[Rev. 1/4/2011 2:56:25 PM]
CHAPTER 687B - CONTRACTS OF INSURANCE
GENERAL PROVISIONS
687B.0005 “Commissioner” defined.
687B.001 “Division” defined.
687B.004 Procedures for filing certain forms.
POLICIES FOR LONG-TERM CARE
687B.005 Definitions.
687B.010 “Applicant” defined.
687B.015 “Certificate” defined.
687B.019 “Converted policy” defined.
687B.025 “Group long-term care insurance” defined.
687B.030 “Long-term care insurance” defined.
687B.031 “Provision for continuation of coverage” defined.
687B.032 “Provision for conversion of coverage” defined.
687B.035 Scope.
687B.040 Compliance required.
687B.045 Modification or suspension of provisions.
687B.050 Organizational requirements.
687B.055 Policies issued in other states.
687B.060 Right to return individual policies; notice of right.
687B.065 Right to return policies issued pursuant to direct-response solicitation; notice of right.
687B.066 Provision for reinstatement in event of lapse of coverage.
687B.067 Applications: Questions; required statements; required information for applicants 80 years of age or older.
687B.068 Right to copy of application or enrollment form.
687B.069 Record of rescissions.
687B.070 Certificate of insurance: Contents.
687B.075 Outline of coverage: Delivery; contents.
687B.076 Offer to purchase protection from inflation required.
687B.077 Requirements for marketing.
687B.078 Restriction on use of certain terms in marketing.
687B.079 Prohibition of certain marketing practices.
687B.080 Definition of terms in policies.
687B.085 Terms for renewal of policies.
687B.090 Exclusions from and limitations on coverage.
687B.095 Extension of benefits; continuation or conversion of coverage.
687B.100 Required disclosures.
687B.105 Prohibited provisions.
687B.108 Prohibited increases in premiums.
687B.111 Coverage for preexisting conditions.
687B.113 Delivery of shopper’s guide to long-term care insurance.
687B.114 Responsibilities of professional, trade or occupational association which endorses or sells policies or certificates to members.
687B.115 Filing and certification requirements for insurer issuing policy or certificate to professional, trade or occupational association.
687B.116 Limitations on conditioning of benefits.
687B.117 Restrictions on limitation or exclusion of benefits.
687B.118 Statement of limitations or conditions upon receipt of benefits.
687B.119 Required reserves for policy or rider.
687B.121 Evaluation of expected loss ratio.
687B.122 General requirements for converted policy.
687B.125 Replacement of policy: Questions on applications.
687B.127 Replacement of policy: Waiver of time applicable to preexisting conditions and probationary period; notice to existing insurer.
687B.130 Replacement of policy: Notice from insurer not using direct-response solicitation.
687B.135 Replacement of policy: Notice from insurer using direct-response solicitation.
687B.140 Replacement of policy: Restrictions concerning group policies for long-term care.
POLICIES SUPPLEMENTARY TO MEDICARE
General Provisions
687B.200 Definitions.
687B.201 “Applicant” defined.
687B.2014 “Certificate” defined.
687B.2018 “Eligible organization” defined.
687B.202 “Employee welfare benefit plan” defined.
687B.2024 “Issuer” defined.
687B.2028 “Medicare” defined.
687B.203 “Medicare Advantage organization” defined.
687B.2034 “Medicare Advantage plan” defined.
687B.2036 “Medicare Part D” defined.
687B.2037 “Medicare select issuer” defined.
687B.2039 “PACE program” defined.
687B.204 “Policy to supplement Medicare” defined.
687B.2045 “Standardized benefit plan” defined.
687B.205 Applicability of provisions.
687B.206 Eligibility for policy to supplement Medicare offered to new enrollees or for certificate offered to new enrollees following certain disenrollment; required policy or certificate; outpatient prescription drug coverage.
687B.2062 Eligibility for policy to supplement Medicare offered to new enrollees or for certificate offered to new enrollees following certain disenrollment, enrollment and subsequent disenrollment; required policy or certificate.
687B.2064 Eligibility for policy to supplement Medicare offered to new enrollees or for certificate offered to new enrollees following certain enrollment and subsequent disenrollment; required policy or certificate.
687B.2068 Policy to supplement Medicare offered to new enrollees or certificate offered to new enrollees: Prohibition against denial of application, placement of condition on issuance or effectiveness, or discrimination in pricing under certain conditions by issuer.
687B.207 Coverage if application is submitted before or during first 6-month period in which person is both 65 years of age or older and enrolled under Medicare Part B; availability of coverage to all qualified applicants.
687B.209 Termination of or disenrollment from plan, certificate or policy to supplement Medicare: Requirements for written notification.
687B.212 Filing and approval of policy forms and certificate forms.
687B.213 Availability and discontinuance of policy forms and certificate forms.
687B.215 Definitions and terms used in policy or certificate.
687B.220 Exclusions from and limitations on coverage and benefits; duplication of benefits provided by Medicare; benefits for outpatient prescription drugs.
687B.225 Minimum standards for coverage: Policy or certificate advertised, solicited or issued for delivery before July 16, 1992.
687B.226 Minimum standards for coverage: Policy or certificate advertised, solicited, delivered, issued for delivery or renewed on or after July 16, 1992, and before July 30, 1992.
687B.227 Policy or certificate advertised, solicited, delivered or issued for delivery or renewed on or after July 30, 1992: General requirements.
687B.229 Filing and approval of rates, rating schedule and supporting documentation required.
687B.230 Rates: Standards for ratios of loss; filing requirements; adjustments; hearing on certain requested increases.
687B.235 Calculation and payment of refunds and credits.
687B.240 Provision for renewal or continuation; acceptance of riders and endorsements; prohibited standards for payment of benefits; disclosure and dissemination of information.
687B.243 Lapse of policy to supplement Medicare or certificate for nonpayment of premium: Notice required before termination of policy or certificate.
687B.245 Lapse of policy to supplement Medicare or certificate for nonpayment of premium: Designation of person to receive notice of lapse or waiver of designation.
687B.247 Lapse of policy to supplement Medicare or certificate for nonpayment of premium: Provision for reinstatement of coverage.
687B.250 Outline of coverage; assistance in understanding health insurance.
687B.255 Elicitation and dissemination of information regarding existing coverage and its replacement; inclusion of certain statements and questions in application.
687B.258 Replacement of existing coverage: Limitations on time periods for preexisting conditions, waiting periods, elimination periods and probationary periods.
687B.260 Policy to supplement Medicare or certificate issued before January 1, 1992: Replacement with standardized benefit plan.
687B.263 Termination and replacement of coverage under group policy.
687B.265 Notice of modifications to policy or certificate; compliance with certain notice requirements.
687B.269 Notice required that certain policies of insurance are not supplementary to Medicare; disclosure of extent to which policy or certificate duplicates coverage of Medicare.
687B.273 Standards of practice for marketing.
687B.275 Compensation of agents and other representatives and producers.
687B.280 Review of proposed advertising.
687B.282 Recommendations for purchase or replacement; sale of multiple policies or certificates; issuance of policy or certificate to person enrolled in Medicare Part C.
687B.283 Reporting of multiple policies or certificates.
687B.286 Compliance with certain provisions of Social Security Act regarding notice and payment of claims.
Standardized Benefit Plans
687B.290 Availability; minimum benefits.
687B.295 General requirements.
687B.300 Standardized Benefit Plan A.
687B.302 Standardized Benefit Plan B.
687B.304 Standardized Benefit Plan C.
687B.306 Standardized Benefit Plan D.
687B.308 Standardized Benefit Plan E.
687B.311 Standardized Benefit Plan F or High Deductible Benefit Plan F.
687B.313 Standardized Benefit Plan G.
687B.315 Standardized Benefit Plan H.
687B.317 Standardized Benefit Plan I.
687B.319 Standardized Benefit Plan J or High Deductible Benefit Plan J.
687B.325 Coverage for short-term services provided to person recovering at home.
687B.330 Provision of new or innovative benefits.
Medicare Select Policies and Certificates
687B.340 Definitions.
687B.342 “Complaint” defined.
687B.344 “Grievance” defined.
687B.346 “Medicare select issuer” defined.
687B.348 “Medicare select policy” and “Medicare select certificate” defined.
687B.350 “Network provider” defined.
687B.352 “Provision for a restricted network” defined.
687B.354 “Service area” defined.
687B.356 Compliance with regulations required before advertising.
687B.358 Authorization to offer and approval to issue.
687B.360 Filing and contents of proposed plan of operation.
687B.362 Proposed changes to plan of operation; update of list of network providers.
687B.364 Payment for covered services provided by persons other than network providers.
687B.366 Full payment required for covered services not available through network provider.
687B.368 Written disclosure of provisions, restrictions and limitations.
687B.370 Procedures for hearing complaints and resolving grievances.
687B.372 Availability of certain policies and certificates offered by Medicare select issuer.
687B.374 Provision for continuation of coverage; availability of policies to supplement Medicare as continuation of coverage.
687B.376 Compliance with requests for data for evaluation of Medicare select program.
REQUIREMENTS FOR DELIVERY
687B.405 Delivery of certificates to policyholder of group insurance.
687B.415 Delivery of other policies, memoranda or certificates of insurance.
CANCELLATION OF POLICIES
687B.520 Refunds to third parties.
687B.530 Notice to agent.
NOTICE OF TERMINATION TO EMPLOYEE LEASING COMPANIES
687B.550 Definitions.
687B.552 “Client company” defined.
687B.554 “Employee leasing company” defined.
687B.556 “Health maintenance organization” defined.
687B.558 “Insurer” defined.
687B.560 “Producer of insurance” defined.
687B.562 Disclosure of names and addresses of client companies; confidentiality.
687B.564 Notice of cancellation or failure to renew policy or contract.
MISCELLANEOUS POLICIES
687B.610 Vendor single interest policies: Marking.
687B.620 Multiple line packages.
687B.630 Health policy, contract or plan that includes grace period for payment of premiums.
POLICIES THAT DUPLICATE BENEFITS PROVIDED UNDER MEDICARE
687B.700 Notice of duplication for policy which provides reimbursement upon both expense-incurred and fixed-indemnity basis.
687B.720 Notice of duplication for policy which provides reimbursement for expenses incurred for specified diseases and other specified impairments.
687B.725 Notice of duplication for policy which provides reimbursement for expenses incurred for specified limited services.
687B.730 Notice of duplication for policy not described in NAC 687B.700 to 687B.725, inclusive.
687B.735 Payment of benefits that are covered under other policies.
POLICIES OF LIABILITY INSURANCE
687B.800 Policy sold by short-term lessor of motor vehicle: Deemed primary coverage; filing requirements.
POLICIES OF MOTOR VEHICLE INSURANCE
687B.850 Chargeable accidents: Restrictions on authority of insurer; filing and use of definition.
GENERAL PROVISIONS
NAC 687B.0005 “Commissioner” defined. (NRS 679B.130) “Commissioner” means the Commissioner of Insurance.
(Added to NAC by Comm’r of Insurance, eff. 11-21-88)—(Substituted in revision for NAC 687B.020)
NAC 687B.001 “Division” defined. (NRS 679B.130) As used in this chapter, unless the context otherwise requires, “Division” means the Division of Insurance of the Department of Business and Industry.
(Added to NAC by Comm’r of Insurance, eff. 5-27-92)
NAC 687B.004 Procedures for filing certain forms. (NRS 679B.130, 679B.136, 687B.120) Any form required to be filed pursuant to the provisions of NRS 687B.120:
1. Must be filed in accordance with the current bulletin issued by the Division that addresses life and health form filing procedures and with the National Association of Insurance Commissioners’ “Uniform Life, Accident and Health, Annuity, Credit Transmittal Document,” which is required to be filed pursuant to that bulletin; and
2. May be filed in accordance with the System for Electronic Rate and Form Filing developed and implemented by the National Association of Insurance Commissioners.
(Added to NAC by Comm’r of Insurance by R115-02, eff. 3-18-2003; A by R129-06, 9-18-2006)
POLICIES FOR LONG-TERM CARE
NAC 687B.005 Definitions. (NRS 679B.130) As used in NAC 687B.005 to 687B.140, inclusive, unless the context otherwise requires, the words and terms defined in NAC 687B.010 to 687B.032, inclusive, have the meanings ascribed to them in those sections.
(Added to NAC by Comm’r of Insurance, eff. 11-21-88; A 1-4-91; 12-15-94)
NAC 687B.010 “Applicant” defined. (NRS 679B.130) “Applicant” means:
1. In the case of an individual policy of long-term insurance, the person who seeks to contract for benefits.
2. In the case of a group policy of long-term care insurance, the proposed holder of the certificate.
(Added to NAC by Comm’r of Insurance, eff. 11-21-88)
NAC 687B.015 “Certificate” defined. (NRS 679B.130) “Certificate” means any certificate issued under a group policy of long-term care insurance which is delivered or issued for delivery in this State.
(Added to NAC by Comm’r of Insurance, eff. 11-21-88)
NAC 687B.019 “Converted policy” defined. (NRS 679B.130) “Converted policy” means an individual policy of long-term care insurance providing benefits identical to, or benefits determined by the Commissioner to be substantially equivalent to, or in excess of, those provided under the group policy of long-term care insurance from which conversion is made.
(Added to NAC by Comm’r of Insurance, eff. 12-15-94)
NAC 687B.025 “Group long-term care insurance” defined. (NRS 679B.130) “Group long-term care insurance” means a policy of long-term care insurance which is delivered or issued for delivery in this State to:
1. One or more employers or labor organizations, or to a trust or to the trustees of a fund established by one or more employers or labor organizations, or both, for employees or former employees, or both, or for members or former members, or both, of the labor organizations;
2. Any professional, trade or occupational association for its members or former or retired members, or any combination thereof, if the association:
(a) Is composed of persons who are or were actively engaged in the same profession, trade or occupation; and
(b) Has been maintained in good faith for purposes other than obtaining insurance;
3. An association or trust, or the trustee of a fund, established, created or maintained for the benefit of members of one or more associations; or
4. Any other group, if the Commissioner finds that:
(a) The issuance of the policy to that group is not contrary to the best interests of the public;
(b) The issuance of the policy would result in economies of acquisition or administration; and
(c) The benefits are reasonable in relation to the premiums charged.
(Added to NAC by Comm’r of Insurance, eff. 11-21-88)
NAC 687B.030 “Long-term care insurance” defined. (NRS 679B.130)
1. “Long-term care insurance” means any policy of insurance or rider advertised, marketed, offered or designed to provide coverage for not less than 24 consecutive months for each person covered by the policy on an expense-incurred, indemnity, prepaid or other basis, for necessary diagnostic, preventive, therapeutic, rehabilitative, maintenance or personal care services provided in a setting other than an acute care unit of a hospital.
2. The term includes group and individual policies or riders whether issued by insurers, fraternal benefit societies, nonprofit medical, hospital and medical service corporations, health maintenance organizations or any other similar organization.
3. The term does not include any policy of insurance which is offered primarily to provide:
(a) Basic coverage to supplement Medicare;
(b) Basic coverage for hospital expenses;
(c) Basic coverage for medical-surgical expenses;
(d) Indemnity coverage for confinement in a hospital;
(e) Coverage for major medical expenses;
(f ) Coverage to protect income received for a disability;
(g) Coverage for accidents only;
(h) Coverage for specified diseases or accidents; or
(i) Limited benefit health coverage.
(Added to NAC by Comm’r of Insurance, eff. 11-21-88)
NAC 687B.031 “Provision for continuation of coverage” defined. (NRS 679B.130) “Provision for continuation of coverage” means a provision allowing coverage to be maintained under the existing group policy, subject only to the continued timely payment of premiums, when such coverage would otherwise terminate.
(Added to NAC by Comm’r of Insurance, eff. 12-15-94)
NAC 687B.032 “Provision for conversion of coverage” defined. (NRS 679B.130) “Provision for conversion of coverage” means a provision that a person:
1. Whose coverage under the group policy would otherwise terminate, or whose coverage has been terminated for any reason, including discontinuance of the group policy in its entirety or with respect to an insured class; and
2. Who has been continuously insured under the group policy and any group policy which it replaced for at least the 6 months immediately preceding the date of termination,
Ê is entitled to the issuance of a converted policy by the insurer under whose group policy he is covered, without evidence of insurability.
(Added to NAC by Comm’r of Insurance, eff. 12-15-94)
NAC 687B.035 Scope. (NRS 679B.130)
1. Except as otherwise provided in this subsection, the provisions of NAC 687B.005 to 687B.135, inclusive, apply to a policy of insurance delivered or issued for delivery in this State on or after November 21, 1988. The provisions of NAC 687B.113, 687B.116 and 687B.118 apply to a policy of insurance delivered or issued for delivery in this State on or after January 11, 1991.
2. The provisions of NAC 687B.005 to 687B.135, inclusive, do not supersede the obligations of entities subject to them to comply with other applicable regulations insofar as they do not conflict with the provisions of NAC 687B.005 to 687B.135, inclusive.
3. Applicable regulations governing policies of insurance which supplement Medicare do not apply to policies of long-term care insurance.
4. A policy of insurance which is not advertised, marketed or offered as long-term care insurance or nursing home insurance is not required to comply with the provisions of NAC 687B.005 to 687B.135, inclusive.
5. NAC 688B.010 and 689B.010 to 689B.080, inclusive, do not apply to policies of long-term care insurance.
(Added to NAC by Comm’r of Insurance, eff. 11-21-88; A 1-4-91)
NAC 687B.040 Compliance required. (NRS 679B.130) A policy of insurance may not be advertised, marketed or offered as long-term care insurance or insurance which provides coverage for care received in a nursing home unless it complies with the provisions of NAC 687B.005 to 687B.140, inclusive.
(Added to NAC by Comm’r of Insurance, eff. 11-21-88; A 1-4-91)
NAC 687B.045 Modification or suspension of provisions. (NRS 679B.130) The Commissioner may, upon receiving a written request therefor and after an administrative hearing, issue an order to modify or suspend any provision of NAC 687B.005 to 687B.140, inclusive, with respect to a specific policy or certificate of long-term care insurance, upon a written finding that:
1. The modification or suspension would be in the best interest of the insureds;
2. The purposes to be achieved would not be effectively or efficiently achieved without the modification or suspension; and
3. One of the following:
(a) The modification or suspension is necessary to the development of an innovative and reasonable approach for insuring long-term care;
(b) The policy or certificate is to be issued to residents of a life care or continuing care retirement community or some other residential community for the elderly, and the modification or suspension is reasonably related to the special needs or nature of that community; or
(c) The modification or suspension is necessary to permit long-term care insurance to be sold as part of, or in conjunction with, another policy of insurance.
(Added to NAC by Comm’r of Insurance, eff. 11-21-88; A 1-4-91)
NAC 687B.050 Organizational requirements. (NRS 679B.130)
1. Before advertising, marketing or offering a policy of group long-term care insurance within this State, the insurer of an association shall file evidence with the Commissioner that it has complied with NAC 679B.036, and that the association has:
(a) At the outset, at least 100 members;
(b) Been organized and maintained in good faith for purposes other than that of obtaining insurance;
(c) Been in active existence for at least 1 year; and
(d) A constitution and bylaws which provide that:
(1) The association holds regular meetings not less than annually to further the purposes of the members;
(2) Except for credit unions, the association collects dues or solicits contributions from members; and
(3) The members have voting privileges and are represented on the governing board and committees.
2. Thirty days after filing the evidence required by subsection 1, the association shall be deemed to satisfy those organizational requirements, unless the Commissioner finds otherwise.
(Added to NAC by Comm’r of Insurance, eff. 11-21-88)
NAC 687B.055 Policies issued in other states. (NRS 679B.130)
1. No policy of group long-term insurance may be offered to a resident of this State under a group policy issued in another state to a group described in subsection 4 of NAC 687B.025, unless this State or another state having statutory and regulatory requirements for long-term care insurance substantially similar to those adopted in this State, has made a determination that those requirements have been met.
2. Before an insurer or similar organization offers group long-term care insurance to a resident of this State pursuant to this section, it shall file with the Commissioner evidence that the group policy or certificate issued pursuant thereto has been approved by a state with similar statutory or regulatory requirements as those adopted in this State.
(Added to NAC by Comm’r of Insurance, eff. 11-21-88)
NAC 687B.060 Right to return individual policies; notice of right. (NRS 679B.130)
1. The holder of an individual policy of long-term care insurance may return the policy within 30 days after its delivery and have the premium refunded if, after examining the policy, he is not satisfied for any reason.
2. An individual policy of long-term care insurance must contain a notice prominently printed on the first page of the policy or attached thereto stating in substance that the policyholder may return the policy within 30 days after its delivery and have the premium refunded if, after examining the policy, he is not satisfied for any reason.
(Added to NAC by Comm’r of Insurance, eff. 11-21-88; A 12-15-94)
NAC 687B.065 Right to return policies issued pursuant to direct-response solicitation; notice of right. (NRS 679B.130)
1. A person insured under a policy of long-term care insurance issued pursuant to a direct-response solicitation may return the policy within 30 days after its delivery and have the premium refunded if, after examining the policy, he is not satisfied for any reason.
2. A policy of long-term care insurance issued pursuant to a direct-response solicitation must have a notice prominently printed on the first page or attached thereto stating in substance that the insured may return the policy within 30 days after its delivery and have the premium refunded if, after examining the policy, he is not satisfied for any reason.
(Added to NAC by Comm’r of Insurance, eff. 11-21-88)
NAC 687B.066 Provision for reinstatement in event of lapse of coverage. (NRS 679B.130)
1. A policy or certificate of long-term care insurance must include a provision which provides that, in the event of a lapse in coverage, coverage will be reinstated if:
(a) The insured provides proof of cognitive impairment;
(b) The insured requests reinstatement of coverage within 5 months of the date of termination of coverage; and
(c) The insured pays any premiums which are past due.
2. For the purposes of subsection 1, the standard of proof of cognitive impairment must not be more stringent than any criteria regarding cognitive impairment used in the policy or certificate to determine eligibility for benefits.
(Added to NAC by Comm’r of Insurance, eff. 12-15-94)
NAC 687B.067 Applications: Questions; required statements; required information for applicants 80 years of age or older. (NRS 679B.130)
1. An application for a policy or certificate of long-term care insurance that is not guaranteed issue must contain clear and unambiguous questions designed to ascertain the condition of the applicant’s health.
2. If an application for a policy or certificate of long-term care insurance contains a question which asks whether the applicant has had medication prescribed by a physician, the applicant must be required to list any medication that has been prescribed. If an insurer knows, or should know, at the time of application that a medication listed by the applicant on the application is directly related to a medical condition for which coverage would otherwise be denied, the insurer shall not later rescind the policy or certificate for that condition.
3. Except for a policy or certificate that is guaranteed issue:
(a) A statement in the following form must be set out conspicuously and in close proximity to the block for the applicant’s signature on an application for a policy or certificate of long-term care insurance:
Caution: If your answers on this application are incorrect or untrue, [Company Name] has the right to deny benefits or rescind your policy.
(b) A statement in substantially the following form must be set out conspicuously on the policy or certificate of long-term care insurance at the time of delivery:
Caution: The issuance of this [policy] [certificate] of long-term care insurance is based upon your responses to the questions on your application. A copy of your [application] [enrollment form] [is enclosed] [was retained by you when you applied]. If your answers are incorrect or untrue, the company has the right to deny benefits or rescind your [policy] [certificate]. The best time to clear up any questions is now, before a claim arises! If, for any reason, any of your answers is incorrect, contact the company at this address: [insert address].
(c) Prior to issuing a policy or certificate of long-term care insurance to an applicant who is at least 80 years old, an insurer shall obtain one of the following:
(1) A report of a physical examination;
(2) An assessment of functional capacity;
(3) An attending physician’s statement; or
(4) Copies of medical records.
(Added to NAC by Comm’r of Insurance, eff. 12-15-94)
NAC 687B.068 Right to copy of application or enrollment form. (NRS 679B.130) An insurer shall deliver a copy of the completed application or enrollment form, whichever is applicable, to the insured no later than at the time of delivery of the policy or certificate of long-term care insurance unless a copy is retained by the applicant at the time of application.
(Added to NAC by Comm’r of Insurance, eff. 12-15-94)
NAC 687B.069 Record of rescissions. (NRS 679B.130) An insurer or other entity selling or issuing benefits for long-term care insurance shall maintain a record of all rescissions of its policies or certificates in this State or in any other state, except those which the insured voluntarily effectuated, and shall, on or before March 1 of each year, furnish this information to the Commissioner in the following format:
RESCISSION REPORTING FORM FOR POLICIES OR
CERTIFICATES OF LONG-TERM CARE INSURANCE
FOR THE STATE OF NEVADA
FOR THE REPORTING YEAR ..........
Company Name: .......................................................................
Address: .......................................................................
.......................................................................
.......................................................................
Phone Number: .......................................................................
Due: March 1 annually
Instructions:
The purpose of this form is to report all rescissions of policies or certificates of long-term care insurance. Those rescissions voluntarily effectuated by an insured are not required to be included in this report. Please furnish one form per rescission.
Date of Date/s
Policy Policy and Name of Policy Claim/s Date of
Form # Certificate # Insured Issuance Submitted Rescission
Detailed reason for rescission:...................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
......................................................................
Signature
......................................................................
Name and Title (please type)
......................................................................
Date
(Added to NAC by Comm’r of Insurance, eff. 12-15-94)
NAC 687B.070 Certificate of insurance: Contents. (NRS 679B.130) A certificate issued pursuant to a policy of group long-term care insurance which is delivered or issued for delivery in this State must include:
1. A description of the principal benefits and coverage provided in the policy;
2. A statement of the principal exclusions, reductions and limitations contained in the policy; and
3. A statement that the group master policy determines governing contractual provisions.
(Added to NAC by Comm’r of Insurance, eff. 11-21-88)
NAC 687B.075 Outline of coverage: Delivery; contents. (NRS 679B.130)
1. An outline of coverage must be delivered to an applicant for a policy or certificate of long-term care insurance at the time of application. In the case of direct-response solicitations, the insurer shall deliver the outline of coverage upon the applicant’s request, or not later than at the time the policy is delivered.
2. The outline of coverage must include:
(a) A description of the principal benefits and coverage provided in the policy;
(b) A statement of the principal exclusions, reductions and limitations contained in the policy;
(c) A statement of the renewal provisions, including any reservation in the policy of a right to change premiums; and
(d) A statement that the outline of coverage is a summary of the policy issued or applied for, and that the policy should be examined to determine governing contractual provisions.
3. The outline of coverage must:
(a) Be a separate and complete document;
(b) Be printed in type no smaller than 10-point;
(c) Not include any material of an advertising nature; and
(d) Contain a statement in substantially the following form, set out conspicuously in the following format:
[COMPANY NAME]
[ADDRESS-CITY & STATE]
[TELEPHONE NUMBER]
LONG-TERM CARE INSURANCE
OUTLINE OF COVERAGE
[Policy Number or Group Master Policy and Certificate Number]
[Except for a policy or certificate that is guaranteed issue, the following statement of caution, or a substantially similar statement, must appear in the outline of coverage.]
Caution: The issuance of this [policy] [certificate] of long-term care insurance is based upon your responses to the questions on your application. A copy of your [application] [enrollment form] [is enclosed] [was retained by you when you applied]. If your answers are incorrect or untrue, the company has the right to deny benefits or rescind your [policy] [certificate]. The best time to clear up any questions is now, before a claim arises! If, for any reason, any of your answers is incorrect, contact the company at this address: [Insert address].
1. This policy is [an individual policy of insurance] [a group policy] which was issued in the [indicate jurisdiction in which policy was issued].
2. PURPOSE OF OUTLINE OF COVERAGE. This outline of coverage provides a very brief description of the important features of the policy. You should compare this outline of coverage to outlines of coverage for other policies available to you. This is not a contract of insurance, but only a summary of coverage. Only the individual or group policy contains governing contractual provisions. This means that the policy or group policy sets forth in detail the rights and obligations of both you and the insurance company. Therefore, if you purchase this coverage, or any other coverage, it is important that you READ YOUR [POLICY] [CERTIFICATE] CAREFULLY!
3. TERMS UNDER WHICH THE [POLICY] [CERTIFICATE] MAY BE CONTINUED IN FORCE OR DISCONTINUED.
(a) [For a policy or certificate of long-term care insurance, describe one of the following permissible provisions regarding renewability of the policy or certificate:
(1) Policies and certificates that are guaranteed renewable must contain the following statement:] RENEWABILITY: THIS [POLICY] [CERTIFICATE] IS GUARANTEED RENEWABLE. This means you have the right, subject to the terms of your [policy] [certificate], to continue this [policy] [certificate] as long as you pay your premiums on time. [Company Name] cannot change any of the terms of your [policy] [certificate] on its own, except that, in the future, IT MAY INCREASE THE PREMIUM YOU PAY.
(2) [Policies and certificates that are noncancellable must contain the following statement:] RENEWABILITY: THIS [POLICY] [CERTIFICATE] IS NONCANCELLABLE. This means that you have the right, subject to the terms of your [policy] [certificate], to continue this [policy] [certificate] as long as you pay your premiums on time. [Company Name] cannot change any of the terms of your [policy] [certificate] on its own and cannot change the premium you currently pay. However, if your [policy] [certificate] contains a feature to protect against inflation where you choose to increase your benefits, [Company Name] may increase your premium at that time for those additional benefits.
(b) [For group coverage, specifically describe the provisions for continuation and conversion applicable to the certificate and group policy.]
(c) [Describe the provisions regarding waiver of premium or state that there are no such provisions.]
(d) [State whether or not the company has a right to change the premium, and if this right exists, describe clearly and concisely each circumstance under which the premium may change.]
4. TERMS UNDER WHICH THE [POLICY] [CERTIFICATE] MAY BE RETURNED AND PREMIUM REFUNDED.
(a) [Provide a brief description of the right to return—the “free look” provision of the policy or certificate.]
(b) [Include a statement whether the policy or certificate contains provisions for a refund or partial refund of the premium upon the death of an insured or surrender of the policy or certificate. If the policy or certificate contains such provisions, include a description of them.]
5. THIS IS NOT MEDICARE SUPPLEMENT COVERAGE. If you are eligible for Medicare, review the Guide to Health Insurance for People with Medicare available from the insurance company.
(a) [For agents] Neither [Company Name] nor its agents represent Medicare, the Federal Government or any state government.
(b) [For direct-response] [Company Name] is not representing Medicare, the Federal Government or any state government.
