Ins 3.39(3)(i)5.b.
b. Coverage supplemental to the coverage provided under chapter 55 of title 10, United States Code; and
Ins 3.39(3)(i)5.c.
c. Similar supplemental coverage provided to coverage under a group health plan.
Ins 3.39(3)(j)
(j) "Employee welfare benefit plan" means a plan, fund or program of employee benefits as defined in
29 USC 1002 (Employee Retirement Income Security Act).
Ins 3.39(3)(k)
(k) "Health care expense" means, for purposes of
sub. (16), expense of health maintenance organizations associated with the delivery of health care services that are analogous to incurred losses of insurers.
Ins 3.39(3)(m)
(m) "Hospital" may be defined in relation to its status, facilities and available services or to reflect its accreditation by the Joint Commission on Accreditation of Hospitals, but not more restrictively than as defined in the Medicare program.
Ins 3.39(3)(o)
(o) "Insolvency" is defined in s.
600.03 (24), Stats., and means when an issuer, licensed to transact the business of insurance in this state, has had a final order of liquidation entered against it by a court of competent jurisdiction in the issuer's state of domicile.
Ins 3.39(3)(p)
(p) "Issuer" includes insurance companies, fraternal benefit societies, health care service plans, health maintenance organizations and any other entity delivering or issuing for delivery in this state Medicare supplement policies or certificates.
Ins 3.39(3)(q)
(q) "Medicare" shall be defined in the policy or certificate. "Medicare" may be substantially defined as "The Health Insurance for the Aged Act, Title XVIII of the Social Security Amendments of 1965 as Then Constituted or Later Amended," or "Title I, Part I of Public Law 89-97, as Enacted by the Eighty-Ninth congress of the United States of America and popularly known as the Health Insurance for the Aged Act, as then constituted and any later amendments or substitutes thereof, or words of similar import.
Ins 3.39(3)(r)
(r) "Medicare Advantage plan" means a plan of coverage for health benefits under Medicare Part C as defined in
42 USC 1395w-28 (b) (1), as amended, and includes any of the following:
Ins 3.39(3)(r)1.
1. Coordinated care plans that provide health care services, including but not limited to health maintenance organization plans (with or without point-of-service option), plans offered by provider-sponsored organizations, and preferred provider plans;
Ins 3.39(3)(r)2.
2. Medical savings account plans coupled with a contribution into a Medicare Advantage medical savings account; and
Ins 3.39(3)(s)
(s) "Medicare eligible expenses" means health care expenses that are covered by Medicare Parts A and B, recognized as medically necessary and reasonable by Medicare, and that may or may not be fully reimbursed by Medicare.
Ins 3.39(3)(t)
(t) "Medicare eligible person" mean a person who qualifies for Medicare.
Ins 3.39(3)(u)
(u) "MMA" means the Medicare Prescription Drugs, Improvement and Modernization Act of 2003, Public Law 108-173, signed into law on December 8, 2003.
Ins 3.39(3)(v)
(v) "Medicare replacement coverage" means coverage that meets the definition in s.
600.03 (28p), Stats., as interpreted by
sub. (2) (a), and that conforms to
subs. (4),
(4s), and
(7). "Medicare replacement coverage" includes Medicare cost and Medicare Advantage plans.
Ins 3.39(3)(w)
(w) "Medicare supplement coverage" means coverage that meets the definition in s.
600.03 (28r), Stats., as interpreted by
sub. (2) (a), and that conforms to
subs. (4),
(4s),
(5),
(5m),
(6),
(30), and
(30m). "Medicare supplement coverage" includes Medicare supplement and Medicare select plans but does not include coverage under Medicare Advantage plans established under Medicare Part C or Outpatient Prescription Drug plans established under Medicare Part D.
Ins 3.39(3)(x)
(x) "Nursing home coverage" means coverage for care that is convalescent or custodial care or care for a chronic condition or terminal illness and provided in an institutional or community-based setting.
Ins 3.39(3)(z)
(z) "Policy form" means the form on which the policy is delivered or issued for delivery by the issuer.
Ins 3.39(3)(za)
(za) "PACE" means Program of All–Inclusive Care for the Elderly (PACE) under section 1894 of the Social Security Act
42 USC 1302 and
1395.
Ins 3.39(3)(zb)
(zb) "Replacement" means any transaction, other than when used to refer to an authorized Medicare Advantage policy, wherein new Medicare supplement or Medicare cost insurance is to be purchased, and it is known to the agent or issuer at the time of application that, as part of the transaction, existing accident and sickness insurance has been or is to be lapsed, cancelled or terminated or the benefits thereof substantially reduced.
