Chapter Ins 3

Ins 3.39(4t)(a)4. 4. Does not indemnify against losses resulting from sickness on a different basis from losses resulting from accident.

Ins 3.39(4t)(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 non-payment of premium. The policy or certificate may not be cancelled or nonrenewed by the issuer on the grounds of deterioration of health. The policy or certificate may be cancelled only for nonpayment of premium or material misrepresentation. If the policy or certificate is issued by a health maintenance organization, the policy or certificate 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(4t)(a)6. 6. Provides that termination of a Medicare supplement policy or certificate or Medicare cost policy 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 or certificate benefit period, if any, or payment of the maximum benefits. Receipt of the Medicare Part D benefits may not be considered in determining a continuous loss.

Ins 3.39(4t)(a)7. 7. Contains statements on the first page and elsewhere in the policy or certificate that satisfy the requirements of s. Ins 3.13 (2) (c), (d) and (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 greatest of the following: 3 months, the period the insured has paid the premium, or the period specified in the policy or certificate.

Ins 3.39(4t)(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(4t)(a)9. 9. Prominently discloses any limitations on the choice of providers or geographical area of service.

Ins 3.39(4t)(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. (5t) or (30t).

Ins 3.39(4t)(a)11. 11. Contains text that is plainly printed in black or blue ink and has a font size that is uniform and not less than 10-point type with a lower-case unspaced alphabet length not less than 120-point type.

Ins 3.39(4t)(a)12. 12. Contains a provision describing any grievance rights as required by s. 632.83, Stats., applicable to Medicare supplement policies and certificates and Medicare cost policies.

Ins 3.39(4t)(a)13. 13. Is approved by the commissioner.

Ins 3.39(4t)(a)14. 14. Contains no exclusion, limitation, or reduction of coverage for a specifically named or described condition after the policy or certificate effective date.

Ins 3.39(4t)(a)15. 15. Provides for midterm cancellation at the request of the insured and provides that, if an insured cancels a policy or certificate midterm or the policy or certificate 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(4t)(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 or certificate if such policy or certificate contains limitations or exclusions on coverage that are more restrictive than those of Medicare.

Ins 3.39(4t)(a)17. 17. No Medicare supplement policy or certificate, Medicare select policy or certificate, or Medicare cost policy in force in this state shall contain benefits that duplicate benefits provided by Medicare.

Ins 3.39(4t)(a)18. 18. A Medicare supplement policy or certificate, Medicare select policy or certificate, or Medicare cost policy 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(4t)(a)19. 19. 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, 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.

Ins 3.39(4t)(a)20. 20. Each Medicare supplement policy or certificate, Medicare select policy or certificate, or Medicare cost policy shall provide, and contain within the policy or certificate, that benefits and premiums under the policy or certificate shall be suspended for any period that may be provided by federal regulation, at the request of the policyholder or certificateholder if the policyholder or certificateholder 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 certificateholder loses coverage under the group health plan, the policy or certificate shall be automatically reinstituted, effective as of the date of loss of coverage, if the policyholder or certificateholder 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(4t)(a)21e. 21e. No Medicare supplement policy or certificate, Medicare select policy or certificate, or Medicare cost policy may provide for any waiting period for resumption of coverage that was in effect before the date of suspension under subd. 18. with respect to treatment of preexisting conditions.

Ins 3.39(4t)(a)21m. 21m. Each Medicare supplement policy or certificate, Medicare select policy or certificate, or Medicare cost policy shall provide for resumption of coverage that is substantially equivalent to coverage that was in effect before the date of suspension in subd. 18. If the suspended Medicare supplement policy or certificate, Medicare select policy or certificate, or Medicare cost policy provided coverage of Medicare Part B medical deductible coverage or if the insured was enrolled or Medicare eligible prior to January 1, 2020, and the insurer offers a plan with Medicare Part B medical deductible coverage, then resumption of the policy shall be with Medicare Part B medical deductible coverage. If the insurer no longer offers a plan with the Medicare Part B medical deductible coverage, then the insurer shall provide the insured with substantially equivalent coverage to the coverage in effect prior to the date of suspension.