6. LONG-TERM CARE COVERAGE.
(a) Policies of this category are designed to provide coverage for one or more necessary or medically necessary services related to diagnostic, preventative, therapeutic, rehabilitative, maintenance or personal care, provided in a setting other than an acute care unit of a hospital, such as in a nursing home, in the community or in the home.
(b) This policy provides coverage in the form of a fixed dollar indemnity benefit for covered long-term care expenses, subject to [limitations] [waiting periods] and [requirements regarding coinsurance] set forth in the [policy] [certificate]. [Modify this paragraph if the policy or certificate is not a policy or certificate of indemnity.]
7. BENEFITS PROVIDED BY THIS [POLICY] [CERTIFICATE].
(a) [Describe covered services, related deductible(s), waiting periods, elimination periods and maximums of benefits.]
(b) [Describe institutional benefits, by skill level.]
(c) [Describe noninstitutional benefits, by skill level.]
[Any screening of benefits must be explained in this section. If screens differ for different benefits, an explanation of each screen should accompany a description of each benefit. If an attending physician or other specified person must certify a certain level of functional dependency in order to be eligible for benefits, this too must be specified. If screens or criteria concerning the insured’s activities of daily living are used to measure the insured’s need for long-term care, such criteria or screens must be explained.]
8. LIMITATIONS AND EXCLUSIONS.
[Describe:
(a) Preexisting conditions;
(b) Noneligible facility or provider;
(c) Noneligible levels of care (for example, unlicensed providers, care or treatment provided by a family member);
(d) Exclusions or exceptions; and
(e) Limitations.]
[This section should provide a brief, specific description of any provision in the policy or certificate which limits, excludes, restricts, reduces, delays or in any other manner operates to qualify payment of benefits for one or more necessary or medically necessary services related to diagnostic, preventative, therapeutic, rehabilitative, maintenance or personal care.]
THIS [POLICY] [CERTIFICATE] MAY NOT COVER ALL THE EXPENSES ASSOCIATED WITH YOUR NEEDS FOR LONG-TERM CARE.
9. RELATIONSHIP OF COST OF CARE AND BENEFITS. Because the costs of services related to long-term care will likely increase over time, you should consider whether and how the benefits of this plan may be adjusted. [As applicable, indicate the following:
(a) That the level of benefits will not increase over time;
(b) Any provisions regarding automatic adjustment of benefits;
(c) Whether the insured will be guaranteed the option to buy additional benefits and the basis upon which benefits will be increased over time if not by a specified amount or percentage;
(d) If there is such a guarantee, include whether additional underwriting or screening of health will be required, the frequency and amounts of the options for upgrading and any significant restrictions or limitations; and
(e) Describe whether there will be any additional charge in premiums imposed and if so, how the additional charge will be calculated.]
10. ALZHEIMER’S DISEASE AND OTHER ORGANIC BRAIN DISORDERS. [State whether the [policy] [certificate] provides coverage for an insured clinically diagnosed as having Alzheimer’s disease or a related degenerative and dementing illness. Specifically describe each screening of benefits or other provision in the policy or certificate that provides preconditions to the availability of benefits for such an insured.]
11. PREMIUM.
[(a) State the total annual premium for the policy.
(b) If the premium varies with an applicant’s choice among options of benefits, indicate the portion of annual premium which corresponds to each option of benefits.]
12. ADDITIONAL FEATURES.
[(a) Indicate if medical underwriting is used.
(b) Describe other important features.]
4. Text of the outline of coverage which is capitalized or italicized in the format set out in paragraph (d) of subsection 3 may be emphasized in the outline of coverage by other means which provide prominence equivalent to capitalization or italicizing.
(Added to NAC by Comm’r of Insurance, eff. 11-21-88; A 12-15-94; 5-13-96)
NAC 687B.076 Offer to purchase protection from inflation required. (NRS 679B.130)
1. An insurer shall not offer a policy of long-term care insurance unless the insurer also offers to the policyholder, in addition to any other protection from inflation, the option to purchase a policy that provides for increasing levels of benefits and increasing maximum benefits at reasonable durations which account for reasonably anticipated increases in the costs of services related to long-term care covered by the policy. An insurer shall offer to each policyholder, at the time of purchase, the option to purchase a policy with a feature to protect against inflation that is no less favorable than one of the following:
(a) Increases levels of benefits annually in a manner so that the increases are compounded annually at a rate not less than 5 percent;
(b) Guarantees the insured the right to periodically increase levels of benefits without providing evidence of insurability or status of health so long as the option for the previous period has not been declined. The amount of the additional benefit must be no less than the difference between the existing benefit and that benefit compounded annually at a rate of at least 5 percent for the period beginning with the purchase of the existing benefit and extending until the year in which the offer is made; or
(c) Covers a specified percentage of actual or reasonable charges and does not include a maximum specified amount or limit of indemnity.
2. Except as otherwise provided in subsection 3, if the policy is issued to a group, the insurer shall make the offer required by subsection 1 to the group policyholder.
3. If the policy is issued to a group described in NAC 687B.025, other than to a retirement community which provides continuing care, the insurer shall make the offer required pursuant to subsection 1 to each proposed holder of a certificate.
4. An insurer offering a policy of long-term care insurance shall include the following information in or with the outline of coverage:
(a) A comparison of the levels of benefits of a policy that increases benefits over the policy period with a policy that does not increase benefits. The comparison must be made through the use of graphs and must show the levels of benefits over a period of at least 20 years.
(b) Any expected increases in premiums or additional premiums to pay for automatic or optional increases in benefits.
Ê An insurer may use a reasonable hypothetical for the purpose of complying with the requirements of this subsection.
5. Increases in benefits under a policy which provides for increased benefits to protect against inflation must continue without regard to an insured’s age, status regarding claims or history of claims or the length of time the person has been insured under the policy.
6. An offer of protection against inflation which provides for automatic increases in benefits must include an offer of a premium which the insurer expects to remain constant and must disclose in a conspicuous manner that the premium may change in the future unless the premium is guaranteed to remain constant.
7. A policy or certificate of long-term care insurance must include protection against inflation as provided in subsection 1 unless the insurer obtains a rejection of protection against inflation signed by the policyholder. A rejection must be included as a part of the application and must state:
I have reviewed the outline of coverage and the graphs that compare the benefits and premiums of this policy with and without protection against inflation. Specifically, I have reviewed Plans ........., and I reject protection against inflation.
8. The provisions of this section do not apply to a policy of life insurance or a rider to a policy of life insurance that contains accelerated benefits for long-term care.
(Added to NAC by Comm’r of Insurance, eff. 12-15-94)
NAC 687B.077 Requirements for marketing. (NRS 679B.130) An insurer, health care plan or other entity who markets, directly or through its agents or other producers, long-term care insurance in this State shall:
1. Establish procedures regarding marketing to assure that any comparison of policies by its agents or other producers will be fair and accurate.
2. Establish procedures regarding marketing to assure excessive insurance is not sold or issued.
3. Display prominently by type, stamp or other appropriate means, on the first page of the outline of coverage and policy, a statement in substantially the following form:
“Notice to buyer: This policy may not cover all of the costs associated with long-term care incurred by the buyer during the period of coverage. The buyer is advised to review carefully all limitations in the policy.”
4. Inquire and otherwise make every reasonable effort to identify whether a prospective applicant or enrollee for long-term care insurance already has a policy for accidents and sickness or long-term care insurance and the types and amounts of any such insurance.
5. Establish auditable procedures for verifying compliance with this section.
6. At the time of solicitation, provide a written notice to the prospective policyholder or holder of a certificate:
(a) Informing him of the availability of a program which provides counseling to elderly persons concerning health insurance; and
(b) Providing the name, address and telephone number of the program.
(Added to NAC by Comm’r of Insurance, eff. 12-15-94)
NAC 687B.078 Restriction on use of certain terms in marketing. (NRS 679B.130) An insurer, health care plan or other entity marketing long-term care insurance in this State, directly or through its agents or other producers, shall not use the terms “noncancellable” or “level premium” in reference to a policy or certificate of long-term care insurance unless the policy or certificate provides that the insured may continue the long-term care insurance by the timely payment of premiums during which period the insurer may not unilaterally make any change in any provision of the insurance or in the premium rate.
(Added to NAC by Comm’r of Insurance, eff. 12-15-94)
NAC 687B.079 Prohibition of certain marketing practices. (NRS 679B.130) An insurer, health care plan or other entity marketing long-term care insurance in this State, directly or through its agents or other producers, shall not engage in the following acts or practices:
1. High pressure tactics, including:
(a) Any method of marketing having the effect of or tending to induce the purchase of insurance through force, fright or threat, whether explicit or implied; and
(b) Undue pressure to purchase or recommend the purchase of insurance.
2. Directly or indirectly making use of any method of marketing which fails to disclose in a conspicuous manner that a purpose of the method of marketing is solicitation of insurance and that contact will be made by an insurance agent or insurance company, commonly referred to as “cold lead advertising.”
(Added to NAC by Comm’r of Insurance, eff. 12-15-94)
NAC 687B.080 Definition of terms in policies. (NRS 679B.130) A policy of long-term care insurance delivered or issued for delivery in this State may not use the following terms unless the terms are defined in the policy as follows:
1. “Medicare” must be defined as:
(a) “The Health Insurance for the Aged Act, Title XVIII of the Social Security Amendments of 1965 as Then Constituted or Later Amended”;
(b) “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
(c) Any words of similar import.
2. “Mental or nervous disorder” must not be defined to include more than neurosis, psychoneurosis, psychopathy, psychosis, or a mental or emotional disease or disorder.
3. “Skilled nursing care,” “intermediate care,” “personal care,” “home care” and any other care received must be defined in relation to the level of skill required, the nature of the care and the setting in which the care must be provided.
4. A provider of services, including, but not limited to, a “skilled nursing facility,” “extended care facility,” “intermediate care facility,” “convalescent nursing home,” “personal care facility” or “home care agency” must be defined in relation to the services and facilities required to be available and the level of the licenses or degrees of those persons providing or supervising the services. The definition may require that the provider be appropriately licensed or certified.
5. “Acute condition” must be defined as a condition making a person medically unstable and requiring frequent monitoring of the person by providers of health care, including physicians and registered nurses, in order to maintain his status of health.
6. “Adult day care” must be defined as a program, for six or more persons, of social and health-related services provided during the day in a community group setting for the purpose of supporting frail, impaired, elderly or disabled adults who can benefit from care in a group setting outside the home.
7. “Services related to home health care” must be defined as medical and nonmedical services, provided to ill, disabled or infirm persons in their residences. Covered services may include the services of a homemaker, assistance with activities of daily living and respite care.
8. “Services related to personal care” must be defined as the provision of personal services to assist a person with activities of daily living, including, but not limited to, bathing, eating, dressing and toileting.
(Added to NAC by Comm’r of Insurance, eff. 11-21-88; A 12-15-94)
NAC 687B.085 Terms for renewal of policies. (NRS 679B.130)
1. The terms “guaranteed renewable” and “noncancellable” may not be used in any individual policy of long-term care insurance without further explanatory language conforming to the disclosure requirements of NAC 687B.100.
2. No individual policy of long-term care insurance may contain renewal provisions other than “guaranteed renewable” or “noncancellable.”
3. The term “guaranteed renewable” may be used only when the insured has the right to continue the long-term care insurance by the timely payment of premiums and the insurer has no unilateral rights to make any change in any provision of the policy or rider while the insurance is in force, and cannot decline to renew the policy, except that the rates may be revised by the insurer on a class basis.
4. The term “noncancellable” may be used only when the insured has the right to continue the long-term care insurance by the timely payment of premiums during which period the insurer has no right to unilaterally make any change in any provision of the insurance or in the premium rate.
(Added to NAC by Comm’r of Insurance, eff. 11-21-88; A 12-15-94)
NAC 687B.090 Exclusions from and limitations on coverage. (NRS 679B.130)
1. A policy of insurance may not be delivered or issued for delivery in this State as long-term care insurance if the policy limits or excludes coverage by type of illness, treatment, medical condition or accident, except for:
(a) Preexisting conditions or diseases.
(b) Mental or nervous disorders, except for the exclusion or limitation of benefits on the basis of Alzheimer’s Disease.
(c) Alcoholism and drug addiction.
(d) Any illness, treatment or medical condition arising out of:
(1) A war or an act of war, whether declared or undeclared.
(2) Participation in a felony, riot or insurrection.
(3) Service in the Armed Forces or units auxiliary thereto.
(4) Suicide, attempted suicide or intentionally self-inflicted injury.
(5) Aviation. This exclusion applies only to passengers who do not pay fares.
(e) Treatment provided in a governmental facility, unless otherwise required by law, services for which benefits are available under Medicare or another governmental program, except Medicaid, and treatment received pursuant to any state or federal program for workmens’ compensation, employer’s liability or occupational disease.
(f ) Treatment provided pursuant to any law governing no-fault insurance for motor vehicles.
(g) Services provided by a member of the insured person’s immediate family.
(h) Services for which no charge is normally made in the absence of insurance.
2. This section does not prohibit the exclusion or limitation of coverage by type of provider or territorial limitations.
3. For the purposes of this section, “preexisting condition” means a medical condition of a person for which he has received treatment during the 6 months preceding the effective date of the policy.
(Added to NAC by Comm’r of Insurance, eff. 11-21-88; A 1-11-90; A 1-4-91)
NAC 687B.095 Extension of benefits; continuation or conversion of coverage. (NRS 679B.130)
1. Any termination of long-term care insurance must be without prejudice to any benefits payable for institutionalization if the institutionalization began while the long-term care insurance was in force and continues without interruption after termination.
2. Such an extension of benefits beyond the period the long-term care insurance is in force may be limited to the duration of the benefit period, if any, or to payment of the maximum benefits, and may be subject to any waiting period contained in the policy or any other applicable provision of the policy.
3. An insurer or similar organization issuing a group policy of long-term care insurance shall include in the group policy:
(a) A provision for continuation of coverage; or
(b) A provision for conversion of coverage.
4. A group policy of long-term care insurance which restricts the provision of benefits and services to certain providers or facilities or which contains incentives to use certain providers or facilities may comply with subsection 3 by containing a provision for the continuation of coverage under a policy which provides benefits which are substantially equivalent to the benefits of the existing group policy. The Commissioner shall make a determination as to the substantial equivalency of benefits, and in doing so, may take into consideration the differences between plans with and without managed care, the arrangement of providing benefits under the plans, the availability of service under the plans, the levels of benefits under the plans and the administrative complexity of the plans.
5. As used in this section, “plan with managed care” means an arrangement for health care or assisted living designed to coordinate care of patients or to control costs through a system that provides, at a minimum, for review of the necessity and appropriateness of the allocation of health care resources and services provided or proposed to be provided to an insured, through management of cases or through use of specific networks of providers.
(Added to NAC by Comm’r of Insurance, eff. 11-21-88; A 12-15-94)
NAC 687B.100 Required disclosures. (NRS 679B.130)
1. An individual policy of long-term care insurance must contain a provision for renewability. Such a provision must be appropriately captioned, appear on the first page of the policy, and clearly state the duration, where limited, of renewability and the duration of the term of coverage for which the policy is issued and for which it may be renewed.
2. Except for riders or endorsements by which the insurer effectuates a request made in writing by the insured under an individual policy of long-term care insurance, all riders or endorsements added to an individual policy of long-term care insurance after the date the policy is issued or when the policy is reinstated or renewed, which reduce or eliminate benefits or coverage in the policy must be signed by the insured. After the date the policy is issued, any rider or endorsement which increases benefits or coverage with a concomitant increase in premium during the term of the policy must be agreed to in writing by the insured, unless the increased benefits or coverage are required by law. Where a separate additional premium is charged for benefits provided in connection with riders or endorsements, the premium charged must be set forth in the policy, rider or endorsement.
3. A policy of long-term care insurance which provides for the payment of benefits based on standards described as “usual and customary,” “reasonable and customary” or words of similar import must include a definition and explanation of those terms in its accompanying outline of coverage.
4. If a policy or certificate of long-term care insurance contains any limitations with respect to preexisting conditions, the limitations must appear as a separate paragraph of the policy or certificate and be labeled as “Preexisting Condition Limitations.”
5. If a policy or certificate of long-term care insurance contains any limitations or conditions with respect to eligibility other than those prohibited pursuant to NAC 687B.116, a statement concerning the limitations or conditions must appear as a separate paragraph of the policy or certificate, must be labeled as “Limitations or Conditions on Eligibility for Benefits” and must include a description of the limitations or conditions, including information regarding any required number of days of confinement.
6. If a policy of life insurance or a rider on a policy of life insurance provides accelerated benefits for long-term care, at the time of application for the policy or rider, a statement disclosing that receipt of accelerated benefits may be taxable and that assistance should be sought from a consultant on taxes must be prominently displayed on the first page of the policy or rider and any other related documents. When a request for payment of accelerated benefits is submitted, a copy of the statement disclosing that receipt of accelerated benefits may be taxable and that assistance should be sought from a consultant on taxes must be provided to the insured.
(Added to NAC by Comm’r of Insurance, eff. 11-21-88; A 12-15-94)
NAC 687B.105 Prohibited provisions. (NRS 679B.130) No policy of long-term care insurance may:
1. Be cancelled, nonrenewed or otherwise terminated on the grounds of the age or the deterioration of the mental or physical health of the insured or the holder of the certificate;
2. Contain a provision establishing a new waiting period if existing coverage is converted to or replaced by a new form within the same company, except with respect to an increase in benefits voluntarily selected by the insured or group policyholder; or
3. Provide coverage for skilled nursing care only or provide significantly more coverage for skilled care provided in a facility than coverage for lower levels of care.
(Added to NAC by Comm’r of Insurance, eff. 11-21-88)
NAC 687B.108 Prohibited increases in premiums. (NRS 679B.130) The premium charged to an insured for long-term care insurance must not increase because of:
1. The increasing age of the insured beyond age 65; or
2. The duration the insured has been covered under the policy.
(Added to NAC by Comm’r of Insurance, eff. 12-15-94)
NAC 687B.111 Coverage for preexisting conditions. (NRS 679B.130)
1. A policy or certificate of long-term care insurance, other than a policy or certificate issued to a group described in subsection 1 of NAC 687B.025, may not:
(a) Define “preexisting condition” in a more restrictive manner than as a condition for which medical advice or treatment was recommended by, or received from a provider of health care within the 6 months preceding the effective date of coverage of the insured.
(b) Exclude coverage for a loss or confinement which is the result of a preexisting condition unless the loss or confinement begins within the 6 months following the effective date of coverage of the insured.
2. An insurer may use an application form designed to elicit the complete medical history of an applicant, and, on the basis of the answers on that application, underwrite a policy of insurance in accordance with that insurer’s established underwriting standards. Unless otherwise provided in the policy or certificate, a preexisting condition, regardless of whether it is disclosed on the application, need not be covered until the waiting period described in paragraph (b) of subsection 1 expires. A policy or certificate of long-term care insurance may not exclude or use waivers or riders of any kind to exclude, limit or reduce coverage or benefits for specifically named or described preexisting diseases or physical conditions beyond the waiting period described in that paragraph.
(Added to NAC by Comm’r of Insurance, eff. 11-21-88)
NAC 687B.113 Delivery of shopper’s guide to long-term care insurance. (NRS 679B.130)
1. Except as otherwise provided in this section, a shopper’s guide to long-term care insurance must be furnished to each prospective applicant. In the case of a group policy, the guide may be delivered to the policyholder for distribution to the certificate holders. The guide must be one developed and approved by the Commissioner or must be in the format developed by the National Association of Insurance Commissioners.
2. An agent who is soliciting an application for long-term care insurance in person shall furnish the prospective applicant with the shopper’s guide before giving him an application or enrollment form. In the case of a direct-response solicitation, the shopper’s guide must be furnished upon request, but in any event not later than the time the policy is issued.
3. An insurer who offers a life insurance policy or rider that contains accelerated long-term care benefits is not required to furnish the shopper’s guide, but shall furnish the outline of coverage required by NAC 687B.075 within the time provided by that section.
(Added to NAC by Comm’r of Insurance, eff. 1-4-91)
NAC 687B.114 Responsibilities of professional, trade or occupational association which endorses or sells policies or certificates to members. (NRS 679B.130)
1. A professional, trade or occupational association, as described in subsection 2 of NAC 687B.025, which endorses or sells long-term care insurance to its members, shall educate its members concerning general issues involving long-term care so that its members can make informed decisions regarding the long-term care insurance.
2. The professional, trade or occupational association shall provide objective information regarding policies or certificates of long-term care endorsed or sold by the association and ensure that members of the association receive a complete explanation of the features in the policies or certificates that are being endorsed or sold.
3. The professional, trade or occupational association shall disclose in any solicitation for long-term care insurance:
(a) The specific nature and amount of compensation, including all fees, commissions and other forms of financial support, that the association receives from endorsement or sale of policies or certificates to its members; and
(b) A brief description of the process under which such policies and the insurer issuing such policies were selected.
4. If a professional, trade or occupational association and an insurer have common ownership or management, the association shall disclose that fact to its members.
5. The board of directors of a professional, trade or occupational association which sells or endorses policies or certificates of long-term care insurance shall review and approve the policies and the agreement regarding compensation it receives from endorsement or sale of policies or certificates to its members.
6. A professional, trade or occupational association shall:
(a) Actively monitor the efforts regarding marketing of the insurer and its agents or other producers; and
(b) Review and approve all marketing materials or other communications regarding policies or certificates of long-term care insurance used to promote sales or sent to members.
(Added to NAC by Comm’r of Insurance, eff. 12-15-94)
NAC 687B.115 Filing and certification requirements for insurer issuing policy or certificate to professional, trade or occupational association. (NRS 679B.130)
1. An insurer shall not issue a group policy or certificate of long-term care insurance to a professional, trade or occupational association unless the insurer files with the Division the following material:
(a) The policy or certificate; and
(b) A corresponding outline of coverage.
2. An insurer shall not issue a policy or certificate of long-term care insurance to a professional, trade or occupational association, or continue to market such a policy or certificate, unless the insurer certifies on or before December 31 of each year that the association has complied with the requirements set forth in NAC 687B.114.
3. Failure to comply with the requirements regarding filing and certification contained in this section constitutes an undefined unfair trade practice pursuant to NRS 686A.170.
(Added to NAC by Comm’r of Insurance, eff. 12-15-94)
NAC 687B.116 Limitations on conditioning of benefits. (NRS 679B.130)
1. A policy of long-term care insurance delivered or issued for delivery in this State may not:
(a) Condition any benefit upon the hospitalization of the insured;
(b) Condition any benefit for an insured who is institutionalized upon his receiving a higher level of institutional care; or
(c) Condition any benefit, other than a waiver of premium or benefits for postconfinement care, postacute care or any recuperative benefit, upon the institutionalization of the insured.
2. If a policy conditions coverage for noninstitutional care upon the receipt of institutional care, the required period of institutional care must not exceed 30 days.
(Added to NAC by Comm’r of Insurance, eff. 1-4-91)
NAC 687B.117 Restrictions on limitation or exclusion of benefits. (NRS 679B.130)
1. A policy or certificate of long-term care insurance that provides benefits for services related to home health care or community care must not limit or exclude benefits:
(a) By requiring that the insured or claimant would need care in a skilled nursing facility if services related to home health care were not provided;
(b) By requiring that the insured or claimant first or simultaneously receive nursing or therapeutic services in a home, community or institutional setting before services related to home health care are covered;
(c) By limiting eligible services provided by registered nurses or licensed practical nurses;
(d) By requiring that a nurse or therapist provide services covered by the policy that can be provided by a home health aide, or other licensed or certified person providing home health care acting within the scope of his licensure or certification;
(e) By excluding coverage for services related to personal care provided by a home health aide;
(f ) By requiring that the provision of services related to home health care be at a level of certification or licensure greater than that required by the eligible service;
(g) By requiring that the insured or claimant have an acute condition before services related to home health care are covered;
(h) By limiting benefits to services provided by agencies or providers certified by Medicare; or
(i) By excluding coverage for services related to adult day care.
2. Except as otherwise provided in subsection 3, a policy or certificate of long-term care insurance that provides for services related to home health care or community care must provide total coverage for home health care or community care in an amount equivalent in dollars to at least one-half of 1 year’s benefits for care received in a nursing home pursuant to the coverage available under the policy or certificate at the time covered services related to home health care or community care are being received.
3. The provisions of subsection 2 do not apply to a policy or certificate issued to a resident of a retirement community which provides continuing care.
4. For the purpose of determining the maximum coverage under the terms of the policy or certificate, coverage for home health care may be applied to the benefits provided in the policy or certificate for care other than home health care.
(Added to NAC by Comm’r of Insurance, eff. 12-15-94)
NAC 687B.118 Statement of limitations or conditions upon receipt of benefits. (NRS 679B.130) Each policy of long-term care insurance which provides coverage for postconfinement care, postacute care or recuperative services, and each certificate issued under such a policy, must contain a prominent statement of any limitations or conditions upon these benefits. The statement:
1. Must be contained in a separate paragraph of the policy or certificate entitled “limitations or conditions on benefits”; and
2. Must specify the length in days of any period that the insured is required to be confined in an institution as a condition of receiving these benefits.
(Added to NAC by Comm’r of Insurance, eff. 1-4-91)
NAC 687B.119 Required reserves for policy or rider. (NRS 679B.130)
1. When benefits for long-term care are provided through the acceleration of benefits under a group or an individual policy of life insurance or a rider to that policy, the reserves for the benefits must be determined in accordance with the provisions of paragraph (g) of subsection 2 of NRS 681B.120. Reserves for a claim must also be established when a policy or rider is in claim status.
2. Reserves for policies and riders subject to the provisions of this section must be based on a multiple decrement model using all relevant decrements except those for rates for voluntary termination. An approximation based upon a single decrement model may be used if the calculation produces similar reserves as the multiple decrement model, the reserves are more conservative than the multiple decrement model or the reserves are immaterial. The calculation may take into account the reduction in benefits for life insurance as the result of payment of benefits for long-term care. However, the reserves for the benefit for long-term care and the benefit for life insurance must not be less than the reserves for the benefit for life insurance assuming no benefit for long-term care.
3. In the development and calculation of reserves for policies and riders subject to the provisions of this section, consideration must be given to the applicable provisions of the policy, administrative procedures and all other factors which have an impact on projected costs of claims, including, but not limited to, the following:
(a) Definition of insured events;
(b) Covered facilities for long-term care;
(c) Existence of coverage for convalescent care at home;
(d) Definition of facilities;
(e) Existence or absence of barriers to eligibility;
(f ) Provisions regarding waiver of premiums;
(g) Renewability;
(h) Ability to raise premiums;
(i) Methods of marketing;
( j) Procedures regarding underwriting;
(k) Procedures regarding adjustment of claims;
(l) Waiting periods;
(m) Maximum benefits;
(n) Availability of eligible facilities;
(o) Margins in costs of a claim;
( p) Optional nature of benefits;
(q ) Delay in eligibility for benefits;
(r) Provisions regarding protection against inflation; and
(s) Option of guaranteed insurability.
Ê Any valuation table for morbidity consulted in the development and calculation of reserves must be certified as appropriate as a statutory valuation table by a member of the American Academy of Actuaries.
4. When benefits for long-term care are provided other than by the method described in subsection 1, reserves must be determined using a table that is:
(a) Established by a qualified actuary for the purpose of setting reserves; and
(b) Acceptable to the Commissioner.
5. As used in this section, “multiple decrement model” means a model in which people in a defined status at any age are subject to more than one contingency at the next age.
6. As used in this section, “single decrement model” means a model in which people in a defined status at any age are subject to only one contingency during the next age.
(Added to NAC by Comm’r of Insurance, eff. 12-15-94)
NAC 687B.121 Evaluation of expected loss ratio. (NRS 679B.130) Benefits under an individual policy of long-term care insurance shall be deemed reasonable in relation to premiums charged if the expected loss ratio is at least 60 percent, calculated in a manner which provides for the adequate reserving of the long-term care insurance risk. In evaluating the expected loss ratio, due consideration will be given to all relevant factors, including:
1. The statistical credibility of incurred claims experience and earned premiums;
2. The period for which rates are computed to provide coverage;
3. Experienced and projected trends;
4. The concentration of experience within early policy duration;
5. Expected claim fluctuation;
6. Experience refunds, adjustments or dividends;
7. Renewability features;
8. All appropriate expense factors;
9. Interest;
10. The experimental nature of the coverage;
11. Policy reserves;
12. The mix of business by risk classification; and
13. Product features such as long elimination periods, high deductibles and high maximum limits.
(Added to NAC by Comm’r of Insurance, eff. 11-21-88; A 1-4-91)
NAC 687B.122 General requirements for converted policy. (NRS 679B.130)
1. A written application by an insured for a converted policy must be made, and the first premium due, if any, must be paid as directed by the insurer within 31 days of the date of termination of coverage under a group policy of long-term care insurance. The converted policy must be issued effective on the day following the termination of coverage under the group policy and must be renewable annually.
2. Unless the group policy from which conversion is made replaced previous group coverage, the premium for the converted policy must be calculated on the basis of the insured’s age at inception of coverage under the group policy from which conversion is made. If the group policy from which conversion is made replaced previous group coverage, the premium for the converted policy must be calculated on the basis of the insured’s age at inception of coverage under the initial group policy that was replaced.
3. Upon termination of coverage under a group policy, the insurer shall provide each insured continuation of coverage or shall issue each insured a converted policy unless:
(a) Termination of group coverage resulted from the failure to make any required payment of premium or contribution when due; or
(b) Within 31 days from the date of termination of coverage, the policy is replaced by a group policy:
(1) Effective on the day following the date of termination of coverage.
(2) The premium for which is calculated as set forth in subsection 2.
(3) Providing benefits identical to, or benefits determined by the Commissioner to be substantially equivalent to, or in excess of, those provided by the previous policy.
4. A converted policy may provide that the benefits payable under the converted policy, together with the benefits payable under the group policy from which conversion is made, must not exceed those that would have been payable had the person’s coverage under the group policy remained in force and effect.
5. Notwithstanding any other provision of this section, a converted policy issued to a person who at the time of conversion is covered by another policy or certificate of long-term care insurance which provides benefits on the basis of incurred expenses, may contain a provision which results in a reduction of benefits payable if the benefits provided under the additional coverage, together with the full benefits provided by the converted policy, would result in payment of more than 100 percent of incurred expenses. The provision may be included in the converted policy only if the converted policy also provides for a decrease in the premium or a refund of a part of the premium which reflects the reduction in benefits payable.
