Purpose: These new regulations are necessary to assure compliance with the standards prescribed by the Medicare Modernization Act (MMA) and are consistent with the amendments to the NAIC Medicare Supplement Insurance Minimum Standards Model Act that were adopted as a result of the MMA. The Centers for Medicare and Medicaid Services (CMS) requires states to implement the updated NAIC model amendments by September 8, 2005.

     Citation of Existing Rules Affected by this Order: Repealing WAC 284-66-077; and amending WAC 284-66-010 through 284-66-400.

     Statutory Authority for Adoption: RCW 48.02.060 and 48.66.165.

      Adopted under notice filed as WSR 05-13-182 on June 22, 2005.

     Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 13, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted on the Agency's Own Initiative: New 1, Amended 21, Repealed 1.

     Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0;      Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 0, Repealed 0.

     Date Adopted: August 4, 2005.

Mike Kreidler

Insurance Commissioner

OTS-8056.3

AMENDATORY SECTION(Amending Order R 92-1, filed 2/25/92, effective 3/27/92)

WAC 284-66-010   Purpose.   The purpose of this chapter is to ((effectuate the provisions of RCW 48.20.450, 48.20.460 and 48.20.470, 48.30.010, 48.44.020, 48.44.050, 48.44.070, 48.46.030, 48.46.130, 48.46.200, and to)) supplement the requirements of chapter 48.66 RCW, the Medicare Supplemental Health Insurance Act; to assure the orderly implementation and conversion of Medicare supplement insurance benefits and premiums due to changes in the federal Medicare program; to provide for the reasonable simplification and standardization of the coverage, terms, and benefits of Medicare supplement insurance policies and certificates, and to eliminate policy provisions ((which)) that may duplicate Medicare benefits as the federal Medicare program changes; to facilitate public understanding and comparison of ((such)) policies and to eliminate provisions contained in ((such)) policies ((which)) that may be misleading or confusing; to establish minimum standards for Medicare supplement insurance, an "outline of coverage" and other disclosure requirements; to prohibit the use of certain provisions in Medicare supplemental insurance policies; to define and prohibit certain acts and practices as unfair methods of competition or unfair or deceptive acts or practices; and to establish loss ratio requirements, policy reserves, filing and reporting procedures.

[Statutory Authority: RCW 48.02.060, 48.20.450, 48.20.460, 48.20.470, 48.30.010, 48.44.020, 48.44.050, 48.44.070, 48.46.030, 48.46.130 and 48.46.200. 92-06-021 (Order R 92-1), § 284-66-010, filed 2/25/92, effective 3/27/92. Statutory Authority: RCW 48.02.060, 48.20.450, 48.20.460, 48.20.470, 48.30.010, 48.44.020, 48.44.050, 48.44.070, 48.46.030, 48.46.130, 48.46.200, 48.66.041, 48.66.050, 48.66.100, 48.66.110, 48.66.120, 48.66.130, 48.66.150 and 48.66.160. 90-07-059 (Order R 90-4), § 284-66-010, filed 3/20/90, effective 4/20/90.]

     (2)(a) Medicare supplement insurance policies delivered ((prior to)) before January 1, 1989, ((which)) that are renewable solely at the option of the insured by the timely payment of premium ((shall be)) are subject to the provisions of this chapter except with respect to WAC 284-66-060, 284-66-200, 284-66-210, 284-66-310, and 284-66-350. To the extent that the provisions of this chapter do not apply to ((such)) these policies, chapter 284-55 WAC ((shall apply)) applies.

     (b) Medicare supplement insurance policies delivered between January 1, 1989, and December 31, 1989, ((and which)) that are renewable solely at the option of the insured by the timely payment of premium ((shall be)) are governed by this chapter except with respect to the requirements of WAC 284-66-210 and 284-66-350.

[Statutory Authority: RCW 48.02.060, 48.66.041 and 48.66.165. 96-09-047 (Matter No. R 96-2), § 284-66-020, filed 4/11/96, effective 5/12/96. Statutory Authority: RCW 48.02.060, 48.20.450, 48.20.460, 48.20.470, 48.30.010, 48.44.020, 48.44.050, 48.44.070, 48.46.030, 48.46.130 and 48.46.200. 92-06-021 (Order R 92-1), § 284-66-020, filed 2/25/92, effective 3/27/92. Statutory Authority: RCW 48.02.060, 48.20.450, 48.20.460, 48.20.470, 48.30.010, 48.44.020, 48.44.050, 48.44.070, 48.46.030, 48.46.130, 48.46.200, 48.66.041, 48.66.050, 48.66.100, 48.66.110, 48.66.120, 48.66.130, 48.66.150 and 48.66.160. 90-07-059 (Order R 90-4), § 284-66-020, filed 3/20/90, effective 4/20/90.]

     Reviser's note: The brackets and enclosed material in the text of the above section occurred in the copy filed by the agency and appear in the Register pursuant to the requirements of RCW 34.08.040.
AMENDATORY SECTION(Amending Order R 92-1, filed 2/25/92, effective 3/27/92)

WAC 284-66-030   Definitions.   For purposes of this chapter:

     (1) "Applicant" means:

     (a) In the case of an individual Medicare supplement insurance policy, the person who seeks to contract for insurance benefits; and

     (b) In the case of a group Medicare supplement insurance policy, the proposed certificate holder.

     (2) "Certificate" means any certificate delivered or issued for delivery in this state under a group Medicare supplement insurance policy regardless of the situs of the group master policy.

     (3) "Certificate form" means the form on which the certificate is delivered or issued for delivery by the issuer.

     (4) "Issuer" includes insurance companies, fraternal benefit societies, health care service contractors, health maintenance organizations, and any other entity delivering or issuing for delivery Medicare supplement policies or certificates.

     (5) "Direct response issuer" means an issuer who, as to a particular transaction, is transacting insurance directly with a potential insured without solicitation by, or the intervention of, a licensed insurance agent.

     (6) "Disability insurance" is insurance against bodily injury, disablement or death by accident, against disablement resulting from sickness, and every insurance ((appertaining thereto)) relating to disability insurance. For purposes of this chapter, disability insurance ((shall)) includes policies or contracts offered by any issuer.

     (7) "Health care expense costs," for purposes of WAC 284-66-200(4), means expenses of a health maintenance organization or health care service contractor associated with the delivery of health care services ((which expenses)) that are analogous to incurred losses of insurers. ((Such expenses shall not include home office and overhead costs, advertising costs, commissions and other acquisition costs, taxes, capital costs, administrative costs, and "claims" processing costs.))

     (8) "Policy" includes agreements or contracts issued by any issuer.

     (9) "Policy form" means the form on which the policy is delivered or issued for delivery by the issuer.

     (10) "Premium" means all sums charged, received, or deposited as consideration for a Medicare supplement insurance policy or the continuance thereof. An assessment or a membership, contract, survey, inspection, service, or other similar fee or charge made by the issuer in consideration for ((such)) the policy is deemed part of the premium. "Earned premium" ((shall)) means the "premium" applicable to an accounting period whether received before, during or after ((such)) that period.

     (11) "Replacement" means any transaction ((in which)) where new Medicare supplement coverage is to be purchased, and it is known or should be known to the proposing agent or other representative of the issuer, or to the proposing issuer if there is no agent, that by reason of ((such)) the transaction, existing Medicare supplement coverage has been or is to be lapsed, surrendered or otherwise terminated.

     (12) "Secretary" means the Secretary of the United States Department of Health and Human Services.

[Statutory Authority: RCW 48.02.060, 48.20.450, 48.20.460, 48.20.470, 48.30.010, 48.44.020, 48.44.050, 48.44.070, 48.46.030, 48.46.130 and 48.46.200. 92-06-021 (Order R 92-1), § 284-66-030, filed 2/25/92, effective 3/27/92. Statutory Authority: RCW 48.02.060, 48.20.450, 48.20.460, 48.20.470, 48.30.010, 48.44.020, 48.44.050, 48.44.070, 48.46.030, 48.46.130, 48.46.200, 48.66.041, 48.66.050, 48.66.100, 48.66.110, 48.66.120, 48.66.130, 48.66.150 and 48.66.160. 90-07-059 (Order R 90-4), § 284-66-030, filed 3/20/90, effective 4/20/90.]

     (1) "Accident," "accidental injury," or "accidental means" ((shall)) must be defined to employ "result" language and ((shall)) may not include words ((which)) that establish an accidental means test or use words such as "external, violent, visible wounds" or similar words or description or characterization.