Ins 3.39(4t)(a)21s. 21s. Each Medicare supplement policy or certificate, Medicare select policy or certificate, or Medicare cost policy shall provide that, upon the resumption of coverage that was in effect before the date of suspension in subd. 18., classification of premiums shall be 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(4t)(a)22. 22. May not use an underwriting standard during open enrollment for persons who are under age 65 that is more restrictive than the underwriting standards that are used for persons age 65 and older.

Ins 3.39(4t)(b) (b) The outline of coverage for the policy or certificate shall comply with all of the following:

Ins 3.39(4t)(b)1. 1. Is provided to all applicants at the same 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(4t)(b)2. 2. Complies with s. Ins 3.27.

Ins 3.39(4t)(b)3. 3. Is substituted to describe properly the policy or certificate as issued, if the outline provided at the time of application did not properly describe the coverage that 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(4t)(b)4. 4. Contains in close conjunction on its first page the designation, printed in a distinctly contrasting color or bold print in 24-point type, and the caption, printed in a distinctly contrasting color or bold print in 18-point type, prescribed in sub. (5t), (7), or (30t).

Ins 3.39(4t)(b)5. 5. Is substantially in the format prescribed in Appendices 3t, 4t, 5t, and 6t, for the appropriate category and printed in a font size that is not less than 12-point type.

Ins 3.39(4t)(b)6. 6. Summarizes or refers to the coverage set out in applicable statutes.

Ins 3.39(4t)(b)7. 7. Contains a listing of the required coverage as set out in sub. (5t) (d), and the optional coverage as set out in sub. (5t) (e), and the annual premiums for each selected coverage, substantially in the format of sub. (11) in Appendix 2t.

Ins 3.39(4t)(b)8. 8. Is approved by the commissioner along with the policy or certificate form.

Ins 3.39(4t)(c) (c) Any rider or endorsement added to the policy or certificate shall comply with all of the following:

Ins 3.39(4t)(c)1. 1. Shall be contained 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 stated in the policy or certificate.

Ins 3.39(4t)(c)2. 2. Shall be agreed to in writing signed by the insured if, after the date of the policy or certificate issue, the rider or endorsement increases benefits or coverages and there is 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(4t)(c)3. 3. Shall only provide coverage as described in sub. (5t) (e), or provide coverage to meet Wisconsin mandated benefits.

Ins 3.39(4t)(d) (d) The schedule of benefits page or the first page of the policy or certificate shall contain a listing giving the coverages and both the annual premium in the format shown in sub. (11) of Appendix 2t and modal premium selected by the applicant.

Ins 3.39(4t)(e) (e) The anticipated loss ratio for any new policy or certificate form, or the expected percentage of the aggregate amount of premiums earned that will be returned to insureds in the form of aggregate benefits, not including anticipated refunds or credits, that is provided under the policy or certificate form:

Ins 3.39(4t)(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 organization on a service rather than reimbursement basis and earned premiums for the entire period that the policy or certificate form provides coverage, in accordance with accepted actuarial principles and practices; and

Ins 3.39(4t)(e)2. 2. Is submitted to the commissioner along with the policy or certificate form and is accompanied by rates and an actuarial demonstration that expected claims in relationship to premiums comply with the loss ratio standards under sub. (16) (d). The policy or certificate form will not be approved by the commissioner unless the anticipated loss ratio along with the rates and actuarial demonstration show compliance with sub. (16) (d).

Ins 3.39(4t)(f) (f) For subsequent rate changes to the policy or certificate form, the issuer shall do all of the following:

Ins 3.39(4t)(f)1. 1. File the rate changes on a rate change transmittal form in a format specified by the commissioner.

Ins 3.39(4t)(f)2. 2. Include in the filing under subd.1. an actuarially sound demonstration that the rate change will not result in a loss ratio over the life of the policy or certificate that would violate the requirements under sub. (16) (d).