6. Notwithstanding any other provision of this section, an insured individual whose eligibility for group long-term care coverage is based upon his relationship to another person is entitled to continuation of coverage under the group policy upon termination of the qualifying relationship by death or dissolution of marriage.
(Added to NAC by Comm’r of Insurance, eff. 12-15-94)
NAC 687B.125 Replacement of policy: Questions on applications. (NRS 679B.130) Application forms for individual policies of long-term care insurance must include the following questions designed to elicit information as to whether the proposed policy is intended to replace any other policy for accidents and sickness or long-term care insurance presently in force:
TO BE COMPLETED BY THE APPLICANT
1. Do you currently have another policy or certificate of long-term care insurance in force (including a contract for health care services or a contract with a health maintenance organization)?
2. Have you had another policy or certificate of long-term care insurance in force during the last 12 months? If so, please answer questions (a) and (b).
(a) With what company was your policy or certificate?
(b) If your policy or certificate lapsed, when did it lapse?
3. Do you currently have coverage under Medicaid?
4. Do you intend to replace any of your current medical or health insurance coverage with this [policy] [certificate]?
TO BE COMPLETED BY THE AGENT
1. Have you sold any other policy of health insurance to this applicant? If so, please answer questions 2 and 3.
2. List each policy you have sold to the applicant that is still in force.
3. List each policy you have sold to the applicant within the past 5 years that is no longer in force.
A supplementary application or other form to be signed by the applicant and the agent containing such questions may be used.
(Added to NAC by Comm’r of Insurance, eff. 11-21-88; A 12-15-94)
NAC 687B.127 Replacement of policy: Waiver of time applicable to preexisting conditions and probationary period; notice to existing insurer. (NRS 679B.130)
1. If a policy or certificate of long-term care insurance replaces another policy or certificate of long-term care insurance, the insurer replacing the policy or certificate shall waive any period of time applicable to preexisting conditions and probationary periods in the new policy or certificate for similar benefits to the extent that similar exclusions have been satisfied under the original policy.
2. Where replacement of the policy or certificate of long-term care insurance is intended, the insurer replacing the policy or certificate shall notify, in writing, the existing insurer of the proposed replacement. The insurer replacing the policy or certificate shall identify the existing policy or certificate by the name of the insurer, the name of the insured and either the number of the policy or certificate or the address of the insured, including the zip code. The written notice must be given not less than 5 working days before the date the application is received by the insurer or the date the policy is issued, whichever is sooner.
(Added to NAC by Comm’r of Insurance, eff. 12-15-94)
NAC 687B.130 Replacement of policy: Notice from insurer not using direct-response solicitation. (NRS 679B.130)
1. Upon determining that a sale will involve the replacement of a policy of insurance, an insurer, other than an insurer using a direct-response solicitation, or its agent, shall furnish the applicant, before the issuance or delivery of the individual policy of long-term care insurance, a notice regarding the replacement of the policy for accidents and sickness or long-term care insurance. One copy of the notice must be retained by the applicant and an additional copy signed by the applicant must be retained by the insurer.
2. The notice required by subsection 1 must be provided in the following form:
NOTICE TO APPLICANT REGARDING REPLACEMENT
OF INDIVIDUAL POLICY FOR ACCIDENTS
AND SICKNESS OR LONG-TERM
CARE INSURANCE
According to [your application] [information you have furnished], you intend to let lapse or otherwise terminate an existing policy for accidents and sickness or long-term care insurance and replace it with an individual policy of long-term care insurance to be issued by [Company Name] Insurance Company. Your new policy provides 30 days within which you may decide, without cost, whether you desire to keep the policy.
You should review this new coverage carefully, comparing it with all insurance coverage you now have for accidents and sickness or long-term care, and terminate your present policy only if, after due consideration, you find that purchase of this coverage for long-term care is a prudent decision. For your own information and protection, you should be aware of and seriously consider the following factors which may affect the protection available to you under the new policy:
1. Health conditions which you may presently have (preexisting conditions), may not be immediately or fully covered under the new policy. This could result in a denial or delay in the payment of benefits under the new policy, whereas a similar claim might have been payable under your present policy.
2. State law provides that your replacement policy or certificate may not contain new preexisting conditions or probationary periods. The insurer will waive any period of time applicable to preexisting conditions or probationary periods in the new policy (or coverage) for similar benefits to the extent such time was spent (depleted) under the original policy.
3. You may wish to secure the advice of your present insurer or its agent regarding the proposed replacement of your present policy. This is not only your right, but it is also in your best interest to make sure you understand all the relevant factors involved in replacing your present coverage.
4. If, after due consideration, you still wish to terminate your present policy and replace it with new coverage, be certain to truthfully and completely answer all questions on the application concerning your medical history. Failure to include all material medical information on an application may provide a basis for the company to deny any future claims and to refund your premium as though your policy had never been in force. After the application has been completed and before you sign it, reread it carefully to be certain that all information has been properly recorded.
................................................................
(Company Name)
(Added to NAC by Comm’r of Insurance, eff. 11-21-88; A 12-15-94)
NAC 687B.135 Replacement of policy: Notice from insurer using direct-response solicitation. (NRS 679B.130)
1. Insurers using a direct-response solicitation shall deliver a notice regarding the replacement of a policy for accidents and sickness or long-term care insurance to the applicant upon issuance of the policy.
2. The notice required by subsection 1 must be provided in the following form:
NOTICE TO APPLICANT REGARDING REPLACEMENT OF POLICY
FOR ACCIDENTS AND SICKNESS OR LONG-TERM
CARE INSURANCE
According to [your application] [information you have furnished], you intend to let lapse or otherwise terminate an existing policy for accidents and sickness or long-term care insurance and replace it with the policy of long-term care insurance delivered with this notice and issued by [Company Name] Insurance Company. Your new policy provides 30 days within which you may decide, without cost, whether you desire to keep the policy. For your own information and protection, you should be aware of and seriously consider the following factors which may affect the protection available to you under the new policy:
1. Health conditions which you may presently have (preexisting conditions), may not be immediately or fully covered under the new policy. This could result in a denial or delay in payment of benefits under the new policy, whereas a similar claim might have been payable under your present policy.
2. State law provides that your replacement policy or certificate may not contain new preexisting conditions or probationary periods. Your insurer will waive any period of time applicable to preexisting conditions or probationary periods in the new policy (or coverage) for similar benefits to the extent such time was spent (depleted) under the original policy.
3. You may wish to secure the advice of your present insurer or its agent regarding the proposed replacement of your present policy. This is not only your right, but it is also in your best interest to make sure you understand all the relevant factors involved in replacing your present coverage.
4. [To be included only if the application is attached to the policy.] If, after due consideration, you wish to terminate your present policy and replace it with new coverage, read the copy of the application attached to our new policy and be sure that all questions are answered fully and correctly. Omissions or misstatements in the application could cause an otherwise valid claim to be denied. Carefully check the application and write to [Company Name and Address] within 30 days if any information is not correct and complete, or if any past medical history has been omitted from the application.
................................................................
(Company Name)
(Added to NAC by Comm’r of Insurance, eff. 11-21-88; A 12-1-94)
NAC 687B.140 Replacement of policy: Restrictions concerning group policies for long-term care. (NRS 679B.130) If a group policy of long-term care insurance is replaced by another group policy of long-term care insurance issued to the same policyholder, the succeeding insurer shall offer coverage to all persons covered under the previous group policy on its date of termination. Coverage provided or offered to an individual by the insurer and the premium charged to persons under the new group policy must not:
1. Result in an exclusion for preexisting conditions that would have been covered under the group policy being replaced; or
2. Vary or otherwise depend on the status of a person’s health or disability, experience with claims or use of services related to long-term care.
(Added to NAC by Comm’r of Insurance, eff. 12-15-94)
POLICIES SUPPLEMENTARY TO MEDICARE
General Provisions
NAC 687B.200 Definitions. (NRS 679B.130, 687B.430) As used in NAC 687B.200 to 687B.330, inclusive, unless the context otherwise requires, the words and terms defined in NAC 687B.201 to 687B.2045, inclusive, have the meanings ascribed to them in those sections.
(Added to NAC by Comm’r of Insurance, 2-21-89, eff. 3-15-89; A 11-16-90; 7-16-92, eff. 7-30-92; 8-2-94; 5-13-96; R110-98, 2-23-99; R075-02, 9-20-2002; R027-04, 8-2-2004; A by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit)
NAC 687B.201 “Applicant” defined. (NRS 679B.130, 687B.430) “Applicant” means:
1. In the case of an individual policy to supplement Medicare, the person who seeks to contract for insurance benefits.
2. In the case of a group policy to supplement Medicare, the proposed certificate holder.
(Added to NAC by Comm’r of Insurance by R110-98, eff. 2-23-99)
NAC 687B.2014 “Certificate” defined. (NRS 679B.130, 687B.430) “Certificate” means any certificate delivered or issued for delivery in this State under a group policy to supplement Medicare.
(Added to NAC by Comm’r of Insurance by R110-98, eff. 2-23-99)
NAC 687B.2015 “Creditable coverage” defined. (NRS 679B.130, 687B.430) “Creditable coverage” has the meaning ascribed to it in NRS 689A.505.
(Added to NAC by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit)
NAC 687B.2018 “Eligible organization” defined. (NRS 679B.130, 687B.430) “Eligible organization” has the meaning ascribed to it in section 1876(b) of the Social Security Act, 42 U.S.C. § 1395mm(b).
(Added to NAC by Comm’r of Insurance by R110-98, eff. 2-23-99)
NAC 687B.202 “Employee welfare benefit plan” defined. (NRS 679B.130, 687B.430) “Employee welfare benefit plan” has the meaning ascribed to it in section 3(1) of the Employee Retirement Income Security Act of 1974, 29 U.S.C. § 1002(1).
(Added to NAC by Comm’r of Insurance by R110-98, eff. 2-23-99)
NAC 687B.2024 “Issuer” defined. (NRS 679B.130, 687B.430) “Issuer” means any insurance company, fraternal benefit society, nonprofit corporation for hospital, medical and dental services or health maintenance organization offering a policy to supplement Medicare which is delivered or issued for delivery in this State.
(Added to NAC by Comm’r of Insurance by R110-98, eff. 2-23-99)
NAC 687B.2028 “Medicare” defined. (NRS 679B.130, 687B.430) “Medicare” means the program of health insurance for aged and disabled persons established pursuant to Title XVIII of the Social Security Act, 42 U.S.C. §§ 1395 et seq.
(Added to NAC by Comm’r of Insurance by R110-98, eff. 2-23-99)
NAC 687B.203 “Medicare Advantage organization” defined. (NRS 679B.130, 687B.430) “Medicare Advantage organization” has the meaning ascribed to it in section 1859(a)(1) of the Social Security Act, 42 U.S.C. § 1395w-28(a)(1).
(Added to NAC by Comm’r of Insurance by R110-98, eff. 2-23-99; A by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit)
NAC 687B.2034 “Medicare Advantage plan” defined. (NRS 679B.130, 687B.430) “Medicare Advantage plan” means a plan of coverage for health benefits under Medicare Part C, as defined in 42 U.S.C. §§ 1395w-28(b)(1), and includes:
1. Coordinated care plans that provide health care services, including, without limitation:
(a) Health maintenance organization plans, with or without a point-of-service provider;
(b) Plans offered by provider-sponsored organizations; and
(c) Preferred provider organization plans;
2. Medical savings account plans that are coupled with a contribution into Medicare Advantage medical savings accounts; and
3. Medicare Advantage private fee-for-service plans.
(Added to NAC by Comm’r of Insurance by R110-98, eff. 2-23-99; A by R075-02, 9-20-2002; A by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit)
NAC 687B.2036 “Medicare Part D” defined. (NRS 679B.130, 687B.430) “Medicare Part D” means the prescription drug benefit created by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, Public Law 108-173, 117 Stat. 2066, December 8, 2003, beginning January 1, 2006.
(Added to NAC by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit)
NAC 687B.2037 “Medicare select issuer” defined. (NRS 679B.130, 687B.430) “Medicare select issuer” has the meaning ascribed to it in NAC 687B.346.
(Added to NAC by Comm’r of Insurance by R110-98, eff. 2-23-99)
NAC 687B.2039 “PACE program” defined. (NRS 679B.130, 687B.430) “PACE program” means the program of all-inclusive care for the elderly established pursuant to section 1894 of the Social Security Act, 42 U.S.C. § 1395eee.
(Added to NAC by Comm’r of Insurance by R075-02, eff. 9-20-2002)
NAC 687B.204 “Policy to supplement Medicare” defined. (NRS 679B.130, 687B.430) “Policy to supplement Medicare” means a group or individual policy of insurance, or a subscriber contract, other than a policy issued pursuant to section 1876 of the Social Security Act, 42 U.S.C. § 1395mm, or pursuant to a demonstration project that is advertised, marketed or designed primarily as a supplement to the reimbursements provided under Medicare for the hospital, medical or surgical expenses of persons eligible for Medicare. The term does not include Medicare Advantage plans established under Medicare Part C, Outpatient Prescription Drug plans established under Medicare Part D, or any Health Care Prepayment Plan (HCPP) that provides benefits pursuant to an agreement under section 1833(a)(1)(A) of the Social Security Act, 42 U.S.C. § 1395l(a)(1)(A).
(Added to NAC by Comm’r of Insurance by R110-98, eff. 2-23-99; A by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit)
NAC 687B.2045 “Standardized benefit plan” defined. (NRS 679B.130, 687B.430) “Standardized benefit plan” means a benefit plan to supplement Medicare that is designated as Standardized Benefit Plan A through L, inclusive, or High Deductible Benefit Plan F or J, as set forth in NAC 687B.300 to 687B.321, inclusive.
(Added to NAC by Comm’r of Insurance by R110-98, eff. 2-23-99; A by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit)
NAC 687B.205 Applicability of provisions. (NRS 679B.130, 687B.430)
1. Except as otherwise provided in NAC 687B.200 to 687B.330, inclusive, the provisions of those sections apply to any:
(a) Policy to supplement Medicare delivered or issued for delivery in this State on or after July 30, 1992.
(b) Certificate.
2. The provisions of NAC 687B.200 to 687B.330, inclusive, do not apply to any policy or contract of one or more employers or labor organizations, or of the trustees of a fund established by one or more employers or labor organizations, or any combination thereof, for employees or former employees, or a combination thereof, or for members or former members, or a combination thereof, of the labor organizations.
(Added to NAC by Comm’r of Insurance, 2-21-89, eff. 3-15-89; A 11-16-90; 7-16-92, eff. 7-30-92; 8-2-94; R110-98, 2-23-99)
NAC 687B.2053 Eligible persons: Description; prohibited actions by insurers. (NRS 679B.130, 687B.430)
1. Eligible persons are those persons described in subsection 3 who seek to enroll under the policy during the period specified in NAC 687B.2056, and who submit evidence of the date of termination, disenrollment or Medicare Part D enrollment with the application for a policy to supplement Medicare.
2. With respect to eligible persons, an issuer shall not deny or condition the issuance or effectiveness of a policy to supplement Medicare described in NAC 687B.2057 that is offered and is available for issuance to new enrollees by the issuer, shall not discriminate in the pricing of such a policy to supplement Medicare because of health status, claims experience, receipt of health care or medical condition, and shall not impose an exclusion of benefits based on a preexisting condition under such a policy to supplement Medicare.
3. An eligible person is a person described in any of the following paragraphs:
(a) The person is enrolled under an employee welfare benefit plan that provides health benefits that supplement the benefits under Medicare, and the plan terminates or the plan ceases to provide all such supplemental health benefits to the person;
(b) The person is enrolled with a Medicare Advantage organization under a Medicare Advantage plan under Medicare Part C, and any of the following circumstances apply, or the person is 65 years of age or older and is enrolled with a PACE program, and there are circumstances similar to those described below that would permit discontinuance of the person’s enrollment with such provider if such person was enrolled in a Medicare Advantage plan:
(1) The certification of the organization or plan has been terminated;
(2) The organization has terminated or otherwise discontinued providing the plan in the area in which the person resides;
(3) The person is no longer eligible to elect the plan because of a change in the person’s place of residence or other change in circumstances specified by the Secretary of Health and Human Services, but not including termination of the person’s enrollment on the basis described in section 1851(g)(3)(B) of the Social Security Act, 42 U.S.C. § 1395w-21(g)(3)(B), where the person has not paid premiums on a timely basis or has engaged in disruptive behavior as specified in standards under section 1856 of the Social Security Act, 42 U.S.C. § 1395w-26, or the plan is terminated for all persons within a residence area;
(4) The person demonstrates, in accordance with guidelines established by the Secretary of Health and Human Services, that:
(I) The organization offering the plan substantially violated a material provision of the organization’s contract under Medicare Part C in relation to the person, including the failure to provide an enrollee on a timely basis medically necessary care for which benefits are available under the plan or the failure to provide such covered care in accordance with applicable quality standards; or
(II) The organization, or agent or other entity acting on the organization’s behalf, materially misrepresented the plan’s provisions in marketing the plan to the person; or
(5) The person meets such other exceptional conditions as the Secretary of Health and Human Services may provide;
(c) The person is enrolled with:
(1) An eligible organization under a contract under section 1876 of the Social Security Act, 42 U.S.C. § 1395mm (Medicare cost);
(2) A similar organization operating under demonstration project authority, effective for periods before April 1, 1999;
(3) An organization under an agreement under section 1833(a)(1)(A) of the Social Security Act, 42 U.S.C. § 1395l(a)(1)(A) (health care prepayment plan); or
(4) An organization under a Medicare Select policy,
Ê and the enrollment ceases under the same circumstances that would permit discontinuance of a person’s election of coverage under paragraph (b);
(d) The person is enrolled under a policy to supplement Medicare and the enrollment ceases because:
(1) Of the insolvency of the issuer or bankruptcy of the nonissuer organization;
(2) Of other involuntary termination of coverage or enrollment under the policy;
(3) The issuer of the policy substantially violated a material provision of the policy; or
(4) The issuer, or an agent or other entity acting on the issuer’s behalf, materially misrepresented the policy’s provisions in marketing the policy to the person;
(e) The person was enrolled under a policy to supplement Medicare and terminates enrollment and subsequently enrolls, for the first time, with any Medicare Advantage organization under a Medicare Advantage plan under Medicare Part C, any eligible organization under a contract under section 1876 of the Social Security Act, 42 U.S.C. § 1395mm (Medicare cost), any similar organization operating under demonstration project authority or any PACE program, and the subsequent enrollment is terminated by the enrollee during any period within the first 12 months of such subsequent enrollment, during which the enrollee is permitted to terminate such subsequent enrollment under section 1851(e) of the Social Security Act, 42 U.S.C. § 1395w-21(e);
(f) The person, upon first becoming eligible for benefits under Medicare Part A at the age of 65 years, enrolls in a Medicare Advantage plan under Medicare Part C or with a PACE program, and disenrolls from the plan or program by not later than 12 months after the effective date of enrollment; or
(g) The person enrolls in a Medicare Part D plan during the initial enrollment period and, at the time of enrollment in Part D, was enrolled under a policy to supplement Medicare that covers outpatient prescription drugs, and the person terminates enrollment in the policy to supplement Medicare and submits evidence of enrollment in Medicare Part D along with the application for a policy described in subsection 5 of NAC 687B.2057.
(Added to NAC by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit)
NAC 687B.2054 Eligible persons: Subsequent enrollment deemed to be initial enrollment under certain circumstances. (NRS 679B.130, 687B.430)
1. In the case of a person described in paragraph (e) of subsection 3 of NAC 687B.2053, or deemed to be so described pursuant to this subsection, whose enrollment with an organization or provider described in paragraph (e) of subsection 3 of NAC 687B.2053 is involuntarily terminated within the first 12 months of enrollment, and who, without an intervening enrollment, enrolls with another such organization or provider, the subsequent enrollment shall be deemed to be an initial enrollment described in paragraph (e) of subsection 3 of NAC 687B.2053.
2. In the case of a person described in paragraph (f) of subsection 3 of NAC 687B.2053, or deemed to be so described pursuant to this subsection, whose enrollment with a plan or in a program described in paragraph (f) of subsection 3 of NAC 687B.2053 is involuntarily terminated within the first 12 months of enrollment, and who, without an intervening enrollment, enrolls in another such plan or program, the subsequent enrollment shall be deemed to be an initial enrollment described in paragraph (f) of subsection 3 of NAC 687B.2053.
3. For purposes of paragraphs (e) and (f) of subsection 3 of NAC 687B.2053, no enrollment of a person with an organization or provider described in paragraph (e) of subsection 3 of NAC 687B.2053, or with a plan or in a program described in paragraph (f) of subsection 3 of NAC 687B.2053, may be deemed to be an initial enrollment under this subsection after the 2-year period beginning on the date on which the person first enrolled with such an organization, provider, plan or program.
(Added to NAC by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit)
NAC 687B.2055 Eligible persons: Notification required upon occurrence of certain events. (NRS 679B.130, 687B.430)
1. At the time of an event described in subsection 3 of NAC 687B.2053 because of which a person loses coverage or benefits because of the termination of a contract or agreement, policy or plan, the organization that terminates the contract or agreement, the issuer terminating the policy or the administrator of the plan being terminated, respectively, shall notify the person of his rights under NAC 687B.2053 to 687B.2057, inclusive, and of the obligations of issuers of policies to supplement Medicare under subsections 1 and 2 of NAC 687B.2053. Such notice must be communicated contemporaneously with the notification of termination.
2. At the time of an event described in subsection 3 of NAC 687B.2053 because of which a person ceases enrollment under a contract or agreement, policy or plan, the organization that offers the contract or agreement, regardless of the basis for the cessation of enrollment, the issuer offering the policy or the administrator of the plan, respectively, shall notify the person of his rights under NAC 687B.2053 to 687B.2057, inclusive, and of the obligations of issuers of policies to supplement Medicare under subsections 1 and 2 of NAC 687B.2053. Such notice must be communicated within 10 working days of the issuer receiving notification of disenrollment.
(Added to NAC by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit)
NAC 687B.2056 Guaranteed issue periods for eligible persons; special enrollment period. (NRS 679B.130, 687B.430)
1. In the case of a person described in paragraph (a) of subsection 3 of NAC 687B.2053, the guaranteed issue period begins on the later of:
(a) The date the person receives a notice of termination or cessation of all supplemental health benefits or, if a notice is not received, notice that a claim has been denied because of a termination or cessation; or
(b) The date that the applicable coverage terminates or ceases,
Ê and ends 63 days thereafter.
2. In the case of a person described in paragraph (b), (c), (e) or (f) of subsection 3 of NAC 687B.2053 whose enrollment is terminated involuntarily, the guaranteed issue period begins on the date that the person receives a notice of termination and ends 63 days after the date the applicable coverage is terminated.
3. In the case of a person described in subparagraph (1) of paragraph (d) of subsection 3 of NAC 687B.2053, the guaranteed issue period begins on the earlier of:
(a) The date that the person receives a notice of termination, a notice of the issuer’s bankruptcy or insolvency, or other such similar notice if any; or
(b) The date that the applicable coverage is terminated,
Ê and ends on the date that is 63 days after the date the coverage is terminated.
4. In the case of a person described in paragraphs (b), (e) and (f), and subparagraphs (2) and (3) of paragraph (d), of subsection 3 of NAC 687B.2053 who disenrolls voluntarily, the guaranteed issue period begins on the date that is 60 days before the effective date of the disenrollment and ends on the date that is 63 days after the effective date.
5. In the case of a person described in paragraph (g) of subsection 3 of NAC 687B.2053, the guaranteed issue period begins on the date the person receives notice pursuant to section 1882(v)(2)(B) of the Social Security Act, 42 U.S.C. § 1395ss(v)(2)(B), from the Medicare supplement issuer during the 60-day period immediately preceding the initial Medicare Part D enrollment period and ends on the date that is 63 days after the effective date of the person’s coverage under Medicare Part D.
6. In the case of a person described in subsection 3 of NAC 687B.2053 but not described in subsections 1 to 5, inclusive, the guaranteed issue period begins on the effective date of disenrollment and ends on the date that is 63 days after the effective date.
7. A special enrollment period is available to persons who postpone enrollment in Medicare Part B until after the age of 65 years because they are working and are enrolled in a group health insurance plan. The special enrollment period for Medicare Part B may take place anytime through their or their spouse’s current employment or during the 8 months following the month that the group health plan coverage of the employer or union ends or when the employment ends, whichever is first.
(Added to NAC by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit)
NAC 687B.2057 Policies to supplement Medicare to which eligible persons are entitled. (NRS 679B.130, 687B.430) The policy to supplement Medicare to which eligible persons are entitled:
1. Under paragraphs (a), (b), (c) and (d) of subsection 3 of NAC 687B.2053 is a policy to supplement Medicare that has a benefit package classified as Plan A, B, C, F (including F with a high deductible), K or L offered by any issuer;
2. Subject to paragraph (e) of subsection 3 of NAC 687B.2053 is the same policy to supplement Medicare in which the person was most recently and previously enrolled, if available from the same issuer or, if not so available, a policy described in subsection 1;
3. After December 31, 2005, if the person was most recently enrolled in a policy to supplement Medicare with an outpatient prescription drug benefit, a policy to supplement Medicare described in this subsection is:
(a) The policy available from the same issuer but modified to remove outpatient prescription drug coverage; or
(b) At the election of the policyholder, an A, B, C, F (including F with a high deductible), K or L policy that is offered by any issuer;
4. Under paragraph (f) of subsection 3 of NAC 687B.2053 shall include any policy to supplement Medicare offered by any issuer; or
5. Under paragraph (g) of subsection 3 of NAC 687B.2053 is a policy to supplement Medicare that has a benefit package classified as Plan A, B, C, F (including F with a high deductible), K or L, and that is offered and is available for issuance to new enrollees by the same issuer that issued the policy to supplement Medicare with outpatient prescription drug coverage.
(Added to NAC by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit)
NAC 687B.206 Eligibility for policy to supplement Medicare offered to new enrollees or for certificate offered to new enrollees following certain disenrollment; required policy or certificate; outpatient prescription drug coverage. (NRS 679B.130, 687B.430)
1. A person is eligible for a policy to supplement Medicare that is offered to new enrollees or for a certificate that is offered to new enrollees if he provides evidence that he disenrolled within the previous 63 days from:
(a) An employee welfare benefit plan that:
(1) Provided health benefits to supplement the benefits provided under Medicare; and
(2) Discontinued providing substantially all such supplemental health benefits to the person.
(b) An employee welfare benefit plan that:
(1) Provided health benefits that were primary to the benefits provided under Medicare; and
(2) Discontinued providing all such health benefits to the person because the employee welfare benefit plan was terminated or the person disenrolled from the employee welfare benefit plan.
(c) A Medicare Advantage plan offered by a Medicare Advantage organization pursuant to Medicare Part C, if the person was allowed to disenroll from the Medicare Advantage plan under any of the following circumstances:
(1) The certification of the organization or the plan has been terminated, or the organization or plan has notified the person of an impending termination of its certification.
(2) The organization has terminated or otherwise discontinued providing the plan in the area in which the person resides, or has notified the person of an impending termination or discontinuance of the plan.
(3) The person was no longer eligible to elect a Medicare Advantage plan because:
(I) His residence changed;
(II) The Medicare Advantage plan was terminated with respect to all persons in the area where the person resided; or
(III) Other circumstances as specified by the Secretary of Health and Human Services changed. Those circumstances do not include terminating the election of the person pursuant to section 1851(g)(3)(B)(i) or (ii) of the Social Security Act, 42 U.S.C. § 1395w-21(g)(3)(B)(i) or (ii).
(4) The person demonstrated in accordance with guidelines established by the Secretary of Health and Human Services that:
(I) The Medicare Advantage organization offering the Medicare Advantage plan substantially violated a material provision of the contract of the Medicare Advantage organization under Medicare Part C with respect to the person, including, without limitation, failing to provide to an enrollee on a timely basis medically necessary care for which benefits are available under the Medicare Advantage plan or failing to provide such care in accordance with applicable quality standards; or
(II) The Medicare Advantage organization, agent or other person acting on behalf of the Medicare Advantage organization made a material misrepresentation of the provisions of the Medicare Advantage plan.
(5) The person met such other exceptional condition as provided by the Secretary of Health and Human Services.
(d) The PACE program if the person is 65 years of age or older and there are circumstances similar to those described in paragraph (c) that would permit discontinuance of the person’s enrollment with the provider if he were enrolled in a Medicare Advantage plan.
(e) If the person disenrolled pursuant to the same circumstances that are required to disenroll from a plan pursuant to paragraph (c), any plan offered by:
(1) An eligible organization that had a risk-sharing contract or a reasonable cost reimbursement contract with the Secretary of Health and Human Services pursuant to section 1876 of the Social Security Act, 42 U.S.C. § 1395mm;
(2) For periods before April 1, 1999, an insurer that operated pursuant to the authority of a demonstration project;
(3) An insurer that had an agreement to provide medical and other health services on a prepaid basis pursuant to section 1833(a)(1)(A) of the Social Security Act, 42 U.S.C. § 1395l(a)(1)(A); or
(4) A Medicare select issuer that had a Medicare select policy.
(f) A policy to supplement Medicare or a certificate, if the person disenrolled from that policy or certificate because:
(1) The insurer filed a voluntary petition in bankruptcy or had an involuntary petition in bankruptcy filed against it and the insurer ceased doing business in this State;
(2) The issuer was adjudicated insolvent by a court of competent jurisdiction in the state of domicile of the issuer;
(3) The insurer involuntarily terminated coverage or enrollment;
(4) The issuer of the policy or certificate substantially violated a material provision of the policy or certificate; or
(5) The issuer, an agent or other person acting on behalf of the issuer made a material misrepresentation of the provisions of the policy or certificate.
2. In lieu of using the date of termination of enrollment for purposes of this section, a person described in paragraph (c) or (d) of subsection 1 may substitute the date on which he was notified by the Medicare Advantage organization of the impending termination or discontinuance of the Medicare Advantage plan offered by the Medicare Advantage organization in the area in which the person resides, but only if the person disenrolls from the plan as a result of that notification. If a person makes the substitution provided in this subsection, the issuer shall accept the application of the person submitted before the date of termination or enrollment, but the coverage under this subsection must become effective only upon termination of coverage under the Medicare Advantage plan involved.