     (a) The definition ((shall)) may not be more restrictive than the following: "Injury or injuries for which benefits are provided means accidental bodily injury sustained by the insured person ((which)) that is the direct result of an accident, independent of disease or bodily infirmity or any other cause, and occurs while insurance coverage is in force."

     (b) ((Such)) The definition may provide that injuries ((shall)) do not include those injuries for which benefits are provided under any workers' compensation, employer's liability or similar law, or motor vehicle no-fault plan, unless prohibited by law.

     (2) "Benefit period" or "Medicare benefit period" may not be defined more restrictively than as defined in the Medicare program.

     (3) "Convalescent nursing home," "extended care facility," or "skilled nursing facility" ((shall)) may not be defined more restrictively than as defined in the Medicare program.

     (((3))) (4) "Hospital" may be defined in relation to its status, facilities and available services or to reflect its accreditation by the Joint Commission on Accreditation of Health Care Organizations, but not more restrictively than as defined in the Medicare program.

     (((4))) (5) "Medicare" ((shall)) must be defined in the policy and certificate((. Medicare may be defined)) as "The Health Insurance for the Aged Act, Title XVIII of the Social Security Amendments of 1965 as then constituted or later amended." ((or "Title I, Part I of Public Law 89-97, as enacted by the Eighty-ninth Congress of the United States of America and popularly known as the Health Insurance for the Aged Act, as then constituted and any later amendments or substitutes thereof," or words of similar import.

     (5))) (6) "Medicare eligible expenses" means expenses of the kinds covered by Medicare Parts A and B, to the extent recognized as reasonable and medically necessary by Medicare.

     (7) "Physician" ((shall)) may not be defined more restrictively than as defined in the Medicare program.

     (((6))) (8) "Sickness" ((shall)) may not be defined to be more restrictive than the following: "Sickness means illness or disease of an insured person ((which)) that first manifests itself after the effective date of insurance and while the insurance is in force." The definition may be further modified to exclude sicknesses or diseases for which benefits are provided under any workers' compensation, occupational disease, employer's liability, or similar law.

[Statutory Authority: RCW 48.02.060, 48.20.450, 48.20.460, 48.20.470, 48.30.010, 48.44.020, 48.44.050, 48.44.070, 48.46.030, 48.46.130 and 48.46.200. 92-06-021 (Order R 92-1), § 284-66-040, filed 2/25/92, effective 3/27/92. Statutory Authority: RCW 48.02.060, 48.20.450, 48.20.460, 48.20.470, 48.30.010, 48.44.020, 48.44.050, 48.44.070, 48.46.030, 48.46.130, 48.46.200, 48.66.041, 48.66.050, 48.66.100, 48.66.110, 48.66.120, 48.66.130, 48.66.150 and 48.66.160. 90-07-059 (Order R 90-4), § 284-66-040, filed 3/20/90, effective 4/20/90.]

     (2) ((No)) A Medicare supplement policy or certificate in force in this state ((shall)) may not contain benefits ((which)) that duplicate benefits provided by Medicare.

     (3) Except for permitted preexisting condition clauses as described in WAC 284-66-063 (1)(a) no policy or certificate may be advertised, solicited, or issued for delivery in this state as a Medicare supplement policy if ((such)) the policy or certificate contains limitations or exclusions on coverage that are more restrictive than those of Medicare.

     (4) The terms "Medicare supplement," "Medicare wrap-around," "Medigap," or words of similar import ((shall)) may not be used to describe an insurance policy unless ((such)) the policy is issued in compliance with chapter 48.66 RCW and this chapter.

     (5) Subject to WAC 284-66-063 (1)(c), a Medicare supplement policy with benefits for outpatient prescription drugs in existence before January 1, 2006, must be renewed for current policyholders who do not enroll in Part D at the option of the policyholder.

     (6) A Medicare supplement policy with benefits for outpatient prescription drugs may not be issued after December 31, 2005.

     (7) After December 31, 2005, a Medicare supplement policy with benefits for outpatient prescription drugs may not be renewed after the policyholder enrolls in Medicare Part D unless:

     (a) The policy is modified to eliminate outpatient prescription coverage for expenses of outpatient prescription drugs incurred after the effective date of the individual's coverage under a Part D plan; and

     (b) Premiums are adjusted to reflect the elimination of outpatient prescription drug coverage at the time of Medicare Part D enrollment, accounting for any claims paid, if applicable.

[Statutory Authority: RCW 48.02.060, 48.20.450, 48.20.460, 48.20.470, 48.30.010, 48.44.020, 48.44.050, 48.44.070, 48.46.030, 48.46.130 and 48.46.200. 92-06-021 (Order R 92-1), § 284-66-050, filed 2/25/92, effective 3/27/92. Statutory Authority: RCW 48.02.060, 48.20.450, 48.20.460, 48.20.470, 48.30.010, 48.44.020, 48.44.050, 48.44.070, 48.46.030, 48.46.130, 48.46.200, 48.66.041, 48.66.050, 48.66.100, 48.66.110, 48.66.120, 48.66.130, 48.66.150 and 48.66.160. 90-07-059 (Order R 90-4), § 284-66-050, filed 3/20/90, effective 4/20/90.]

     (1) Coverage of Part A Medicare eligible expenses for hospitalization to the extent not covered by Medicare from the 61st day through the 90th day in any Medicare benefit period;

     (2) Coverage for either all or none of the Medicare Part A inpatient hospital deductible amount;

     (3) Coverage of Part A Medicare eligible expenses incurred as daily hospital charges during use of Medicare's lifetime hospital inpatient reserve days;

     (4) Upon exhaustion of all Medicare hospital inpatient coverage including the lifetime reserve days, coverage of ninety percent of all Medicare Part A eligible expenses for hospitalization not covered by Medicare subject to a lifetime maximum benefit of an additional three hundred sixty-five days;

     (5) Coverage under Medicare Part A for the reasonable cost of the first three pints of blood (or equivalent quantities of packed red blood cells, as defined under federal regulations) unless replaced in accordance with federal regulations or already paid for under Part B;

     (6) Coverage for the coinsurance amount of Medicare eligible expenses under Part B regardless of hospital confinement, subject to a maximum calendar year out-of-pocket amount equal to the Medicare Part B deductible;

     (7) Coverage under Medicare Part B for the reasonable cost of the first three pints of blood (or equivalent quantities of packed red blood cells, as defined under federal regulations), unless replaced in accordance with federal regulations or already paid for under Part A, subject to the Medicare deductible amount.

[Statutory Authority: RCW 48.02.060, 48.20.450, 48.20.460, 48.20.470, 48.30.010, 48.44.020, 48.44.050, 48.44.070, 48.46.030, 48.46.130 and 48.46.200. 92-06-021 (Order R 92-1), § 284-66-060, filed 2/25/92, effective 3/27/92. Statutory Authority: RCW 48.02.060, 48.20.450, 48.20.460, 48.20.470, 48.30.010, 48.44.020, 48.44.050, 48.44.070, 48.46.030, 48.46.130, 48.46.200, 48.66.041, 48.66.050, 48.66.100, 48.66.110, 48.66.120, 48.66.130, 48.66.150 and 48.66.160. 90-07-059 (Order R 90-4), § 284-66-060, filed 3/20/90, effective 4/20/90.]

     (1) General standards. The following standards apply to Medicare supplement policies and certificates and are in addition to all other requirements of this regulation.

     (a) A Medicare supplement policy or certificate ((shall)) may not exclude or limit benefits for losses incurred more than three months from the effective date of coverage because it involved a preexisting condition. The policy or certificate may 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 three months before the effective date of coverage.

     (b) ((No)) A Medicare supplement policy or certificate ((shall)) may not provide for termination of coverage of a spouse solely because of the occurrence of an event specified for termination of coverage of the insured, other than the nonpayment of premium.

     (c) Each Medicare supplement policy ((shall)) must be guaranteed renewable and:

     (i) The issuer ((shall)) may not cancel or nonrenew the policy solely on the ground of health status of the individual; and

     (ii) The issuer ((shall)) may not cancel or nonrenew the policy for any reason other than nonpayment of premium or material misrepresentation.

     (iii) If the Medicare supplement policy is terminated by the group policy holder and is not replaced as provided under (c)(v) of this subsection, the issuer ((shall)) must offer certificateholders an individual Medicare supplement policy ((which)) that (at the option of the certificateholder) provides for continuation of the benefits contained in the group policy, or provides for ((such)) benefits ((as)) that otherwise meet((s)) the requirements of this subsection.