Ins 3.39(5) (5) Authorized Medicare supplement policy and certificate designation, captions, required coverages, and permissible additional benefits for policies or certificates offered to persons first eligible for Medicare prior to June 1, 2010. This subsection applies only to a Medicare supplement policy or certificate that meets the requirements of sub. (4), that is issued or effective after December 31, 1990, and prior to June 1, 2010, and that shall contain the authorized designation, caption and required coverage. A health maintenance organization shall place the letters HMO in front of the required designation on any approved Medicare supplement policy or certificate. A Medicare supplement policy or certificate shall include all of the following:

Ins 3.39(5)(a) (a) The designation: MEDICARE SUPPLEMENT INSURANCE.

Ins 3.39(5)(b) (b) The caption, except that the word “certificate” may be used instead of “policy,” if appropriate: “The Wisconsin Insurance Commissioner has set standards for Medicare supplement insurance. This policy meets these standards. It, along with Medicare, may not cover all of your medical costs. You should review carefully all policy limitations. For an explanation of these standards and other important information, see ‘Wisconsin Guide to Health Insurance for People with Medicare,’ given to you when you applied for this policy. Do not buy this policy if you did not get this guide.”

Ins 3.39(5)(c) (c) The following required coverages, to be referred to as “Basic Medicare Supplement coverage” for a policy issued to persons first eligible for Medicare after December 31, 1990 and prior to June 1, 2010, shall comply with all the following:

Ins 3.39(5)(c)1. 1. Upon exhaustion of Medicare hospital inpatient psychiatric coverage, at least 175 days per lifetime for inpatient psychiatric hospital care;

Ins 3.39(5)(c)2. 2. Medicare Part A eligible expenses in a skilled nursing facility for the copayments for the 21st through the 100th day;

Ins 3.39(5)(c)3. 3. All Medicare Part A eligible expenses for blood to the extent not covered by Medicare;

Ins 3.39(5)(c)4. 4. All Medicare Part B eligible expenses to the extent not paid by Medicare, or in the case of hospital outpatient department services paid under a prospective payment system, the copayment amount, including outpatient psychiatric care, subject to the Medicare Part B calendar year deductible;

Ins 3.39(5)(c)5. 5. Payment of the usual and customary home care expenses to a minimum of 40 visits per 12-month period as required under s. 632.895 (1) and (2), Stats., and s. Ins 3.54;

Ins 3.39(5)(c)6. 6. Skilled nursing care and kidney disease treatment as required under s. 632.895 (3) and (4), Stats. Coverage for skilled nursing care shall be in addition to the required coverage under subd. 2. and payment of the Medicare Part A copayment for Medicare eligible skilled nursing care shall not count as satisfying the coverage requirement of at least 30 days of non-Medicare eligible skilled nursing care under s. 632.895 (3), Stats.;

Ins 3.39(5)(c)7. 7. In group policies, nervous and mental disorder and alcoholism and other drug abuse coverage as required under s. 632.89, Stats.;

Ins 3.39(5)(c)8. 8. Payment in full for all usual and customary expenses for chiropractic services required by s. 632.87 (3), Stats. Issuers are not required to duplicate benefits paid by Medicare;

Ins 3.39(5)(c)9. 9. Coverage for the first 3 pints of blood payable under Part B;

Ins 3.39(5)(c)10. 10. Coverage of Part A Medicare eligible expenses for hospitalization to the extent not covered by Medicare from the 61st day through the 90th day in any Medicare benefit period;

Ins 3.39(5)(c)11. 11. Coverage of Part A Medicare eligible expenses incurred as daily hospital charges during use of Medicare’s lifetime hospital inpatient reserve days;

Ins 3.39(5)(c)12. 12. Upon exhaustion of all Medicare hospital inpatient coverage including the lifetime reserve days, coverage of all Medicare Part A expenses for hospitalization not covered by Medicare to the extent the hospital is permitted to charge by federal law and regulation and subject to the Medicare reimbursement rate;

Ins 3.39(5)(c)13. 13. Prior to January 1, 2006, payment in full for all usual and customary expenses for treatment of diabetes required by s. 632.895 (6), Stats. After December 31, 2005, payment in accordance with s. 632.895 (6), Stats., including non-prescription insulin or any other non-prescription equipment and supplies for the treatment of diabetes, but not including any other outpatient prescription medications. Issuers are not required to duplicate expenses paid by Medicare.