3. A person who is eligible for a policy to supplement Medicare or a certificate pursuant to subsection 1 is entitled to obtain from any issuer a policy to supplement Medicare or a certificate that has a benefit plan that is designated as Standardized Benefit Plan A, B, C, F (including F with a high deductible), K or L.
4. After December 31, 2005, a person currently enrolled in a policy to supplement Medicare with an outpatient prescription drug benefit is eligible to:
(a) Retain their current plan with outpatient prescription drug coverage;
(b) Enroll in a plan from the same issuer that is modified to exclude outpatient prescription drug coverage with the option to select Medicare Part D; or
(c) Enroll in an A, B, C, F (including F with a high deductible), K or L policy that is offered by any issuer with an option to select Medicare Part D.
5. As used in this section, “Medicare select policy” has the meaning ascribed to it in NAC 687B.348.
(Added to NAC by Comm’r of Insurance by R110-98, eff. 2-23-99; A by R075-02, 9-20-2002; A by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit)
NAC 687B.2062 Eligibility for policy to supplement Medicare offered to new enrollees or for certificate offered to new enrollees following certain disenrollment, enrollment and subsequent disenrollment; required policy or certificate. (NRS 679B.130, 687B.430)
1. A person is eligible for a policy to supplement Medicare that is offered to new enrollees or for a certificate that is offered to new enrollees if he provides evidence that he:
(a) Disenrolled from such a policy or certificate;
(b) Subsequently enrolled for the first time in:
(1) A Medicare Advantage plan offered by a Medicare Advantage organization pursuant to Medicare Part C;
(2) A plan offered by an eligible organization, insurer or a Medicare select issuer listed in paragraph (e) of subsection 1 of NAC 687B.206; or
(3) Any PACE program; and
(c) Disenrolled within the previous 63 days from the subsequent plan within 12 months after his enrollment as authorized pursuant to section 1851(e) of the Social Security Act, 42 U.S.C. § 1395w-21(e).
2. A person who is eligible for a policy to supplement Medicare or a certificate pursuant to subsection 1 is entitled to obtain a policy to supplement Medicare or a certificate with the same benefits as his original policy or certificate from the same issuer if the issuer offers the same policy or certificate or, if that policy or certificate is no longer offered, he is entitled to obtain from any issuer a policy to supplement Medicare or a certificate that has a benefit plan that is designated as Standardized Benefit Plan A, B, C, F (including F with a high deductible), K or L.
(Added to NAC by Comm’r of Insurance by R110-98, eff. 2-23-99; A by R075-02, 9-20-2002; A by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit)
NAC 687B.2064 Eligibility for policy to supplement Medicare offered to new enrollees or for certificate offered to new enrollees following certain enrollment and subsequent disenrollment; required policy or certificate. (NRS 679B.130, 687B.430)
1. A person is eligible for a policy to supplement Medicare that is offered to new enrollees or for a certificate that is offered to new enrollees if he provides evidence that he has disenrolled within the previous 63 days from a Medicare Advantage plan offered by a Medicare Advantage organization pursuant to Medicare Part C, or from a PACE program, if he:
(a) Enrolled in that plan or program during the first 6-month period during which he was both 65 years of age or older and was enrolled for benefits under Medicare Part B; and
(b) Disenrolled from the plan or program not later than 12 months after the effective date of enrollment.
2. A person who is eligible for a policy to supplement Medicare or a certificate pursuant to subsection 1 is entitled to obtain from any issuer any policy to supplement Medicare or certificate.
(Added to NAC by Comm’r of Insurance by R110-98, eff. 2-23-99; A by R075-02, 9-20-2002; A by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit)
NAC 687B.2068 Policy to supplement Medicare offered to new enrollees or certificate offered to new enrollees: Prohibition against denial of application, placement of condition on issuance or effectiveness, or discrimination in pricing under certain conditions by issuer. (NRS 679B.130, 687B.430) If an application for a policy to supplement Medicare that is offered to new enrollees or for a certificate that is offered to new enrollees is submitted to an issuer by a person who is eligible for such a policy or certificate pursuant to NAC 687B.206, 687B.2062 or 687B.2064, the issuer shall not deny or condition the issuance or effectiveness of the policy or certificate or discriminate in the pricing of the policy or certificate on the basis of:
1. The health status of the applicant;
2. The claims experience of the applicant;
3. The receipt of health care by the applicant;
4. The medical condition of the applicant; or
5. A preexisting condition of the applicant.
(Added to NAC by Comm’r of Insurance by R110-98, eff. 2-23-99)
NAC 687B.207 Coverage if application is submitted before or during first 6-month period in which person is both 65 years of age or older and enrolled under Medicare Part B; availability of coverage to all qualified applicants. (NRS 679B.130, 687B.430)
1. If an application for a policy to supplement Medicare or a certificate is submitted to an issuer before or during the first 6-month period during which a person is both 65 years of age or older and is enrolled for benefits under Medicare Part B, the issuer may not deny or condition the issuance or effectiveness of the policy or certificate or discriminate in the pricing of the policy or certificate on the basis of:
(a) The health status of the applicant;
(b) The claims experience of the applicant;
(c) The receipt of health care by the applicant; or
(d) The medical condition of the applicant.
2. A policy to supplement Medicare or a certificate which is available from an issuer must be made available to all qualified applicants, regardless of age.
3. Except as otherwise provided in subsection 4, the provisions of subsection 1 do not prevent the exclusion of benefits under a policy to supplement Medicare or a certificate, for the first 6 months, based on a preexisting condition for which the policyholder or certificate holder received treatment or was otherwise diagnosed during the 6 months before the policy or certificate became effective.
4. If an applicant submits an application to an issuer in the manner set forth in subsection 1 and, as of the date on which he submits the application, the applicant has not had a break of more than 63 consecutive days in his creditable coverage and has had an aggregate period of creditable coverage for:
(a) Six months or more, the issuer shall not exclude any benefits based on a preexisting condition of the applicant; or
(b) Less than 6 months, the issuer shall use the method of reduction set forth in 45 C.F.R. § 146.111(a)(1)(iii) to reduce the period of exclusion for a preexisting condition.
5. As used in this section, “creditable coverage” has the meaning ascribed to it in NRS 689A.505.
(Added to NAC by Comm’r of Insurance, 7-16-92, eff. 7-30-92; A 8-2-94; 5-13-96; R110-98, 2-23-99)
NAC 687B.209 Termination of or disenrollment from plan, certificate or policy to supplement Medicare: Requirements for written notification. (NRS 679B.130, 687B.430)
1. Any time a plan, certificate or policy to supplement Medicare is terminated or a person disenrolls from a plan, certificate or policy to supplement Medicare, the issuer, insurer, Medicare Advantage organization, eligible organization or Medicare select issuer that offered the plan, certificate or policy shall provide written notification informing the person that:
(a) He may be entitled to obtain a certificate or a policy to supplement Medicare pursuant to NAC 687B.206, 687B.2062 or 687B.2064; and
(b) The issuer of such a certificate or policy must comply with the provisions of NAC 687B.2068.
2. If the plan, certificate or policy was terminated, the notification required pursuant to subsection 1 must be provided with the notification of termination. If the person disenrolled from the plan, certificate or policy, the notification required pursuant to subsection 1 must be provided within 10 working days after the issuer, insurer, Medicare Advantage organization, eligible organization or Medicare select issuer received notification of the disenrollment.
3. As used in this section, “plan” means:
(a) A Medicare Advantage plan;
(b) An employee welfare benefit plan; or
(c) A plan offered by an eligible organization, insurer or a Medicare select issuer listed in paragraph (e) of subsection 1 of NAC 687B.206.
(Added to NAC by Comm’r of Insurance by R110-98, eff. 2-23-99; A by R075-02, 9-20-2002; A by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit)
NAC 687B.212 Filing and approval of policy forms and certificate forms. (NRS 679B.130, 687B.120, 687B.430)
1. An issuer shall not deliver or issue for delivery in this State a policy to supplement Medicare or a certificate unless the policy form or certificate form has been filed with and approved by the Commissioner pursuant to NRS 687B.120.
2. An issuer shall file any riders or amendments to policy forms or certificate forms to delete outpatient prescription drug benefits as required by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, Public Law 108-173, 117 Stat. 2066, December 8, 2003, with the commissioner in the state in which the policy or certificate was issued.
3. Except as otherwise provided in this subsection, an issuer shall not file for approval more than one policy form or certificate form for each type of policy in a standardized benefit plan to supplement Medicare. An issuer may offer, with the approval of the Commissioner, not more than four additional forms for the same type of policy in a standardized benefit plan to supplement Medicare:
(a) For the inclusion of new or innovative benefits;
(b) For the addition of a direct-response or agent-marketing method;
(c) For the addition of guaranteed issue or underwritten coverage; or
(d) To offer coverage to persons eligible for Medicare because of a disability.
4. For the purposes of this section:
(a) “Type of policy” means an individual or group policy.
(b) A policy issued as a result of any solicitation made by mail or by advertising using the mass media, including any written or broadcasted advertisement, shall be deemed to be an individual policy.
(Added to NAC by Comm’r of Insurance, 7-16-92, eff. 7-30-92; A by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit)
NAC 687B.213 Availability and discontinuance of policy forms and certificate forms. (NRS 679B.130, 687B.120, 687B.430)
1. Except as otherwise provided in subsection 2, an issuer shall make available for sale on or after July 30, 1992, any policy form or certificate form that has been previously approved by the Commissioner. A form shall be deemed available for purchase if the issuer has actively offered it for sale in the previous 12 months.
2. An issuer may discontinue a policy form or certificate form if he notifies the Commissioner in writing at least 30 days before he intends to discontinue the form. The issuer may not offer the form for sale in this State after the notice is received by the Commissioner.
3. If an issuer discontinues a policy form or certificate form, he may not file for approval a new form of the same type as the discontinued form for the same standardized benefit plan to supplement Medicare for 5 years after notice is given to the Commissioner pursuant to subsection 2, unless the Commissioner reduces the period of discontinuance.
4. For the purposes of this section:
(a) The sale or transfer of an issuer’s business for supplementing Medicare to another issuer shall be deemed a discontinuance of a policy form or certificate form.
(b) A change in the rating structure for a policy to supplement Medicare or a certificate shall be deemed a discontinuance of the form for that policy or certificate unless the issuer:
(1) Files with the Commissioner, in a form and manner prescribed by the Commissioner, an actuarial memorandum describing the manner in which the revised rating structure and resultant rates differ from the existing structure and existing rates; and
(2) Does not subsequently put into effect a change of rates or rating factors that cause the percentage differential between the discontinued rates and the new rates as described in the memorandum to change. The Commissioner may approve a change to a percentage differential which is in the public interest.
(Added to NAC by Comm’r of Insurance, 7-16-92, eff. 7-30-92)
NAC 687B.215 Definitions and terms used in policy or certificate. (NRS 679B.130, 687B.430)
1. Each policy to supplement Medicare or certificate advertised, solicited or issued for delivery in this State must contain definitions or terms conforming to the requirements of this section.
2. “Accident,” “accidental injury” or “accidental means” must be defined to employ “result” language and may not include words that establish an accidental means test or use words such as “external,” “violent,” “visible wounds” or similar words of description or characterization. The definition:
(a) May not define the terms more restrictively than as the direct result of an accident, independent of disease or bodily infirmity or any other cause, that occurs while insurance coverage is in force.
(b) Unless prohibited by law, may provide that the terms do not include any injury for benefits which are provided or available under any workers’ compensation, employer’s liability or similar law, or motor vehicle no-fault plan.
3. “Benefit period” or “Medicare benefit period” may not be defined more restrictively than as defined by Medicare.
4. “Convalescent nursing home,” “extended care facility” or “skilled nursing facility” may not be defined more restrictively than as defined by Medicare.
5. “Health care expenses” means the expenses of a health maintenance organization associated with the delivery of services for health care that are analogous to the incurred losses of an issuer.
6. “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 Hospitals. The definition must not be more restrictive than as defined by Medicare.
7. “Medicare” must be defined in the policy and certificate. The term 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 89th 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.
8. “Medicare eligible expenses” means expenses for health care of the kinds covered by Medicare Parts A and B, to the extent recognized as reasonable and medically necessary by Medicare.
9. “Physician” may not be defined more restrictively than as defined by Medicare.
10. Except as otherwise provided in this subsection, “sickness” must not be defined more restrictively than the following:
“Sickness” means an illness or disease of an insured person that first manifests itself after the effective date of insurance and while the insurance is in force.
The definition may be modified to exclude sicknesses or diseases for which benefits are provided under any workers’ compensation, occupational disease, employer’s liability or similar law.
(Added to NAC by Comm’r of Insurance, 2-21-89, eff. 3-15-89; A 7-16-92, eff. 7-30-92; 8-2-94; A by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit)
NAC 687B.220 Exclusions from and limitations on coverage and benefits; duplication of benefits provided by Medicare; benefits for outpatient prescription drugs. (NRS 679B.130, 687B.430)
1. Except as otherwise provided in paragraphs (a) and (b) of subsection 2 of NAC 687B.226 and paragraphs (a) and (b) of subsection 2 of NAC 687B.227, a policy or certificate may not be advertised, solicited or issued for delivery in this State as a policy to supplement Medicare if the policy or certificate contains limitations or exclusions on coverage that are more restrictive than those of Medicare.
2. A policy to supplement Medicare or a certificate must not use a waiver to exclude, limit or reduce coverage or benefits for specifically named or described preexisting diseases or physical conditions.
3. A policy to supplement Medicare or a certificate must not contain benefits that duplicate the benefits provided by Medicare.
4. A policy to supplement Medicare with benefits for outpatient prescription drugs in existence before January 1, 2006, must be renewed for current policyholders who do not enroll in Medicare Part D at the option of the policyholder.
5. A policy to supplement Medicare with benefits for outpatient prescription drugs must not be issued after December 31, 2005.
6. After December 31, 2005, a policy to supplement Medicare 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 drug coverage for expenses of outpatient prescription drugs incurred after the effective date of the person’s coverage under a Medicare 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.
(Added to NAC by Comm’r of Insurance, 2-21-89, eff. 3-15-89; A 11-16-90; 7-16-92, eff. 7-30-92; 8-2-94; A by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit)
NAC 687B.225 Minimum standards for coverage: Policy or certificate advertised, solicited or issued for delivery before July 16, 1992. (NRS 679B.130, 687B.430)
1. A policy of insurance or subscriber contract must not be advertised, solicited or issued for delivery in this State as a policy or certificate to supplement Medicare before July 16, 1992, if it fails to meet the standards established by this section. These are minimum standards and do not preclude the inclusion of other provisions or benefits that are not inconsistent with these standards.
2. A policy to supplement Medicare or a certificate issued for delivery in this State before July 16, 1992, must not:
(a) Deny a claim for losses incurred more than 6 months after the effective date of coverage for a preexisting condition.
(b) Define a preexisting condition more restrictively than as 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.
(c) Indemnify against any loss resulting from sickness on a different basis than for a loss resulting from an accident.
3. A policy to supplement Medicare or a certificate must provide that benefits designed to cover cost-sharing amounts under Medicare will be changed automatically to coincide with any changes in the applicable Medicare deductible amount and copayment percentage factors. Premiums may be modified to correspond with such changes.
4. A “noncancellable,” “guaranteed renewable” or “noncancellable and guaranteed renewable” policy must not:
(a) 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 premiums; or
(b) Be cancelled or denied renewal by the insurer solely on the grounds of deterioration of health.
5. Termination of a policy to supplement Medicare or of a certificate must be without prejudice to any continuous loss that commenced while the policy was in force, but the extension of benefits beyond the period during which the policy was in force may be predicated upon the continuous total disability of the insured, limited to the duration of the policy benefit period, if any, or to payment of the maximum benefits.
6. A policy to supplement Medicare that is subject to the minimum standards adopted pursuant to the Medicare Catastrophic Coverage Act of 1988 must provide at least the following benefits:
(a) Coverage of Medicare Part A eligible expenses for hospitalization to the extent not covered by Medicare from the 61st day through the 90th day in any Medicare benefit period.
(b) Coverage for either all or none of the Medicare Part A inpatient hospital deductible amount.
(c) Coverage of Medicare Part A eligible expenses incurred as daily hospital charges during use of Medicare’s lifetime hospital inpatient reserve days.
(d) Upon exhaustion of all Medicare hospital inpatient coverage, including the lifetime reserve days, coverage of 90 percent of all Medicare Part A eligible expenses for hospitalization that are not covered by Medicare, subject to a lifetime maximum benefit of an additional 365 days.
(e) Coverage under Medicare Part A for the reasonable cost of the first 3 pints of blood, or an equivalent quantity of packed red blood cells, as defined by federal regulations, unless replaced in accordance with federal regulations or already paid for pursuant to Part B. Plans K and L provide for 50 percent and 75 percent coverage of the cost, respectively.
(f) Coverage for the coinsurance amount, or, for services from a hospital outpatient department paid under a prospective payment system, the copayment amount, of Medicare eligible expenses under Part B regardless of hospital confinement, subject to a maximum calendar year out-of-pocket amount that is equal to the Medicare Part B deductible of $124.
(g) Coverage under Medicare Part B for the reasonable cost of the first 3 pints of blood, or equivalent quantities of packed red blood cells, as defined by federal regulations, unless replaced in accordance with federal regulations or already paid for pursuant to Part A, subject to the Medicare deductible amount. Plans K and L provide for 50 percent and 75 percent coverage of the cost, respectively.
7. For the purposes of this section:
(a) “Medicare eligible expenses” means expenses for health care of the kind covered by Medicare, to the extent recognized as reasonable by Medicare. Payment of benefits by an insurer for such expenses may be conditioned upon the same or less restrictive conditions of payment, including determinations of medical necessity, as are applicable to Medicare claims.
(b) “Policy to supplement Medicare” means a group or individual policy of accident and sickness insurance, or a subscriber contract of one or more hospital and medical service associations or health maintenance organizations, that is advertised, marketed or designed primarily as a supplement to the reimbursement provided under Medicare for the hospital, medical or surgical expenses of one or more persons eligible for Medicare by reason of age.
(Added to NAC by Comm’r of Insurance, 2-21-89, eff. 3-15-89; A 11-16-90; 7-16-92; 8-2-94; R075-02, 9-20-2002; A by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit)
NAC 687B.226 Minimum standards for coverage: Policy or certificate advertised, solicited, delivered, issued for delivery or renewed on or after July 16, 1992, and before July 30, 1992. (NRS 679B.130, 687B.430)
1. A policy or certificate must not be advertised, solicited, originally delivered or issued for delivery, or renewed in this State as a policy or certificate to supplement Medicare on or after July 16, 1992, and before July 30, 1992, if it fails to meet or exceed the minimum standards established by this section. These standards do not preclude the inclusion of other provisions or benefits that are not inconsistent with these standards.
2. A policy to supplement Medicare or a certificate originally delivered or issued for delivery, or renewed, in this State on or after July 16, 1992, and before July 30, 1992, must not:
(a) Exclude or limit benefits for losses incurred more than 6 months after the effective date of coverage because of a preexisting condition.
(b) Define a preexisting condition more restrictively than as 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.
(c) Indemnify against any loss resulting from sickness on a different basis than for a loss resulting from an accident.
3. A policy to supplement Medicare or a certificate must provide that benefits designed to cover cost-sharing amounts under Medicare will be changed automatically to coincide with any changes in the applicable Medicare deductible amount and copayment percentage factors. Premiums may be modified to correspond with such changes.
4. A “noncancellable,” “guaranteed renewable” or “noncancellable and guaranteed renewable” policy must not:
(a) 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 premiums; or
(b) Be cancelled or denied renewal by the insurer solely on the grounds of deterioration of health.
5. Except as otherwise authorized by the Commissioner, an issuer shall not cancel or refuse to renew a policy to supplement Medicare or a certificate for any other reason than the nonpayment of premiums or for a material misrepresentation.
6. If a group policy to supplement Medicare or a certificate is terminated by the group policyholder and is not replaced as provided in subsection 8, the issuer shall offer to each certificate holder:
(a) An individual policy to supplement Medicare currently offered by the issuer that provides comparable benefits to those contained in the terminated policy; or
(b) An individual policy to supplement Medicare that provides only those benefits as are required by NAC 687B.290.
7. If a certificate holder is provided coverage under a group policy to supplement Medicare or a certificate and he terminates his membership in the group, the issuer shall:
(a) Offer the certificate holder an individual policy to supplement Medicare pursuant to subsection 6; or
(b) At the request of the group policyholder, continue coverage for the certificate holder under the group policy to supplement Medicare.
8. If a group policy to supplement Medicare or a certificate is replaced by another group policy to supplement Medicare or another certificate which is purchased by the same person, the issuer of the replacement policy or certificate shall offer coverage to all persons who are covered under the policy or certificate that is being replaced on the date it is terminated. The replacement policy or certificate may not provide for the exclusion of coverage for preexisting conditions that were covered under the policy or certificate that is being replaced.
9. Termination of a policy to supplement Medicare or of a certificate must be without prejudice to any continuous loss that commenced while the policy was in force, but the extension of benefits beyond the period during which the policy was in force may be predicated upon the continuous total disability of the insured, limited to the duration of the policy benefit period, if any, or to payment of the maximum benefits. Receipt of Medicare Part D benefits will not be considered in determining a continuous loss.
10. If a policy to supplement Medicare eliminates an outpatient prescription drug benefit as a result of requirements imposed by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, Public Law 108-173, 117 Stat. 2066, December 8, 2003, the modified policy shall be deemed to satisfy the guaranteed renewal requirements of this section.
11. A policy to supplement Medicare that is subject to the minimum standards must provide at least the following benefits:
(a) Coverage of Medicare Part A eligible expenses for hospitalization to the extent not covered by Medicare from the 61st day through the 90th day in any Medicare benefit period.
(b) Coverage for either all or none of the Medicare Part A inpatient hospital deductible amount.
(c) Coverage of Medicare Part A eligible expenses incurred as daily hospital charges during use of Medicare’s lifetime hospital inpatient reserve days.
(d) Upon exhaustion of all Medicare hospital inpatient coverage, including the lifetime reserve days, coverage of 90 percent of all Medicare Part A eligible expenses for hospitalization that are not covered by Medicare, subject to a lifetime maximum benefit of an additional 365 days.
(e) Coverage under Medicare Part A for the reasonable cost of the first 3 pints of blood, or an equivalent quantity of packed red blood cells, as defined by federal regulations, unless replaced in accordance with federal regulations or already paid for pursuant to Part B. Plans K and L provide for 50 percent and 75 percent of the cost, respectively.
(f) Coverage for the coinsurance amount, or, for services from a hospital outpatient department paid under a prospective payment system, the copayment amount, of Medicare eligible expenses under Part B regardless of hospital confinement, subject to a maximum calendar year out-of-pocket amount that is equal to the Medicare Part B deductible of $124. This coverage must include coverage for Medicare eligible expenses for drugs used by an outpatient for immune suppressive therapy.
(g) Coverage under Medicare Part B for the reasonable cost of the first 3 pints of blood, or equivalent quantities of packed red blood cells, as defined by federal regulations, unless replaced in accordance with federal regulations or already paid for pursuant to Part A, subject to the Medicare deductible amount. Plans K and L provide for 50 percent and 75 percent of the coverage of the cost, respectively.
(Added to NAC by Comm’r of Insurance, eff. 7-16-92; A by R075-02, 9-20-2002; A by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit)
NAC 687B.227 Policy or certificate advertised, solicited, delivered or issued for delivery or renewed on or after July 30, 1992: General requirements. (NRS 679B.130, 687B.430)
1. A policy or certificate must not be advertised, solicited, originally delivered or issued for delivery, or renewed in this State as a policy or certificate to supplement Medicare on or after July 30, 1992, if it fails to comply with the requirements set forth in this section.
2. A policy to supplement Medicare or a certificate originally delivered or issued for delivery, or renewed, in this State on or after July 30, 1992, must not:
(a) Exclude or limit benefits for losses incurred more than 6 months after the effective date of coverage because of a preexisting condition.
(b) Define a preexisting condition more restrictively than as a condition for which medical advice was given or treatment recommended by or received from a physician during the 6 months immediately preceding the effective date of coverage.
(c) Indemnify against any loss resulting from sickness on a different basis than for a loss resulting from an accident.
3. A policy to supplement Medicare or a certificate must provide that benefits designed to cover cost-sharing amounts under Medicare will be changed automatically to coincide with any changes in the applicable Medicare deductible amount and copayment percentage factors. Premiums may be modified to correspond with such changes.
4. A policy to supplement Medicare or a certificate must not provide for the termination of coverage of a spouse solely because of the occurrence of an event specified for the termination of coverage for the insured, other than the nonpayment of premiums.
5. A policy to supplement Medicare or a certificate must be guaranteed renewable. The issuer may not cancel or refuse to renew the policy or certificate solely because of the health of the insured or for any other reason than the nonpayment of premiums or for a material misrepresentation.
6. Termination of a policy to supplement Medicare or a certificate must be without prejudice to any continuous loss that commenced while the policy was in force, but the extension of benefits beyond the period during which the policy was in force may be predicated upon the continuous total disability of the insured, and limited to the duration of the policy benefit period, if any, or to the payment of the maximum benefits. Receipt of Medicare Part D benefits will not be considered in determining a continuous loss.
7. Benefits and premiums must be suspended at the request of the policyholder or certificate holder for the period, not to exceed 24 months, during which the holder has applied for and is determined to be eligible for medical assistance under Title XIX of the Social Security Act, 42 U.S.C. §§ 1396 et seq., if the holder notifies the issuer of the policy or certificate within 90 days after the date he becomes eligible for such assistance.
8. If benefits and premiums are suspended pursuant to subsection 7 and the policyholder or certificate holder loses his eligibility for assistance under Title XIX of the Social Security Act, 42 U.S.C. §§ 1396 et seq., the policy to supplement Medicare or the certificate must be automatically reinstated effective as of the date the holder is no longer eligible for assistance if he:
(a) Gives notice of his loss of eligibility to the issuer within 90 days; and
(b) Pays the premium attributable to his period of eligibility.
9. Benefits and premiums must be suspended at the request of the policyholder or certificate holder for any period that may be provided by federal regulation, during which the holder is entitled to benefits under section 226(b) of the Social Security Act, 42 U.S.C. § 426, and is covered under a group health plan, as that term is defined in section 1862(b)(1)(A)(v) of the Social Security Act, 42 U.S.C. § 1395y(b)(1)(A)(v). If benefits and premiums are suspended pursuant to this subsection and the policyholder or certificate holder loses coverage under the group health plan, the policy to supplement Medicare or the certificate must be automatically reinstated effective as of the date of loss of coverage if the policyholder or certificate holder provides notice of loss of coverage within 90 days after the date of the loss.
10. If a policy to supplement Medicare or a certificate is reinstated pursuant to subsection 8 or 9:
(a) A waiting period for the treatment of any preexisting condition must not be required;
(b) The coverage provided must be substantially equivalent to the coverage in effect before the benefits and premiums were suspended; and
(c) The terms for the classification of premiums must be at least as favorable to the policyholder or certificate holder as the terms in effect before the benefits and premiums were suspended.
(Added to NAC by Comm’r of Insurance, 7-16-92, eff. 7-30-92; A 5-13-96; R075-02, 9-20-2002; A by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit)
NAC 687B.229 Filing and approval of rates, rating schedule and supporting documentation required. (NRS 679B.130, 687B.430) An issuer shall not use or change the premium rates for a policy to supplement Medicare or a certificate unless the rates, rating schedule and supporting documentation have been filed with and approved by the Commissioner.
(Added to NAC by Comm’r of Insurance, 7-16-92, eff. 7-30-92)
NAC 687B.230 Rates: Standards for ratios of loss; filing requirements; adjustments; hearing on certain requested increases. (NRS 679B.130, 687B.120, 687B.430)
1. A policy to supplement Medicare or a certificate must not be delivered or issued for delivery in this State unless the policy form or certificate form can be expected, as estimated for the entire period for which rates are computed to provide coverage, to return to the policyholder or certificate holder the following amounts in the form of aggregate benefits provided under the policy, not including anticipated refunds or credits:
(a) In the case of a group policy, at least 75 percent of the aggregate amount of premiums earned.
(b) In the case of an individual policy, at least 65 percent of the aggregate amount of premiums earned. For the purposes of this paragraph, a policy issued as a result of any solicitation made by mail or by advertising using the mass media, including any written or broadcasted advertisement, shall be deemed to be an individual policy.
Ê The aggregate benefits must be calculated on the basis of incurred claims experience or incurred expenses for health care if coverage is provided by a health maintenance organization on the basis of payments made to the provider of health care rather than reimbursements made to the insured, and must be calculated in accordance with accepted actuarial principles and practices. Incurred health care expenses where coverage is provided by a health maintenance organization must not include:
(1) Home office and overhead costs;
(2) Advertising costs;
(3) Commissions and other acquisition costs;
(4) Taxes;
(5) Capital costs;
(6) Administrative costs; and
(7) Claims processing costs.
2. All filings of rates and rating schedules must demonstrate that expected claims in relation to premiums comply with the requirements of this section when combined with actual experience as of the date of the filing. Filing of revisions of rates must also demonstrate that the anticipated loss ratio during the period for which the revised rates are computed can be expected to meet the appropriate standards for the loss ratio.
3. Each issuer providing a policy to supplement Medicare or a certificate in this State shall file annually with the Division its rates, rating schedule and supporting documentation, including ratios of incurred losses to earned premiums by policy duration, for approval by the Commissioner. The supporting documentation must:
(a) Demonstrate in accordance with actuarial standards of practice using reasonable assumptions that the appropriate standards for loss ratios can be expected to be met during the entire period for which the rates are computed; and
(b) Exclude active life reserves.
Ê An expected third-year loss ratio that is greater than or equal to the applicable percentage must be demonstrated for policies to supplement Medicare or certificates in force less than 3 years.
4. As soon as practicable before the effective date of any enhancements to Medicare benefits, every issuer shall file with the Division in accordance with NRS 687B.120:
(a) Appropriate adjustments of premiums necessary to produce loss ratios as anticipated for the current premiums for the applicable policies or certificates, together with such supporting documents as are necessary to justify the adjustment; and
(b) Any appropriate riders, endorsements or policy forms needed to accomplish the modifications to the policy to supplement Medicare or the certificate which are necessary to eliminate any duplication of Medicare benefits. Any such riders, endorsements or policy forms must provide a clear description of the benefits to supplement Medicare that are provided by the policy or certificate.
