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)1.1. The person has attained age 65 on or after January 1, 2020.
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)(y)(y) “Outline of coverage” means a printed statement as defined by s. Ins 3.27 (5) (L), that meets the requirements of sub. (4) (b), (4m) (b), or (4t) (b), as applicable.
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)(zag)(zag) “Policyholder” has the meaning provided at s. 600.03 (37), Stat.
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)(zd)
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)(3g)Medicare eligible person.
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)(3r)Open enrollment.
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: