Ins 3.39(3)(i)1.c.
c. Part A or Part B of Title XVIII of the social security act (Medicare);
Ins 3.39(3)(i)1.d.
d. Title XIX of the social security act (Medicaid), other than coverage consisting solely of benefits under section 1928;
Ins 3.39(3)(i)1.e.
e. Chapter
55 of Title 10 United States Code, commonly referred to as TRICARE (formerly known as CHAMPUS);
Ins 3.39(3)(i)1.f.
f. A medical care program of the Indian Health Service or of a tribal organization;
Ins 3.39(3)(i)1.h.
h. A health plan offered under chapter 89 of Title 5 United States Code commonly referred to as the Federal Employees Health Benefits Program;
Ins 3.39(3)(i)1.j.
j. A health benefit plan under Section 5 (e) of the Peace Corps Act (22 United States Code 2504 (e)).
Ins 3.39(3)(i)2.
2. “Creditable coverage" does not include any of the following:
Ins 3.39(3)(i)2.a.
a. Coverage only for accident or disability income insurance, or any combination thereof;
Ins 3.39(3)(i)2.c.
c. Liability insurance, including general liability insurance and automobile liability insurance;
Ins 3.39(3)(i)2.h.
h. Other similar insurance coverage, specified in federal regulations, under which benefits for medical care are secondary or incidental to other insurance benefits.
Ins 3.39(3)(i)3.
3. “Creditable coverage" shall not include the following benefits if they are provided under a separate policy, certificate or contract of insurance or are otherwise not an integral part of the plan:
Ins 3.39(3)(i)3.b.
b. Benefits for long-term care, nursing home care, home health care, community-based care, or any combination; and
Ins 3.39(3)(i)3.c.
c. Such other similar, limited benefits as are specified in federal regulations.
Ins 3.39(3)(i)4.
4. “Creditable coverage" shall not include the following benefits if offered as independent, non-coordinated benefits:
Ins 3.39(3)(i)5.
5. “Creditable coverage" shall not include the following if it is offered as a separate policy, certificate or contract of insurance:
Ins 3.39(3)(i)5.a.
a. Medicare supplemental health insurance as defined under section 1882 (g) (1) of the social security act;
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)(jm)
(jm) “Grievance" means dissatisfaction with the administration, claims practices or provision of services concerning a Medicare select issuer or its network providers that is expressed in writing by a policyholder or certificateholder under a Medicare select policy or certificate.
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)(pm)
(pm) “MACRA” means the Medicare Access and CHIP Reauthorization Act of 2015, PL
114-10, signed April 16, 2015.
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.
Ins 3.39(3)(rm)
(rm) “Medicare cost policy” means a Medicare replacement policy that is offered by an issuer that has a contract with CMS to provide coverage when services are provided within the issuer's geographic service area and through network medical providers selected by the issuer. A “Medicare cost policy” is issued to an individual who is the policyholder.
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)(v)
(v) “Medicare replacement policy" or “Medicare replacement insurance policy” means a policy that is described in s.
600.03 (28p) (a) or
(c), Stats., as interpreted
by sub. (2) (a), and that provides coverage that conforms
to su
bs. (4
), (4m), (
4t), and (7). “Medicare replacement policy" includes Medicare cost policies.
Ins 3.39(3)(ve)
(ve) “Medicare select certificate" means a policy that is issued to a group that provides Medicare supplement coverage to the group's members when services are obtained through network medical providers selected by the issuer. Individuals that receive coverage through the group Medicare select policy receive a Medicare select certificate that demonstrates participation in the group coverage.
Ins 3.39(3)(vm)
(vm) “Medicare select policy" means a policy that is issued to an individual or policyholder that provides Medicare supplement coverage when services are obtained by the policyholder through a network of medical providers selected by the issuer.
Ins 3.39(3)(vs)
(vs) “Medicare supplement certificate” means a policy that is issued to a group that provides Medicare supplement coverage to the group's members. Individuals that receive coverage through the group Medicare supplement policy receive a Medicare supplement certificate that demonstrates participation in the group coverage.
Ins 3.39(3)(w)
(w) “Medicare supplement coverage" or “Medicare supplement insurance” means coverage that meets the definition in s.
600.03 (28r), Stats., as interpreted by sub.
(2) (a), and that conforms to subs.
(4),
(4m),
(4t),
(5),
(5m),
(5t),
(6),
(30),
(30m), and
(30t). “Medicare supplement coverage" is advertised, marketed or designed primarily as a supplement to reimbursements under Medicare for the hospital, medical or surgical expense of persons eligible for Medicare. “Medicare supplement coverage” includes group and individual Medicare supplement and group and individual Medicare select policies and certificates 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)(we)
(we) “Medicare supplement policy” means a policy that is issued to an individual or policyholder that provides Medicare supplement coverage.
Ins 3.39(3)(wg)
(wg) “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)(wm)
(wm) “Network provider," means a provider of health care, or a group of providers of health care, that have entered into a written agreement with the issuer to provide health care benefits to an insured under a Medicare select policy or Medicare select certificate.
Ins 3.39(3)(ws)
(ws) “Newly eligible” means a person who meets one of the following criteria:
Ins 3.39(3)(ws)2.
2. The person is entitled to benefits under Medicare Part A pursuant to section 226 (b) or 226A of the social security act, or is deemed to be eligible for benefits under section 226 (a) of the social security act on or after January 1, 2020.
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)(zar)
(zar) “Policy or certificate forms of the same type” means, for purposes of calculating loss ratios, rates, refunds or premium credits, each type of form filed with the commissioner including individual Medicare supplement policy forms, individual Medicare select policy forms, individual Medicare cost policy forms, group Medicare select certificate forms, and group Medicare supplement certificate forms.
Ins 3.39(3)(zb)
(zb) “Replacement” means any transaction, other than when used to refer to an authorized Medicare Advantage policy, where new individual or group Medicare supplement or individual 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 are substantially reduced. “Replacement” includes transactions replacing a Medicare supplement policy or certificate, Medicare select policy or certificate, or Medicare cost policy within the same insurer or affiliates of the insurer.
Ins 3.39(3)(zbm)
(zbm) “Restricted network provision," means any provision that conditions the payment of benefits, in whole or in part, on the use of network providers.
Ins 3.39(3)(zc)
(zc) “Secretary" means the secretary of the United States department of health and human services.
Ins 3.39(3)(zcm)
(zcm) “Service area" means the geographic area approved by the commissioner within which an issuer is authorized to offer a Medicare select policy or certificate.
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(3g)(a)
(a) Generally, an individual who attains age 65 or older, an individual under the age of 65 with certain disabilities, or an individual with end-stage renal disease is eligible to enroll in Medicare. The date a person is first eligible for Medicare Part B or first elected Medicare Part A establishes the benefits available regardless of the date of election provided the benefit is offered in the market. In addition to the provisions that apply to all Medicare supplement and Medicare cost policies, the following identify the benefits and coverage subsections that have provisions tied to the date and year when a person is first eligible for Medicare Parts A and B:
Ins 3.39(3g)(a)1.
1. For persons first eligible for Medicare Part A and B before June 1, 2010, subs.
(4),
(5),
(7) (a), and
(30) describe benefits and coverage available as contained in Appendix 1, and are applicable in addition to any provision in this section that generally pertains to Medicare eligible persons.
Ins 3.39(3g)(a)2.
2. For persons first eligible for Medicare Part A and B on or after June 1, 2010, and prior to January 1, 2020, subs.
(4m),
(5m),
(7) (dm),
(14m), and
(30m) describe benefits and coverage available as contained in Appendices 2m, 3m, 4m, 5m and 6m and are applicable in addition to any provision in this section that generally pertains to Medicare eligible persons.
Ins 3.39(3g)(a)3.