5. An issuer shall make such adjustments to premiums pursuant to paragraph (a) of subsection 4 as are necessary to produce an expected loss ratio that conforms to the minimum standards for loss ratios for policies to supplement Medicare or certificates which are expected to result in a loss ratio that is at least as great as the ratio originally anticipated for the rates used by the issuer to calculate current premiums for the policy to supplement Medicare or the certificate. An adjustment to premiums which modifies the loss ratio, other than an adjustment made pursuant to this section, may not be made at any time other than upon the renewal of the policy or certificate or its anniversary date. If an issuer makes an adjustment to premiums which is not acceptable to the Commissioner, the Commissioner may order an adjustment to premiums, a refund or a credit which he deems necessary to achieve the loss ratio required by this section.
6. The Commissioner may conduct a hearing to obtain information concerning a request submitted by an issuer for an increase in the rates for a policy to supplement Medicare or a certificate if the experience incurred during the reporting period does not comply with the applicable standard for loss ratios. The Commissioner will determine whether the experience complies with the applicable standard without considering any refund or credit required for the reporting period.
7. The provisions of this section apply to any policy to supplement Medicare or any certificate delivered or issued for delivery in this State, regardless of the date of its delivery or issuance.
(Added to NAC by Comm’r of Insurance, 2-21-89, eff. 3-15-89; A 11-16-90; 5-27-92; 7-16-92, eff. 7-30-92; A by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit)
NAC 687B.235 Calculation and payment of refunds and credits. (NRS 679B.130, 687B.430)
1. An issuer shall collect and file with the Commissioner by May 31 of each year the data contained in the reporting form prescribed by the Commissioner for each type of policy in a standardized benefit plan to supplement Medicare. The appropriate reporting form may be obtained from the Office of the Commissioner.
2. If, on the basis of the experience reported, the loss ratio since inception, commonly referred to as ratio 1, exceeds the loss ratio adjusted for experience incurred since inception, commonly referred to as ratio 3, a refund or credit must be calculated. The refund must be calculated on a statewide basis for each type of policy in a standardized benefit plan to supplement Medicare. To calculate the refund or credit, experience incurred for:
(a) Policies to supplement Medicare issued within the reporting year must be excluded.
(b) All policy forms and certificate forms of the same type in a standardized benefit plan to supplement Medicare must be combined.
(c) A policy form or certificate form assumed pursuant to an agreement to assume reinsurance must not be combined with the experience incurred for other forms.
3. An issuer shall pay a refund or credit to the policyholder or certificate holder if the loss ratio since inception exceeds the loss ratio adjusted for experience incurred since inception and the amount to be refunded or credited is not de minimis.
4. An issuer shall calculate the refund or credit due on policies or certificates issued before July 16, 1992, on an individual basis, by using the combined loss ratios of all individual policies, including all group policies subject to an individual loss ratio standard when issued and all other group policies combined for experience after May 13, 1996.
5. A refund or credit must include interest from the end of the calendar year to the date of the refund or credit at a rate specified by the Secretary of Health and Human Services, but in no event may the rate be less than the average rate of interest for 13-week United States treasury notes.
6. Any refund or credit made against premiums due must be made by September 30th following the year of experience upon which the refund or credit is based.
7. The provisions of this section apply to any policy to supplement Medicare or certificate delivered or issued for delivery in this State, regardless of the date of its delivery or issuance.
(Added to NAC by Comm’r of Insurance, 2-21-89, eff. 3-15-89; A 11-16-90; 7-16-92, eff. 7-30-92; 8-2-94; 5-13-96)
NAC 687B.240 Provision for renewal or continuation; acceptance of riders and endorsements; prohibited standards for payment of benefits; disclosure and dissemination of information. (NRS 679B.130, 687B.430)
1. Each policy to supplement Medicare or certificate must include a renewal or continuation provision. The language or specifications of the provision must be consistent with the type of contract issued. The provision must:
(a) Be captioned appropriately;
(b) Appear on the first page of the policy;
(c) Include any reservation by the issuer to change premiums; and
(d) Include any automatic increases in premiums at the time of renewal which are based on the age of the policyholder.
2. Except for riders or endorsements by which the issuer:
(a) Effectuates a request made in writing by the insured;
(b) Exercises a specifically reserved right under a policy to supplement Medicare; or
(c) Is required to reduce or eliminate benefits to avoid a duplication of benefits provided by Medicare,
Ê any rider or endorsement added to a policy to supplement Medicare after the date of its issue, or upon reinstatement or renewal, which reduces or eliminates benefits or coverage provided by the policy, requires a signed acceptance by the insured. After the date the policy or certificate is issued, any rider or endorsement that increases benefits or coverage with a concomitant increase in premiums during the term of the policy must be agreed to in writing signed by the insured, unless the benefits are required by the minimum standards for such policies to supplement Medicare, or if the increased benefits or coverage are required by law. If an additional premium is charged for benefits provided in connection with riders or endorsements, that premium must be set forth in the policy.
3. A policy to supplement Medicare or a certificate must not provide for the payment of benefits based upon standards described as “usual and customary,” “reasonable and customary” or words of similar import.
4. If a policy to supplement Medicare or a certificate contains any limitations with respect to preexisting conditions, those limitations must appear as a separate paragraph of the policy and must be labeled “limitations for preexisting conditions.”
5. Each policy to supplement Medicare or certificate must contain a notice, prominently printed on its first page or attached to that page, stating in substance that the policyholder or certificate holder is entitled to return the policy or certificate within 30 days after its delivery and to have the premium refunded if, after examination of the policy or certificate, the policyholder or certificate holder is not satisfied for any reason.
6. An issuer of an accident or sickness policy or certificate providing hospital or medical expense coverage on an expense incurred or indemnity basis to a person eligible for Medicare shall provide to all applicants a guide which must be entitled Guide to Health Insurance for People with Medicare and which:
(a) Uses the language, format, type size, proportional spacing, bold type and line spacing developed jointly by the National Association of Insurance Commissioners and the Centers for Medicare & Medicaid Services; and
(b) Is in not less than 12-point type.
Ê The Guide to buyers required by this subsection must be delivered whether or not the policy or certificate is advertised, solicited or issued as a policy or certificate to supplement Medicare. Except as otherwise provided in this subsection, delivery of the Guide must be made to the applicant at the time of application. An acknowledgment of receipt of the Guide must be obtained by the issuer. Direct response issuers shall deliver the Guide to the applicant upon request but not later than at the time the policy is delivered.
(Added to NAC by Comm’r of Insurance, 2-21-89, eff. 3-15-89; A 11-16-90; 7-16-92, eff. 7-30-92; 5-13-96; R075-02, 9-20-2002)
NAC 687B.243 Lapse of policy to supplement Medicare or certificate for nonpayment of premium: Notice required before termination of policy or certificate. (NRS 679B.130, 687B.430)
1. An issuer may not terminate a policy to supplement Medicare or certificate advertised, solicited or issued for delivery in this State based on the lack of payment of the premium on or before the date the premium is required to be paid, unless the insured and each person designated by the insured pursuant to NAC 687B.245 has received a notice sent by the issuer stating that the policy has lapsed and may be terminated for nonpayment of the premium.
2. For the purposes of this section, the notice:
(a) Must be sent by first-class mail, postage prepaid, and addressed to the person at his last known address.
(b) Shall be deemed to have been received by the insured or the person designated by the insured pursuant to NAC 687B.245 on the fifth day after the date on which the issuer mails the notice.
(Added to NAC by Comm’r of Insurance by R027-04, eff. 8-2-2004)
NAC 687B.245 Lapse of policy to supplement Medicare or certificate for nonpayment of premium: Designation of person to receive notice of lapse or waiver of designation. (NRS 679B.130, 687B.430)
1. An issuer shall not issue a policy to supplement Medicare or certificate advertised, solicited or issued for delivery in this State until the issuer has received from the applicant a designation of one or more persons to receive notice of lapse or a waiver pursuant to subsection 2.
2. Each applicant shall submit to the issuer of the policy to supplement Medicare or the certificate:
(a) A written designation of one or more persons other than the applicant to receive notice from the issuer that the policy to supplement Medicare or the certificate has lapsed and may be terminated for nonpayment of a premium; or
(b) A written waiver which is dated and signed by the applicant and which:
(1) Indicates that the applicant does not wish to designate any person other than the applicant to receive notice that the policy to supplement Medicare or the certificate has lapsed and may be terminated for nonpayment of a premium; and
(2) Includes the statement required pursuant to subsection 4.
3. The form provided by an issuer for making a designation pursuant to paragraph (a) of subsection 2 must provide space clearly designated for listing at least one person to receive notice. A designation made pursuant to paragraph (a) of subsection 2:
(a) Must include the full name and address of the person designated; and
(b) Does not constitute acceptance by the person designated of any liability for services provided to the applicant.
4. A waiver submitted pursuant to paragraph (b) of subsection 2, must contain the following statement:
Protection Against Unintended Lapse
I understand that I have the right to designate at least one person other than myself to receive notice of lapse of this policy to supplement Medicare or certificate for nonpayment of a premium. I elect NOT to designate a person to receive this notice.
5. An issuer shall, at least once every 2 years, notify an insured of his right to make or change a written designation pursuant to subsection 2.
(Added to NAC by Comm’r of Insurance by R027-04, eff. 8-2-2004)
NAC 687B.247 Lapse of policy to supplement Medicare or certificate for nonpayment of premium: Provision for reinstatement of coverage. (NRS 679B.130, 687B.430) A policy to supplement Medicare or certificate advertised, solicited or issued for delivery in this State must include a provision which provides that, in the event of a lapse in coverage of the policy or certificate for nonpayment of a premium, coverage will be reinstated if:
1. Reinstatement is requested within 2 months after the date of lapse of coverage; and
2. Proof of cognitive impairment or loss of functional capacity of the insured before the lapse of coverage or the expiration of any grace period contained in the policy to supplement Medicare or the certificate is provided to the issuer.
(Added to NAC by Comm’r of Insurance by R027-04, eff. 8-2-2004)
NAC 687B.250 Outline of coverage; assistance in understanding health insurance. (NRS 679B.130, 687B.430)
1. Each issuer shall provide an outline of coverage to each applicant at the time the application is presented to the applicant and, except in the case of a direct response policy, shall obtain an acknowledgment from the applicant that he has received the outline.
2. If an outline of coverage is provided at the time of application and the policy to supplement Medicare or the certificate is issued on a basis that would require revision of the outline, a substitute outline of coverage properly describing the policy or certificate must accompany the policy or certificate when it is delivered. The substitute outline must contain the following statement, in not less than 12-point type, immediately above the name of the company:
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.
3. The outline of coverage provided to the applicant must consist of:
(a) A cover page;
(b) Information regarding premiums;
(c) Disclosure pages; and
(d) Charts displaying the features of each benefit plan offered by the issuer as set forth in subsection 7.
4. Standardized Benefit Plans A through L, inclusive, and High Deductible Benefit Plans F and J, must be shown on the cover page and the plans offered by the issuer must be prominently identified.
5. Information regarding premiums for benefit plans to supplement Medicare offered by the issuer must be shown on the cover page or immediately following the cover page and must be prominently displayed. The premium and mode must be stated for all plans that are offered to the applicant. All possible premiums must be illustrated.
6. An insured may contact the Commissioner of Insurance or the Nevada State Health Insurance Assistance Program (SHIP) of the Aging Services Division of the Department of Health and Human Services for help in understanding his health insurance.
7. The outline of coverage must be printed in not less than 12-point type, using the following language and format:
(COMPANY NAME)
Outline of Medicare Supplement Coverage - Cover Page:
Benefit Plan(s)___ [insert letter(s) of plan(s) being offered]
This chart shows the benefits included in each of the Standard Medicare Supplement Plans.
Every company must make available Plan “A.”
See Outlines of Coverage sections for details about ALL plans.
Basic Benefits for Plans A-J, inclusive:
Hospitalization: Part A coinsurance plus coverage for 365 additional days after Medicare benefits end.
Medical Expenses: Part B coinsurance (generally 20% of Medicare-approved expenses) or copayments for hospital outpatient services.
Blood: First 3 pints of blood each year.
|
A |
B |
C |
D |
E |
F |
High Deductible F* |
G |
H |
I |
J |
High Deductible J* |
|
Basic Benefits |
Basic Benefits |
Basic Benefits |
Basic Benefits |
Basic Benefits |
Basic Benefits |
Basic Benefits |
Basic Benefits |
Basic Benefits |
Basic Benefits |
Basic Benefits |
Basic Benefits |
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|
|
Skilled Nursing Facility Coinsurance |
Skilled Nursing Facility Coinsurance |
Skilled Nursing Facility Coinsurance |
Skilled Nursing Facility Coinsurance |
Skilled Nursing Facility Coinsurance |
Skilled Nursing Facility Coinsurance |
Skilled Nursing Facility Coinsurance |
Skilled Nursing Facility Coinsurance |
Skilled Nursing Facility Coinsurance |
Skilled Nursing Facility Coinsurance |
|
|
Part A Deductible |
Part A Deductible |
Part A Deductible |
Part A Deductible |
Part A Deductible |
Part A Deductible |
Part A Deductible |
Part A Deductible |
Part A Deductible |
Part A Deductible |
Part A Deductible |
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|
|
Part B Deductible |
|
|
Part B Deductible |
Part B Deductible |
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|
|
Part B Deductible |
Part B Deductible |
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|
|
|
|
|
Part B Excess (100%) |
Part B Excess (100%) |
Part B Excess (80%) |
|
Part B Excess (100%) |
Part B Excess (100%) |
Part B Excess (100%) |
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|
|
Foreign Travel Emergency |
Foreign Travel Emergency |
Foreign Travel Emergency |
Foreign Travel Emergency |
Foreign Travel Emergency |
Foreign Travel Emergency |
Foreign Travel Emergency |
Foreign Travel Emergency |
Foreign Travel Emergency |
Foreign Travel Emergency |
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|
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At-Home Recovery |
|
|
|
At-Home Recovery |
|
At-Home Recovery |
At-Home Recovery |
At-Home Recovery |
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|
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|
|
Preventive Care NOT covered by Medicare |
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|
|
|
|
Preventive Care NOT covered by Medicare |
Preventive Care NOT covered by Medicare |
* The High Deductible Benefit Plans F and J offer benefits similar to the benefits offered by the Standardized Benefit Plans F and J except that the high deductible benefit plans require a higher deductible. The annual deductibles for the High Deductible Benefit Plans F and J are subject to change. For the current deductibles, please consult the most current version of the Guide to Health Insurance for People with Medicare which must be provided by an issuer to an applicant pursuant to NAC 687B.240. The cover page of the outline of coverage which must be provided to an applicant by an issuer pursuant to this section must specify the current amount of the deductible. The annual deductibles for the High Deductible Benefit Plans F and J may be adjusted annually by the Secretary of the United States Department of Health and Human Services to reflect the change in the Consumer Price Index for All Urban Consumers published by the United States Department of Labor for the calendar year ending on July 31 of the immediately preceding year, and rounded to the nearest multiple of $10. Benefits for the High Deductible Benefit Plans F and J begin after the insured has paid the annual deductible for expenses that would ordinarily be paid by the plans, including, without limitation, the Medicare Part A deductible and the Medicare Part B deductible. The annual deductible must be paid in addition to the premium and in addition to any other deductibles relating to a specific benefit, including, without limitation, the deductible for prescription drugs, if applicable, and the deductible for emergency care received in a foreign country.
(COMPANY NAME)
Outline of Medicare Supplement Coverage-Cover Page 2
Basic Benefits for Plans K and L include similar services as plans A-J, inclusive, but cost sharing for the basic benefits is at different levels.
|
|
K** |
L** |
|
Basic Benefits |
100% of Part A Hospitalization Coinsurance plus coverage for 365 Days after Medicare Benefits End 50% Hospice cost sharing 50% of Medicare-eligible expenses for the first 3 pints of blood 50% Part B Coinsurance, except 100% Coinsurance for Part B Preventive Services |
100% of Part A Hospitalization Coinsurance plus coverage for 365 Days after Medicare Benefits End 75% Hospice cost sharing 75% of Medicare-eligible expenses for the first 3 pints of blood 75% Part B Coinsurance, except 100% Coinsurance for Part B Preventive Services |
|
Skilled Nursing Facility 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 |
|
|
|
Preventive Care NOT covered by Medicare |
|
|
|
|
$4,000 Out of Pocket Annual Limit*** |
$2,000 Out of Pocket Annual Limit*** |
** Plans K and L provide for different cost sharing for items and services than Plans A-J, inclusive.
Once you reach the annual limit, the plan pays 100% of the Medicare copayments, coinsurance and deductibles for the rest of the 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.
PREMIUM INFORMATION (Boldface type)
We (insert issuer’s name) can only raise your premium if we raise the premium for all policies like yours in this State. (If the premium is based on the increasing age of the insured, include information specifying when premiums will change.)
DISCLOSURES (Boldface type)
Use this outline to compare benefits and premiums among policies.
READ YOUR POLICY VERY CAREFULLY
(Boldface type)
This is only an outline describing your policy’s most important features. The policy is your insurance contract. You must read the policy to understand all of the rights and duties of you and your insurance company.
RIGHT TO RETURN POLICY (Boldface type)
If you find that you are not satisfied with your policy, you may return it to (insert issuer’s address). If you send the policy back to us within 30 days after you receive it, we will treat the policy as if it had never been issued and return all of your payments.
POLICY REPLACEMENT (Boldface type)
If you are replacing another policy of health insurance, do NOT cancel it until you have actually received your new policy and are sure you want to keep it.
NOTICE (Boldface type)
This policy may not cover all of your medical costs.
(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 Medicare & You for more details.
COMPLETE ANSWERS ARE VERY IMPORTANT
(Boldface type)
When you fill out the application for the new policy, be sure to answer truthfully and completely all questions about your medical and health history. The company may cancel your policy and refuse to pay any claims if you leave out or falsify important medical information. (If the policy or certificate is guaranteed issue, this paragraph need not appear.)
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, and the same uniform layout and format as shown in the charts set forth in this subsection. No more than four plans may be shown on one chart. An issuer may use additional designations for benefit plans on these charts as authorized by subsection 4 of NAC 687B.295.)
(Include an explanation of any innovative benefits on the cover page and in the chart, in the manner approved by the Commissioner.)
PLAN A
MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD
* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 consecutive days.
** Medicare benefits are subject to change. For the current Medicare benefits, please consult the most current version of the Guide to Health Insurance for People with Medicare which must be provided by an issuer to an applicant pursuant to NAC 687B.240.
*** The plan pays all costs that Medicare does not pay.
**** You pay all costs that Medicare does not pay.
|
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
|
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies: First 60 days 61st thru 90th day 91st day and after: While using 60 lifetime reserve days Once lifetime reserve days are used: Additional 365 days
Beyond the additional 365 days |
** **
**
$0
$0 |
$0 ***
***
100% of Medicare Eligible Expenses $0 |
**** (Part A Deductible) $0
$0
$0
All costs |
|
SKILLED NURSING FACILITY CARE* You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital: First 20 days 21st thru 100th day 101st day and after |
All approved amounts ** $0 |
$0 $0 $0 |
$0 **** All costs |
|
BLOOD First 3 pints Additional amounts |
$0 100% |
3 pints $0 |
$0 $0 |
|
HOSPICE CARE Available as long as your doctor certifies you are terminally ill and you elect to receive these services
|
All but very limited coinsurance for outpatient drugs and inpatient respite care |
$0
|
Balance
|
PLAN A
MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR
* Once you have been billed $124 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.
|
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
|
MEDICAL EXPENSES IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment: First $124 of Medicare-approved amounts* Remainder of Medicare-approved amounts |
$0 Generally 80% |
$0 Generally 20% |
$124 (Part B Deductible) $0 |
|
Part B Excess Charges (Above Medicare-approved amounts) |
$0 |
$0 |
All costs |
|
BLOOD First 3 pints Next $124 of Medicare-approved amounts* Remainder of Medicare-approved amounts |
$0 $0 80% |
All costs $0 20% |
$0 $124 (Part B Deductible) $0 |
|
CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES |
100% |
$0 |
$0 |
PARTS A & B
* Once you have been billed $124 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.
|
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
|
HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically necessary skilled care services and medical supplies Durable medical equipment: First $124 of Medicare-approved amounts* Remainder of Medicare-approved amounts |
100%
$0 80% |
$0
$0 20% |
$0
$124 (Part B Deductible) $0 |
PLAN B
MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD
* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 consecutive days.
** Medicare benefits are subject to change. For the current Medicare benefits, please consult the most current version of the Guide to Health Insurance for People with Medicare which must be provided by an issuer to an applicant pursuant to NAC 687B.240.
*** The plan pays all costs that Medicare does not pay.
**** You pay all costs that Medicare does not pay.
|
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
|
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies: First 60 days 61st thru 90th day 91st day and after: While using 60 lifetime reserve days Once lifetime reserve days are used: Additional 365 days
Beyond the additional 365 days |
** **
**
$0
$0 |
*** (Part A Deductible) ***
***
100% of Medicare Eligible Expenses $0 |
$0 $0
$0
$0
All costs |
|
SKILLED NURSING FACILITY CARE* You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital: First 20 days 21st thru 100th day 101st day and after |
All approved amounts ** $0 |
$0 $0 $0 |
$0 **** All costs |
|
BLOOD First 3 pints Additional amounts |
$0 100% |
3 pints $0 |
$0 $0 |
|
HOSPICE CARE Available as long as your doctor certifies you are terminally ill and you elect to receive these services |
All but very limited coinsurance for outpatient drugs and inpatient respite care |
$0 |
Balance |
PLAN B
MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR
* Once you have been billed $124 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.
|
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
|
MEDICAL EXPENSES - IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment: First $124 of Medicare-approved amounts* Remainder of Medicare-approved amounts |
$0 Generally 80% |
$0 Generally 20% |
$124 (Part B Deductible) $0 |
|
Part B Excess Charges (Above Medicare-approved amounts) |
$0 |
$0 |
All costs |
|
BLOOD First 3 pints Next $124 of Medicare-approved amounts* Remainder of Medicare-approved amounts |
$0 $0 80% |
All costs $0 20% |
$0 $124 (Part B Deductible) $0 |
|
CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES |
100% |
$0 |
$0 |
PARTS A & B
* Once you have been billed $124 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.
|
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
|
HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically necessary skilled care services and medical supplies Durable medical equipment: First $124 of Medicare-approved amounts* Remainder of Medicare-approved amounts |
100%
$0 80% |
$0
$0 20% |
$0
$124 (Part B Deductible) $0 |
PLAN C
MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD
* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 consecutive days.
** Medicare benefits are subject to change. For the current Medicare benefits, please consult the most current version of the Guide to Health Insurance for People with Medicare which must be provided by an issuer to an applicant pursuant to NAC 687B.240.
*** The plan pays all costs that Medicare does not pay.
|
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
|
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies: First 60 days 61st thru 90th day 91st day and after: While using 60 lifetime reserve days Once lifetime reserve days are used: Additional 365 days
Beyond the additional 365 days |
** **
**
$0
$0 |
*** (Part A Deductible) ***
***
100% of Medicare Eligible Expenses $0 |
$0 $0
$0
$0
All costs |
|
SKILLED NURSING FACILITY CARE* You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital: First 20 days 21st thru 100th day 101st day and after |
All approved amounts ** $0 |
$0 *** $0 |
$0 $0 All costs |
|
BLOOD First 3 pints Additional amounts |
$0 100% |
3 pints $0 |
$0 $0 |
|
HOSPICE CARE Available as long as your doctor certifies you are terminally ill and you elect to receive these services |
All but very limited coinsurance for outpatient drugs and inpatient respite care |
$0 |
Balance |
PLAN C
MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR
* Once you have been billed $124 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.
|
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
|
MEDICAL EXPENSES - IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment: First $124 of Medicare-approved amounts* Remainder of Medicare-approved amounts |
$0 Generally 80% |
$124 (Part B Deductible) Generally 20% |
$0 $0 |
|
Part B Excess Charges (Above Medicare-approved amounts) |
$0 |
$0 |
All costs |
|
BLOOD First 3 pints Next $124 of Medicare-approved amounts* Remainder of Medicare-approved amounts |
$0 $0 80% |
All costs $124 (Part B Deductible) 20% |
$0 $0 $0 |
|
CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES |
100% |
$0 |
$0 |
PARTS A & B
* Once you have been billed $124 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.
|
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
|
HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically necessary skilled care services and medical supplies Durable medical equipment: First $124 of Medicare-approved amounts* Remainder of Medicare-approved amounts |
100%
$0 80% |
$0
$124 (Part B Deductible) 20% |
$0
$0 $0 |
OTHER BENEFITS - NOT COVERED BY MEDICARE
|
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
|
FOREIGN TRAVEL - NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the United States: First $250 each calendar year Remainder of charges
|
$0 $0
|
$0 80% to a lifetime maximum benefit of $50,000 |
$250 20% and amounts over the $50,000 lifetime maximum |
PLAN D
MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD
* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 consecutive days.
** Medicare benefits are subject to change. For the current Medicare benefits, please consult the most current version of the Guide to Health Insurance for People with Medicare which must be provided by an issuer to an applicant pursuant to NAC 687B.240.
*** The plan pays all costs that Medicare does not pay.
|
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
|
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies: First 60 days 61st thru 90th day 91st day and after: While using 60 lifetime reserve days Once lifetime reserve days are used: Additional 365 days
Beyond the additional 365 days |
** **
**
$0
$0 |
*** (Part A Deductible) ***
***
100% of Medicare Eligible Expenses $0 |
$0 $0
$0
$0
All costs |
|
SKILLED NURSING FACILITY CARE* You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital: First 20 days 21st thru 100th day 101st day and after |
All approved amounts ** $0 |
$0 *** $0 |
$0 $0 All costs |
|
BLOOD First 3 pints Additional amounts |
$0 100% |
3 pints $0 |
$0 $0 |
|
HOSPICE CARE Available as long as your doctor certifies you are terminally ill and you elect to receive these services |
All but very limited coinsurance for outpatient drugs and inpatient respite care |
$0 |
Balance |
PLAN D
MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR
* Once you have been billed $124 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.
|
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
|
MEDICAL EXPENSES - IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment: First $124 of Medicare-approved amounts* Remainder of Medicare-approved amounts |
$0 Generally 80% |
$0 Generally 20% |
$124 (Part B Deductible) $0 |
|
Part B Excess Charges (Above Medicare-approved amounts) |
$0 |
$0 |
All costs |
|
BLOOD First 3 pints Next $124 of Medicare-approved amounts* Remainder of Medicare-approved amounts |
$0 $0 80% |
All costs $0 20% |
$0 $124 (Part B Deductible) $0 |
|
CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES |
100% |
$0 |
$0 |
PARTS A & B
* Once you have been billed $124 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.
|
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
|
HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically necessary skilled care services and medical supplies Durable medical equipment: First $124 of Medicare-approved amounts* Remainder of Medicare-approved amounts |
100%
$0 80% |
$0
$0 20% |
$0
$124 (Part B Deductible) $0 |
|
AT-HOME RECOVERY SERVICES - NOT COVERED BY MEDICARE Home care certified by your doctor, for personal care during recovery from an injury or sickness for which Medicare approved a Home Care Treatment Plan: Benefit for each visit
Number of visits covered (must be received within 8 weeks of last Medicare-approved visit)
Calendar year maximum |
$0
$0
$0 |
Actual charges to $40 a visit Up to the number of Medicare-approved visits, not to exceed seven each week $1,600 |
Balance |
PLAN D
OTHER BENEFITS - NOT COVERED BY MEDICARE
|
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
|
FOREIGN TRAVEL - NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the United States: First $250 each calendar year Remainder of charges
|
$0 $0
|
$0 80% to a lifetime maximum benefit of $50,000 |
$250 20% and amounts over the $50,000 lifetime maximum |
PLAN E
MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD
* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 consecutive days.
** Medicare benefits are subject to change. For the current Medicare benefits, please consult the most current version of the Guide to Health Insurance for People with Medicare which must be provided by an issuer to an applicant pursuant to NAC 687B.240.
*** The plan pays all costs that Medicare does not pay.
|
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
|
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies: First 60 days 61st thru 90th day 91st day and after: While using 60 lifetime reserve days Once lifetime reserve days are used: Additional 365 days
Beyond the additional 365 days |
** **
**
$0
$0 |
*** (Part A Deductible) ***
***
100% of Medicare Eligible Expenses $0 |
$0 $0
$0
$0
All costs |
|
SKILLED NURSING FACILITY CARE* You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital: First 20 days 21st thru 100th day 101st day and after |
All approved amounts ** $0 |
$0 *** $0 |
$0 $0 All costs |
|
BLOOD First 3 pints Additional amounts |
$0 100% |
3 pints $0 |
$0 $0 |
|
HOSPICE CARE Available as long as your doctor certifies you are terminally ill and you elect to receive these services
|
All but very limited coinsurance for outpatient drugs and inpatient respite care |
$0
|
Balance
|
PLAN E
MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR
* Once you have been billed $124 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.
|
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
|
MEDICAL EXPENSES - IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment: First $124 of Medicare-approved amounts* Remainder of Medicare-approved amounts |
$0 Generally 80% |
$0 Generally 20% |
$124 (Part B Deductible) $0 |
|
Part B Excess Charges (Above Medicare-approved amounts) |
$0 |
$0 |
All costs |
|
BLOOD First 3 pints Next $124 of Medicare-approved amounts* Remainder of Medicare-approved amounts |
$0 $0 80% |
All costs $0 20% |
$0 $124 (Part B Deductible) $0 |
|
CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES |
100% |
$0 |
$0 |
PARTS A & B
* Once you have been billed $124 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.
|
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
|
HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically necessary skilled care services and medical supplies Durable medical equipment: First $124 of Medicare-approved amounts* Remainder of Medicare-approved amounts |
100%
$0 80% |
$0
$0 20% |
$0
$124 (Part B Deductible) $0 |
PLAN E
OTHER BENEFITS - NOT COVERED BY MEDICARE
* Medicare benefits are subject to change. For the current Medicare benefits, please consult the most current version of the Guide to Health Insurance for People with Medicare which must be provided by an issuer to an applicant pursuant to NAC 687B.240.
|
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
|
FOREIGN TRAVEL - NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the United States: First $250 each calendar year Remainder of charges
|
$0 $0
|
$0 80% to a lifetime maximum benefit of $50,000 |
$250 20% and amounts over the $50,000 lifetime maximum |
|
PREVENTIVE MEDICAL CARE BENEFIT - NOT COVERED BY MEDICARE* Some annual physical and preventive tests and services administered or ordered by your doctor when not covered by Medicare: First $120 each calendar year Additional charges |
$0 $0 |
$120 $0 |
$0 All costs |
PLAN F
MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD
* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 consecutive days.