     (iv) If an individual is a certificateholder in a group Medicare supplement policy and the individual terminates membership in the group, the issuer ((shall)) must offer the certificateholder the conversion opportunity described in (c)(iii) of this subsection, or at the option of the group policyholder, offer the certificateholder continuation of coverage under the group policy.

     (v) If a group Medicare supplement policy is replaced by another group Medicare supplement policy purchased by the same policyholder, the issuer of the replacement policy ((shall)) must offer coverage to all persons covered under the old group policy on its date of termination. Coverage under the new policy ((shall)) may not result in any exclusion for preexisting conditions that would have been covered under the group policy being replaced.

     (d) Termination of a Medicare supplement policy or certificate ((shall)) must be without prejudice to any continuous loss ((which commenced)) that began while the policy was in force, but the extension of benefits beyond the period ((during which)) that the policy was in force may be conditioned upon the continuous total disability of the insured, limited to the duration of the policy benefit period, if any, or payment of the maximum benefits. Receipt of Medicare Part D benefits will not be considered in determining a continuous loss.

     (e) If a Medicare supplement policy or certificate eliminates an outpatient prescription drug benefit as a result of requirements imposed by the Medicare Prescription Drug Improvement and Modernization Act of 2003, the modified policy or certificate is deemed to satisfy the guaranteed renewal requirements of this section.

     (f)(i) A Medicare supplement policy or certificate ((shall)) must 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 twenty-four months) ((in which)) that the policyholder or certificateholder has applied for and is determined to be entitled to medical assistance under Title XIX of the Social Security Act, but only if the policyholder or certificateholder notifies the issuer of ((such)) the policy or certificate within ninety days after the date the individual becomes entitled to ((such)) the assistance.

     (ii) If ((such)) the suspension occurs and if the policyholder or certificateholder loses entitlement to ((such)) medical assistance, ((such)) the policy or certificate ((shall)) must be automatically reinstituted ((())effective as of the date of termination of ((such)) the entitlement(() as of the termination of such entitlement)) if the policyholder or certificateholder provides notice of loss of ((such)) the entitlement within ninety days after the date of ((such)) the loss and pays the premium attributable to the period((, effective as of the date of termination of such entitlement)).

     (iii) Each Medicare supplement policy must provide that benefits and premiums under the policy will be suspended (for any period that may be provided by federal regulation) at the request of the policyholder if the policyholder is entitled to benefits under Section 226(b) of the 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). If suspension occurs and if the policyholder or certificateholder loses coverage under the group health plan, the policy must be automatically reinstituted (effective as of the date of loss of coverage within ninety days after the date of the loss).

     (g) Reinstitution of ((such)) the coverages;

     (((A) Shall)) (i) May not provide for any waiting period with respect to treatment of preexisting conditions;

     (((B) Shall)) (ii) Must provide for resumption of coverage ((which)) that is substantially equivalent to coverage in effect before the date of ((such)) the suspension((; and)). If the suspended Medicare Supplement policy or certificate provided coverage for outpatient prescription drugs, reinstitution of the policy for Medicare Part D enrollees must be without coverage for outpatient prescription drugs and must otherwise provide substantially equivalent coverage to the coverage in effect before the date of suspension; and

     (((C) Shall)) (iii) Must provide for classification of premiums 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.

     (2) Standards for basic ("core") benefits common to ((all)) benefit plans A-J. Every issuer ((shall)) must make available a policy or certificate including only the following basic "core" package of benefits to each prospective insured. An issuer may make available to prospective insureds any of the other Medicare supplement insurance benefit plans in addition to the basic "core" package, but not in ((lieu thereof)) place of the basic "core" package.

     (a) Coverage of Part A Medicare eligible expenses for hospitalization to the extent not covered by Medicare from the sixty-first day through the ninetieth day in any medicare benefit period;

     (b) Coverage of Part A Medicare eligible expenses incurred for hospitalization to the extent not covered by Medicare for each Medicare lifetime inpatient reserve day used;

     (c) Upon exhaustion of the Medicare hospital inpatient coverage including the lifetime reserve days, coverage of one hundred percent of the Medicare Part A eligible expenses for hospitalization paid at the ((diagnostic related group (DRG) day outlier per diem)) applicable prospective payment system (PPS) rate or other appropriate Medicare standard of payment, subject to a lifetime maximum benefit of an additional three hundred sixty-five days. The provider must accept the issuer's payment as payment in full and may not bill the insured for any balance;

     (d) Coverage under Medicare Parts A and B for the reasonable cost of the first three pints of blood (or equivalent quantities of packaged red blood cells, as defined under federal regulations) unless replaced in accordance with federal regulations;

     (e) Coverage for the coinsurance amount, or in the case of hospital; outpatient department services paid under a prospective payment system, the copayment amount, of Medicare eligible expenses under Part B regardless of hospital confinement, subject to the Medicare Part B deductible;

     (3) Standards for additional benefits. The following additional benefits ((shall)) must be included in Medicare supplement benefit plans "B" through "J" only as provided by WAC 284-66-066.

     (a) Medicare Part A deductible: Coverage for all of the Medicare Part A inpatient hospital deductible amount per benefit period.

     (b) Skilled nursing facility care: Coverage for the actual billed charges up to the coinsurance amount from the twenty-first day through the one hundredth day in a Medicare benefit period for posthospital skilled nursing facility care eligible under Medicare Part A;

     (c) Medicare Part B deductible: Coverage for all of the Medicare Part B deductible amount per calendar year regardless of hospital confinement.

     (d) Eighty percent of the Medicare Part B excess charges: Coverage for eighty percent of the difference between the actual Medicare Part B charge as billed, not to exceed any charge limitation established by the Medicare program or state law, and the Medicare-approved Part B charge.

     (e) One hundred percent of the Medicare Part B excess charges: Coverage for all of the difference between the actual Medicare Part B charge as billed, not to exceed any charge limitation established by the Medicare program or state law, and the Medicare-approved Part B charge.

     (f) Basic outpatient prescription drug benefit: Coverage for fifty percent of outpatient prescription drug charges, after a two hundred fifty dollar calendar year deductible, to a maximum of one thousand two hundred fifty dollars in benefits received by the insured per calendar year, to the extent not covered by Medicare. The outpatient prescription drug benefit may not be included for sale or issuance in a Medicare supplement policy after December 31, 2005.

     (g) Extended outpatient prescription drug benefit: Coverage for fifty percent of outpatient prescription drug charges, after a two hundred fifty dollar calendar year deductible to a maximum of three thousand dollars in benefits received by the insured per calendar year, to the extent not covered by Medicare. The outpatient prescription drug benefit may not be included for sale or issuance in a Medicare supplement policy after December 31, 2005.

     (h) Medically necessary emergency care in a foreign country: Coverage to the extent not covered by Medicare for eighty percent of the billed charges for Medicare-eligible expenses for medically necessary emergency hospital, physician, and medical care received in a foreign country, ((which care)) that would have been covered by Medicare if provided in the United States and ((which care)) that began during the first sixty consecutive days of each trip outside the United States, subject to a calendar year deductible of two hundred fifty dollars, and a lifetime maximum benefit of fifty thousand dollars. For purposes of this benefit, "emergency care" ((shall)) means care needed immediately because of an injury or an illness of sudden and unexpected onset.

     (i) Preventive medical care benefit: Coverage for the following preventive health services not covered by Medicare:

     (i) An annual clinical preventive medical history and physical examination that may include tests and services from (((i)))(ii) of this subsection and patient education to address preventive health care measures.

     (ii) ((Any one or a combination of the following)) Preventive screening tests or preventive services, the selection and frequency ((of which)) that is ((considered)) determined to be medically appropriate((:

     (A) Feccal occult blood test and/or digital rectal examination;

     (B) Mammogram;

     (C) Dipstick urinalysis for hematuria, bacteriuria, and proteinauria;

     (D) Pure tone (air only) hearing screening test, administered or ordered by a physician;

     (E) Serum cholesterol screening (every five years);

     (F) Thyroid function test;

     (G) Diabetes screening.

     (iii) Influenza vaccine administered at any appropriate time during the year and Tetanus and Diphtheria booster (every ten years).

     (iv) Any other tests or preventive measures determined appropriate)) by the attending physician.

     Reimbursement ((shall)) must be for the actual charges up to one hundred percent of the Medicare-approved amount for each service, as if Medicare were to cover the service as identified in American Medical Association Current Procedural Terminology (AMA CPT) codes, to a maximum of one hundred twenty dollars annually under this benefit. This benefit ((shall)) may not include payment for any procedure covered by Medicare.