Ins 3.39(3)(zc)
(zc) "Secretary" means the secretary of the United States department of health and human services.
Ins 3.39(3)(zd)1.1. "Sickness" shall not be defined to be more restrictive than illness or disease of an insured person that first manifests itself after the effective date of insurance and while the insurance is in force.
Ins 3.39(3)(zd)2.
2. The definition of "sickness" may be further modified to exclude any illness or disease for which benefits are provided under any workers' compensation, occupational disease, employer's liability or similar law.
Ins 3.39(3)(ze)
(ze) "Specified disease coverage" means coverage that is limited to named or defined sickness conditions. The term does not include dental or vision care coverage.
Ins 3.39(4)
(4) Medicare supplement and Medicare replacement policy and certificate requirements for policies and certificates effective dates prior to June 1, 2010. Except as explicitly allowed by
subs. (5),
(7) and
(30), no disability insurance policy or certificate shall relate its coverage to Medicare or be structured, advertised, solicited, delivered or issued for delivery in this state after December 31, 1990 for policies or certificates with effective dates prior to June 1, 2010, as a Medicare supplement policy or certificate or as a Medicare replacement policy or certificate, as defined in s.
600.03 (28p) (a) and
(c), Stats., unless it complies with the following:
Ins 3.39(4)(a)1.
1. Provides only the coverage set out in
sub. (5),
(7) or
(30) and applicable statutes and contains no exclusions or limitations other than those permitted by
sub. (8). No issuer may issue a Medicare cost or Medicare select policy without prior approval from the commissioner and compliance with
subs. (7) and
(30), respectively.
Ins 3.39(4)(a)2.
2. Discloses on the first page any applicable pre-existing conditions limitation, contains no pre-existing condition waiting period longer than 6 months and shall not define a pre-existing condition more restrictively than a condition for which medical advice was given or treatment was recommended by or received from a physician within 6 months before the effective date of coverage.
Ins 3.39(4)(a)3.
3. Contains no definitions of terms such as "Medicare eligible expenses," "accident," "sickness," "mental or nervous disorders," skilled nursing facility," "hospital," "nurse," "physician," "Medicare approved expenses," "benefit period," "convalescent nursing home," or "outpatient prescription drugs" that are worded less favorably to the insured person than the corresponding Medicare definition or the definitions contained in
sub. (3), and defines "Medicare" as in accordance with
sub. (3) (q).
Ins 3.39(4)(a)4.
4. Does not indemnify against losses resulting from sickness on a different basis from losses resulting from accident;
Ins 3.39(4)(a)5.
5. Is "guaranteed renewable" and does not provide for termination of coverage of a spouse solely because of an event specified for termination of coverage of the insured, other than the nonpayment of premium. The policy shall not be cancelled or nonrenewed by the insurer on the grounds of deterioration of health. The policy may be cancelled only for nonpayment of premium or material misrepresentation. If the policy is issued by a health maintenance organization as defined by s.
609.01 (2), Stats., the policy may, in addition to the above reasons, be cancelled or nonrenewed by the issuer if the insured moves out of the service area;
Ins 3.39(4)(a)6.
6. Provides that termination of a Medicare supplement or Medicare cost policy or certificate shall be without prejudice to a continuous loss that commenced while the policy or certificate was in force, although the extension of benefits may be predicated upon the continuous total disability of the insured, limited to the duration of the policy benefit period, if any, or payment of the maximum benefits. Receipt of Medicare Part D benefits shall not be considered in determining a continuous loss.
Ins 3.39(4)(a)7.
7. Contains statements on the first page and elsewhere in the policy which satisfy the requirements of
s. Ins 3.13 (2) (c),
(d) or
(e), and clearly states on the first page or schedule page the duration of the term of coverage for which the policy or certificate is issued and for which it may be renewed (the renewal period cannot be less than the greater of 3 months, the period for which the insured has paid the premium or the period specified in the policy);
Ins 3.39(4)(a)8.
8. Changes benefits automatically to coincide with any changes in the applicable Medicare deductible amount, coinsurance, and copayment percentage factors, although there may be a corresponding modification of premiums in accordance with the policy or certificate provisions and
ch. 625, Stats.
Ins 3.39(4)(a)9.
9. Prominently discloses any limitations on the choice of providers or geographical area of service;
Ins 3.39(4)(a)10.
10. Contains on the first page the designation, printed in 18-point type, and in close conjunction the caption printed in 12-point type, prescribed in
sub. (5),
(7) or
(30);
Ins 3.39(4)(a)11.
11. Contains text which is plainly printed in black or blue ink the size of which is uniform and not less than 10-point with a lower-case unspaced alphabet length not less than 120-point;
Ins 3.39(4)(a)12.