** Medicare benefits are subject to change. For the current Medicare benefits, please consult the most current version of the Guide to Health Insurance for People with Medicare which must be provided by an issuer to an applicant pursuant to NAC 687B.240.
*** The plan pays all costs that Medicare does not pay.
|
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
|
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies: First 60 days 61st thru 90th day 91st day and after: While using 60 lifetime reserve days Once lifetime reserve days are used: Additional 365 days
Beyond the additional 365 days |
** **
**
$0
$0 |
*** (Part A Deductible) ***
***
100% of Medicare Eligible Expenses $0 |
$0 $0
$0
$0
All costs |
|
SKILLED NURSING FACILITY CARE* You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital: First 20 days 21st thru 100th day 101st day and after |
All approved amounts ** $0 |
$0 *** $0 |
$0 $0 All costs |
|
BLOOD First 3 pints Additional amounts |
$0 100% |
3 pints $0 |
$0 $0 |
|
HOSPICE CARE Available as long as your doctor certifies you are terminally ill and you elect to receive these services
|
All but very limited coinsurance for outpatient drugs and inpatient respite care |
$0
|
Balance
|
PLAN F
MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR
* Once you have been billed $124 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.
|
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
|
MEDICAL EXPENSES - IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment: First $124 of Medicare-approved amounts* Remainder of Medicare-approved amounts |
$0 Generally 80% |
$124 (Part B Deductible) Generally 20% |
$0 $0 |
|
Part B Excess Charges (Above Medicare-approved amounts) |
$0 |
100% |
$0 |
|
BLOOD First 3 pints Next $124 of Medicare-approved amounts* Remainder of Medicare-approved amounts |
$0
$0 80% |
All costs
$124 (Part B Deductible) 20% |
$0
$0 $0 |
|
CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES |
100% |
$0 |
$0 |
PARTS A & B
* Once you have been billed $124 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.
|
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
|
HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically necessary skilled care services and medical supplies Durable medical equipment: First $124 of Medicare-approved amounts* Remainder of Medicare-approved amounts |
100%
$0 80% |
$0
$124 (Part B Deductible) 20% |
$0
$0 $0 |
OTHER BENEFITS - NOT COVERED BY MEDICARE
|
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
|
FOREIGN TRAVEL - NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the United States: First $250 each calendar year Remainder of charges
|
$0 $0
|
$0 80% to a lifetime maximum benefit of $50,000 |
$250 20% and amounts over the $50,000 lifetime maximum |
HIGH DEDUCTIBLE BENEFIT PLAN F
MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD
* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 consecutive days.
** Medicare benefits are subject to change. For the current Medicare benefits, please consult the most current version of the Guide to Health Insurance for People with Medicare which must be provided by an issuer to an applicant pursuant to NAC 687B.240.
*** The plan pays the costs that Medicare does not pay after you pay the deductible.
**** The High Deductible Benefit Plan F offers benefits similar to the benefits offered by the Standardized Benefit Plan F except that the high deductible benefit plan requires the insured to pay a higher annual deductible. The annual deductible for the High Deductible Benefit Plan F is subject to change. For the current deductible, please consult the most current version of the Guide to Health Insurance for People with Medicare which must be provided by an issuer to an applicant pursuant to NAC 687B.240. The cover page of the outline of coverage which must be provided to an applicant by an issuer pursuant to this section must specify the current amount of the deductible. The annual deductible for the High Deductible Benefit Plan F may be adjusted annually by the Secretary of the United States Department of Health and Human Services to reflect the change in the Consumer Price Index for All Urban Consumers published by the United States Department of Labor for the calendar year ending on July 31 of the immediately preceding year, and rounded to the nearest multiple of $10. Benefits for the High Deductible Benefit Plan F begin after the insured has paid the annual deductible for expenses that would ordinarily be paid by the plan, including, without limitation, the Medicare Part A deductible and the Medicare Part B deductible. The annual deductible must be paid in addition to the premium and in addition to any other deductibles relating to a specific benefit, including, without limitation, the deductible for emergency care received in a foreign country.
|
SERVICES |
MEDICARE PAYS |
AFTER YOU PAY THE DEDUCTIBLE PLAN PAYS**** |
IN ADDITION TO THE DEDUCTIBLE YOU PAY**** |
|
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies: First 60 days 61st thru 90th day 91st day and after: While using 60 lifetime reserve days Once lifetime reserve days are used: Additional 365 days
Beyond the additional 365 days |
** **
**
$0
$0 |
*** (Part A Deductible) ***
***
100% of Medicare Eligible Expenses $0 |
$0 $0
$0
$0
All costs |
|
SKILLED NURSING FACILITY CARE* You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital: First 20 days 21st thru 100th day 101st day and after |
All approved amounts ** $0 |
$0 *** $0 |
$0 $0 All costs |
|
BLOOD First 3 pints Additional amounts |
$0 100% |
3 pints $0 |
$0 $0 |
|
HOSPICE CARE Available as long as your doctor certifies you are terminally ill and you elect to receive these services
|
All but very limited coinsurance for outpatient drugs and inpatient respite care |
$0
|
Balance
|
HIGH DEDUCTIBLE BENEFIT PLAN F
MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR
* Once you have been billed $124 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year. The $124 Part B Deductible will be applied toward the annual deductible for the calendar year set forth in NAC 687B.311.
** The High Deductible Benefit Plan F offers benefits similar to the benefits offered by the Standardized Benefit Plan F except that the high deductible benefit plan requires the insured to pay a higher annual deductible. The annual deductible for the High Deductible Benefit Plan F is subject to change. For the current deductible, please consult the most current version of the Guide to Health Insurance for People with Medicare which must be provided by an issuer to an applicant pursuant to NAC 687B.240. The cover page of the outline of coverage which must be provided to an applicant by an issuer pursuant to this section must specify the current amount of the deductible. The annual deductible for the High Deductible Benefit Plan F may be adjusted annually by the Secretary of the United States Department of Health and Human Services to reflect the change in the Consumer Price Index for All Urban Consumers published by the United States Department of Labor for the calendar year ending on July 31 of the immediately preceding year, and rounded to the nearest multiple of $10. Benefits for the High Deductible Benefit Plan F begin after the insured has paid the annual deductible for expenses that would ordinarily be paid by the plan, including, without limitation, the Medicare Part A deductible and the Medicare Part B deductible. The annual deductible must be paid in addition to the premium and in addition to any other deductibles relating to a specific benefit, including, without limitation, the deductible for emergency care received in a foreign country.
|
SERVICES |
MEDICARE PAYS |
AFTER YOU PAY THE DEDUCTIBLE PLAN PAYS** |
IN ADDITION TO THE DEDUCTIBLE YOU PAY** |
|
MEDICAL EXPENSES - IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment: First $124 of Medicare-approved amounts* Remainder of Medicare-approved amounts |
$0 Generally 80% |
$124 (Part B Deductible) Generally 20% |
$0 $0 |
|
Part B Excess Charges (Above Medicare-approved amounts) |
$0 |
100% |
$0 |
|
BLOOD First 3 pints Next $124 of Medicare-approved amounts* Remainder of Medicare-approved amounts |
$0
$0 80% |
All costs
$124 (Part B Deductible) 20% |
$0
$0 $0 |
|
CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES |
100% |
$0 |
$0 |
HIGH DEDUCTIBLE BENEFIT PLAN F
MEDICARE (PARTS A & B)
* Once you have been billed $124 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year. The $124 Part B Deductible will be applied toward the annual deductible for the calendar year set forth in NAC 687B.311.
** The High Deductible Benefit Plan F offers benefits similar to the benefits offered by the Standardized Benefit Plan F except that the high deductible benefit plan requires the insured to pay a higher annual deductible. The annual deductible for the High Deductible Benefit Plan F is subject to change. For the current deductible, please consult the most current version of the Guide to Health Insurance for People with Medicare which must be provided by an issuer to an applicant pursuant to NAC 687B.240. The cover page of the outline of coverage which must be provided to an applicant by an issuer pursuant to this section must specify the current amount of the deductible. The annual deductible for the High Deductible Benefit Plan F may be adjusted annually by the Secretary of the United States Department of Health and Human Services to reflect the change in the Consumer Price Index for All Urban Consumers published by the United States Department of Labor for the calendar year ending on July 31 of the immediately preceding year, and rounded to the nearest multiple of $10. Benefits for the High Deductible Benefit Plan F begin after the insured has paid the annual deductible for expenses that would ordinarily be paid by the plan, including, without limitation, the Medicare Part A deductible and the Medicare Part B deductible. The annual deductible must be paid in addition to the premium and in addition to any other deductibles relating to a specific benefit, including, without limitation, the deductible for emergency care received in a foreign country.
|
SERVICES |
MEDICARE PAYS |
AFTER YOU PAY THE DEDUCTIBLE PLAN PAYS** |
IN ADDITION TO THE DEDUCTIBLE YOU PAY** |
|
HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically necessary skilled care services and medical supplies Durable medical equipment: First $124 of Medicare-approved amounts* Remainder of Medicare-approved amounts |
100%
$0 80% |
$0
$124 (Part B Deductible) 20% |
$0
$0 $0 |
OTHER BENEFITS - NOT COVERED BY MEDICARE
* The High Deductible Benefit Plan F offers benefits similar to the benefits offered by the Standardized Benefit Plan F except that the high deductible benefit plan requires the insured to pay a higher annual deductible. The annual deductible for the High Deductible Benefit Plan F is subject to change. For the current deductible, please consult the most current version of the Guide to Health Insurance for People with Medicare which must be provided by an issuer to an applicant pursuant to NAC 687B.240. The cover page of the outline of coverage which must be provided to an applicant by an issuer pursuant to this section must specify the current amount of the deductible. The annual deductible for the High Deductible Benefit Plan F may be adjusted annually by the Secretary of the United States Department of Health and Human Services to reflect the change in the Consumer Price Index for All Urban Consumers published by the United States Department of Labor for the calendar year ending on July 31 of the immediately preceding year, and rounded to the nearest multiple of $10. Benefits for the High Deductible Benefit Plan F begin after the insured has paid the annual deductible for expenses that would ordinarily be paid by the plan, including, without limitation, the Medicare Part A deductible and the Medicare Part B deductible. The annual deductible must be paid in addition to the premium and in addition to any other deductibles relating to a specific benefit, including, without limitation, the deductible for emergency care received in a foreign country.
|
SERVICES |
MEDICARE PAYS |
AFTER YOU PAY THE DEDUCTIBLE PLAN PAYS* |
IN ADDITION TO THE DEDUCTIBLE YOU PAY* |
|
FOREIGN TRAVEL - NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the United States: First $250 each calendar year Remainder of charges
|
$0 $0
|
$0 80% to a lifetime maximum benefit of $50,000 |
$250 20% and amounts over the $50,000 lifetime maximum |
PLAN G
MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD
* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 consecutive days.
** Medicare benefits are subject to change. For the current Medicare benefits, please consult the most current version of the Guide to Health Insurance for People with Medicare which must be provided by an issuer to an applicant pursuant to NAC 687B.240.
*** The plan pays the costs that Medicare does not pay.
|
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
|
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies: First 60 days 61st thru 90th day 91st day and after: While using 60 lifetime reserve days Once lifetime reserve days are used: Additional 365 days
Beyond the additional 365 days |
** **
**
$0
$0 |
*** (Part A Deductible) ***
***
100% of Medicare Eligible Expenses $0 |
$0 $0
$0
$0
All costs |
|
SKILLED NURSING FACILITY CARE* You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital: First 20 days 21st thru 100th day 101st day and after |
All approved amounts ** $0 |
$0 *** $0 |
$0 $0 All costs |
|
BLOOD First 3 pints Additional amounts |
$0 100% |
3 pints $0 |
$0 $0 |
|
HOSPICE CARE Available as long as your doctor certifies you are terminally ill and you elect to receive these services
|
All but very limited coinsurance for outpatient drugs and inpatient respite care |
$0
|
Balance
|
MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR
* Once you have been billed $124 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.
|
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
|
MEDICAL EXPENSES - IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment: First $124 of Medicare-approved amounts* Remainder of Medicare-approved amounts |
$0 Generally 80% |
$0 Generally 20% |
$124 (Part B Deductible) $0 |
|
Part B Excess Charges (Above Medicare-approved amounts) |
$0 |
80% |
20% |
|
BLOOD First 3 pints Next $124 of Medicare-approved amounts* Remainder of Medicare-approved amounts |
$0 $0 80% |
All costs $0 20% |
$0 $124 (Part B Deductible) $0 |
|
CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES |
100% |
$0 |
$0 |
PLAN G
PARTS A & B
* Once you have been billed $124 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.
|
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
|
HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically necessary skilled care services and medical supplies Durable medical equipment: First $124 of Medicare-approved amounts* Remainder of Medicare-approved amounts |
100%
$0 80% |
$0
$0 20% |
$0
$124 (Part B Deductible) $0 |
|
AT-HOME RECOVERY SERVICES - NOT COVERED BY MEDICARE Home care certified by your doctor, for personal care during recovery from an injury or sickness for which Medicare approved a Home Care Treatment Plan: Benefit for each visit
Number of visits covered (must be received within 8 weeks of last Medicare-approved visit)
Calendar year maximum |
$0
$0
$0 |
Actual charges to $40 a visit Up to the number of Medicare-approved visits, not to exceed seven each week $1,600 |
Balance |
PLAN G
OTHER BENEFITS - NOT COVERED BY MEDICARE
|
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
|
FOREIGN TRAVEL - NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the United States: First $250 each calendar year Remainder of charges
|
$0 $0
|
$0 80% to a lifetime maximum benefit of $50,000 |
$250 20% and amounts over the $50,000 lifetime maximum |
PLAN H
MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD
* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 consecutive days.
** Medicare benefits are subject to change. For the current Medicare benefits, consult the most current version of the Guide to Health Insurance for People with Medicare which must be provided by an issuer to an applicant pursuant to NAC 687B.240.
*** The plan pays the costs that Medicare does not pay.
|
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
|
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies: First 60 days 61st thru 90th day 91st day and after: While using 60 lifetime reserve days Once lifetime reserve days are used: Additional 365 days
Beyond the additional 365 days |
** **
**
$0
$0 |
*** (Part A Deductible) ***
***
100% of Medicare Eligible Expenses $0 |
$0 $0
$0
$0
All costs |
|
SKILLED NURSING FACILITY CARE* You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital: First 20 days 21st thru 100th day 101st day and after |
All approved amounts ** $0 |
$0 *** $0 |
$0 $0 All costs |
|
BLOOD First 3 pints Additional amounts |
$0 100% |
3 pints $0 |
$0 $0 |
|
HOSPICE CARE Available as long as your doctor certifies you are terminally ill and you elect to receive these services
|
All but very limited coinsurance for outpatient drugs and inpatient respite care |
$0
|
Balance
|
MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR
* Once you have been billed $124 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.
|
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
|
MEDICAL EXPENSES - IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment: First $124 of Medicare-approved amounts* Remainder of Medicare-approved amounts |
$0 Generally 80% |
$0 Generally 20% |
$124 (Part B Deductible) $0 |
|
Part B Excess Charges (Above Medicare-approved amounts) |
$0 |
$0 |
All costs |
|
BLOOD First 3 pints Next $124 of Medicare-approved amounts* Remainder of Medicare-approved amounts |
$0 $0 80% |
All costs $0 20% |
$0 $124 (Part B Deductible) $0 |
|
CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES |
100% |
$0 |
$0 |
PLAN H
PARTS A & B
* Once you have been billed $124 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.
|
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
|
HOME HEALTH CARE MEDICARE - APPROVED SERVICES Medically necessary skilled care services and medical supplies Durable medical equipment: First $124 of Medicare-approved amounts* Remainder of Medicare-approved amounts |
100%
$0 80% |
$0
$0 20% |
$0
$124 (Part B Deductible) $0 |
OTHER BENEFITS - NOT COVERED BY MEDICARE
Note: A policy to supplement Medicare with benefits for outpatient prescription drugs in existence before January 1, 2006, must be renewed for current policyholders who do not enroll in Medicare Part D at the option of the policyholder.
|
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
|
FOREIGN TRAVEL - NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the United States: First $250 each calendar year Remainder of charges |
$0 $0 |
$0 80% of a lifetime maximum benefit of $50,000 |
$250 20% and amounts over the $50,000 lifetime maximum |
PLAN I
MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD
* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 consecutive days.
** Medicare benefits are subject to change. For the current Medicare benefits, consult the most current version of the Guide to Health Insurance for People with Medicare which must be provided by an issuer to an applicant pursuant to NAC 687B.240.
*** The plan pays the costs that Medicare does not pay.
|
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
|
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies: First 60 days 61st thru 90th day 91st day and after: While using 60 lifetime reserve days Once lifetime reserve days are used: Additional 365 days
Beyond the additional 365 days |
** **
**
$0
$0 |
*** (Part A Deductible) ***
***
100% of Medicare Eligible Expenses $0 |
$0 $0
$0
$0
All costs |
|
SKILLED NURSING FACILITY CARE* You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital: First 20 days 21st thru 100th day 101st day and after |
All approved amounts ** $0 |
$0 *** $0 |
$0 $0 All costs |
|
BLOOD First 3 pints Additional amounts |
$0 100% |
3 pints $0 |
$0 $0 |
|
HOSPICE CARE Available as long as your doctor certifies you are terminally ill and you elect to receive these services
|
All but very limited coinsurance for outpatient drugs and inpatient respite care |
$0
|
Balance
|
MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR
* Once you have been billed $124 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.
|
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
|
MEDICAL EXPENSES - IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment: First $124 of Medicare-approved amounts* Remainder of Medicare-approved amounts |
$0 Generally 80% |
$0 Generally 20% |
$124 (Part B Deductible) $0 |
|
Part B Excess Charges (Above Medicare-approved amounts) |
$0 |
100% |
$0 |
|
BLOOD First 3 pints Next $124 of Medicare-approved amounts* Remainder of Medicare-approved amounts |
$0 $0 80% |
All costs $0 20% |
$0 $124 (Part B Deductible) $0 |
|
CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES |
100% |
$0 |
$0 |
PLAN I
PARTS A & B
* Once you have been billed $124 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.
|
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
|
HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically necessary skilled care services and medical supplies Durable medical equipment: First $124 of Medicare-approved amounts* Remainder of Medicare-approved amounts |
100%
$0 80% |
$0
$0 20% |
$0
$124 (Part B Deductible) $0 |
|
AT-HOME RECOVERY SERVICES - NOT COVERED BY MEDICARE Home care certified by your doctor, for personal care during recovery from an injury or sickness for which Medicare approved a Home Care Treatment Plan: Benefit for each visit
Number of visits covered (must be received within 8 weeks of last Medicare-approved visit)
Calendar year maximum |
$0
$0
$0 |
Actual charges to $40 a visit Up to the number of Medicare-approved visits, not to exceed seven each week $1,600 |
Balance
|
OTHER BENEFITS - NOT COVERED BY MEDICARE
Note: A policy to supplement Medicare with benefits for outpatient prescription drugs in existence before January 1, 2006, must be renewed for current policyholders who do not enroll in Medicare Part D at the option of the policyholder.
|
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
|
FOREIGN TRAVEL - NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the United States: First $250 each calendar year Remainder of charges
|
$0 $0
|
$0 80% to a lifetime maximum benefit of $50,000 |
$250 20% and amounts over the $50,000 lifetime maximum |
PLAN J
MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD
* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 consecutive days.
** Medicare benefits are subject to change. For the current Medicare benefits, consult the most current version of the Guide to Health Insurance for People with Medicare which must be provided by an issuer to an applicant pursuant to NAC 687B.240.
*** The plan pays the costs that Medicare does not pay.
|
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
|
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies: First 60 days 61st thru 90th day 91st day and after: While using 60 lifetime reserve days Once lifetime reserve days are used: Additional 365 days
Beyond the additional 365 days |
** **
**
$0
$0 |
*** (Part A Deductible) ***
***
100% of Medicare Eligible Expenses $0 |
$0 $0
$0
$0
All costs |
|
SKILLED NURSING FACILITY CARE* You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital: First 20 days 21st thru 100th day 101st day and after |
All approved amounts ** $0 |
$0 *** $0 |
$0 $0 All costs |
|
BLOOD First 3 pints Additional amounts |
$0 100% |
3 pints $0 |
$0 $0 |
|
HOSPICE CARE Available as long as your doctor certifies you are terminally ill and you elect to receive these services
|
All but very limited coinsurance for outpatient drugs and inpatient respite care |
$0
|
Balance
|
PLAN J
MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR
* Once you have been billed $124 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.
|
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
|
MEDICAL EXPENSES - IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment: First $124 of Medicare-approved amounts* Remainder of Medicare-approved amounts |
$0 Generally 80% |
$124 (Part B Deductible) Generally 20% |
$0 $0 |
|
Part B Excess Charges (Above Medicare-approved amounts) |
$0 |
100% |
$0 |
|
BLOOD First 3 pints Next $124 of Medicare-approved amounts* Remainder of Medicare-approved amounts |
$0 $0 80% |
All costs $124 (Part B Deductible) 20% |
$0 $0 $0 |
|
CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES |
100% |
$0 |
$0 |
PARTS A & B
* Once you have been billed $124 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.
|
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
|
HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically necessary skilled care services and medical supplies Durable medical equipment: First $124 of Medicare-approved amounts* Remainder of Medicare-approved amounts |
100%
$0 80% |
$0
$124 (Part B Deductible) 20% |
$0
$0 $0 |
|
AT-HOME RECOVERY SERVICES - NOT COVERED BY MEDICARE Home care certified by your doctor, for personal care during recovery from an injury or sickness for which Medicare approved a Home Care Treatment Plan: Benefit for each visit Number of visits covered (must be received within 8 weeks of last Medicare-approved visit)
Calendar year maximum |
$0 $0
$0 |
Actual charges to $40 a visit Up to the number of Medicare-approved visits, not to exceed seven each week $1,600 |
Balance
|
PLAN J
OTHER BENEFITS - NOT COVERED BY MEDICARE
* Medicare benefits are subject to change. For the current Medicare benefits, consult the most current version of the Guide to Health Insurance for People with Medicare which must be provided by an issuer to an applicant pursuant to NAC 687B.240.
Note: A policy to supplement Medicare with benefits for outpatient prescription drugs in existence before January 1, 2006, must be renewed for current policyholders who do not enroll in Medicare Part D at the option of the policyholder.
|
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
|
FOREIGN TRAVEL - NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the United States: First $250 each calendar year Remainder of charges
|
$0 $0
|
$0 80% to a lifetime maximum benefit of $50,000
|
$250 20% and amounts over the $50,000 lifetime maximum |
|
PREVENTIVE MEDICAL CARE BENEFIT - NOT COVERED BY MEDICARE* Some annual physical and preventive tests and services administered or ordered by your doctor when not covered by Medicare: First $120 each calendar year Additional charges |
$0 $0 |
$120 $0 |
$0 All costs |
HIGH DEDUCTIBLE BENEFIT PLAN J
MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD
* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 consecutive days.
** Medicare benefits are subject to change. For the current Medicare benefits, consult the most current version of the Guide to Health Insurance for People with Medicare which must be provided by an issuer to an applicant pursuant to NAC 687B.240.
*** The plan pays the costs that Medicare does not pay after you pay the deductible.
**** The High Deductible Benefit Plan J offers benefits similar to the benefits offered by the Standardized Benefit Plan J except that the high deductible benefit plan requires the insured to pay a higher annual deductible. The annual deductible for the High Deductible Benefit Plan J is subject to change. For the current deductible, please consult the most current version of the Guide to Health Insurance for People with Medicare which must be provided by an issuer to an applicant pursuant to NAC 687B.240. The cover page of the outline of coverage which must be provided to an applicant by an issuer pursuant to this section must specify the current amount of the deductible. The annual deductible for the High Deductible Benefit Plan J may be adjusted annually by the Secretary of the United States Department of Health and Human Services to reflect the change in the Consumer Price Index for All Urban Consumers published by the United States Department of Labor for the calendar year ending on July 31 of the immediately preceding year, and rounded to the nearest multiple of $10. Benefits for the High Deductible Benefit Plan J begin after the insured has paid the annual deductible for expenses that would ordinarily be paid by the plan, including, without limitation, the Medicare Part A deductible and the Medicare Part B deductible. The annual deductible must be paid in addition to the premium and in addition to any other deductibles relating to a specific benefit, including, without limitation, the deductible for prescription drugs and the deductible for emergency care received in a foreign country.
|
SERVICES |
MEDICARE PAYS |
AFTER YOU PAY THE DEDUCTIBLE PLAN PAYS**** |
IN ADDITION TO THE DEDUCTIBLE YOU PAY**** |
|
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies: First 60 days 61st thru 90th day 91st day and after: While using 60 lifetime reserve days Once lifetime reserve days are used: Additional 365 days
Beyond the additional 365 days |
** **
**
$0
$0 |
*** (Part A Deductible) ***
***
100% of Medicare Eligible Expenses $0 |
$0 $0
$0
$0
All costs |
|
SKILLED NURSING FACILITY CARE* You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital: First 20 days 21st thru 100th day 101st day and after |
All approved amounts ** $0 |
$0 *** $0 |
$0 $0 All costs |
|
BLOOD First 3 pints Additional amounts |
$0 100% |
3 pints $0 |
$0 $0 |
|
HOSPICE CARE Available as long as your doctor certifies you are terminally ill and you elect to receive these services
|
All but very limited coinsurance for outpatient drugs and inpatient respite care |
$0
|
Balance
|
HIGH DEDUCTIBLE BENEFIT PLAN J
MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR
* Once you have been billed $124 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year. The $124 Part B Deductible will be applied toward the annual deductible for the calendar year set forth in NAC 687B.319.
** The High Deductible Benefit Plan J offers benefits similar to the benefits offered by the Standardized Benefit Plan J except that the high deductible benefit plan requires the insured to pay a higher deductible. The annual deductible for the High Deductible Benefit Plan J is subject to change. For the current deductible, please consult the most current version of the Guide to Health Insurance for People with Medicare which must be provided by an issuer to an applicant pursuant to NAC 687B.240. The cover page of the outline of coverage which must be provided to an applicant by an issuer pursuant to this section must specify the current amount of the deductible. The annual deductible for the High Deductible Benefit Plan J may be adjusted annually by the Secretary of the United States Department of Health and Human Services to reflect the change in the Consumer Price Index for All Urban Consumers published by the United States Department of Labor for the calendar year ending on July 31 of the immediately preceding year, and rounded to the nearest multiple of $10. Benefits for the High Deductible Benefit Plan J begin after the insured has paid the annual deductible for expenses that would ordinarily be paid by the plan, including, without limitation, the Medicare Part A deductible and the Medicare Part B deductible. The annual deductible must be paid in addition to the premium and in addition to any other deductibles relating to a specific benefit, including, without limitation, the deductible for prescription drugs and the deductible for emergency care received in a foreign country.
|
SERVICES |
MEDICARE PAYS |
AFTER YOU PAY THE DEDUCTIBLE PLAN PAYS** |
IN ADDITION TO THE DEDUCTIBLE YOU PAY** |
|
MEDICAL EXPENSES - IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment: First $124 of Medicare-approved amounts* Remainder of Medicare-approved amounts |
$0 Generally 80% |
$124 (Part B Deductible) 20% |
$0 $0 |
|
Part B Excess Charges (Above Medicare-approved amounts) |
$0 |
100% |
$0 |
|
BLOOD First 3 pints Next $124 of Medicare-approved amounts* Remainder of Medicare-approved amounts |
$0 $0 80% |
All costs $124 (Part B Deductible) 20% |
$0 $0 $0 |
|
CLINICAL LABORATORY SERVICES -TESTS FOR DIAGNOSTIC SERVICES |
100% |
$0 |
$0 |
HIGH DEDUCTIBLE BENEFIT PLAN J
MEDICARE (PARTS A & B)
* Once you have been billed $124 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year. The $124 Part B Deductible will be applied toward the annual deductible for the calendar year set forth in NAC 687B.319.
** The High Deductible Benefit Plan J offers benefits similar to the benefits offered by the Standardized Benefit Plan J except that the high deductible benefit plan requires the insured to pay a higher annual deductible. The annual deductible for the High Deductible Benefit Plan J is subject to change. For the current deductible, please consult the most current version of the Guide to Health Insurance for People with Medicare which must be provided by an issuer to an applicant pursuant to NAC 687B.240. The cover page of the outline of coverage which must be provided to an applicant by an issuer pursuant to this section must specify the current amount of the deductible. The annual deductible for the High Deductible Benefit Plan J may be adjusted annually by the Secretary of the United States Department of Health and Human Services to reflect the change in the Consumer Price Index for All Urban Consumers published by the United States Department of Labor for the calendar year ending on July 31 of the immediately preceding year, and rounded to the nearest multiple of $10. Benefits for the High Deductible Benefit Plan J begin after the insured has paid the annual deductible for expenses that would ordinarily be paid by the plan, including, without limitation, the Medicare Part A deductible and the Medicare Part B deductible. The annual deductible must be paid in addition to the premium and in addition to any other deductibles relating to a specific benefit, including, without limitation, the deductible for prescription drugs and the deductible for emergency care received in a foreign country.
|
SERVICES |
MEDICARE PAYS |
AFTER YOU PAY THE DEDUCTIBLE PLAN PAYS** |
IN ADDITION TO THE DEDUCTIBLE YOU PAY** |
|
HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically necessary skilled care services and medical supplies Durable medical equipment: First $124 of Medicare- approved amounts* Remainder of Medicare-approved amounts |
100%
$0 80% |
$0
$124 (Part B Deductible) 20% |
$0
$0 $0 |
|
HOME HEALTH CARE AT-HOME RECOVERY SERVICES - NOT COVERED BY MEDICARE Home care certified by your doctor, for personal care during recovery from an injury or sickness for which Medicare approved a Home Care Treatment Plan: Benefit for each visit Number of visits covered (must be received within 8 weeks of last Medicare-approved visit)
Calendar year maximum |
$0 $0
$0 |
Actual charges to $40 a visit Up to the number of Medicare-approved visits, not to exceed seven each week $1,600 |
Balance
|
HIGH DEDUCTIBLE BENEFIT PLAN J
OTHER BENEFITS - NOT COVERED BY MEDICARE
* The High Deductible Benefit Plan J offers benefits similar to the benefits offered by the Standardized Benefit Plan J except that the high deductible benefit plan requires the insured to pay a higher annual deductible. The annual deductible for the High Deductible Benefit Plan J is subject to change. For the current deductible, please consult the most current version of the Guide to Health Insurance for People with Medicare which must be provided by an issuer to an applicant pursuant to NAC 687B.240. The cover page of the outline of coverage which must be provided to an applicant by an issuer pursuant to this section must specify the current amount of the deductible. The annual deductible for the High Deductible Benefit Plan J may be adjusted annually by the Secretary of the United States Department of Health and Human Services to reflect the change in the Consumer Price Index for All Urban Consumers published by the United States Department of Labor for the calendar year ending on July 31 of the immediately preceding year, and rounded to the nearest multiple of $10. Benefits for the High Deductible Benefit Plan J begin after the insured has paid the annual deductible for expenses that would ordinarily be paid by the plan, including, without limitation, the Medicare Part A deductible and the Medicare Part B deductible. The annual deductible must be paid in addition to the premium and in addition to any other deductibles relating to a specific benefit, including, without limitation, the deductible for prescription drugs and the deductible for emergency care received in a foreign country.