     (j) At-home recovery benefit: Coverage for services to provide short term, at-home assistance with activities of daily living for those recovering from an illness, injury, or surgery.

     (i) For purposes of this benefit, the following definitions ((shall)) apply:

     (A) "Activities of daily living" include, but are not limited to bathing, dressing, personal hygiene, transferring, eating, ambulating, assistance with drugs that are normally self-administered, and changing bandages or other dressings.

     (B) "Care provider" means a duly qualified or licensed home health aide/homemaker, personal care aide, or nurse provided through a licensed home health care agency or referred by a licensed referral agency or licensed nurses registry.

     (C) "Home" ((shall)) means any place used by the insured as a place of residence, provided that ((such)) the place would qualify as a residence for home health care services covered by Medicare. A hospital or skilled nursing facility ((shall)) is not ((be)) considered the insured's place of residence.

     (D) "At-home recovery visit" means the period of a visit required to provide at home recovery care, without limit on the duration of the visit, except each consecutive four hours in a twenty-four hour period of services provided by a care provider is one visit.

     (ii) Coverage requirements and limitations.

     (A) At-home recovery services provided must be primarily services ((which)) that assist in activities of daily living.

     (B) The insured's attending physician must certify that the specific type and frequency of at-home recovery services are necessary because of a condition for which a home care plan of treatment was approved by Medicare.

     (C) Coverage is limited to:

     (I) No more than the number and type of at-home recovery visits certified as necessary by the insured's attending physician. The total number of at-home recovery visits ((shall)) may not exceed the number of Medicare approved home health care visits under a Medicare approved home care plan of treatment.

     (II) The actual charges for each visit up to a maximum reimbursement of forty dollars per visit.

     (III) One thousand six hundred dollars per calendar year.

     (IV) Seven visits in any one week.

     (V) Care furnished on a visiting basis in the insured's home.

     (VI) Services provided by a care provider as defined in this section.

     (VII) At-home recovery visits while the insured is covered under the policy or certificate and not otherwise excluded.

     (VIII) At-home recovery visits received during the period the insured is receiving Medicare approved home care services or no more than eight weeks after the service date of the last Medicare approved home health care visit.

     (iii) Coverage is excluded for: Home care visits paid for by Medicare or other government programs; and care provided by family members, unpaid volunteers, or providers who are not care providers.

     (((k) New or innovative benefits: An issuer may, with the prior approval of the commissioner, offer policies or certificates with new or innovative benefits in addition to the benefits provided in a policy or certificate that otherwise complies with the applicable standards. Such new or innovative benefits may include benefits that are appropriate to Medicare supplement insurance, new or innovative, not otherwise available, cost-effective, and offered in a manner which is consistent with the goal of simplification of Medicare supplement policies.)) (3) Standardized Medicare supplement benefit plan "K" must consist of the following:

     (a) Coverage of one hundred percent of the Part A hospital coinsurance amount for each day used from the sixty-first through the ninetieth day in any Medicare benefit period;

     (b) Coverage of one hundred percent of the Part A hospital coinsurance amount for each Medicare lifetime inpatient reserve day used from the ninety-first through the one hundred fiftieth day in any Medicare benefit period;

     (c) Upon exhaustion of the Medicare hospital inpatient coverage, including the lifetime reserve days, coverage of one hundred percent of the Medicare Part A eligible expenses for hospitalization paid at the applicable prospective payment system (PPS) rate, or other appropriate Medicare standard of payment, subject to a lifetime maximum benefit of an additional three hundred sixty-five days. The provider must accept the issuer's payment as payment in full and may not bill the insured for any balance;

     (d) Medicare Part A deductible: Coverage for fifty percent of the Medicare Part A inpatient hospital deductible amount per benefit period until the out-of-pocket limitation is met as described in (j) of this subsection;

     (e) Skilled nursing facility care: Coverage for fifty percent of the coinsurance amount for each day used from the twenty-first day through the one hundredth day in a Medicare benefit period for post-hospital skilled nursing facility care eligible under Medicare Part A until the out-of-pocket limitation is met as described in (j) of this subsection;

     (f) Hospice care: Coverage for fifty percent of cost sharing for all Part A Medicare eligible expenses and respite care until the out-of-pocket limitation is met as described in (j) of this subsection;

     (g) Coverage for fifty percent, under Medicare Part A or B, of the reasonable cost of the first three pints of blood (or equivalent quantities of packed red blood cells, as defined under federal regulation) unless replaced in accordance with federal regulations until the out-of-pocket limitation is met as described in (j) of this subsection;

     (h) Except for coverage provided in (i) of this subsection, coverage for fifty percent of the cost sharing otherwise applicable under Medicare Part B after the policyholder pays the Part B deductible until the out-of-pocket limitation is met as described in (j) of this subsection;

     (i) Coverage of one hundred percent of the cost sharing for Medicare Part B preventive services after the policyholder pays the Part B deductible; and

     (j) Coverage of one hundred percent of all cost sharing under Medicare Parts A and B for the balance of the calendar year after the individual has reached the out-of-pocket limitation on annual expenditures under Medicare Parts A and B of four thousand dollars in 2006, indexed each year by the appropriate inflation adjustment specified by the Secretary of the U.S. Department of Health and Human Services.

     (4) Standardized Medicare supplement benefit plan "L" must consist of the following:

     (a) The benefits described in subsection (3)(a),(b),(c) and (i) of this section;

     (b) The benefit described in subsection (3)(d),(e),(f) and (h) of this section but substituting seventy-five percent for fifty percent; and

     (c) The benefit described in subsection (3)(j) of this section but substituting two thousand dollars for four thousand dollars.

[Statutory Authority: RCW 48.02.060, 48.66.041 and 48.66.165. 96-09-047 (Matter No. R 96-2), § 284-66-063, filed 4/11/96, effective 5/12/96. Statutory Authority: RCW 48.02.060, 48.20.450, 48.20.460, 48.20.470, 48.30.010, 48.44.020, 48.44.050, 48.44.070, 48.46.030, 48.46.130 and 48.46.200. 92-06-021 (Order R 92-1), § 284-66-063, filed 2/25/92, effective 3/27/92.]

     Reviser's note: The typographical errors in the above section occurred in the copy filed by the agency and appear in the Register pursuant to the requirements of RCW 34.08.040.
AMENDATORY SECTION(Amending Order R 92-7, filed 8/19/92, effective 9/19/92)

WAC 284-66-066   Standard Medicare supplement benefit plans.   (1) An issuer ((shall)) must make available to each prospective policyholder and certificateholder a policy form or certificate form containing only the basic "core" benefits, as defined in WAC 284-66-063(2) of this regulation.

     (2) No groups, packages, or combinations of Medicare supplement benefits other than those listed in this section ((shall)) may be offered for sale in this state, except as ((may be)) permitted in WAC ((284-66-063 (3)(k))) 284-66-066(7) and in WAC 284-66-073.

     (3) Benefit plans ((shall)) must be uniform in structure, language, designation, and format to the standard benefit plans "A" through (("J")) "L" listed in this subsection and conform to the definitions in WAC 284-66-030 and 284-66-040. Each benefit ((shall)) must be structured ((in accordance with)) according to the format provided in WAC 284-66-063(2) ((and 284-66-063(3))), (3) or (4) and list the benefits in the order shown in this subsection. For purposes of this section, "structure, language, and format" means style, arrangement, and overall content of benefit.

     (4) An issuer may use, in addition to the benefit plan designations required in subsection (3) of this section, other designations to the extent permitted by law.

     (5) Make-up of benefit plans:

     (a) Standardized Medicare supplement benefit plan "A" ((shall)) must be limited to only the basic ("core") benefits common to all benefit plans, as defined ((at)) in WAC 284-66-063(2).

     (b) Standardized Medicare supplement benefit plan "B" ((shall include)) consists of only the following: The core benefit as defined ((at)) in WAC 284-66-063(2), plus the Medicare Part A deductible as defined ((at)) in WAC 284-66-063 (3)(a).

     (c) Standardized Medicare supplement benefit plan "C" ((shall include)) consists of only the following: The core benefit as defined ((at)) in WAC 284-66-063(2), plus the Medicare Part A deductible, skilled nursing facility care, Medicare Part B deductible and medically necessary emergency care in a foreign country as defined ((at)) in WAC 284-66-063 (3)(a), (b), (c), and (h), respectively.