12. Contains a provision describing the review and appeal procedure for denied claims required by s.
632.84, Stats., and a provision describing any grievance rights required by s.
632.83, Stats., applicable to Medicare supplement and Medicare replacement policies; and
Ins 3.39(4)(a)14.
14. Contains no exclusion, limitation, or reduction of coverage for a specifically named or described condition after the policy effective date.
Ins 3.39(4)(a)15.
15. Provides for midterm cancellation at the request of the insured and that, if an insured cancels a policy midterm or the policy terminates midterm because of the insured's death, the issuer shall issue a pro rata refund to the insured or the insured's estate.
Ins 3.39(4)(a)16.
16. Except for permitted preexisting condition clauses as described in
subd. 2., no policy or certificate may be advertised, solicited or issued for delivery in this state as a Medicare supplement policy if such policy or certificate contains limitations or exclusions on coverage that are more restrictive than those of Medicare.
Ins 3.39(4)(a)17.
17. No Medicare supplement policy or certificate in force in this state shall contain benefits that duplicate benefits provided by Medicare.
Ins 3.39(4)(a)18.
18. A Medicare supplement policy or certificate shall provide that benefits and premiums under the policy or certificate shall be suspended at the request of the policyholder or certificateholder for the period not to exceed 24 months in which the policyholder or certificateholder has applied for and is determined to be entitled to medical assistance under Title XIX of the Social Security Act, but only if the policyholder or certificateholder notifies the issuer of the policy or certificate within 90 days after the date the individual becomes entitled to the assistance.
Ins 3.39(4)(a)18m.
18m. If the suspension in
subd. 18. occurs and if the policyholder or certificateholder loses entitlement to medical assistance, the policy or certificate shall be automatically reinstituted (effective as of the date of termination of the entitlement) as of the termination of the entitlement if the policyholder or certificateholder provides notice of loss of the entitlement within 90 days after the date of the loss and pays the premium attributable to the period, effective as of the date of termination of the entitlement.
Ins 3.39(4)(a)18p.
18p. Each Medicare supplement policy shall provide, and contain within the policy, that benefits and premiums under the policy shall be suspended for any period that may be provided by federal regulation, at the request of the policyholder if the policyholder is entitled to benefits under section 226 (b) of the Social Security Act and is covered under a group health plan, as defined in section 1862 (b)(1)(A)(v)of the Social Security Act. If suspension occurs and if the policyholder or certificate holder loses coverage under the group health plan, the policy shall be automatically reinstituted, effective as of the date of loss of coverage, if the policyholder provides notice of loss of coverage within 90 days after the date of such loss and pays the premium attributable to the period, effective as of the date of termination of enrollment in the group health plan.
Ins 3.39(4)(a)18r.a.
a. Shall not provide for any waiting period with respect to treatment of preexisting conditions;
Ins 3.39(4)(a)18r.b.
b. Shall provide for resumption of coverage that was in effect before the date of suspension in
subd. 18. If the suspended Medicare supplement or Medicare cost policy provided coverage for outpatient prescription drugs, reinstitution of the policy shall be without coverage for outpatient prescription drugs and shall otherwise provide substantially equivalent coverage to the coverage in effect before the date of suspension; and
Ins 3.39(4)(a)18r.c.
c. Shall provide for classification of premiums on terms at least as favorable to the policyholder or certificateholder as the premium classification terms that would have applied to the policyholder or certificateholder had the coverage not been suspended.
Ins 3.39(4)(a)19.
19. Shall not use an underwriting standard for under age 65 that is more restrictive than that used for age 65 and above.
Ins 3.39(4)(a)20.a.a. A policy with benefits for outpatient prescription drugs in existence prior to January 1, 2006, shall be renewed for current policyholders who do not enroll in Medicare Part D at the option of the policyholder.
Ins 3.39(4)(a)20.b.
b. A policy with benefits for outpatient prescription drugs shall not be issued after December 31, 2005.
Ins 3.39(4)(a)20.c.
c. After December 31, 2005, a policy with benefits for outpatient prescription drugs may not be renewed after the policyholder enrolls in Medicare Part D unless the policy is modified to eliminate outpatient prescription drug coverage for expenses of outpatient prescription drugs incurred after the effective date of the individual's coverage under a Medicare Part D plan and the premiums are adjusted appropriately to reflect elimination of that coverage.
Ins 3.39(4)(a)21.
21. If a policy that provides Medicare supplement or Medicare cost coverage eliminates an outpatient prescription drug benefit as a result of requirements imposed by the MMA, the modified policy shall be deemed to satisfy the guaranteed renewal requirements of
subd. 5.
Ins 3.39(4)(b)
(b) The outline of coverage for the policy or certificate.
