Ins 3.39(4m)(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(4m)(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(4m)(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(4m)(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(4m)(b)(b) The outline of coverage for the policy or certificate shall comply with all of the following:
Ins 3.39(4m)(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(4m)(b)2.2. Complies with s. Ins 3.27.
Ins 3.39(4m)(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(4m)(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. (5m), (7) or (30m).
Ins 3.39(4m)(b)5.5. Is substantially in the format prescribed in Appendices 3m, 4m, 5m, and 6m for the appropriate category and printed in a font size that is not less than 12-point type.
Ins 3.39(4m)(b)6.6. Summarizes or refers to the coverage set out in applicable statutes.
Ins 3.39(4m)(b)7.7. Contains a listing of the required coverage as set out in sub. (5m) (d) and the optional coverage as set out in sub. (5m) (e), and the annual premiums for each selected coverage, substantially in the format of sub. (11) in Appendix 2m.
Ins 3.39(4m)(b)8.8. Is approved by the commissioner along with the policy or certificate form.
Ins 3.39(4m)(c)(c) Any rider or endorsement added to the policy or certificate shall comply with the following:
Ins 3.39(4m)(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(4m)(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 coverage 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(4m)(c)3.3. Shall only provide coverage as defined in sub. (5m) (e) or provide coverage to meet Wisconsin mandated benefits.
Ins 3.39(4m)(d)(d) The schedule of benefits page or the first page of the policy or certificate contains a listing giving the coverages and both the annual premium in the format shown in sub. (11) of Appendix 2m and modal premium selected by the applicant.
Ins 3.39(4m)(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(4m)(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 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
Ins 3.39(4m)(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(4m)(f)(f) For subsequent rate changes to the policy or certificate form, the insurer shall do all of the following:
Ins 3.39(4m)(f)1.1. File the rate changes on a rate change transmittal form in a format specified by the commissioner.
Ins 3.39(4m)(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(4t)(4t)Medicare supplement policy and certificate, Medicare select policy and certificate, and Medicare cost policy requirements for policies and certificates offered to persons first eligible for Medicare on or after January 1, 2020.
Ins 3.39(4t)(a)(a) Except as explicitly allowed by subs. (5t), (7), and (30t), no disability insurance policy or certificate shall relate its coverage to Medicare or be structured, advertised, solicited, marketed or issued to persons newly eligible for Medicare on or after January 1, 2020, as a Medicare supplement policy or certificate, as a Medicare select policy or certificate, or as a Medicare cost policy unless the policy or certificate is in compliance with the following:
Ins 3.39(4t)(a)1.1. Provides only the coverage set out in sub. (5t), (7) or (30t), and applicable statutes, and contains no exclusions or limitations other than those permitted by sub. (8). No issuer may issue a Medicare supplement policy or certificate, Medicare select policy or certificate, or Medicare cost policy without prior approval from the commissioner and compliance with sub. (30t).
Ins 3.39(4t)(a)2.2. Discloses on the first page any applicable preexisting conditions limitation, contains no preexisting condition waiting period longer than 6 months and does 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 6 months before the effective date of coverage.
Ins 3.39(4t)(a)3.3. Contains no definitions of terms such as “Medicare eligible expenses,” “accident,” “sickness,” “mental or nervous disorders,” skilled nursing facility,” “hospital,” “nurse,” “physician,” “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).