INS 3.39 (3) (fm) “Certificateholder” means an individual member of a group that is receives a certificate that identifies the individual as a participant in the group Medicare supplement policy or the group Medicare select policy issued in this state.
SECTION 16. INS 3.39 (3) (g) is amended to read:
INS 3.39 (g) “Certificate form" means, in this section, the form on which the certificate is delivered or issued for delivery by the issuer to a group that receives insurance coverage through a group Medicare supplement policy, or a group Medicare select policy.
SECTION 17. INS 3.39 (3) (gm) is created to read:
INS 3.39 (3) (gm) “Complaint" means any dissatisfaction expressed by an individual concerning a Medicare select issuer or its network providers.
SECTION 18. INS 3.39 (3) (i) 1. c. and d., and 5. a. are amended to read:
INS 3.39 (3) (i) 1. c. Part A or Part B of Title XVIII of the Social Security Act social security act (Medicare);
d. Title XIX of the Social Security Act social security act (Medicaid), other than coverage consisting solely of benefits under section 1928;
5. a. Medicare supplemental health insurance as defined under section 1882 (g) (1) of the Social Security Act social security act;
SECTION 19. INS 3.39 (3) (jm), and (pm) are created to read:
INS 3.39 (3) (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.
(pm) “MACRA” means the Medicare Access and CHIP Reauthorization Act of 2015, PL 114-10, signed April 16, 2015. SECTION 20. INS 3.39 (3) (r) (intro.) is renumbered INS 3.39 (3) (r) and amended to read:
INS 3.39 (3) (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:. SECTION 21. INS 3.39 (3) (r) 1. to 3. are repealed.
SECTION 22. INS 3.39 (3) (um) is created to read:
INS 3.39 (3) (um) “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.
SECTION 23. INS 3.39 (3) (v) is amended to read:
INS 3.39 (3) (v) “Medicare replacement coverage policy" or “Medicare replacement insurance policy” means coverage a policy that meets the definition is described in s. 600.03 (28p) (a) or (c), Stats., as interpreted by sub. (2) (a), and that provides coverage that conforms to subs. (4), (4m), (4s) (4t), and (7). “Medicare replacement coverage policy" includes Medicare cost and Medicare Advantage plans policies. SECTION 24. INS 3.39 (3) (ve), (vm), and (vs) are created to read:
INS 3.39 (3) (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.
(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.
(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.
SECTION 25. INS 3.39 (3) (w) is amended to read:
INS 3.39 (3) (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), (4s)(4t), (5), (5m), (5t), (6), (30), and (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 plans 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. SECTION 26. INS 3.39 (3) (we), (wm), and (ws) are created to read:
INS 3.39 (3) (we) “Medicare supplement policy” means a policy that is issued to an individual or policyholder that provides Medicare supplement coverage.
(wm) “Network provider," means a provider of health care, or a group of providers of health care, which has 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.
(ws) “Newly eligible” means a person who meets one of the following criteria:
1. The person has attained age 65 on or after January 1, 2020.
2. The person, by reason of entitlement to benefits under Medicare Part A pursuant to section 226 (b) or 226A of the social security act, or who is deemed to be eligible for benefits under section 226 (a) of the social security act on or after January 1, 2020.
SECTION 27. INS 3.39 (3) (y) and (za) are amended to read:
INS 3.39 (3) (y) “Outline of coverage” means a printed statement as defined by s. Ins 3.27 (5) (L), which that meets the requirements of sub. subs. (4 ) (b), (4m) (b), or (4t) (b), as applicable. (za) “PACE" means Program of All–Inclusive Care for the Elderly (PACE) under section 1894 of the Social Security Act social security act 42 USC 1302 and 1395. SECTION 28. INS 3.39 (3) (zag) and (zar) are created to read:
INS 3.39 (3) (zag) “Policyholder” has the meaning provided at s. 600.03 (37), Stat. (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.
SECTION 29. INS 3.39 (3) (zb) is amended to read:
INS 3.39 (3) (zb) “Replacement” means any transaction, other than when used to refer to an authorized Medicare Advantage policy, wherein 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 thereof 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.
SECTION 30. INS 3.39 (3) (zbm), (zcm) and (3g) are created to read:
INS 3.39 (3) (zbm) “Restricted network provision," means any provision that conditions the payment of benefits, in whole or in part, on the use of network providers.
(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.
(3g) Medicare eligible person. (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:
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.
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.
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.
(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.
SECTION 31. INS 3.39 (4) (title), (intro.), (a) (intro.), 1. to 7., 9. to 12., 16., 18., and 18p. are amended to read:
INS 3.39 (4) Medicare supplement policy and certificate, Medicare select policy and certificate and Medicare replacement cost policy and certificate 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 with effective dates prior to June 1, 2010, as a Medicare supplement policy or certificate, as a Medicare select policy or certificate, or as a Medicare replacement cost policy or certificate, as defined in s. 600.03 (28p) (a) and (c), Stats., unless it the policy or certificate complies, as applicable, with all of the following : (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:
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.