Ins 3.39(4)(b)1.
1. Is provided to all applicants at the time application is made and, except in the case of direct response insurance, the issuer obtains written acknowledgement from the applicant that the outline was received;
Ins 3.39(4)(b)3.
3. Is substituted to properly describe the policy or certificate as issued, if the outline provided at the time of application did not properly describe the coverage which was issued. The substituted outline shall accompany the policy or certificate when it is delivered and shall contain the following statement in no less than 12-point type and 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.";
Ins 3.39(4)(b)4.
4. Contains in close conjunction on its first page the designation, printed in a distinctly contrasting color in 24-point type, and the caption, printed in a distinctly contrasting color in 18-point type prescribed in
sub. (5),
(7) or
(30);
Ins 3.39(4)(b)5.
5. Is substantially in the format prescribed in Appendix 1 to this section for the appropriate category and printed in no less than 12-point type;
Ins 3.39(4)(b)6.
6. Summarizes or refers to the coverage set out in applicable statutes;
Ins 3.39(4)(b)7.
7. Contains a listing of the required coverage as set out in
sub. (5) (c) and the optional coverages as set out in
sub. (5) (i), and the annual premiums therefor, substantially in the format of
sub. (11) of Appendix 1; and
Ins 3.39(4)(b)8.
8. Is approved by the commissioner along with the policy or certificate form.
Ins 3.39(4)(c)
(c) Any rider or endorsement added to the policy or certificate:
Ins 3.39(4)(c)1.
1. Shall be set forth in the policy or certificate and, if a separate, additional premium is charged in connection with the rider or endorsement, the premium charge shall be set forth in the policy or certificate; and
Ins 3.39(4)(c)2.
2. After the date of policy or certificate issue, shall be agreed to in writing signed by the insured, if the rider or endorsement increases benefits or coverage with an accompanying increase in premium during the term of the policy or certificate, unless the increase in benefits or coverage is required by law.
Ins 3.39(4)(c)3.
3. Shall only provide coverage as defined in
sub. (5) (i) or provide coverage to meet statutory mandated provisions.
Ins 3.39(4)(d)
(d) The schedule of benefits page or the first page of the policy or certificate contains a listing giving the coverages and both the annual premium in the format shown in
sub. (11) of Appendix 1 and modal premium selected by the applicant.
Ins 3.39(4)(e)
(e) The anticipated loss ratio for any new policy form, that is, the expected percentage of the aggregate amount of premiums earned which will be returned to insureds in the form of aggregate benefits, not including anticipated refunds or credits, provided under the policy form or certificate form:
Ins 3.39(4)(e)1.
1. Is computed on the basis of anticipated incurred claims or incurred health care expenses where coverage is provided by a health maintenance organizations on a service rather than reimbursement basis and earned premiums for the entire period for which the policy form provides coverage, in accordance with accepted actuarial principles and practices;
Ins 3.39(4)(e)2.
2. Is submitted to the commissioner along with the policy form and is accompanied by rates and an actuarial demonstration that expected claims in relationship to premiums comply with the loss ratio standards in
sub. (16) (d). The policy form will not be approved unless the anticipated loss ratio along with the rates and actuarial demonstration show compliance.
Ins 3.39(4)(g)
(g) As regards subsequent rate changes to the policy form, the insurer:
Ins 3.39(4)(g)1.
1. Files such changes on a rate change transmittal form in a format specified by the commissioner.
Ins 3.39(4)(g)2.
2. Includes in its filing an actuarially sound demonstration that the rate change will not result in a loss ratio over the life of the policy which would violate
sub. (16) (d).
Ins 3.39(4)(h)1.1. Medicare supplement policies written prior to January 1, 1992, shall comply with the standards then in effect, except that the appropriate loss ratios specified in
sub. (16) (d) shall be used to demonstrate compliance with minimum loss ratio requirements and refund calculations for policies and certificates renewed after December 31, 1995, and with
sub. (14) (c).
Ins 3.39(4)(h)2.
2. For purposes of loss ratio and refund calculations, policies and certificates renewed after December 31, 1995, shall be treated as if they were issued in 1996.
Ins 3.39(4m)(a)(a) An issuer may not deny or condition the issuance or effectiveness of, or discriminate in the pricing of, basic Medicare supplement coverage, Medicare cost or Medicare select policies permitted under
subs. (5),
(7) and
(30) or riders permitted under
sub. (5) (i) for which an application is submitted prior to or during the 6-month period beginning with the first month in which an individual first enrolled for benefits under Medicare Part B or the month in which an individual turns age 65 for any individual who was first enrolled in Medicare Part B when under the age of 65 on any of the following grounds:
