Legal Unit - OCI Rule Comment for Rule Ins 3.39 and 3.55, Wis. Adm. Code.
Office of the Commissioner of Insurance
PO Box 7873
Madison WI 53707-7873
Street address:
Julie E. Walsh
Legal Unit - OCI Rule Comment for Rule Ins 3.39 and 3.55, Wis. Adm. Code.
Office of the Commissioner of Insurance
125 South Webster St – 2nd Floor
Madison WI 53703-3474
Email address:
Julie E. Walsh
The proposed rule changes are:
Section 1.
INS 3.13 (2) (j) Except as provided in s. Ins 3.39 (7) (d), (dm), and (dt), the provision or notice regarding the right to return the policy required by s. 632.73, Stats., shall comply with all of the following: 3. Provide an unrestricted right to return the policy, within 10 days from the date it is received by the policyholder, to the issuer at its home or branch office, if any, or to the agent through whom it was purchased; except it shall provide an unrestricted right to return the policy within 30 days of the date it is received by the policyholder in the case of a Medicare supplement policy subject to s. Ins 3.39 (4), (4s) (4m), (4t), (5), (5m), (5t), and (6), issued pursuant to a direct response solicitation. Provision shall not be made to require the policyholder to set out in writing the reasons for returning the policy, to require the policyholder to first consult with an agent of the issuer regarding the policy, or to limit the reasons for return. Note: Paragraph (j) was adopted to assist in the application of s. 204.31 (2) (a), Stats., to the review of accident and sickness policy and other contract forms. Those statutory requirements are presently included in s. 632.73, Stats. The original statute required that the provision of notice regarding the right to return the policy must be appropriately captioned or titled. Since the important rights given the insured are to examine the policy and to return the policy, the rule requires that the caption or title must refer to at least one of these rights—examine or return. Without such reference, the caption or title is not considered appropriate. The original statute permitted the insured to return the policy for refund to the home office or branch office of the insurer or to the agency with whom it was purchased. In order to assure the refund is made promptly, some insurers prefer to instruct the insured to return the policy to a particular office or agent for a refund. Notices or provisions with such requirements will be approved on the basis that the insurer must recognize an insured’s right to receive a full refund if the policy is returned to any other office or agent mentioned in the statute.
Also, the statute permits the insured to return a policy for refund within 10 days from the date of receipt. Some insurers’ notices or provisions regarding such right, however, refer to delivery to the insured instead of receipt by the insured or do not specifically provide for the running of the 10 days from the date the insured receives the policy. Notices or provisions containing such wording will be approved on the basis that the insurer will not refuse refund if the insured returns the policy within 10 days from the date of receipt of the policy.
Sections 632.73 (2m) and 600.03 (35) (e), as created by Chapter 82, Laws of 1981, provide for the right of return provisions in certain certificates of group Medicare supplement policies. Therefore, for purposes of this subparagraph, the word policy includes a Medicare supplement certificate subject to s. Ins 3.39 (4), (4s) (4m), (4t), (5), (5m), (5t), and (6). Section 2.
Section 3.
(7) (b) The notice required by sub. (6) for a Medicare supplement policy subject to s. Ins 3.39 (4), (4s) (4m), (4t), (5), (5m), (5t), and (7), shall include an introductory statement in substantially the following form: Your new policy provides _______ days within which you may decide without cost whether you desire to keep the policy. Section 4.
INS 3.39 (1) (a) This section establishes requirements for health and other disability insurance policies primarily sold to Medicare eligible persons. Disclosure provisions are required for other disability policies sold to Medicare eligible person because such policies frequently are represented to, and purchased by, the Medicare eligible as supplements to Medicare products including Medicare Advantage and Medicare Prescription Drug plans.
(b) This section seeks to reduce abuses and confusion associated with the sale of disability insurance to Medicare eligible persons by providing for reasonable standards. The disclosure requirements and established benefit standards are intended to provide to Medicare eligible persons guidelines that they can use to compare disability insurance policies and certificates as described in s. Ins 6.75 (1) (c), and to aid them in the purchase of policies and certificates intended to supplement Medicare and Medicare Advantage plans policies that are suitable for their needs. This section is designed not only to improve the ability of the Medicare eligible consumer to make an informed choice when purchasing disability insurance, but also to assure the Medicare eligible persons of this state that the commissioner will not approve a policy or certificate as “Medicare supplement” or as a “Medicare replacement cost” unless it meets the requirements of this section. SECTION 4. INS 3.39 (1) (c) is repealed.
SECTION 5. INS 3.39 (1) (d) is amended to read:
INS 3.39 (1) (d) Wisconsin statutes interpreted and implemented by this rule are ss. 185.983 (1m), 600.03, 601.01 (2), 601.42, 609.01 (1g) (b), 625.16, 628.34 (12), 628.38, 631.20 (2), 632.73 (2m), 632.76 (2) (b), 632.81, 632.895 (2), (3), (4) and (6) and (9), Stats. SECTION 6. INS 3.39 (2) (a) (intro.), 1. and 3. are amended to read:
INS 3.39 (2) (a) Except as provided in pars. (d) and (e), this section applies to any group or individual Medicare supplement policy or certificate, or Medicare select policy or certificate as defined described in s. 600.03 (28r), Stats., or any Medicare replacement cost policy as defined described in s. 600.03 (28p) (a) and (c), Stats., including all of the following: 1. Any Medicare supplement policy, Medicare select policy, or Medicare replacement cost policy issued by a voluntary sickness care plan subject to ch. 185, Stats.; 2. Any certificate issued under a group Medicare supplement policy or group Medicare replacement select policy;.
3. Any individual or group policy sold in Wisconsin predominantly to individuals or groups of individuals who are 65 years of age or older which that offers hospital, medical, surgical, or other disability coverage, except for a policy which that offers solely nursing home, hospital confinement indemnity, or specified disease coverage; and.
SECTION 7. INS 3.39 (2) (a) 4. is repealed.
SECTION 8. INS 3.39 (2) (a) 5. and (b) are amended to read:
INS 3.39 (2) (a) 5. Any individual or group policy or certificate sold in Wisconsin to persons under 65 years of age and eligible for medicare Medicare by reason of disability which that offers hospital, medical, surgical or other disability coverage, except for a policy or certificate which that offers solely nursing home, hospital confinement indemnity or specified disease coverage.
(b) Except as provided in pars. (d) and (e), subs. (9) and (11) apply to any individual disability policy sold to a person eligible for Medicare which that is not a Medicare supplement, Medicare select, or a Medicare replacement cost policy as described in par. (a).
SECTION 9. INS 3.39 (2) (c) (intro.) and 2. are consolidated and renumbered INS 3.39 (2) (c) and, as renumbered, are amended to read:
INS 3.39 (2) (c) Except as provided in par. (e), sub. (10) applies to:
2. Any any individual or group hospital or medical policy which that continues with changed benefits after the insured becomes eligible for Medicare.
SECTION 10. INS 3.39 (2) (c) 1. is repealed.
SECTION 11. INS 3.39 (2) (d) (intro.) is amended to read:
INS 3.39 (2) (d) Except as provided in subs. (10) and (13), this section does not apply to any of the following:
SECTION 12. INS 3.39 (2) (d) 4. is repealed.
SECTION 13. INS 3.39 (2) (e) (intro.) and 1. are amended to read:
INS 3.39 (2) (e) This section does not apply to either of the following:
1. A policy providing solely accident, dental, vision, disability income, or credit disability income coverage; or.
SECTION 14. INS 3.39 (3) (c) (intro.) and 1., (ce), (e) and (f) are amended to read:
INS 3.39 (3) (c) “Applicant" means either of the following:
1. In the case of an individual Medicare supplement, Medicare select, or Medicare replacement cost policy, the person who seeks to contract for insurance benefits.
(ce) “Balance bill" means seeking: to bill, charge, or collect a deposit, remuneration or compensation from; to file or threaten to file with a credit reporting agency; or to have any recourse against an enrollee insured or any person acting on the enrollee’s insured’s behalf for health care costs for which the enrollee insured is not liable. The prohibition on recovery does not affect the liability of an enrollee insured for any deductibles, coinsurance or copayments, or for premiums owed under the policy or certificate.
(e) “CMS” means the Centers for Medicare & Medicaid Services within the U.S. department of health and human services.
(f) “Certificate" means, any in this section, a certificate delivered or issued for delivery in this state under a group Medicare supplement policy or under a Medicare select policy that is issued on a group basis, i.e. employer retiree group.
SECTION 15. INS 3.39 (3) (fm) is created to read:
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.