     (d) Standardized Medicare supplement plan "D" ((shall include)) consists of only the following: The core benefit, as defined ((at)) in WAC 284-66-063(2), plus the Medicare Part A deductible, skilled nursing facility care, medically necessary emergency care in a foreign country and the at-home recovery benefit as defined ((at)) in WAC 284-66-063 (3)(a), (b), (h), and (j), respectively.

     (e) Standardized Medicare supplement benefit plan "E" ((shall include)) consists of only the following: The core benefit as defined ((at)) in WAC 284-66-063(2), plus the Medicare Part A deductible, skilled nursing facility care, medically necessary emergency care in a foreign country and preventive medical care as defined ((at)) in WAC 284-66-063 (3)(a), (b), (h), and (i), respectively.

     (f) Standardized Medicare supplement benefit plan "F" ((shall include)) consists of only the following: The core benefit as defined ((at)) in WAC 284-66-063(2), plus the Medicare Part A deductible, the skilled nursing facility care, the Part B deductible, one hundred percent of the Medicare Part B excess charges, and medically necessary emergency care in a foreign country as defined ((at)) in WAC 284-66-063 (3)(a), (b), (c), (e), and (h), respectively.

     (g) Standardized Medicare supplement benefit high deductible plan "F" consists of only the following: One hundred percent of covered expenses following the payment of the annual high deductible plan "F" deductible. The covered expenses include the core benefit as defined in WAC 284-66-063(2), plus the Medicare Part A deductible, skilled nursing facility care, the Medicare Part B deductible, one hundred percent of the Medicare Part B excess charges, and medically necessary emergency care in a foreign country as defined in WAC 284-66-063 (3)(a), (b), (c), (e) and (h) respectively. The annual high deductible plan "F" deductible must consist of out-of-pocket expenses, other than premiums, for services covered by the Medicare supplement plan "F" policy, and must be in addition to any other specific benefit deductibles. The annual high deductible plan "F" deductible is one thousand seven hundred thirty dollars for 2005, and is based on the calendar year. The deductible will be adjusted annually by the secretary to reflect the change in the Consumer Price Index for all urban consumers for the twelve-month period ending with August of the preceding year, and rounded to the nearest multiple of ten dollars.

     (h) Standardized Medicare supplement benefit plan "G" ((shall include)) consists of only the following: The core benefit as defined at WAC 284-66-063(2), plus the Medicare Part A deductible, skilled nursing facility care, eighty percent of the Medicare Part B excess charges, medically necessary emergency care in a foreign country, and the at-home recovery benefit as defined ((at)) in WAC 284-66-063 (3)(a), (b), (d), (h), and (j), respectively.

     (((h))) (i) Standardized Medicare supplement benefit plan "H" ((shall include)) consists of only the following: The core benefit as defined ((at)) in WAC 284-66-063(2), plus the Medicare Part A deductible, skilled nursing facility care, basic prescription drug benefit, and medically necessary emergency care in a foreign country as defined ((at)) in WAC 284-66-063 (3)(a), (b), (f), and (h), respectively. The outpatient prescription drug benefit may not be included in a Medicare supplement policy sold after December 31, 2005.

     (((i))) (j) Standardized Medicare supplement benefit plan "I" ((shall include)) consists of only the following: The core benefit as defined ((at)) in WAC 284-66-063(2), plus the Medicare Part A deductible, skilled nursing facility care, one hundred percent of the Medicare Part B excess charges, basic prescription drug benefit, medically necessary emergency care in a foreign country, and at-home recovery benefit as defined ((at)) in WAC 284-66-063 (3)(a), (b), (e), (f), (h), and (j), respectively. The outpatient prescription drug benefit may not be included in a Medicare supplement policy sold after December 31, 2005.

     (((j))) (k) Standardized Medicare supplement benefit plan "J" ((shall include)) consists of only the following: The core benefit as defined ((at)) in WAC 284-66-063(2), plus the Medicare Part A deductible, skilled nursing facility care, Medicare Part B deductible, one hundred percent of the Medicare Part B excess charges, extended prescription drug benefit, medically necessary emergency care in a foreign country, preventive medical care, and at-home recovery benefit as defined ((at)) in WAC 284-66-063 (3)(a), (b), (c), (e), (g), (h), (i), and (j), respectively. The outpatient prescription drug benefit may not be included in a Medicare supplement policy sold after December 31, 2005.

     (l) Standardized Medicare supplement benefit high deductible plan "J" consists of only the following: One hundred percent of covered expenses following the payment of the annual high deductible plan "J" deductible. The covered expenses include the core benefit as defined in WAC 284-66-063(2), plus the Medicare Part A deductible, skilled nursing facility care, Medicare Part B deductible, one hundred percent of the Medicare Part B excess charges, extended outpatient prescription drug benefit, medically necessary emergency care in a foreign country, preventative medical care benefit and at-home recovery benefit as defined in WAC 284-66-063 (3)(a), (b), (c), (e), (g), (h), (i) and (j) respectively. The annual high deductible plan "J" deductible must consist of out-of-pocket expenses, other than premiums, for services covered by the Medicare supplement plan "J" policy, and must be in addition to any other specific benefit deductibles. The annual deductible is one thousand seven hundred thirty dollars for 2005, and is based on the calendar year. The deductible will be adjusted annually by the secretary to reflect the change in the Consumer Price Index for all urban consumers for the twelve-month period ending with August of the preceding year, and rounded to the nearest multiple of ten dollars. The outpatient prescription drug benefit may not be included in a Medicare supplement policy sold after December 31, 2005.

     (6) Make-up of two Medicare supplement plans mandated by The Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA):

     (a) Standardized Medicare supplement benefit plan "K" consists of only those benefits described in WAC 284-66-063(3).

     (b) Standardized Medicare supplement benefit plan "L" consists of only those benefits described in WAC 284-66-063(4).

     (7) New or innovative benefits: An issuer may, with the prior approval of the commissioner, offer policies or certificates with new or innovative benefits in addition to the benefits provided in a policy or certificate that otherwise complies with the applicable standards. The new or innovative benefits may include benefits that are appropriate to Medicare supplement insurance, new or innovative, not otherwise available, cost-effective, and offered in a manner which is consistent with the goal of simplification of Medicare supplement policies. After December 31, 2005, the innovative benefits may not include an outpatient prescription drug benefit.

[Statutory Authority: RCW 48.02.060. 92-17-078 (Order R 92-7), § 284-66-066, filed 8/19/92, effective 9/19/92. Statutory Authority: RCW 48.02.060, 48.20.450, 48.20.460, 48.20.470, 48.30.010, 48.44.020, 48.44.050, 48.44.070, 48.46.030, 48.46.130 and 48.46.200. 92-06-021 (Order R 92-1), § 284-66-066, filed 2/25/92, effective 3/27/92.]

     (b) No policy or certificate may be advertised as a

Medicare SELECT policy or certificate unless it meets the requirements of this section.

     (2) For the purposes of this section:

     (a) "Complaint" means any dissatisfaction expressed by an individual concerning a Medicare SELECT issuer or its network providers.

     (b) "Grievance" means dissatisfaction expressed in writing by an individual insured under a Medicare SELECT policy or certificate with the administration, claims practices, or provision of services concerning a Medicare SELECT issuer or its network providers.

     (c) "Medicare SELECT issuer" means an issuer offering, or seeking to offer, a Medicare SELECT policy or certificate.

     (d) "Medicare SELECT policy" or "Medicare SELECT certificate" means respectively a Medicare supplement policy or certificate that contains restricted network provisions.

     (e) "Network provider" means a provider of health care, or a group of providers of health care, ((which)) that has entered into a written agreement with the issuer to provide benefits insured under a Medicare SELECT policy.

     (f) "Restricted network provision" means any provision ((which)) that conditions the payment of benefits, in whole or in part, on the use of network providers.

     (g) "Service area" means the geographic area approved by the commissioner ((within which)) where an issuer is authorized to offer a Medicare SELECT policy.

     (3) The commissioner may authorize an issuer to offer a Medicare SELECT policy or certificate, ((pursuant to)) under this section and section 4358 of the Omnibus Budget Reconciliation Act (OBRA) of 1990 if the commissioner finds that the issuer has satisfied all of the requirements of this regulation.

     (4) A Medicare SELECT issuer ((shall)) may not issue a Medicare SELECT policy or certificate in this state until its plan of operation has been approved by the commissioner.

