 3, cr. (5m) (k), (7) (cm), (dm), (30m) (p) 6., (34) (b) 1. c., 1s. and (f) 3., r. (30m) (q) 1., renum. (30m) (q) 2. and 3. to be (30m) (q) 1. and 2. Register May 2010 No. 653, eff. 6-1-10; correction in (7) (cm) made under s. 13.93 (2m) (b) 7., Stats., Register, May 2010 No. 653.
Ins 3.39 APPENDIX 1
For policies with an effective date prior to June 1, 2010 the following information shall be inserted prior to each outline of coverage provided to an insured and include the information specific to the plan type.
PREMIUM INFORMATION
We can only raise your premium if we raise the premium for all policies like yours in this state. [Include information specifying when premiums will change.]
If your policy was issued as an under age 65 policy due to disability, when you turn 65 premiums will remain at the disabled rates. [Include this statement within premium information when issuer does not change premium to age 65 rate.]
DISCLOSURES
Use this outline to compare benefits and premiums among policies.
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 (insert issuer's address). 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 return all your payments directly to you.
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.
(1) The outline of coverage for a Medicare replacement insurance policy as defined in s. 600.03 (28p) a. and c., Stats., shall contain the following language: Medicare replacement insurance policy: This policy provides basic Medicare hospital and physician benefits. It also includes benefits beyond those provided by Medicare. This policy is a replacement for Medicare and is subject to certain limitations in choice of providers and area of service. The policy does not provide benefits for custodial care such as help in walking, getting in and out of bed, eating, dressing, bathing, and taking medicine.
(2) (a) In 24–point type: For Medicare supplement policies marketed by intermediaries:
Neither (insert company's name) nor its agents are connected with Medicare.
(b) In 24–point type: For Medicare supplement policies marketed by direct response:
(insert company's name) is not connected with Medicare.
(c) For Medicare replacement policies as defined in s. 600.03 (28p) a. and c., Stats.:
(insert company's name) has contracted with Medicare to provide Medicare benefits. Except for emergency care anywhere or urgently needed care when you are temporarily out of the service area, all services, including all Medicare services, must be provided or authorized by (insert company's name).
(3) (a) For Medicare supplement policies, provide a brief summary of the major benefits and gaps in Medicare Parts A and B with a parallel description of supplemental benefits, including dollar amounts, as outlined in these charts.
(b) For Medicare replacement policies, as defined in s. 600.03 (28p) a. and c., Stats., provide a brief summary of both the basic Medicare benefits in the policy and additional benefits using the basic format as outlined in these charts and modified to accurately reflect the benefits.
(c) If the coverage is provided by a health maintenance organization as defined in s. 609.01 (2), Stats., provide a brief summary of the coverage for emergency care anywhere and urgent care received outside the service area if this care is treated differently than other covered benefits.
(4) If the plan is a Medicare Supplement High Deductible Plan as defined in sub. (5) (n) or (o), add the following text in a bold or contrasting color: You will pay [half (for plans defined in sub. (5) (n))] [one quarter (for plans defined in sub. (5) (o))] of the cost-sharing of some covered services until you reach the annual out-of-pocket maximum of [$4,000 (for plans defined in sub. (5) (n))] [$2,000 (for plan defined in sub. (5) (o))] each calendar year. The amounts you must pay are noted in the chart below. Once you reach the annual limit, the plan pays for 100% for the items or services noted in the chart.
The following information shall be inserted AFTER the specific plan type outline of coverage that is provided to all insureds. The information shall include the information specific to the plan type.
(5) All limitations and exclusions, including each of the following, must be listed under the caption "LIMITATIONS AND EXCLUSIONS" if benefits are not provided:
(a) Nursing home care costs beyond what is covered by Medicare and the additional 30–day skilled nursing mandated by s. 632.895 (3), Stats.
(b) Home health care above the number of visits covered by Medicare and the 365 visits mandated by s. 632.895 (2), Stats. [For Medicare select policies only.]
(c) Physician charges above Medicare's approved charge.
(d) Outpatient prescription drugs.
(e) Most care received outside of U.S.A.
(f) Dental care, dentures, checkups, routine immunizations, cosmetic surgery, routine foot care, examinations for and the cost of eyeglasses or hearing aids, unless eligible under Medicare.
(g) Coverage for emergency care anywhere or for care received outside the service area if this care is treated differently than other covered benefits.
(h) Waiting period for pre–existing conditions.
(i) Limitations on the choice of providers or the geographical area served (if applicable for Medicare select policies only).
(j) Usual, customary, and reasonable limitations.
(6) CONSPICUOUS STATEMENTS AS FOLLOWS:
This outline of coverage does not give all the details of Medicare coverage. Contact your local Social Security Office or consult "Medicare & You" for more details.
(7) A description of policy provisions respecting renewability or continuation of coverage, including any reservation of rights to change premium.
(8) Information on how to file a claim for services received from non–participating providers because of an emergency within or outside of the service area shall be prominently disclosed.
Loading...
Loading...
Published under authority of s. 35.93, Stats. Updated on the first day of each month. Entire code is alwaycurrent. The date shown on each chapter is the date the chapter was last published.