2. Discloses on the first page any applicable pre-existing preexisting conditions limitation, contains no pre-existing preexisting condition waiting period longer than 6 months and shall does not define a pre-existing 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.
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).
4. Does not indemnify against losses resulting from sickness on a different basis from losses resulting from accident;.
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 Medicare supplement policy or certificate, Medicare select policy or certificate, or Medicare cost policy shall not be cancelled or nonrenewed by the insurer on the grounds of deterioration of health. The Medicare supplement policy or certificate, Medicare select policy or certificate, or Medicare cost policy may be cancelled only for nonpayment of premium or material misrepresentation. If the Medicare supplement policy or certificate, Medicare select policy or certificate, or Medicare cost policy is issued by a health maintenance organization as defined by s. 609.01 (2), Stats., 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;. 6. Provides that termination of a Medicare supplement policy or certificate, Medicare select policy or certificate, 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 policyholder, 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.
7. Contains statements on the first page and elsewhere in the Medicare supplement policy or certificate, Medicare select policy or certificate, or Medicare cost policy which that 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. (theThe renewal period cannot be less than the greater greatest of the following: 3 months, the period for which the insured has paid the premium, or the period specified in the policy); or certificate. 9. Prominently discloses any limitations on the choice of providers or geographical area of service;.
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);.
11. Contains text which that is plainly printed in black or blue ink the and has a font size of which that is uniform and not less than 10-point with a lower-case unspaced alphabet length not less than 120-point;.
12. Contains a provision describing the review and appeal procedure for denied claims as required by s. 632.84, Stats., and a provision describing any grievance rights as required by s. 632.83, Stats., applicable to Medicare supplement policy and certificate, Medicare select policy and certificate, and Medicare replacement cost policies; and. 16. Except for permitted preexisting condition clauses as described in subd. 2., no Medicare supplement policy or certificate, Medicare select policy or certificate, or Medicare cost policy or certificate may be advertised, solicited or issued for delivery in this state as a Medicare supplement policy or certificate, Medicare select policy or certificate or Medicare cost policy if such policy or certificate contains limitations or exclusions on coverage that are more restrictive than those of Medicare.
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 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.
18p. Each Medicare supplement policy or certificate, Medicare select policy or certificate or Medicare cost policy shall provide, and contain within the policy, 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 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 social security act. If suspension occurs and if the policyholder or certificate holder 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.
SECTION 32. INS 3.39 (4) (a) 18r. (intro.) is repealed.
SECTION 33. INS 3.39 (4) (a) 18r. a. to c. are renumbered INS 3.39 (4) (a) 18s., 18u., and 18x. and amended to read:
INS 3.39 (4) (a) 18s. Shall No Medicare supplement policy or certificate, Medicare select policy or certificate, or Medicare cost policy may not 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.
18u. Shall Each Medicare supplement policy or certificate, Medicare select policy or certificate, or Medicare cost policy shall provide for resumption of 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 for outpatient prescription drugs, reinstitution resumption 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. 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 the policyholder or certificateholder may elect or renew coverage with the 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 policyholder or certificateholder with substantially equivalent coverage to the coverage in effect prior to the date of suspension.
18x. Shall Each Medicare supplement policy or certificate, Medicare select policy or certificate, or Medicare cost policy shall provide for 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.
SECTION 34. INS 3.39 (4) (b) (intro.), and 1. to 7., (c), (e), and (g) are amended to read:
INS 3.39 (4) (b) The outline of coverage for the Medicare supplement policy or certificate, Medicare select policy or certificate, or Medicare cost policy or certificate. shall comply with all of the following:
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;.
and 4.
3. Is substituted to properly describe the Medicare supplement policy or certificate, Medicare select policy or certificate, or Medicare cost 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 Medicare supplement policy or certificate, Medicare select policy or certificate, or Medicare cost 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.";
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);.
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;.
6. Summarizes or refers to the coverage set out in applicable statutes;.
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, for each selected coverage, substantially in the format of sub. (11) of Appendix 1; and.
(c) Any rider or endorsement added to the Medicare supplement policy or certificate, Medicare select policy or certificate, or Medicare cost policy or certificate shall comply with all of the following:
1. Shall be set forth 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 set forth stated in the policy or certificate; and.
2. After Shall be agreed to in writing signed by the insured if, after the date of the Medicare supplement policy or certificate, Medicare select policy or certificate, or Medicare cost 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 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.
3. Shall only provide coverage as defined described in sub. (5) (i) or provide coverage to meet statutory Wisconsin mandated provisions.
(e) The anticipated loss ratio for any new Medicare supplement policy or certificate, Medicare select policy or certificate, or Medicare cost policy or certificate form, that is, 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:
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.; and
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 in 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).
(g) As regards For subsequent rate changes to the policy or certificate form, the insurer shall do all of the following:
1. Files such File the rate changes on a rate change transmittal form in a format specified by the commissioner.
2. Includes Include in its 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 which that would violate the requirements under sub. (16) (d).
