44-3604. Policies and certificates; director; powers and duties; preexisting condition; coverage.

419 words·~2 min read·/ne/chapter-44/44-3604

A research copy — for the controlling text, always check the official state or federal source. Not legal advice.

(1)No medicare supplement policy or certificate in force in the state shall contain benefits that duplicate benefits provided by medicare.

(2)Notwithstanding any other provision of law, a medicare supplement policy or certificate shall not exclude or limit benefits for losses incurred more than six months from the effective date of coverage because it involved a preexisting condition. The policy or certificate shall 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 six months before the effective date of coverage.

(3)The director shall adopt and promulgate reasonable rules and regulations to establish specific standards for policy provisions of medicare supplement policies and certificates. Such standards shall be in addition to and in accordance with applicable laws of this state. No requirement of Chapter 44 relating to minimum required policy benefits, other than the minimum standards contained in the Medicare Supplement Insurance Minimum Standards Act, shall apply to medicare supplement policies and certificates. The standards may include, but shall not be limited to:

(a)Terms of renewability;

(b)Initial and subsequent conditions of eligibility;

(c)Nonduplication of coverage;

(d)Probationary periods;

(e)Benefit limitations, exceptions, and reductions;

(f)Elimination periods;

(g)Requirements for replacement;

(h)Recurrent conditions; and

(i)Definitions of terms.

(4)The director shall adopt and promulgate reasonable rules and regulations to establish minimum standards for benefits, claims payment, marketing practices and compensation arrangements, and reporting practices for medicare supplement policies and certificates.

(5)The director may adopt and promulgate rules and regulations necessary to conform medicare supplement policies and certificates to the requirements of federal law and regulations promulgated under federal law, including:

(a)Requiring refunds or credits if the policies or certificates do not meet loss-ratio requirements;

(b)Establishing a uniform methodology for calculating and reporting loss ratios;

(c)Assuring public access to policies, premiums, and loss-ratio information of issuers of medicare supplement insurance;

(d)Establishing a process for approving or disapproving policy forms and certificate forms and proposed premium increases;

(e)Establishing a policy for holding public hearings prior to approval of premium increases; and

(f)Establishing standards for medicare select policies and certificates.

(6)The director may adopt and promulgate reasonable rules and regulations which specify prohibited policy provisions not otherwise specifically authorized by statute which, in the opinion of the director, are unjust, unfair, or unfairly discriminatory to any person insured or proposed to be insured under a medicare supplement policy or certificate.