Sec. 38a-495a. Medicare supplement policies and certificates. Minimum required policy benefits and standards. Regulations.
Sec. 38a-495a. Medicare supplement policies and certificates. Minimum required policy benefits and standards. Regulations. (a) As used in this section:
(1) "Applicant" means (A) in the case of an individual Medicare supplement policy,
a person who seeks to contract for insurance benefits or (B) in the case of a group
Medicare supplement policy, a proposed certificate holder.
(2) "Certificate" means any certificate delivered or issued for delivery in this state
under a group Medicare supplement policy.
(3) "Certificate form" means a form on which the certificate is delivered or issued
for delivery by an insurer.
(4) "Commissioner" means the Insurance Commissioner.
(5) "Issuer" means any insurance company, fraternal benefit society, hospital or
medical service corporation, health care center or any other entity which delivers or
issues for delivery, in this state, any Medicare supplement policies or certificates.
(6) "Medicare" means the Health Insurance for the Aged Act, Title XVIII of the
Social Security Amendments of 1965, as then constituted or later amended.
(7) "Medicare supplement policy" means (A) a group or individual policy of accident and sickness insurance or (B) a subscriber contract of hospital and medical service
corporations or health care centers, other than a policy issued pursuant to a contract
under Section 1876 of the federal Social Security Act (42 USC Section 1395 et seq.),
or (C) an issued policy under a demonstration project specified in 42 USC Section
1395ss(g)(1), which is advertised, marketed or designed primarily as a supplement to
reimbursements under Medicare for the hospital, medical or surgical expenses of persons
eligible for Medicare.
(8) "Policy form" means the form on which the policy is delivered or issued for
delivery by the issuer.
(b) Except as otherwise specifically excluded, this section shall apply to all Medicare supplement policies and certificates delivered or issued for delivery in this state
on or after July 30, 1992.
(c) This section shall not apply to a policy of one or more employers or labor organizations, or of the trustees of a fund established by one or more employers or labor
organizations, or combination thereof, for employees or former employees or a combination thereof, or for members or former members, or a combination thereof, of the labor
organizations.
(d) Except as otherwise specifically provided in subdivision (4) of subsection (l)
of this section, the provisions of this section shall not apply to insurance policies or
health care benefit plans, including group conversion policies, provided to Medicare
eligible persons which policies are not marketed or held to be Medicare supplement
policies or benefit plans.
(e) No Medicare supplement policy or certificate in force in this state shall contain
benefits that duplicate benefits provided by Medicare.
(f) Notwithstanding any other provision of law to the contrary, a Medicare supplement policy or certificate shall not exclude or limit benefits for losses incurred more
than six months from the effective date of coverage because it involved a preexisting
condition. The policy or certificate shall 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 six months before the effective date of
coverage.
(g) The commissioner shall adopt regulations in accordance with chapter 54 to establish specific standards for policy provisions of Medicare supplement policies and
certificates. No requirements of this title relating to minimum required policy benefits,
other than the minimum standards contained in this section, shall apply to Medicare
supplement policies and certificates. The standards may include but need not be limited
to the following: (1) Terms of renewability; (2) initial and subsequent conditions of
eligibility; (3) nonduplication of coverage; (4) probationary periods; (5) benefit limitations, exceptions and reductions; (6) elimination periods; (7) requirements for replacement; (8) recurrent conditions; and (9) definitions of terms.
(h) The commissioner shall adopt regulations, in accordance with chapter 54, to
establish minimum standards for benefits, claim payments, marketing practices, compensation arrangements and reporting practices for Medicare supplement policies and
certificates.
(i) The commissioner may adopt such regulations, in accordance with chapter 54,
as are necessary to conform Medicare supplement policies and certificates to the requirements of federal law. Such regulations may include but need not be limited to: (1)
Requiring refunds or credits if the policies or certificates do not meet loss ratio requirements; (2) establishing a uniform methodology for calculating and reporting loss ratios;
(3) assuring public access to policies, premiums and loss ratio information of issuers of
Medicare supplement insurance; (4) establishing a process for approving or disapproving policy forms, certificate forms and proposed premium increases; (5) establishing
a policy for holding public hearings prior to approval of premium increases; and (6)
establishing standards for Medicare select policies and certificates.