     (5) A Medicare SELECT issuer ((shall)) must file a proposed plan of operation with the commissioner in a format prescribed by the commissioner. The plan of operation ((shall)) must contain at least the following information:

     (a) Evidence that all covered services that are subject to restricted network provisions are available and accessible through network providers, including a demonstration that:

     (i) ((Such)) The services can be provided by network providers with reasonable promptness with respect to geographic location, hours of operation and after-hour care. The hours of operation and availability of after-hour care ((shall)) must reflect usual practice in the local area. Geographic availability ((shall)) must reflect the usual travel times within the community.

     (ii) The number of network providers in the service area is sufficient, with respect to current and expected policyholders, either:

     (A) To deliver adequately all services that are subject to a restricted network provision; or

     (B) To make appropriate referrals.

     (iii) There are written agreements with network providers describing specific responsibilities.

     (iv) Emergency care is available twenty-four hours per day and seven days per week.

     (v) In the case of covered services that are subject to a restricted network provision and are provided on a prepaid basis, there are written agreements with network providers prohibiting ((such)) the providers from billing or otherwise seeking reimbursement from or recourse against any individual insured under a Medicare SELECT policy or certificate. This paragraph ((shall)) does not apply to supplemental charges or coinsurance amounts as stated in the Medicare SELECT policy or certificate.

     (b) A statement or map providing a clear description of the service area.

     (c) A description of the grievance procedure to be ((utilized)) used.

     (d) A description of the quality assurance program, including:

     (i) The formal organizational structure;

     (ii) The written criteria for selection, retention, and removal of network providers; and

     (iii) The procedures for evaluating quality of care provided by network providers, and the process to initiate corrective action when warranted.

     (e) A list and description, by specialty, of the network providers.

     (f) Copies of the written information proposed to be used by the issuer to comply with subsection (9) of this section.

     (g) Any other information requested by the commissioner.

     (6)(a) A Medicare SELECT issuer ((shall)) must file any proposed changes to the plan of operation, except for changes to the list of network providers, with the commissioner ((prior to)) before implementing ((such)) the changes. ((Such)) The changes ((shall)) will be considered approved by the commissioner after thirty days unless specifically disapproved.

     (b) An updated list of network providers ((shall)) must be filed with the commissioner at least quarterly.

     (7) A Medicare SELECT policy or certificate ((shall)) may not restrict payment for covered services provided by nonnetwork providers if:

     (a) The services are for symptoms requiring emergency care or are immediately required for an unforeseen illness, injury, or a condition; and

     (b) It is not reasonable to obtain ((such)) the services through a network provider.

     (8) A Medicare SELECT policy or certificate ((shall)) must provide payment for full coverage under the policy for covered services that are not available through network providers.

     (9) A Medicare SELECT issuer ((shall)) must make full and fair disclosure in writing of the provisions, restrictions, and limitations of the Medicare SELECT policy or certificate to each applicant. This disclosure ((shall)) must include at least the following:

     (a) An outline of coverage sufficient to permit the applicant to compare the coverage and premiums of the Medicare SELECT policy or certificate with:

     (i) Other Medicare supplement policies or certificates offered by the issuer; and

     (ii) Other Medicare SELECT policies or certificates.

     (b) A description (including address, phone number, and hours of operation) of the network providers, including primary care physicians, specialty physicians, hospitals, and other providers. Except to the extent specified in the policy or certificate, expenses incurred when using out-of-network providers do not count toward the out-of-pocket annual limit contained in plans K and L.

     (c) A description of the restricted network provisions, including payments for coinsurance and deductibles when providers other than network providers are ((utilized)) used.

     (d) A description of coverage for emergency and urgently needed care and other out-of-service area coverage.

     (e) A description of limitations on referrals to restricted network providers and to other providers.

     (f) A description of the policyholder's rights to purchase any other Medicare supplement policy or certificate otherwise offered by the issuer.

     (g) A description of the Medicare SELECT issuer's quality assurance program and grievance procedure.

     (10) ((Prior to)) Before the sale of a Medicare SELECT policy or certificate, a Medicare SELECT issuer ((shall)) must obtain from the applicant a signed and dated form stating that the applicant has received the information provided ((pursuant to)) under subsection (9) of this section and that the applicant understands the restrictions of the Medicare SELECT policy or certificate.

     (11) A Medicare SELECT issuer ((shall)) must have and use procedures for hearing complaints and resolving written grievances from the subscribers. ((Such)) The procedures ((shall)) must be aimed at mutual agreement for settlement and may include arbitration procedures.

     (a) The grievance procedure ((shall)) must be described in the policy and certificates and in the outline of coverage.

     (b) At the time the policy or certificate is issued, the issuer ((shall)) must provide detailed information to the policyholder describing how a grievance may be registered with the issuer.

     (c) Grievances ((shall)) must be considered in a timely manner and ((shall)) must be transmitted to appropriate decision-makers who have authority to fully investigate the issue and take corrective action.

     (d) If a grievance is found to be valid, corrective action ((shall)) must be taken promptly.

     (e) All concerned parties ((shall)) must be notified about the results of a grievance.

     (f) The issuer ((shall)) must report no later than each March 31st to the commissioner regarding its grievance procedure. The report ((shall)) must be in a format prescribed by the commissioner and ((shall)) must contain the number of grievances filed in the past year and a summary of the subject, nature, and resolution of ((such)) the grievances.

     (12) At the time of initial purchase, a Medicare SELECT issuer ((shall)) must make available to each applicant for a Medicare SELECT policy or certificate the opportunity to purchase any Medicare supplement policy or certificate otherwise offered by the issuer.

     (13)(a) At the request of an individual insured under a Medicare SELECT policy or certificate, a Medicare SELECT issuer ((shall)) must make available to the individual insured the opportunity to purchase a Medicare supplement policy or certificate offered by the issuer ((which)) that has comparable or lesser benefits and ((which)) does not contain a restricted network provision. The issuer ((shall)) must make ((such)) the policies or certificates available without requiring evidence of insurability after the Medicare supplement policy or certificate has been in force for ((six)) three months.

     (b) For the purposes of this subsection, a Medicare supplement policy or certificate will be considered to have comparable or lesser benefits unless it contains one or more significant benefits not included in the Medicare SELECT policy or certificate being replaced. For the purposes of this paragraph, a significant benefit means coverage for the Medicare Part A deductible, ((coverage for prescription drugs,)) coverage for at-home recovery services, or coverage for Part B excess charges.

     (14) Medicare SELECT policies and certificates ((shall)) must provide for continuation of coverage in the event the Secretary of Health and Human Services determines that Medicare SELECT policies and certificates issued ((pursuant to)) under this section should be discontinued due to either the failure of the Medicare SELECT program to be reauthorized under law or its substantial amendment.

     (a) Each Medicare SELECT issuer ((shall)) must make available to each individual insured under a Medicare SELECT policy or certificate the opportunity to purchase any Medicare supplement policy or certificate offered by the issuer ((which)) that has comparable or lesser benefits and ((which)) does not contain a restricted network provision. The issuer ((shall)) must make ((such)) the policies and certificates available without requiring evidence of insurability.

     (b) For the purposes of this subsection, a Medicare supplement policy or certificate will be considered to have comparable or lesser benefits unless it contains one or more significant benefits not included in the Medicare SELECT policy or certificate being replaced. For the purposes of this paragraph, a significant benefit means coverage for the Medicare Part A deductible, ((coverage for prescription drugs,)) coverage for at-home recovery services, or coverage for Part B excess charges.

     (15) A Medicare SELECT issuer ((shall)) must comply with reasonable requests for data made by state or federal agencies, including the United States Department of Health and Human Services, for the purpose of evaluating the Medicare SELECT program.

[Statutory Authority: RCW 48.02.060, 48.20.450, 48.20.460, 48.20.470, 48.30.010, 48.44.020, 48.44.050, 48.44.070, 48.46.030, 48.46.130 and 48.46.200. 92-06-021 (Order R 92-1), § 284-66-073, filed 2/25/92, effective 3/27/92.]

     (2) The "outline of coverage," ((shall)) must be completed in substantially the form set forth in WAC 284-66-092. The form of outline of coverage ((shall)) must be filed with the commissioner ((prior to use)) before being used in this state.