3. For persons first eligible for Medicare Part A and B on or after January 1, 2020, MACRA designated Medicare eligible persons as “newly eligible” to distinguish them from a person eligible prior to January 1, 2020. For these newly eligible persons, subs.
(4t),
(5t),
(7) (dt),
(14t), and
(30t) describe benefits and coverage available as contained in Appendices 2t, 3t, 4t, 5t, and 6t and are applicable in addition to any provision in this section that generally pertains to Medicare eligible persons.
Ins 3.39(3g)(b)
(b) Medicare supplement policies and certificates and Medicare select policies and certificates are guaranteed renewable for life. Therefore, a Medicare eligible person can, at his or her choice, elect to receive benefits and coverage under a policy that may have fewer riders available. An insurer may not require the Medicare eligible person to replace existing coverage with coverage reflecting recent changes, including changes due to MACRA. This means insurers may no longer actively market the Medicare Part B medical deductible rider to persons who are newly eligible for Medicare on or after January 1, 2020. A Medicare eligible person who is first eligible for Medicare prior to January 1, 2020, may elect the Medicare Part B medical deductible rider coverage at any time, provided an insurer is offering that coverage. If an insured was eligible for Medicare prior to January 1, 2020 and elected the Medicare Part B medical deductible rider coverage, upon renewal of the policy or certificate that person shall be eligible to continue to receive benefits provided by the Medicare Part B medical deductible rider in accordance with the terms of the Medicare supplement policy or certificate or Medicare select policy or certificate.
Ins 3.39(3r)(a)(a) An issuer may not deny nor condition the issuance or effectiveness of, or discriminate in the pricing of, basic Medicare supplement policies or certificates, Medicare cost policy, or Medicare select policies or certificates permitted, as applicable, under subs.
(5),
(5m),
(5t),
(7),
(30),
(30m), and
(30t), or riders permitted under sub.
(5) (i),
(5m) (e), or
(5t) (e), for which an application is submitted prior to or during the 6-month period beginning with the first month that an individual first enrolled for benefits under Medicare Part B or the month that 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:
Ins 3.39(3r)(b)
(b) Except as provided in pars.
(c) and
(d), and sub.
(34), this section shall not prevent the application of any preexisting condition limitation that is in compliance with sub.
(4) (a) 2. Ins 3.39(3r)(c)
(c) If an applicant qualifies under par.
(a) and submits an application during the time period referenced in par.
(a) and, as of the date of application, has had a continuous period of creditable coverage of at least 6 months, the issuer may not exclude benefits based on a preexisting condition.
Ins 3.39(3r)(d)
(d) If the applicant qualifies under par.
(a) and submits an application during the time period referenced in par.
(a) and, as of the date of application, has had a continuous period of creditable coverage that is less than 6 months, the issuer shall reduce the period of any preexisting condition exclusion by the aggregate of the period of creditable coverage applicable to the applicant as of the enrollment date. The secretary shall specify the manner of the reduction under this paragraph.
Ins 3.39(4)
(4)
Medicare supplement policy and certificate, Medicare select policy and certificate and Medicare cost policy requirements for policies and certificates offered to persons first eligible for Medicare 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 issued to persons who were first eligible for Medicare prior to June 1, 2010, as a Medicare supplement policy or certificate, as a Medicare select policy or certificate, or as a Medicare cost policy unless the policy or certificate complies, as applicable, with all of the following:
Ins 3.39(4)(a)
(a) The Medicare supplement policy and certificate, Medicare select policy or certificate, or the Medicare cost policy complies, as applicable, with all the following requirements:
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 policy, Medicare supplement policy or certificate, or Medicare select policy or certificate without prior approval from the commissioner and compliance with subs.
(5),
(7) and
(30), respectively.
Ins 3.39(4)(a)2.
2. Discloses on the first page any applicable preexisting conditions limitation, contains no preexisting condition waiting period longer than 6 months and does 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 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,” “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).