(j) The commissioner may adopt regulations, in accordance with chapter 54, that
specify prohibited policy provisions not otherwise specifically authorized which in the
opinion of the commissioner, are unjust, unfair or unfairly discriminatory to any person
insured or proposed to be insured under a Medicare supplement policy or certificate.
(k) Medicare supplement policies shall return to policyholders benefits which are
reasonable in relation to the premiums charged. The commissioner shall adopt regulations, in accordance with chapter 54, to establish minimum standards for loss ratios of
Medicare supplement policies on the basis of incurred claim experience, or incurred
health care expenses where coverage is provided by a health care center on a service
rather than a reimbursement basis, and earned premiums in accordance with accepted
actuarial principles and practices.
(l) (1) In order to provide for full and fair disclosure in the sale of Medicare supplement policies, no Medicare supplement policy or certificate shall be delivered in this
state unless an outline of coverage is delivered to the applicant at the time application
is made.
(2) The commissioner shall adopt regulations in accordance with the provisions of
chapter 54 to prescribe the format and content of the outline of coverage required by
this subsection. For purposes of this subsection, "format" means style, arrangements
and overall appearance, including such items as the size, color and prominence of type
and arrangement of text and captions. The outline of coverage shall include: (A) A
description of the principal benefits and coverage provided in the policy; (B) a statement
of the renewal provisions, including any reservation by the issuer of a right to change
premiums; and (C) a statement that the outline of coverage is a summary of the policy
issued or applied for and that the policy should be consulted to determine the governing
contractual provisions.
(3) The commissioner may prescribe by regulation a standard form and the contents
of an informational brochure for persons eligible for Medicare, which is intended to
improve the buyer's ability to select the most appropriate coverage and improve the
buyer's understanding of Medicare. Except for direct response insurance policies, the
commissioner may require by regulation that the informational brochure be provided
to any prospective insured eligible for Medicare concurrently with the delivery of the
outline of coverage. With respect to direct response insurance policies, the commissioner
may require by regulation that the prescribed brochure be provided upon request to any
prospective insured eligible for Medicare, but in no event later than the time of policy
delivery.
(4) The commissioner may adopt regulations, in accordance with chapter 54, for
captions or notice requirements, determined to be in the public interest and designed to
inform the prospective insured that particular insurance coverages are not Medicare
supplement coverages, for all accident and sickness insurance policies sold to persons
eligible for Medicare, other than: (A) Medicare supplement policies; or (B) disability
income policies.
(5) The commissioner may adopt regulations, in accordance with chapter 54, to
govern the full and fair disclosure of the information in connection with the replacement
of accident and sickness policies, subscriber contracts or certificates by persons eligible
for Medicare.
(m) 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 applicant shall have the right to return the policy or certificate within thirty days
of its delivery and to have the premium refunded if, after examination of the policy or
certificate, the applicant is not satisfied for any reason. Any refund made pursuant to
this section shall be paid directly to the applicant by the issuer in a timely manner.
(n) Every issuer of Medicare supplement insurance policies or certificates in this
state shall provide a copy of any Medicare supplement advertisement intended for use
in this state, whether through written, radio or television medium to the commissioner
for his review or approval to the extent required by regulations, adopted pursuant to
section 38a-819.
(o) In addition to any other applicable penalties for violations of this title, the commissioner may require issuers violating any provision of this section or any regulations
promulgated pursuant to this section to cease marketing any Medicare supplement policies or certificates in this state which is related directly or indirectly to a violation or
take such actions as are necessary to comply with the provisions of this section, or both.
(P.A. 92-111, S. 1, 4; P.A. 93-390, S. 6, 8; P.A. 97-57, S. 1-4.)
History: P.A. 93-390 amended Subsec. (l) by deleting provision requiring outline of coverage to include automatic
renewal premium increases in policyholders' premiums based on age, effective January 1, 1994; P.A. 97-57 amended
Subsec. (a)(7) to delete reference to Section 1833 of the federal Social Security Act and replaced "demonstration project
authorized pursuant to amendments to the federal Social Security Act" with "demonstration project specified in 42 USC
Section 1395ss(g)(1), amended Subsec. (d) to make subsection subject to Subsec. (l)(4) of section and amended said Subsec.
(l)(4) to delete reference to policies issued by reason of age, and to delete Subparas. (C) and (D), effective May 14, 1997.
See Sec. 38a-495 re Medicare supplement policies and certificates.
See Sec. 38a-522 re group Medicare supplement policies and certificates.