Ins 3.39(5)(c)14. 14. Coverage for preventive health care services not covered by Medicare and as determined to be medically appropriate by an attending physician. These benefits shall be included in the basic policy. Reimbursement shall be for the actual charges up to 100% of the Medicare approved amount for each service, as if Medicare were to cover the service, as identified in the American Medical Association Current Procedural Terminology (AMA CPT) codes, to a minimum of $120 annually under this benefit. This benefit shall not include payment for any procedure covered by Medicare.

Ins 3.39(5)(c)15. 15. Coverage for at least 80% of the charges for outpatient prescription drugs after a drug deductible of no more than $6,250 per calendar year. Subject to sub. (4) (a) 20., this coverage may only be included in a Medicare supplement policy issued before January 1, 2006.

Ins 3.39(5)(c)16. 16. Payment in full for all usual and customary expenses of hospital and ambulatory surgery center charges and anesthetics for dental care required by s. 632.895 (12), Stats. Issuers are not required to duplicate benefits paid by Medicare.

Ins 3.39(5)(c)17. 17. Payment in full for all usual and customary expenses for breast reconstruction required by s. 632.895 (13), Stats. Issuers are not required to duplicate benefits paid by Medicare.

Ins 3.39(5)(i) (i) Permissible additional coverage only added to the policy as separate riders. The issuer shall issue a separate rider for each coverage the issuer chooses to offer. Issuers shall ensure that the riders offered are compliant with MMA, that each rider is priced separately, available for purchase separately at any time, subject to underwriting and the pre-existing limitation allowed in sub. (4) (a) 2., and may consist of the following:

Ins 3.39(5)(i)1. 1. Coverage for the Medicare Part A hospital deductible. The rider shall be designated: MEDICARE PART A DEDUCTIBLE RIDER;

Ins 3.39(5)(i)2. 2. Coverage for home health care for an aggregate of 365 visits per policy year as required by s. 632.895 (1) and (2), Stats. The rider shall be designated as: ADDITIONAL HOME HEALTH CARE RIDER;

Ins 3.39(5)(i)3. 3. Coverage for the Medicare Part B medical deductible. The rider shall be designated as: MEDICARE PART B DEDUCTIBLE RIDER;

Ins 3.39(5)(i)4. 4. Coverage for the difference between Medicare’s Part B eligible charges and the amount charged by the provider which shall be no greater than the actual charge or the limiting charge allowed by Medicare. The rider shall be designated as: MEDICARE PART B EXCESS CHARGES RIDER;

Ins 3.39(5)(i)5. 5. Coverage for benefits obtained outside the United States. An issuer which offers this benefit shall not limit coverage to Medicare deductibles and copayments. Coverage may contain a deductible of up to $250. Coverage shall pay at least 80% of the billed charges for Medicare-eligible expenses for medically necessary emergency hospital, physician and medical care received in a foreign country, which care would have been covered by Medicare if provided in the United States and which care began during at least the first 60 consecutive days of each trip outside the United States and a lifetime maximum benefit of at least $50,000. For purposes of this benefit, “emergency hospital, physicians and medical care” shall mean care needed immediately because of an injury or an illness of sudden and unexpected onset. The rider shall be designated as: FOREIGN TRAVEL RIDER.

Ins 3.39(5)(i)7. 7. At least 50% of the charges for outpatient prescription drugs after a deductible of no greater than $250 per year to a maximum of at least $3,000 in benefits received by the insured per year. The rider shall be designated as: OUTPATIENT PRESCRIPTION DRUG RIDER. This rider may only be offered for issuance or sale until January 1, 2006 in accordance with MMA.

Ins 3.39(5)(j) (j) For HMO Medicare select policies, only the benefits specified in sub. (30) (p), (r) and (s), in addition to Medicare benefits.