** Medicare benefits are subject to change. For the current Medicare benefits, please consult the most current version of the Guide to Health Insurance for People with Medicare which must be provided by an issuer to an applicant pursuant to NAC 687B.240.
Note: A policy to supplement Medicare with benefits for outpatient prescription drugs in existence before January 1, 2006, must be renewed for current policyholders who do not enroll in Medicare Part D at the option of the policyholder.
|
SERVICES |
MEDICARE PAYS |
AFTER YOU PAY THE DEDUCTIBLE PLAN PAYS* |
IN ADDITION TO THE DEDUCTIBLE YOU PAY* |
|
FOREIGN TRAVEL - NOT COVERED BY MEDICARE** Medically necessary emergency care services beginning during the first 60 days of each trip outside the United States: First $250 each calendar year Remainder of charges
|
$0 $0
|
$0 80% to a lifetime maximum benefit of $50,000 |
$250 20% and amounts over the $50,000 lifetime maximum |
|
PREVENTIVE MEDICAL CARE BENEFIT - NOT COVERED BY MEDICARE** Some annual physical and preventive tests and services administered or ordered by your doctor when not covered by Medicare: First $120 each calendar year Additional charges |
$0 $0 |
$120 $0 |
$0 All costs |
PLAN K
MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD
* You will pay half the cost sharing of some covered services until you reach the annual out-of-pocket limit of $4,000 each calendar year.
¿ The amounts that count toward your annual limit are noted with diamonds (¿) in the chart below. Once you reach the annual limit, the plan pays 100% of your Medicare copayment and coinsurance for the rest of the calendar year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called “Excess Charges”) and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.
** A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 consecutive days.
*** Medicare benefits are subject to change. For the current Medicare benefits, consult the most current version of the Guide to Health Insurance for People with Medicare which must be provided by an issuer to an applicant pursuant to NAC 687B.240.
**** The plan pays the costs that Medicare does not pay after you pay the deductible.
|
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY* |
|
HOSPITALIZATION** Semiprivate room and board, general nursing and miscellaneous services and supplies: First 60 days
61st thru 90th day 91st day and after: While using 60 lifetime reserve days Once lifetime reserve days are used: Additional 365 days
Beyond the additional 365 days |
***
***
***
$0
$0 |
*** (50% of Part A Deductible) ***
***
100% of Medicare Eligible Expenses $0 |
*** (50% of Part A Deductible)¿ $0
$0
$0
All costs |
|
SKILLED NURSING FACILITY CARE** You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital: First 20 days 21st thru 100th day 101st day and after |
All approved amounts *** $0 |
$0 *** $0 |
$0 ***¿ All costs |
|
BLOOD First 3 pints Additional amounts |
$0 100% |
50% $0 |
50%¿ $0 |
|
HOSPICE CARE Available as long as your doctor certifies you are terminally ill and you elect to receive these services
|
Generally, most Medicare Eligible Expenses for out-patient drugs and inpatient respite care |
50% of coinsurance or copayments
|
50% of coinsurance or copayments¿
|
PLAN K
MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR
* Once you have been billed $124 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.
¿¿ This plan limits your annual out-of-pocket payments for Medicare-approved amounts to $4,000 per year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called “Excess Charges”) and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.
|
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY¿¿ |
|
MEDICAL EXPENSES - IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment: First $124 of Medicare-approved amounts*
Preventive Benefits for Medicare-covered services
Remainder of Medicare-approved amounts |
$0
Generally 75% or more of Medicare-approved amounts Generally 80% |
$0
Remainder of Medicare-approved amounts Generally 10% |
$124 (Part B Deductible)¿ All costs above Medicare-approved amounts Generally 10%¿ |
|
Part B Excess Charges (Above Medicare-approved amounts)¿¿ |
$0 |
$0 |
All costs |
|
BLOOD First 3 pints Next $124 of Medicare-approved amounts*
Remainder of Medicare-approved amounts |
$0 $0
Generally 80% |
50% $0
Generally 10% |
50%¿ $124 (Part B Deductible)¿ Generally 10%¿ |
|
CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES |
100% |
$0 |
$0 |
PARTS A & B
** Medicare benefits are subject to change. For the current Medicare benefits, consult the latest Guide to Health Insurance for People with Medicare which must be provided by an issuer to an applicant pursuant to NAC 687B.240.
|
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY** |
|
HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically necessary skilled care services and medical supplies Durable medical equipment: First $124 of Medicare-approved amounts** Remainder of Medicare-approved amounts |
100%
$0 80% |
$0
$0 10% |
$0
$124 (Part B Deductible)¿ 10%¿ |
PLAN L
MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD
* You will pay one-fourth the cost sharing of some covered services until you reach the annual out-of-pocket limit of $2,000 each calendar year.
¿ The amounts that count toward your annual limit are noted with diamonds (¿) in the chart below. Once you reach the annual limit, the plan pays 100% of your Medicare copayment and coinsurance for the rest of the calendar year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called “Excess Charges”) and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.
** A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 consecutive days.
*** Medicare benefits are subject to change. For the current Medicare benefits, consult the most current version of the Guide to Health Insurance for People with Medicare which must be provided by an issuer to an applicant pursuant to NAC 687B.240.
**** The plan pays the costs that Medicare does not pay after you pay the deductible.
|
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY* |
|
HOSPITALIZATION** Semiprivate room and board, general nursing and miscellaneous services and supplies: First 60 days
61st thru 90th day 91st day and after: While using 60 lifetime reserve days Once lifetime reserve days are used: Additional 365 days
Beyond the additional 365 days |
***
***
***
$0
$0 |
*** (75% of Part A Deductible) ***
***
100% of Medicare Eligible Expenses $0 |
*** (25% of Part A Deductible)¿ $0
$0
$0
All costs |
|
SKILLED NURSING FACILITY CARE** You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital: First 20 days 21st thru 100th day 101st day and after |
All approved amounts *** $0 |
$0 *** $0 |
$0 ***¿ All costs |
|
BLOOD First 3 pints Additional amounts |
$0 100% |
75% $0 |
25%¿ $0 |
|
HOSPICE CARE Available as long as your doctor certifies you are terminally ill and you elect to receive these services
|
Generally, most Medicare Eligible Expenses for out-patient drugs and inpatient respite care |
75% of coinsurance or copayments
|
25% of coinsurance or copayments¿
|
PLAN L
MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR
* Once you have been billed $124 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.
¿¿ This plan limits your annual out-of-pocket payments for Medicare-approved amounts to $2,000 per year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called “Excess Charges”) and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.
|
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY¿¿ |
|
MEDICAL EXPENSES - IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment: First $124 of Medicare-approved amounts*
Preventive Benefits for Medicare-covered services
Remainder of Medicare-approved amounts |
$0
Generally 75% or more of Medicare-approved amounts Generally 80% |
$0
Remainder of Medicare-approved amounts
Generally 15% |
$124 (Part B Deductible)¿ All costs above Medicare-approved amounts Generally 5%¿ |
|
Part B Excess Charges (Above Medicare-approved amounts)¿¿ |
$0
|
$0
|
All costs
|
|
BLOOD First 3 pints Next $124 of Medicare-approved amounts*
Remainder of Medicare-approved amounts |
$0 $0
Generally 80% |
75% $0
Generally 15% |
25%¿ $124 (Part B Deductible)¿ Generally 5%¿ |
|
CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES |
100% |
$0 |
$0 |
PARTS A & B
** Medicare benefits are subject to change. For the current Medicare benefits, consult the latest Guide to Health Insurance for People with Medicare which must be provided by an issuer to an applicant pursuant to NAC 687B.240.
|
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY** |
|
HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically necessary skilled care services and medical supplies Durable medical equipment: First $124 of Medicare-approved amounts** Remainder of Medicare-approved amounts |
100%
$0 80% |
$0
$0 15% |
$0
$124 (Part B Deductible)¿ 5%¿ |
(Added to NAC by Comm’r of Insurance, 2-21-89, eff. 3-15-89; A 5-27-92, 7-16-92, eff. 7-30-98; 8-2-94; R110-98, 2-23-99; R075-02, 9-20-2002; R027-04, 8-2-2004; A by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit)
NAC 687B.255 Elicitation and dissemination of information regarding existing coverage and its replacement; inclusion of certain statements and questions in application. (NRS 679B.130, 687B.430)
1. An application for a policy to supplement Medicare must include questions designed to elicit information about whether, as of the date of the application, the applicant currently has another policy to supplement Medicare, Medicare Advantage, Medicaid coverage, or another health insurance policy or certificate in force or whether the policy to supplement Medicare or the certificate is intended to replace any other policy or certificate presently in force. A supplementary application or other form containing such questions and statements may be used if it is signed by the applicant and the issuer or its agent.
2. An application must contain the following statements and questions:
(a) You do not need more than one policy to supplement Medicare.
(b) You may be eligible for benefits under Medicaid and may not need a policy to supplement Medicare.
(c) If, after purchasing this policy, you become eligible for Medicaid, the benefits and premiums under your policy to supplement Medicare may, if requested, be suspended during your entitlement to benefits under Medicaid for 24 months. You must request this suspension within 90 days after becoming eligible for Medicaid. If you are no longer entitled to Medicaid, your suspended policy to supplement Medicare or, if that is no longer available, a substantially equivalent policy will be reinstituted if requested within 90 days after loss of eligibility. If the policy to supplement Medicare 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.
(d) If you are eligible for, and have enrolled in a policy to supplement Medicare by reason of disability and you later become covered by an employer or union-based group health plan, the benefits and premiums under your policy to supplement Medicare can be suspended, if requested, while you are covered under the employer or union-based group health plan. If you suspend your policy to supplement Medicare under these circumstances, and later lose your employer or union-based group health plan, your suspended policy to supplement Medicare 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 policy to supplement Medicare 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.
(e) Counseling services may be available in your state to provide advice concerning your purchase of a policy to supplement Medicare and concerning medical assistance available through the state Medicaid program, including benefits available to qualified Medicare beneficiaries, as that term is defined in 42 U.S.C. § 1396d(p)(1), and to specified low-income Medicare beneficiaries, as described in 42 U.S.C. § 1396a(a)(10)(E)(iii).
(f) If you lost or are losing your health insurance coverage and received a notice from your prior insurer saying that you were eligible for guaranteed issue of a policy to supplement Medicare, or that you had certain rights to buy such a policy, you may be guaranteed acceptance in one or more of our policies to supplement Medicare. Please include a copy of the notice from your prior insurer with your application. PLEASE ANSWER ALL QUESTIONS.
(g) [Please mark Yes or No below with an “X”]
To the best of your knowledge,
(1) (a) Did you turn age 65 in the last 6 months?
Yes _____ No _____
(b) Did you enroll in Medicare Part B in the last 6 months?
Yes _____ No _____
(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 _____ No _____
If yes,
(a) Will Medicaid pay your premiums for this policy to supplement Medicare?
Yes _____ No _____
(b) Do you receive any benefits from Medicaid OTHER THAN payments toward your Medicare Part B premium?
Yes _____ No _____
(3) (a) If you had coverage from any Medicare plan other than the 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 policy to supplement Medicare?
Yes _____ No _____
(c) Was this your first time in this type of Medicare plan?
Yes _____ No _____
(d) Did you drop a policy to supplement Medicare to enroll in the Medicare plan?
Yes _____ No _____
(4) (a) Do you have another policy to supplement Medicare in force?
Yes _____ No _____
(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 policy to supplement Medicare with this policy?
Yes _____ No _____
(5) Have you had coverage under any other health insurance within the past 63 days? (For example, an employer, union or individual plan)
Yes _____ No _____
(a) If so, with what company and what kind of policy?
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
(b) What are your dates of coverage under the policy?
Start ___/___/___ End ___/___/___
(If you are still covered under the other policy, leave “End” blank.)
3. An issuer shall provide to the applicant a list of any other policies of health insurance he has sold to the applicant. The list must include policies sold to the applicant which are in force at the time of the application and policies sold to the applicant in the previous 5 years which are no longer in force.
4. If the issuer is a direct response issuer, a copy of the application or supplemental form, signed by the applicant and acknowledged by the issuer, must be returned to the applicant by the issuer upon delivery of the policy to supplement Medicare.
5. Upon determining that the sale will involve the replacement of coverage to supplement Medicare, the issuer or its agent shall, before issuing or delivering the policy to supplement Medicare or the certificate, furnish the applicant with a notice regarding the replacement of coverage to supplement Medicare. One copy of the notice, signed by the applicant and the agent, must be provided to the applicant and another copy, signed by the applicant, must be retained by the issuer.
6. A direct response issuer shall deliver the notice required by subsection 5 to the applicant at the time of the issuance of the policy to supplement Medicare.
7. The notice required by subsection 5:
(a) Must be in a form prescribed by the Division;
(b) Must be in not less than 12-point type; and
(c) Except as otherwise provided in subsection 8, must be in substantially the following form:
NOTICE TO APPLICANT REGARDING REPLACEMENT
OF INSURANCE TO SUPPLEMENT MEDICARE
OR MEDICARE ADVANTAGE
(Insurance company’s name and address)
SAVE THIS NOTICE! IT MAY BE IMPORTANT TO YOU IN THE FUTURE.
According to (your application) (information you have furnished), you intend to terminate existing insurance to supplement Medicare or Medicare Advantage and replace it with a policy to be issued by (company name) Insurance Company. Your new policy will provide 30 days within which you may decide, without cost, whether you desire to keep the policy.
You should review this new coverage carefully. Compare it with all coverage for accidents and sickness you now have. If, after due consideration, you find that the purchase of this coverage to supplement Medicare is a wise decision, you should terminate your present policy to supplement Medicare or Medicare Advantage. You should evaluate the need for other accident and sickness coverage you have that may duplicate this policy.
STATEMENT TO APPLICATION BY ISSUER, AGENT (BROKER OR OTHER REPRESENTATIVE):
I have reviewed the coverage provided by your current policies of medical or health insurance. This policy to supplement Medicare will not duplicate your existing policy to supplement Medicare or, if applicable, Medicare Advantage because you intend to terminate your existing policy to supplement Medicare or leave your Medicare Advantage plan. The replacement policy is being purchased for the following reason(s) (check one):
_______________ Additional benefits.
_______________ No change in benefits, but lower premiums.
_______________ Fewer benefits and lower premiums.
_______________ My plan has outpatient prescription drug coverage, and I am enrolling in Medicare Part D.
_______________ Disenrollment from a Medicare Advantage plan. Please explain reason for disenrollment. [optional only for Direct Mailers]
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
_______________ Other (please specify).
Note: If the issuer of the policy to supplement Medicare being applied for does not, or is otherwise prohibited from, imposing preexisting condition limitations, please skip to the next statement below. Any health condition which you may presently have (preexisting conditions) may not be immediately or fully covered under the new policy. This could result in the denial of a claim for benefits or a delay in the payment of a claim under the new policy, whereas a similar claim might be payable under your present policy.
State law provides that your replacement policy or certificate may not contain any new preexisting condition, waiting period, elimination period or probationary period. The issuer will waive any time periods applicable to preexisting conditions, waiting periods, elimination periods or probationary periods in the new policy (or coverage) for similar benefits to the extent such time was spent (depleted) under the original policy.
If you still wish to terminate your present policy and replace it with new coverage, be certain to answer truthfully and completely all questions on the application concerning your medical and health history. Failure to include all material medical information on an application may provide a basis for the company to deny any future claims and to refund your premium as though your policy had never been in force. After the application has been completed and before you sign it, review it carefully to be certain that all information has been properly recorded. (If the policy or certificate is guaranteed issue, this paragraph need not appear.)
Do not cancel your present policy until you have received your new policy and are sure that you want to keep it.
..................................................................
(Signature of Agent, Broker or Other Representative)*
..................................................................
[Typed Name and Address of Issuer, Agent or Broker]
..................................................................
(Applicant’s Signature)
..................................................................
(Date)
*Signature not required for direct response sales.
8. The provisions of the replacement notice applicable to preexisting conditions may be deleted by an issuer if the replacement does not involve the application of a new limitation on a preexisting condition.
(Added to NAC by Comm’r of Insurance, 2-21-89, eff. 3-15-89; A 5-27-92; 7-16-92, eff. 7-30-92; 8-2-94; 5-13-96; A by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit)
NAC 687B.258 Replacement of existing coverage: Limitations on time periods for preexisting conditions, waiting periods, elimination periods and probationary periods. (NRS 679B.130, 687B.430)
1. If a policy to supplement Medicare or a certificate replaces another policy to supplement Medicare or certificate, the replacing issuer shall waive any time periods for preexisting conditions, waiting periods, elimination periods and probationary periods in the new policy or certificate for similar benefits to the extent that such time was spent under the original policy.
2. If a policy to supplement Medicare or a certificate replaces another policy to supplement Medicare or certificate which has been in effect for at least 6 months, the replacing policy or certificate must not provide any time period for preexisting conditions, waiting periods, elimination periods or probationary periods for benefits similar to those contained in the original policy or certificate.
(Added to NAC by Comm’r of Insurance, eff. 11-16-90; A 7-16-92, eff. 7-30-92)
NAC 687B.260 Policy to supplement Medicare or certificate issued before January 1, 1992: Replacement with standardized benefit plan. (NRS 679B.130, 687B.430)
1. Except as otherwise provided in subsection 2, an issuer shall, at the request of an insured, replace a policy to supplement Medicare which was issued before January 1, 1992, or a certificate which was issued before January 1, 1992, with any standardized benefit plan offered by the issuer. An insured may submit a request to replace a policy to supplement Medicare or certificate pursuant to this subsection not more than once.
2. An issuer may refuse a request made pursuant to subsection 1 for the issuance of a standardized benefit plan to replace a policy to supplement Medicare or certificate which was issued before January 1, 1992, if:
(a) The standardized benefit plan includes coverage for prescription drugs; or
(b) The insured does not otherwise qualify for the standardized benefit plan.
3. If an insured requests a standardized benefit plan to replace a policy to supplement Medicare or certificate pursuant to subsection 1 from an issuer that establishes the rates of a standardized benefit plan on the basis of the age of an applicant, the issuer must use the attained age of the insured on the date his request is submitted to establish the rate for the standardized benefit plan.
(Added to NAC by Comm’r of Insurance by R027-04, eff. 8-2-2004; A by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit)
NAC 687B.263 Termination and replacement of coverage under group policy. (NRS 679B.130, 687B.430)
1. If a group policy to supplement Medicare or a certificate is terminated by the group policyholder or certificate holder and is not replaced as provided in subsection 3, the issuer shall offer each certificate holder an individual policy to supplement Medicare or a certificate. The issuer shall offer the certificate holder an individual policy that provides for the continuation of the benefits contained in the group policy.
2. If a certificate holder is provided coverage under a group policy to supplement Medicare or a certificate and he terminates his membership in the group, the issuer shall:
(a) Offer the certificate holder an individual policy to supplement Medicare pursuant to subsection 1; or
(b) At the request of the group policyholder, continue coverage for the certificate holder under the group policy to supplement Medicare.
3. If a group policy to supplement Medicare or a certificate is replaced by another group policy to supplement Medicare or certificate which is purchased by the same person, the issuer of the replacement policy or certificate shall offer coverage to all persons who are covered under the policy or certificate that is being replaced on the date it is terminated. The replacement policy or certificate may not provide for the exclusion of coverage for preexisting conditions that were covered under the policy or certificate that is being replaced.
4. If a group policy to supplement Medicare eliminates an outpatient prescription drug benefit as a result of requirements imposed by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, Public Law 108-173, 117 Stat. 2066, December 8, 2003, the modified policy shall be deemed to satisfy the guaranteed renewal requirements of this section.
(Added to NAC by Comm’r of Insurance, eff. 11-16-90; A 7-16-92, eff. 7-30-92; 8-2-94; A by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit)
NAC 687B.265 Notice of modifications to policy or certificate; compliance with certain notice requirements. (NRS 679B.130, 687B.430)
1. As soon as practicable, but not later than 30 days before the annual effective date of any changes in Medicare benefits, an issuer shall notify each policyholder and certificate holder of any modifications it has made to the policy to supplement Medicare or the certificate. The notice must:
(a) Include a description of any revisions to the Medicare program and a description of each modification made to the coverage provided under the policy or certificate.
(b) Inform each policyholder or certificate holder of the date on which any adjustment of premiums is to be made because of changes in Medicare.
(c) Be in outline form and in clear and simple terms so as to facilitate comprehension.
(d) Be in a format which is acceptable to the Commissioner.
2. The notice must not contain or be accompanied by any solicitation.
3. Issuers shall comply with any notice requirements of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, Public Law 108-173, 117 Stat. 2066, December 8, 2003.
(Added to NAC by Comm’r of Insurance, 2-21-89, eff. 3-15-89; A 11-16-90; 7-16-92, eff. 7-30-92; A by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit)
NAC 687B.269 Notice required that certain policies of insurance are not supplementary to Medicare; disclosure of extent to which policy or certificate duplicates coverage of Medicare. (NRS 679B.130, 687B.430)
1. An insurer that delivers or issues for delivery in this State:
(a) An insurance policy that provides coverage for accidents or sickness, including a policy to provide income in case of a disability, other than a policy to supplement Medicare;
(b) A policy of insurance issued pursuant to a contract under section 1876 of the Social Security Act, 42 U.S.C. §§ 1395 et seq.; or
(c) A policy of insurance identified in subsection 2 of NAC 687B.205,
Ê to a person who is eligible for Medicare shall give notice to the insureds under the policy that the policy is not a policy to supplement Medicare.
2. Such notice must be:
(a) Printed on or attached to the first page of the outline of coverage delivered to the insureds under the policy or, if an outline of coverage is not delivered to the insureds, to the first page of the policy or certificate delivered to the insureds.
(b) In not less than 12-point type and contain the following language:
THIS (POLICY OR CERTIFICATE) IS NOT A (POLICY OR CONTRACT) TO SUPPLEMENT MEDICARE. If you are eligible for Medicare, review the Guide to Health Insurance for People with Medicare which is available from the insurance company.
3. Applications for the health insurance policies or certificates described in subsection 1 provided to persons eligible for Medicare must disclose on the appropriate statement developed by the National Association of Insurance Commissioners and approved by the Commissioner the extent to which the health insurance policy or certificate duplicates the coverage of Medicare. The disclosure must be provided as part of or together with the application for the policy or certificate.
(Added to NAC by Comm’r of Insurance, 7-16-92, eff. 7-30-92; A 5-13-96)
NAC 687B.273 Standards of practice for marketing. (NRS 679B.130, 687B.430)
1. An issuer, directly or through its producers, shall:
(a) Establish marketing procedures to ensure that any comparison of policies to supplement Medicare by its agents or other producers is fair and accurate.
(b) Establish marketing procedures to ensure that excessive insurance is not sold or issued.
(c) Establish marketing procedures which set forth a mechanism or formula for determining whether a replacement policy or certificate contains benefits clearly and substantially greater than the benefits under the replaced policy.
(d) Display prominently by type, stamp or other appropriate means, on the first page of the policy to supplement Medicare the following notice:
“Notice to buyer: This policy may not cover all of your medical expenses.”
(e) Inquire and otherwise make every reasonable effort to determine whether a prospective applicant or person enrolled for a policy to supplement Medicare has accident and sickness insurance and identify the types and amounts of any such insurance.
(f ) Establish procedures that may be audited for verifying compliance with this section.
2. In addition to the practices prohibited in chapters 686A of NRS and NAC, the following practices are prohibited:
(a) Knowingly making any misleading representation or incomplete or fraudulent comparison of any policies of insurance or issuers to induce or tend to induce any person to allow to lapse, forfeit, surrender, terminate, retain, pledge, assign, borrow on or convert any policy of insurance or to take out a policy of insurance with another issuer, commonly referred to as “twisting.”
(b) High-pressure tactics, including:
(1) Any method of marketing that has the effect of or tends to induce the purchase of insurance through force, fright or threat, whether explicit or implied; and
(2) Undue pressure to purchase or recommend the purchase of insurance.
(c) Directly or indirectly making use of any method of marketing which fails to disclose in a conspicuous manner that a purpose of the method of marketing is the solicitation of insurance and that contact will be made by an agent or insurance company, commonly referred to as “cold lead advertising.”
(d) Using the terms “Medicare Supplement,” “Medigap,” “Medicare Wrap-Around” or words of similar import in a policy to supplement Medicare or a certificate if the policy or certificate does not comply with the provisions of NAC 687B.200 to 687B.330, inclusive.
(Added to NAC by Comm’r of Insurance, eff. 11-16-90; A 7-16-92, eff. 7-30-92)
NAC 687B.275 Compensation of agents and other representatives and producers. (NRS 679B.130, 687B.430)
1. An issuer or other entity may provide a commission or other compensation to an agent or other representative for the sale of a policy to supplement Medicare or a certificate only if the commission or other compensation for the first year is no more than 200 percent of the commission or other compensation paid for selling or servicing the policy or certificate in the second year or period.
2. The commission or other compensation provided in a subsequent renewal year must be:
(a) The same as that provided in the second year or period; and
(b) Provided for not less than 5 renewal years.
3. An issuer or other entity shall not provide to its agents or other producers, and an agent or producer shall not accept, compensation that is greater than the compensation for renewal that would have been paid by the replacing issuer on a renewal policy to supplement Medicare or a certificate if the existing policy or certificate is replaced.
4. As used in this section, “compensation” includes pecuniary or nonpecuniary remuneration of any kind relating to the sale or renewal of the policy to supplement Medicare or the certificate, including, but not limited to, any bonus, gift, prize, award or finders fee.
(Added to NAC by Comm’r of Insurance, 2-21-89, eff. 3-15-89; A 11-16-90; 7-16-92, eff. 7-30-92)
NAC 687B.280 Review of proposed advertising. (NRS 679B.130, 687B.430) Each issuer shall furnish the Division, for its review, with a copy of any advertisement for a policy to supplement Medicare which is intended for use in this State, including any written, radio, television or newspaper advertisement.
(Added to NAC by Comm’r of Insurance, 2-21-89, eff. 3-15-89; A 5-27-92; 7-16-92, eff. 7-30-92)
NAC 687B.282 Recommendations for purchase or replacement; sale of multiple policies or certificates; issuance of policy or certificate to person enrolled in Medicare Part C. (NRS 679B.130, 687B.430)
1. If an agent recommends the purchase or replacement of any policy to supplement Medicare or certificate, the agent shall make reasonable efforts to determine the appropriateness of the recommended purchase or replacement.
2. Any sale of a policy to supplement Medicare or a certificate that provides a person with more than one policy to supplement Medicare or certificate is prohibited.
3. An issuer shall not issue a policy to supplement Medicare or certificate to a person enrolled in Medicare Part C unless the effective date of the coverage is after the termination date of the person’s Part C coverage.
(Added to NAC by Comm’r of Insurance, eff. 11-16-90; A 7-16-92, eff. 7-30-92; A by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit)
NAC 687B.283 Reporting of multiple policies or certificates. (NRS 679B.130, 687B.430)
1. On or before March 1 of each year, an issuer shall report the number of the policy, the certificate number and the date of issuance for each resident of this State for whom the issuer has in force more than one policy to supplement Medicare or certificate. The report must include all this information for each individual policyholder in a format prescribed by the Commissioner.
2. The provisions of this section apply to an issuer of a policy to supplement Medicare delivered or issued for delivery in this State, regardless of the date the policy was delivered or issued for delivery.
(Added to NAC by Comm’r of Insurance, eff. 11-16-90; A 7-16-92, eff. 7-30-92)
NAC 687B.286 Compliance with certain provisions of Social Security Act regarding notice and payment of claims. (NRS 679B.130, 687B.430)
1. An issuer shall comply with the provisions of section 1882(c)(3) of the Social Security Act, 42 U.S.C. §§ 1395 et seq., as enacted by section 4081(b)(2)(c) of the Omnibus Budget Reconciliation Act of 1987, Public Law No. 100-203, by:
(a) Accepting a notice from a Medicare carrier on an assigned claim submitted by a participating physician or supplier as a claim for benefits in lieu of any other claim form otherwise required;
(b) Making a determination for payment on the basis of the information contained in that notice;
(c) Notifying the participating physician or supplier and the beneficiary of the determination for payment;
(d) Paying the participating physician or supplier directly;
(e) Furnishing each enrollee, at the time of enrollment, with a card listing the name and number of the policy and a central mailing address to which notices from a Medicare carrier may be sent;
(f ) Paying the user fees for claim notices that are transmitted electronically or otherwise; and
(g) Providing to the Secretary of Health and Human Services, at least annually, a central mailing address to which all claims may be sent by Medicare carriers.
2. Compliance with the requirements set forth in subsection 1 must be certified on the form for reporting experience incurred for policies to supplement Medicare and certificates which is prescribed by the Commissioner.
3. The provisions of this section apply to an issuer of a policy to supplement Medicare or a certificate which is delivered or issued for delivery in this State, regardless of the date the policy or certificate was delivered or issued for delivery.