     (3) If an outline of coverage is provided at the time of application and the Medicare supplement policy or certificate is issued on a basis ((which)) that would require revision of the outline, a substitute outline of coverage properly describing the policy or certificate must accompany ((such)) the policy or certificate when it is delivered and contain the following statement, in no less than twelve point type, 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) The outline of coverage provided to applicants ((pursuant to)) set forth in this section consists of four parts: A cover page, premium information, disclosure pages, and charts displaying the features of each benefit plan offered by the issuer. The outline of coverage ((shall)) must be in the language and format prescribed in WAC 284-66-092 in no less than twelve point type. All plans ((A-J shall)) A-L must be shown on the cover page, and the plan(s) that are offered by the issuer ((shall)) must be prominently identified. Premium information for plans that are offered ((shall)) must be shown on the cover page or immediately following the cover page and ((shall)) must be prominently displayed. The premium and mode ((shall)) must be stated for all plans that are offered to the prospective applicant. All possible premiums for the prospective applicant ((shall)) must be illustrated.

     (5) Where inappropriate terms are used, such as "insurance," "policy," or "insurance company," a fraternal benefit society, health care service contractor, or health maintenance organization ((shall)) must substitute appropriate terminology.

[Statutory Authority: RCW 48.02.060, 48.20.450, 48.20.460, 48.20.470, 48.30.010, 48.44.020, 48.44.050, 48.44.070, 48.46.030, 48.46.130 and 48.46.200. 92-06-021 (Order R 92-1), § 284-66-080, filed 2/25/92, effective 3/27/92. Statutory Authority: RCW 48.02.060, 48.20.450, 48.20.460, 48.20.470, 48.30.010, 48.44.020, 48.44.050, 48.44.070, 48.46.030, 48.46.130, 48.46.200, 48.66.041, 48.66.050, 48.66.100, 48.66.110, 48.66.120, 48.66.130, 48.66.150 and 48.66.160. 90-07-059 (Order R 90-4), § 284-66-080, filed 3/20/90, effective 4/20/90.]

[COMPANY NAME]
Outline of Medicare Supplement Coverage-Cover Page:
Benefit Plan(s) [insert letter(s) of plan(s) being offered]

See Outlines of Coverage sections for details about ALL plans

[COMPANY NAME]
Outline of Medicare Supplement Coverage-Cover Page 2

J	K**	L**
Basic Benefits	100% of Part A Hospitalization Coinsurance plus coverage for 365 Days after Medicare Benefits End	100% of Part A Hospitalization Coinsurance plus coverage for 365 Days after Medicare Benefits End
	50% Hospice cost-sharing	75% Hospice cost-sharing
	50% of Medicare-eligible expenses for the first three pints of blood	75% of Medicare-eligible expenses for the first three pints of blood
	50% Part B Coinsurance, except 100% Coinsurance for Part B Preventative Services	75% Part B Coinsurance, except 100% Coinsurance for Part B Preventative Services
Skilled Nursing Coinsurance	50% Skilled Nursing Facility Coinsurance	75% Skilled Nursing Facility Coinsurance
Part A Deductible	50% Part A Deductible	75% Part A Deductible
Part B Deductible
Part B Excess (100%)
Foreign Travel Emergency
At-Home Recovery
Preventative Care NOT covered by Medicare
	$[ ] Out-of-Pocket Annual Limit***	$[ ] Out-of-Pocket Annual Limit***

	**Plan K and L provide for different cost-sharing for items and services A-J.
	Once you reach the annual limit, the plan pays 100% of the Medicare copayments, coinsurance, and deductibles for the rest of calendar year. The out-of-pocket annual limit does NOT include charges from your provider that exceed Medicare-approved amounts, called "Excess Charges." You will be responsible for paying excess charges.
	***The out-of-pocket annual limit will increase each year for inflation.
	See Outlines of Coverage for details and exceptions.

     (2) Disclosure page(s):

     [for agents:]

Neither [insert company's name] nor its agents are connected with Medicare.

[for direct response:]

[insert company's name] is not connected with Medicare.

This outline of coverage does not give all the details of Medicare coverage. Contact your local Social Security office or consult (("The Medicare Handbook")) Medicare and You for more details.

Review the application carefully before you sign it. Be certain that all information has been properly recorded.

[Include for each plan prominently identified in the cover page, a chart showing the services, Medicare payments, plan payments and insured payments for each plan, using the same language, in the same order, using uniform layout and format as shown in the charts below. No more than four plans may be shown on one chart. For purposes of illustration, charts for each plan are included in this regulation. An issuer may use additional benefit plan designations on these charts ((pursuant to)) as noted in WAC 284-66-066(4).]

[Include an explanation of any innovative benefits on the cover page and in the chart, in a manner approved by the commissioner.]

     (3) Charts displaying the feature of each benefit plan offered by the issuer:

PLAN A

MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD

PLAN A

MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR

PLAN A

PARTS A & B

PLAN B

MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD

PLAN B

MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR

PLAN B

PARTS A & B

PLAN C

MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD

PLAN C

MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR

PLAN C

PARTS A & B

PLAN C (continued)

OTHER BENEFITS - NOT COVERED BY MEDICARE

PLAN D

MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD

PLAN D

MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR

PLAN D

PARTS A & B

OTHER BENEFITS - NOT COVERED BY MEDICARE

PLAN E

MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD

PLAN E

MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR

PLAN E

PARTS A & B

PLAN E (continued)

OTHER BENEFITS - NOT COVERED BY MEDICARE

[PLAN F] [HIGH DEDUCTIBLE PLAN F]

MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD

[PLAN F] [HIGH DEDUCTIBLE PLAN F]

MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR

[PLAN F] [HIGH DEDUCTIBLE PLAN F]

PARTS A & B

PLAN F (continued)

OTHER BENEFITS - NOT COVERED BY MEDICARE

PLAN G

MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD

PLAN G (continued)

MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR

PLAN G (continued)

PARTS A & B

OTHER BENEFITS - NOT COVERED BY MEDICARE

PLAN H

MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD

PLAN H

MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR

PLAN H

PARTS A & B

PLAN H (continued)

OTHER BENEFITS - NOT COVERED BY MEDICARE

PLAN I

MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD

PLAN I

MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR

PLAN I (continued)

PARTS A & B

OTHER BENEFITS - NOT COVERED BY MEDICARE

[PLAN J] [HIGH DEDUCTIBLE PLAN J]

MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD

[PLAN J] [HIGH DEDUCTIBLE PLAN J]

MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR

[PLAN J] [HIGH DEDUCTIBLE PLAN J] (continued)

PARTS A & B

[PLAN J] [HIGH DEDUCTIBLE PLAN J]

OTHER BENEFITS - NOT COVERED BY MEDICARE

PLAN K

PLAN K

MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR

PLAN K (continued)

PARTS A & B

PLAN L

PLAN L

MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR

PLAN L (continued)

PARTS A & B

[Statutory Authority: RCW 48.02.060. 92-17-078 (Order R 92-7), § 284-66-092, filed 8/19/92, effective 9/19/92. Statutory Authority: RCW 48.02.060, 48.20.450, 48.20.460, 48.20.470, 48.30.010, 48.44.020, 48.44.050, 48.44.070, 48.46.030, 48.46.130 and 48.46.200. 92-06-021 (Order R 92-1), § 284-66-092, filed 2/25/92, effective 3/27/92.]

     Reviser's note: The brackets and enclosed material in the text of the above section occurred in the copy filed by the agency and appear in the Register pursuant to the requirements of RCW 34.08.040.
AMENDATORY SECTION(Amending Matter No. R 96-2, filed 4/11/96, effective 5/12/96)

WAC 284-66-110   Buyer's guide.   (1) Issuers of disability insurance policies or certificates that provide hospital or medical expense coverage on an expense incurred or indemnity basis to persons eligible for Medicare must provide to all such applicants the pamphlet "Guide to Health Insurance for People with Medicare," developed jointly by the National Association of Insurance Commissioners and ((Health Care Financing Administration)) the Centers for Medicare and Medicaid Services, (CMS), or any reproduction or official revision of that pamphlet. The guide ((shall)) must be printed in a style and with a type character that is easily read by an average person eligible for Medicare supplement insurance and in no case may the type size be smaller than 12-point type. (Specimen copies may be obtained from the Superintendent of Documents, United States Government Printing Office, Washington, D.C.)

     (2) Delivery of the guide ((shall)) must be made whether or not ((such)) the policies or certificates are advertised, solicited, or issued as Medicare supplement insurance policies or certificates.

     (3) Except in the case of a direct response issuers, delivery of the guide ((shall)) must be made to the applicant at the time of application and acknowledgement of receipt of the guide ((shall)) must be obtained by the issuer. Direct response issuers ((shall)) must deliver the guide to the applicant upon request but not later than at the time the policy is delivered.