Ins 3.39(5)(k) (k) For the Medicare supplement high deductible plan that may be issued only prior to December 31, 2005 or renewed thereafter in accordance with sub. (29) (b) 1., the following:

Ins 3.39(5)(k)1. 1. The designation: MEDICARE SUPPLEMENT INSURANCE - HIGH DEDUCTIBLE PLAN.

Ins 3.39(5)(k)2. 2. 100% of the covered benefits described in pars. (c) and (i) 1., 2., 3., 4. and 5. following the payment of the annual high deductible.

Ins 3.39(5)(k)3. 3. The annual high deductible shall consist of out-of-pocket expenses, other than premiums, for services covered in subd. 2. and shall be in addition to any other specific benefit deductibles.

Ins 3.39(5)(k)4. 4. The annual high deductible shall be $1500 for 1999, and shall be based on the calendar year. It shall be adjusted annually thereafter by the secretary to reflect the change in the Consumer Price Index for all urban consumers for the twelve-month period ending with August of the preceding year, and rounded to the nearest multiple of $10.

Ins 3.39(5)(m) (m) For the Medicare supplement high deductible drug plan that may be issued only prior to December 31, 2005 or renewed thereafter in accordance with sub. (4) (a) 20., the following:

Ins 3.39(5)(m)1. 1. The designation: MEDICARE SUPPLEMENT INSURANCE - HIGH DEDUCTIBLE DRUG PLAN.

Ins 3.39(5)(m)2. 2. 100% of the covered benefits described in pars. (c) and (i) 1., 2., 3., 4., 5. and 7. following the payment of the annual high deductible.

Ins 3.39(5)(m)3. 3. The annual high deductible shall consist of out-of-pocket expenses, other than premiums, for services covered in subd. 2. and shall be in addition to any other specific benefit deductibles.

Ins 3.39(5)(m)4. 4. The annual high deductible shall be $1500 for 1999, and shall be based on the calendar year. It shall be adjusted annually thereafter by the secretary to reflect the change in the Consumer Price Index for all urban consumers for the twelve-month period ending with August of the preceding year, and rounded to the nearest multiple of $10.

Ins 3.39(5)(n) (n) For the Medicare Supplement 50% Cost-Sharing plans, only the following:

Ins 3.39(5)(n)1. 1. The designation: MEDICARE SUPPLEMENT 50% COST-SHARING PLAN;

Ins 3.39(5)(n)2. 2. Coverage of 100% of the Medicare Part A hospital coinsurance amount for each day used from the 61st through the 90th day in any Medicare benefit period;

Ins 3.39(5)(n)3. 3. Coverage for 100% of the Medicare Part A hospital coinsurance amount for each Medicare lifetime inpatient reserve day used from the 91st through the 150th day in any Medicare benefit period;

Ins 3.39(5)(n)4. 4. Upon exhaustion of the Medicare hospital inpatient coverage, including the lifetime reserve days, coverage of 100% of the Medicare Part A eligible expenses for hospitalization paid at the applicable prospective payment system rate, or other appropriate Medicare standard of payment, subject to a lifetime limitation benefit of an additional 365 days;

Ins 3.39(5)(n)5. 5. Medicare Part A Deductible: Coverage for 50% of the Medicare Part A inpatient hospital deductible amount per benefit period until the out-of-pocket limitation is met as described in subd. 12.;

Ins 3.39(5)(n)6. 6. Skilled Nursing Facility Care: Coverage for 50% of the coinsurance amount for each day used from the 21st day through the 100th day in a Medicare benefit period for post-hospital skilled nursing facility care eligible under Medicare Part A until the out-of-pocket limitation is met as described in subd. 12.;

Ins 3.39(5)(n)7. 7. Hospice Care: Coverage for 50% of cost sharing for all Part A Medicare eligible expenses and respite care until the out-of-pocket limitation is met as described in subd. 12.;

Ins 3.39(5)(n)8. 8. Coverage for 50%, under Medicare Part A or B, of the reasonable cost of the first 3 pints of blood, or equivalent quantities of packed red blood cells, as defined under federal regulations, unless replaced in accordance with federal regulations until the out-of-pocket limitation is met as described in subd. 12.;