     (4) The guide ((shall)) must be reproduced in a form that is substantially identical in language, format, type size, type proportional spacing, bold character, and line spacing to the guide developed jointly by the National Association of Insurance Commissioners and ((the Health Care Financing Administration)) CMS.

[Statutory Authority: RCW 48.02.060, 48.66.041 and 48.66.165. 96-09-047 (Matter No. R 96-2), § 284-66-110, filed 4/11/96, effective 5/12/96. Statutory Authority: RCW 48.02.060, 48.20.450, 48.20.460, 48.20.470, 48.30.010, 48.44.020, 48.44.050, 48.44.070, 48.46.030, 48.46.130 and 48.46.200. 92-06-021 (Order R 92-1), § 284-66-110, filed 2/25/92, effective 3/27/92. Statutory Authority: RCW 48.02.060, 48.20.450, 48.20.460, 48.20.470, 48.30.010, 48.44.020, 48.44.050, 48.44.070, 48.46.030, 48.46.130, 48.46.200, 48.66.041, 48.66.050, 48.66.100, 48.66.110, 48.66.120, 48.66.130, 48.66.150 and 48.66.160. 90-07-059 (Order R 90-4), § 284-66-110, filed 3/20/90, effective 4/20/90.]

[Statutory Authority: RCW 48.02.060, 48.66.041 and 48.66.165. 96-09-047 (Matter No. R 96-2), § 284-66-120, filed 4/11/96, effective 5/12/96. Statutory Authority: RCW 48.02.060, 48.20.450, 48.20.460, 48.20.470, 48.30.010, 48.44.020, 48.44.050, 48.44.070, 48.46.030, 48.46.130 and 48.46.200. 92-06-021 (Order R 92-1), § 284-66-120, filed 2/25/92, effective 3/27/92. Statutory Authority: RCW 48.02.060, 48.20.450, 48.20.460, 48.20.470, 48.30.010, 48.44.020, 48.44.050, 48.44.070, 48.46.030, 48.46.130, 48.46.200, 48.66.041, 48.66.050, 48.66.100, 48.66.110, 48.66.120, 48.66.130, 48.66.150 and 48.66.160. 90-07-059 (Order R 90-4), § 284-66-120, filed 3/20/90, effective 4/20/90.]

     (2) If you purchase this policy, you may want to evaluate your existing health coverage and decide if you need multiple coverages.

     (3) If you are sixty-five or older, you may be eligible for benefits under Medicaid and may not need a Medicare supplement policy.

     (4) If, after purchasing this policy, you become eligible for Medicaid, the benefits and premiums under your Medicare supplement policy can be suspended if requested during your entitlement to benefits under Medicaid for twenty-four months. You must request this suspension within ninety days of becoming eligible for Medicaid. If you are no longer entitled to Medicaid, your suspended Medicare supplement policy (or, if that is no longer available, a substantially equivalent policy) will be reinstituted if requested within ninety days of losing Medicaid eligibility. If the Medicare supplement policy provided coverage for outpatient prescription drugs and you enrolled in Medicare Part D while your policy was suspended, the reinstituted policy will not have outpatient prescription drug coverage, but will otherwise be substantially equivalent to your coverage before the date of the suspension.

     (5) If you are eligible for, and have enrolled in a Medicare supplement policy by reason of disability and you later become covered by an employer or union-based group health plan, the benefits and premiums under your Medicare supplement policy can be suspended, if requested, while you are covered under the employer or union-based group health benefit plan. If you suspend your Medicare supplement policy under these circumstances, and later lose your employer or union-based group health plan, your suspended Medicare supplement policy (or, if that is no longer available, a substantially equivalent policy) will be reinstituted if requested within 90 days of losing your employer or union-based group health plan. If the Medicare supplement policy provided coverage for outpatient prescription drugs and you enrolled in Medicare Part D while your policy was suspended, the reinstituted policy will not have outpatient prescription drug coverage, but will otherwise be substantially equivalent to your coverage before the date of the suspension.

     (6) Counseling services may be available in your state to provide advice concerning your purchase of Medicare supplement insurance and concerning medical assistance through the state Medicaid program, including benefits as a "Qualified Medicare Beneficiary" (QMB) and a "Specified Low-Income Medicare Beneficiary" (SLMB).

[Please mark Yes or No below with an "X"]

To the best of your knowledge.

     (1) ((Do you have another Medicare supplement policy or certificate in force?

     (a) If so, with which company?

     (b) If so, do you intend to replace your current Medicare supplemental policy with this policy or certificate?

     (2) Do you have any other health insurance coverage that provides benefits similar to this Medicare supplement policy?

     (a) If so, with which company?

     (b) What kind of policy?

     (3) Are you covered for medical assistance through the state Medicaid program:

     (a) As a "Specified Low-Income Medicare Beneficiary" (SLMB)?

     (b) As a "Qualified Medicare Beneficiary" (QMB)?

     (c) For other Medicaid medical benefits?)) (a) Did you turn age 65 in the last 6 months?

Yes &lhlsqbul;

No &lhlsqbul;

     (b) Did you enroll in Medicare Part B in the last 6 months?

Yes &lhlsqbul;

No &lhlsqbul;

     (c) If yes, what is the effective date?

     (2) Are you covered for medical assistance through the state Medicaid program?

     [NOTE TO APPLICANT; If you are participating in a "Spend- Down Program" and have not met your "Share of Cost," please answer NO to this question.]

Yes &lhlsqbul;

No &lhlsqbul;

     If yes,

     (a) Will Medicaid pay your premiums for this Medicare supplement policy?

Yes &lhlsqbul;

No &lhlsqbul;

     (b) Do you receive any benefits from Medicaid OTHER THAN payments toward your Medicare Part B premium?

Yes &lhlsqbul;

No &lhlsqbul;

     (3)(a) If you had coverage from any Medicare plan other than original Medicare within the past 63 days (for example, a Medicare Advantage plan, or a Medicare HMO or PPO), fill in your start and end dates below. If you are still covered under this plan, leave "END" blank.

START / /

END / /

     (b) If you are still covered under the Medicare plan, do you intend to replace your current coverage with this new Medicare supplement policy?

Yes &lhlsqbul;

No &lhlsqbul;

     (c) Was this your first time in this type of Medicare plan?

Yes &lhlsqbul;

No &lhlsqbul;

     (d) Did you drop a Medicare supplement policy to enroll in the Medicare plan?

Yes &lhlsqbul;

No &lhlsqbul;

     (4)(a) Do you have another Medicare supplement policy in force?

Yes &lhlsqbul;

No &lhlsqbul;

     (b) If so, with what company and what plan do you have [optional for Direct Mailers]?

     (c) If so, do you intend to replace your current Medicare supplement policy with this policy?

Yes &lhlsqbul;

No &lhlsqbul;

     (5) Have you had coverage under any other health insurance within the past 63 days? (For example, an employer, union or individual plan.)

Yes &lhlsqbul;

No &lhlsqbul;

     (a) If so, with what company and what kind of policy?

     (b) What are your dates of coverage under the other policy?

START / /

END / /

     (If you are still covered under the other policy, leave "END" blank.)

     (2) Agents ((shall)) must list any other medical or health insurance policies sold to the applicant.

     (a) List policies sold ((which)) that are still in force.

     (b) List policies sold in the past five years ((which)) that are no longer in force.

     (3) In the case of a direct response issuer, a copy of the application or supplemental form, signed by the applicant, and acknowledged by the insurer, ((shall)) must be returned to the applicant by the insurer upon delivery of the policy.

     (4) Upon determining that a sale will involve replacement of Medicare Supplement Coverage, an issuer, other than a direct response issuer, or its agent, ((shall)) must furnish the applicant, ((prior to issuance or delivery of)) before issuing or delivering the Medicare supplement insurance policy or certificate, a notice regarding replacement of Medicare supplement insurance coverage. One copy of ((such)) the notice, signed by the applicant and the agent (except where the coverage is sold without an agent), ((shall)) must be provided to the applicant and an additional signed copy ((shall)) must be ((retained)) kept by the issuer. A direct response issuer ((shall)) must deliver to the applicant at the time of the issuance of the policy the notice regarding replacement of Medicare supplement insurance coverage.

     (5) The notice required by subsection (4) of this section for an issuer, ((shall)) must be provided in substantially the form set forth in WAC 284-66-142 in no smaller than twelve point type, and ((shall)) must be filed with the commissioner ((prior to use)) before being used in this state.