(Added to NAC by Comm’r of Insurance, 7-16-92, eff. 7-30-92)
Standardized Benefit Plans
NAC 687B.290 Availability; minimum benefits. (NRS 679B.130, 687B.430)
1. An issuer who delivers or issues for delivery in this State a policy to supplement Medicare or a certificate on or after July 30, 1992, shall make available to each prospective insured a policy or certificate that provides only the following benefits:
(a) Coverage of Medicare Part A eligible expenses for hospitalization to the extent they are not covered by Medicare from the 61st day through the 90th day in any Medicare benefit period.
(b) Coverage of Medicare Part A eligible expenses incurred for hospitalization to the extent they are 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 100 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 365 days.
(d) Plans A to J, inclusive, provide coverage under Medicare Parts A and B for the reasonable cost of the first 3 pints of blood, or an equivalent quantity of packed red blood cells, as defined by federal regulations, unless replaced in accordance with federal regulations. Plans K and L provide for 50 percent and 75 percent, respectively, of the reasonable cost for the first 3 pints of blood.
(e) Coverage for the coinsurance amount of Medicare eligible expenses under Part B regardless of confinement in a hospital, subject to the Medicare Part B deductible.
2. In addition to the benefits required by subsection 1, an issuer may make available to prospective insureds any other standardized benefit plans to supplement Medicare as set forth in NAC 687B.295 to 687B.321, inclusive.
(Added to NAC by Comm’r of Insurance, 7-16-92, eff. 7-30-92; A by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit)
NAC 687B.295 General requirements. (NRS 679B.130, 687B.430)
1. Except as otherwise provided in NAC 687B.330, a standardized benefit plan to supplement Medicare may not be delivered or issued for delivery in this State on or after July 30, 1992, unless it complies with the provisions of NAC 687B.300 to 687B.321, inclusive.
2. Except as otherwise provided in subsection 4, a standardized benefit plan must:
(a) Have the same style, arrangement, overall content and designation as the standardized benefit plans set forth in NAC 687B.300 to 687B.321, inclusive.
(b) Conform to the definitions set forth in NAC 687B.201 to 687B.2045, inclusive.
3. Each benefit must be structured in accordance with the format and listed in the order indicated in NAC 687B.300 to 687B.321, inclusive.
4. In addition to the designations for standardized benefit plans set forth in NAC 687B.300 to 687B.321, inclusive, an issuer may use other designations if he obtains the prior approval of the Commissioner.
(Added to NAC by Comm’r of Insurance, 7-16-92, eff. 7-30-92; A by R110-98, 2-23-99)
NAC 687B.300 Standardized Benefit Plan A. (NRS 679B.130, 687B.430) A benefit plan to supplement Medicare which is designated as Standardized Benefit Plan A must be limited to the benefits required by NAC 687B.290.
(Added to NAC by Comm’r of Insurance, 7-16-92, eff. 7-30-92)
NAC 687B.302 Standardized Benefit Plan B. (NRS 679B.130, 687B.430) A benefit plan to supplement Medicare which is designated as Standardized Benefit Plan B must provide the following benefits:
1. The benefits required by NAC 687B.290.
2. Coverage for all of the Medicare Part A inpatient hospital deductible amount per benefit period.
(Added to NAC by Comm’r of Insurance, 7-16-92, eff. 7-30-92)
NAC 687B.304 Standardized Benefit Plan C. (NRS 679B.130, 687B.430) A benefit plan to supplement Medicare which is designated as Standardized Benefit Plan C must provide the following benefits:
1. The benefits required by NAC 687B.290.
2. Coverage for all of the Medicare Part A inpatient hospital deductible amount per benefit period.
3. For Medicare Part A eligible expenses for posthospital care received at a skilled nursing facility, coverage for the actual billed charges up to the coinsurance amount from the 21st day through the 100th day in any Medicare benefit period.
4. Coverage for all of the Medicare Part B deductible amount per calendar year, regardless of whether the insured has been confined in a hospital.
5. Coverage of Medicare eligible expenses for 80 percent of the billed charges for medically necessary emergency care received in a foreign country to the extent not covered by Medicare, if such care would have been covered by Medicare if provided in the United States and the care began during the first 60 consecutive days of the trip outside the United States. The benefit is subject to the payment of a deductible of $250 per calendar year and a lifetime maximum benefit of $50,000. As used in this subsection, “emergency care” means medical care needed immediately because of a sudden and unexpected injury or illness.
(Added to NAC by Comm’r of Insurance, 7-16-92, eff. 7-30-92)
NAC 687B.306 Standardized Benefit Plan D. (NRS 679B.130, 687B.430) A benefit plan to supplement Medicare which is designated as Standardized Benefit Plan D must provide the following benefits:
1. The benefits required by NAC 687B.290.
2. Coverage for all of the Medicare Part A inpatient hospital deductible amount per benefit period.
3. For Medicare Part A eligible expenses for posthospital care received at a skilled nursing facility, coverage for the actual billed charges up to the coinsurance amount from the 21st day through the 100th day in any Medicare benefit period.
4. Coverage of Medicare eligible expenses for 80 percent of the billed charges for medically necessary emergency care received in a foreign country to the extent not covered by Medicare, if such care would have been covered by Medicare if provided in the United States and the care began during the first 60 consecutive days of the trip outside the United States. The benefit is subject to the payment of a deductible of $250 per calendar year and a lifetime maximum benefit of $50,000. As used in this subsection, “emergency care” means medical care needed immediately because of a sudden and unexpected injury or illness.
5. Coverage for short-term services that provide to a person recovering from an illness, injury or surgery in his home, assistance with daily activities such as bathing, dressing, personal hygiene, eating, ambulating, administering prescription drugs and changing bandages and other dressings. The coverage must comply with the requirements of NAC 687B.325.
(Added to NAC by Comm’r of Insurance, 7-16-92, eff. 7-30-92)
NAC 687B.308 Standardized Benefit Plan E. (NRS 679B.130, 687B.430) A benefit plan to supplement Medicare which is designated as Standardized Benefit Plan E must provide the following benefits:
1. The benefits required by NAC 687B.290.
2. Coverage for all of the Medicare Part A inpatient hospital deductible amount per benefit period.
3. For Medicare Part A eligible expenses for posthospital care received at a skilled nursing facility, coverage for the actual billed charges up to the coinsurance amount from the 21st day through the 100th day in any Medicare benefit period.
4. Coverage of Medicare eligible expenses for 80 percent of the billed charges for medically necessary emergency care received in a foreign country to the extent not covered by Medicare, if such care would have been covered by Medicare if provided in the United States and the care began during the first 60 consecutive days of the trip outside the United States. The benefit is subject to the payment of a deductible of $250 per calendar year and a lifetime maximum benefit of $50,000. As used in this subsection, “emergency care” means medical care needed immediately because of a sudden and unexpected injury or illness.
5. Coverage for the following preventative health services for the actual amount charged for each service not to exceed 100 percent of the amount approved by Medicare for that service, as identified in the American Medical Association’s Current Procedural Terminology (AMA CPT) codes, not to exceed $120 per year, and to the extent not covered by Medicare:
(a) An annual clinical medical history and physical examination that may include the tests and services set forth in paragraph (b) and educational services that address measures to be taken for preventative health care.
(b) Preventive screening tests or preventive services, the selection and frequency of which is determined to be medically appropriate by the attending physician.
(Added to NAC by Comm’r of Insurance, 7-16-92, eff. 7-30-92; A 5-13-96; R110-98, 2-23-99; A by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit)
NAC 687B.311 Standardized Benefit Plan F or High Deductible Benefit Plan F. (NRS 679B.130, 687B.430)
1. A benefit plan to supplement Medicare which is designated as Standardized Benefit Plan F or High Deductible Benefit Plan F must provide the following benefits:
(a) The benefits required by NAC 687B.290.
(b) Coverage for all of the Medicare Part A inpatient hospital deductible amount per benefit period.
(c) For Medicare Part A eligible expenses for posthospital care received at a skilled nursing facility, coverage for the actual billed charges up to the coinsurance amount from the 21st day through the 100th day in any Medicare benefit period.
(d) Coverage for all of the Medicare Part B deductible amount per calendar year, regardless of whether the insured has been confined in a hospital.
(e) Coverage for 100 percent of the Medicare Part B excess charge calculated by determining the difference between the actual Medicare Part B charge as billed, not to exceed any limitation on that charge established by the Medicare program or state law, and the Medicare Part B charge that has been approved.
(f ) Coverage of Medicare eligible expenses for 80 percent of the billed charges for medically necessary emergency care received in a foreign country to the extent not covered by Medicare, if such care would have been covered by Medicare if provided in the United States and the care began during the first 60 consecutive days of the trip outside the United States. The benefit is subject to the payment of a deductible of $250 per calendar year and a lifetime maximum benefit of $50,000. As used in this paragraph, “emergency care” means medical care needed immediately because of a sudden and unexpected injury or illness.
2. In addition to the requirements of subsection 1, a benefit plan to supplement Medicare which is designated as High Deductible Benefit Plan F must require the insured to pay an annual deductible. The annual deductible for High Deductible Benefit Plan F is subject to change. For the current deductible, please consult the most current version of the Guide to Health Insurance for People with Medicare which must be provided by an issuer to an applicant pursuant to NAC 687B.240. The cover page of the outline of coverage which must be provided to an applicant by an issuer pursuant to NAC 687B.250 must specify the current amount of the deductible. The annual deductible for High Deductible Benefit Plan F may be adjusted annually by the Secretary of the United States Department of Health and Human Services to reflect the change in the Consumer Price Index for All Urban Consumers published by the United States Department of Labor for the calendar year ending on July 31 of the immediately preceding year, and rounded to the nearest multiple of $10. The deductible must be paid in addition to the premium and in addition to any other deductibles relating to a specific benefit.
(Added to NAC by Comm’r of Insurance, 7-16-92, eff. 7-30-92; A by R110-98, 2-23-99; R075-02, 9-20-2002; R027-04, 8-2-2004)
NAC 687B.313 Standardized Benefit Plan G. (NRS 679B.130, 687B.430) A benefit plan to supplement Medicare which is designated as Standardized Benefit Plan G must provide the following benefits:
1. The benefits required by NAC 687B.290.
2. Coverage for all of the Medicare Part A inpatient hospital deductible amount per benefit period.
3. For Medicare Part A eligible expenses for posthospital care received at a skilled nursing facility, coverage for the actual billed charges up to the coinsurance amount from the 21st day through the 100th day in any Medicare benefit period.
4. Coverage for 80 percent of the Medicare Part B excess charge calculated by determining the difference between the actual Medicare Part B charge as billed, not to exceed any limitation on that charge established by the Medicare program or state law, and the Medicare Part B charge that has been approved.
5. Coverage of Medicare eligible expenses for 80 percent of the billed charges for medically necessary emergency care received in a foreign country to the extent not covered by Medicare, if such care would have been covered by Medicare if provided in the United States and the care began during the first 60 consecutive days of the trip outside the United States. The benefit is subject to the payment of a deductible of $250 per calendar year and a lifetime maximum benefit of $50,000. As used in this subsection, “emergency care” means medical care needed immediately because of a sudden and unexpected injury or illness.
6. Coverage for short-term services that provide to a person recovering from an illness, injury or surgery in his home, assistance with daily activities such as bathing, dressing, personal hygiene, eating, ambulating, administering prescription drugs and changing bandages and other dressings. The coverage must comply with the requirements of NAC 687B.325.
(Added to NAC by Comm’r of Insurance, 7-16-92, eff. 7-30-92)
NAC 687B.315 Standardized Benefit Plan H. (NRS 679B.130, 687B.430) A benefit plan to supplement Medicare which is designated as Standardized Benefit Plan H must provide the following benefits:
1. The benefits required by NAC 687B.290.
2. Coverage for all of the Medicare Part A inpatient hospital deductible amount per benefit period.
3. For Medicare Part A eligible expenses for posthospital care received at a skilled nursing facility, coverage for the actual billed charges up to the coinsurance amount from the 21st day through the 100th day in any Medicare benefit period.
4. For plans sold or issued before January 1, 2006, as a basic benefit, coverage is provided for 50 percent of the charges for prescription drugs received as an outpatient, after payment of a deductible of $250 per calendar year, not to exceed $1,250 in benefits received by the insured per calendar year, and to the extent not covered by Medicare. This subsection only applies to those persons currently covered by Plan H and who do not apply for Medicare Part D.
5. Coverage of Medicare eligible expenses for 80 percent of the billed charges for medically necessary emergency care received in a foreign country to the extent not covered by Medicare, if such care would have been covered by Medicare if provided in the United States and the care began during the first 60 consecutive days of the trip outside the United States. The benefit is subject to the payment of a deductible of $250 per calendar year and a lifetime maximum benefit of $50,000. As used in this subsection, “emergency care” means medical care needed immediately because of a sudden and unexpected injury or illness.
(Added to NAC by Comm’r of Insurance, 7-16-92, eff. 7-30-92; A by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit)
NAC 687B.317 Standardized Benefit Plan I. (NRS 679B.130, 687B.430) A benefit plan to supplement Medicare which is designated as Standardized Benefit Plan I must provide the following benefits:
1. The benefits required by NAC 687B.290.
2. Coverage for all of the Medicare Part A inpatient hospital deductible amount per benefit period.
3. For Medicare Part A eligible expenses for posthospital care received at a skilled nursing facility, coverage for the actual billed charges up to the coinsurance amount from the 21st day through the 100th day in any Medicare benefit period.
4. Coverage for 100 percent of the Medicare Part B excess charge calculated by determining the difference between the actual Medicare Part B charge as billed, not to exceed any limitation on that charge established by the Medicare program or state law, and the Medicare Part B charge that has been approved.
5. For plans sold or issued before January 1, 2006, as a basic benefit, coverage is provided for 50 percent of the charges for prescription drugs received as an outpatient, after payment of a deductible of $250 per calendar year, not to exceed $1,250 in benefits received by the insured per calendar year, to the extent not covered by Medicare. This subsection only applies to those persons currently covered by Plan I and who do not apply for Medicare Part D.
6. Coverage of Medicare eligible expenses for 80 percent of the billed charges for medically necessary emergency care received in a foreign country to the extent not covered by Medicare, if such care would have been covered by Medicare if provided in the United States and the care began during the first 60 consecutive days of the trip outside the United States. The benefit is subject to the payment of a deductible of $250 per calendar year and a lifetime maximum benefit of $50,000. As used in this subsection, “emergency care” means medical care needed immediately because of a sudden and unexpected injury or illness.
7. Coverage for short-term services that provide to a person recovering from an illness, injury or surgery in his home, assistance with daily activities such as bathing, dressing, personal hygiene, eating, ambulating, administering prescription drugs and changing bandages and other dressings. The coverage must comply with the requirements of NAC 687B.325.
(Added to NAC by Comm’r of Insurance, 7-16-92, eff. 7-30-92; A by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit)
NAC 687B.319 Standardized Benefit Plan J or High Deductible Benefit Plan J. (NRS 679B.130, 687B.430)
1. A benefit plan to supplement Medicare which is designated as Standardized Benefit Plan J or High Deductible Benefit Plan J must provide the following benefits:
(a) The benefits required by NAC 687B.290.
(b) Coverage for all of the Medicare Part A inpatient hospital deductible amount per benefit period.
(c) For Medicare Part A eligible expenses for posthospital care received at a skilled nursing facility, coverage for the actual billed charges up to the coinsurance amount from the 21st day through the 100th day in any Medicare benefit period.
(d) Coverage for all of the Medicare Part B deductible amount per calendar year, regardless of whether the insured has been confined in a hospital.
(e) Coverage for 100 percent of the Medicare Part B excess charge calculated by determining the difference between the actual Medicare Part B charge as billed, not to exceed any limitation on that charge established by the Medicare program or state law, and the Medicare Part B charge that has been approved.
(f) For plans sold or issued before January 1, 2006, as an extended benefit, coverage is provided for 50 percent of the charges for prescription drugs received as an outpatient, after payment of a deductible of $250 per calendar year, not to exceed $3,000 in benefits received by the insured per calendar year, to the extent not covered by Medicare. This paragraph only applies to those persons currently covered by Plan J and who do not apply for Medicare Part D.
(g) Coverage of Medicare eligible expenses for 80 percent of the billed charges for medically necessary emergency care received in a foreign country to the extent not covered by Medicare, if such care would have been covered by Medicare if provided in the United States and the care began during the first 60 consecutive days of the trip outside the United States. The benefit is subject to the payment of a deductible of $250 per calendar year and a lifetime maximum benefit of $50,000. As used in this paragraph, “emergency care” means medical care needed immediately because of a sudden and unexpected injury or illness.
(h) Coverage for the following preventative health services for the actual amount charged for each service not to exceed 100 percent of the amount approved by Medicare for that service, as identified in the American Medical Association’s Current Procedural Terminology (AMA CPT) codes, not to exceed $120 per year, to the extent not covered by Medicare:
(1) An annual clinical medical history and physical examination that may include the tests and services set forth in subparagraph (2) and educational services that address measures to be taken for preventative health care.
(2) Preventive screening tests or preventive services, the selection and frequency of which is determined to be medically appropriate by the attending physician.
(i) Coverage for short-term services that provide to a person recovering from an illness, injury or surgery in his home, assistance with daily activities such as bathing, dressing, personal hygiene, eating, ambulating, administering prescription drugs and changing bandages and other dressings. The coverage must comply with the requirements of NAC 687B.325.
2. In addition to the requirements of subsection 1, a benefit plan to supplement Medicare which is designated as High Deductible Benefit Plan J must require the insured to pay an annual deductible. The annual deductible for High Deductible Benefit Plan J is subject to change. For the current deductible, please consult the most current version of the Guide to Health Insurance for People with Medicare which must be provided by an issuer to an applicant pursuant to NAC 687B.240. The cover page of the outline of coverage which must be provided to an applicant by an issuer pursuant to NAC 687B.250 must specify the current amount of the deductible. The annual deductible for High Deductible Benefit Plans F and J may be adjusted annually by the Secretary of Health and Human Services to reflect the change in the Consumer Price Index for All Urban Consumers published by the United States Department of Labor for the calendar year ending on July 31 of the immediately preceding year, and rounded to the nearest multiple of $10. The deductible must be paid in addition to the premium and in addition to any other deductibles relating to a specific benefit.
(Added to NAC by Comm’r of Insurance, 7-16-92, eff. 7-30-92; A 5-13-96; R110-98, 2-23-99; R075-02, 9-20-2002; R027-04, 8-2-2004; A by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit)
NAC 687B.320 Standardized Benefit Plan K. (NRS 679B.130, 687B.430) A benefit plan to supplement Medicare which is designated as Standardized Benefit Plan K must provide the following benefits:
1. The benefits required by NAC 687B.290.
2. Coverage for 50 percent of the Medicare Part A inpatient hospital deductible amount per benefit period until the out-of-pocket limitation is met as described in subsection 8.
3. Coverage for 50 percent of the coinsurance amount for each day used from the 21st day through the 100th day in a Medicare benefit period for posthospital skilled nursing facility care eligible under Medicare Part A until the out-of-pocket limitation is met as described in subsection 8.
4. Coverage for 50 percent of cost sharing for all Medicare Part A eligible expenses and respite care until the out-of-pocket limitation is met as described in subsection 8.
5. Coverage for 50 percent, under Medicare Part A or B, of the reasonable cost of the first 3 pints of blood, or equivalent quantities of packed red blood cells, as defined under federal regulations, unless replaced in accordance with federal regulations, until the out-of-pocket limitation is met as described in subsection 8.
6. Except for coverage provided in subsection 8, coverage for 50 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 subsection 8.
7. Coverage of 100 percent of the cost sharing for Medicare Part B preventive services after the policyholder pays the Part B deductible.
8. Coverage of 100 percent of all cost sharing under Medicare Parts A and B for the balance of the calendar year after the person has reached the out-of-pocket limitation on annual expenditures under Medicare Parts A and B of $4,000 in 2006, indexed each year by the appropriate inflation adjustment specified by the Secretary of Health and Human Services.
(Added to NAC by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit)
NAC 687B.321 Standardized Benefit Plan L. (NRS 679B.130, 687B.430) A benefit plan to supplement Medicare which is designated as Standardized Benefit Plan L must provide the following benefits:
1. The benefits required by NAC 687B.290.
2. Coverage for 75 percent of the Medicare Part A inpatient hospital deductible amount per benefit period until the out-of-pocket limitation is met as described in subsection 8.
3. Coverage for 75 percent of the coinsurance amount for each day used from the 21st day through the 100th day in a Medicare benefit period for posthospital skilled nursing facility care eligible under Medicare Part A until the out-of-pocket limitation is met as described in subsection 8.
4. Coverage for 75 percent of cost sharing for all Medicare Part A eligible expenses and respite care until the out-of-pocket limitation is met as described in subsection 8.
5. Coverage for 75 percent, under Medicare Part A or B, of the reasonable cost of the first 3 pints of blood, or equivalent quantities of packed red blood cells, as defined under federal regulations, unless replaced in accordance with federal regulations, until the out-of-pocket limitation is met as described in subsection 8.
6. Except for coverage provided in subsection 8, coverage for 75 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 subsection 8.
7. Coverage of 100 percent of the cost sharing for Medicare Part B preventive services after the policyholder pays the Part B deductible.
8. Coverage of 100 percent of all cost sharing under Medicare Parts A and B for the balance of the calendar year after the person has reached the out-of-pocket limitation on annual expenditures under Medicare Parts A and B of $2,000 in 2006, indexed each year by the appropriate inflation adjustment specified by the Secretary of Health and Human Services.
(Added to NAC by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit)
NAC 687B.325 Coverage for short-term services provided to person recovering at home. (NRS 679B.130, 687B.430)
1. Coverage for short-term services provided to a person recovering from an illness, injury or surgery in his home must comply with the following requirements:
(a) The insured’s attending physician must certify that the specific type and frequency of recovery services provided at home are necessary because of a condition for which a plan of treatment provided at home was approved by Medicare.
(b) Coverage must be limited to:
(1) No more than the number and type of recovery visits certified as necessary by the insured’s attending physician. The total number of recovery visits may not exceed the number of visits approved by Medicare pursuant to a plan of treatment provided at home that has been approved by Medicare.
(2) The actual charges for each recovery visit not to exceed a maximum reimbursement of $40 per visit.
(3) A maximum reimbursement of $1,600 per calendar year.
(4) Seven visits in any 1 week.
(5) Care furnished on a visiting basis in the insured’s home.
(6) Services provided by a provider of health care.
(7) Recovery visits received:
(I) While the insured is covered under the policy to supplement Medicare or the certificate and not otherwise excluded.
(II) During the period the insured is receiving services at home which are approved by Medicare or no later than 8 weeks after the date of the last recovery visit approved by Medicare.
(c) Coverage must be excluded for:
(1) Recovery visits paid for by Medicare or another governmental program.
(2) Care provided by members of the insured’s family, unpaid volunteers or other persons who are not providers of health care.
2. As used in this section:
(a) “Home” means any location used by the insured as a place of residence if that location would qualify as a residence for health care services provided at home which are covered by Medicare. The term does not include a hospital or skilled nursing facility.
(b) “Provider of health care” means a qualified or licensed aide or homemaker who provides health care in the home, an aide who provides personal care or a nurse provided through a licensed agency for home health care or referred by a licensed referral agency or licensed registry for nurses.
(c) “Recovery visit” means a visit required to provide care to the insured at home, without a limit on the duration of the visit, except each consecutive 4 hours of services in a 24-hour period is one visit.
(Added to NAC by Comm’r of Insurance, 7-16-92, eff. 7-30-92)
NAC 687B.330 Provision of new or innovative benefits. (NRS 679B.130, 687B.430)
1. An issuer may, with the prior approval of the Commissioner, offer a policy to supplement Medicare or a certificate with new or innovative benefits in addition to the benefits required by NAC 687B.290 to 687B.321, inclusive. The new or innovative benefits may include benefits that are:
(a) Appropriate to supplement Medicare;
(b) Not otherwise available;
(c) Cost-effective; and
(d) Offered in a manner that is consistent with the goal of simplifying policies to supplement Medicare.
2. After December 31, 2005, an innovative benefit must not include an outpatient prescription drug benefit.
(Added to NAC by Comm’r of Insurance, 7-16-92, eff. 7-30-92; A by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit)
Medicare Select Policies and Certificates
NAC 687B.340 Definitions. (NRS 679B.130, 687B.430) As used in NAC 687B.340 to 687B.376, inclusive, unless the context otherwise requires, the words and terms defined in NAC 687B.342 to 687B.354, inclusive, have the meanings ascribed to them in those sections.
(Added to NAC by Comm’r of Insurance, eff. 5-13-96)
NAC 687B.342 “Complaint” defined. (NRS 679B.130, 687B.430) “Complaint” means any dissatisfaction with a Medicare select issuer or a network provider expressed by a holder of a Medicare select policy or certificate.
(Added to NAC by Comm’r of Insurance, eff. 5-13-96)
NAC 687B.344 “Grievance” defined. (NRS 679B.130, 687B.430) “Grievance” means any dissatisfaction with the administration, claims practices or provision of services of a Medicare select issuer or a network provider that is expressed in writing by a holder of a Medicare select policy or certificate.
(Added to NAC by Comm’r of Insurance, eff. 5-13-96)
NAC 687B.346 “Medicare select issuer” defined. (NRS 679B.130, 687B.430) “Medicare select issuer” means an issuer who is offering or seeking to offer a Medicare select policy or certificate.
(Added to NAC by Comm’r of Insurance, eff. 5-13-96)
NAC 687B.348 “Medicare select policy” and “Medicare select certificate” defined. (NRS 679B.130, 687B.430) “Medicare select policy” or “Medicare select certificate” means a policy or certificate to supplement Medicare that contains a provision for a restricted network.
(Added to NAC by Comm’r of Insurance, eff. 5-13-96)
NAC 687B.350 “Network provider” defined. (NRS 679B.130, 687B.430) “Network provider” means a provider of health care or a group of providers of health care that has entered into a written agreement with a Medicare select issuer to provide benefits insured under a Medicare select policy.
(Added to NAC by Comm’r of Insurance, eff. 5-13-96)
NAC 687B.352 “Provision for a restricted network” defined. (NRS 679B.130, 687B.430) “Provision for a restricted network” means a provision of a policy or certificate to supplement Medicare that conditions the payment of benefits, in whole or in part, on the use of network providers.
(Added to NAC by Comm’r of Insurance, eff. 5-13-96)
NAC 687B.354 “Service area” defined. (NRS 679B.130, 687B.430) “Service area” means the geographic area approved by the Commissioner within which a Medicare select issuer is authorized to offer a Medicare select policy.
(Added to NAC by Comm’r of Insurance, eff. 5-13-96)
NAC 687B.356 Compliance with regulations required before advertising. (NRS 679B.130, 687B.430) No policy or certificate may be advertised as a Medicare select policy or certificate unless it meets the requirements of NAC 687B.200 to 687B.376.
(Added to NAC by Comm’r of Insurance, eff. 5-13-96)
NAC 687B.358 Authorization to offer and approval to issue. (NRS 679B.130, 687B.430)
1. The Commissioner may authorize an issuer to offer a Medicare select policy or certificate, pursuant to NAC 687B.340 to 687B.376, inclusive, and section 4358 of the Omnibus Budget Reconciliation Act of 1990, 42 U.S.C. § 1395ss(t), if the Commissioner:
(a) Determines that the issuer has satisfied all of the requirements of NAC 687B.200 to 687B.376; and
(b) Approves the issuer’s plan of operation.
2. An issuer may not issue a Medicare select policy or certificate in this State until the Commissioner has approved its plan of operation.
(Added to NAC by Comm’r of Insurance, eff. 5-13-96)
NAC 687B.360 Filing and contents of proposed plan of operation. (NRS 679B.130, 687B.430) A Medicare select issuer shall file a proposed plan of operation with the Commissioner which must include:
1. Evidence that all services covered under the policy that are subject to a provision for a restricted network are available and accessible through network providers, including evidence that:
(a) Such services are available from network providers with reasonable promptness with respect to geographic location, hours of operation during regular business hours and hours of operation after regular business hours. The reasonableness of hours of operation and availability must be based on the usual practice in the local area. The reasonableness of the geographic location must be based on average travel times within the community.
(b) The number of network providers in the service area is sufficient in relation to the number of current and expected policyholders and certificate holders to:
(1) Deliver adequately services that are subject to a provision for a restricted network; or
(2) Make appropriate referrals.
(c) The Medicare select issuer has executed written agreements with network providers that describe the specific responsibilities of those providers.
(d) Emergency care is available 24 hours a day and 7 days a week.
(e) For such services that are provided on a prepaid basis, the Medicare select issuer has executed written agreements with network providers that prohibit such providers from billing or otherwise seeking additional reimbursement or recourse against any policyholder or certificate holder, other than seeking collection of supplemental charges or coinsurance payments that are required under the Medicare select policy or certificate.
2. A statement or map providing a clear description of the service area.
3. A description of the procedure that will be utilized for addressing grievances.
4. A description of the program that will be utilized for quality assurance, including details regarding:
(a) The formal organizational structure of the program;
(b) The written criteria for selecting, retaining and removing network providers;
(c) The procedure for evaluating the quality of care provided by network providers; and
(d) The process used for initiating corrective action when warranted.
5. A list and description of the network providers, categorized by their specialties.
6. Copies of the written information, including the contracts and written agreements executed between the Medicare select issuer and the network providers, proposed to be used by the Medicare select issuer to ensure that all services covered under the policy that are subject to a provision for a restricted network are available and accessible through a network provider.
7. Any other information requested by the Commissioner.
(Added to NAC by Comm’r of Insurance, eff. 5-13-96)
NAC 687B.362 Proposed changes to plan of operation; update of list of network providers. (NRS 679B.130, 687B.430)
1. A Medicare select issuer shall file any proposed changes to the plan of operation, other than changes to the list of network providers, with the Commissioner before implementing the changes. If the Commissioner does not approve or disapprove the proposed changes within 30 days after their receipt, the changes shall be deemed approved.
2. A Medicare select issuer shall file an updated list of network providers with the Commissioner every 3 months.
(Added to NAC by Comm’r of Insurance, eff. 5-13-96)
NAC 687B.364 Payment for covered services provided by persons other than network providers. (NRS 679B.130, 687B.430) A Medicare select policy or certificate must not restrict payment for services covered under the policy that are provided by persons other than network providers if:
1. The services were for symptoms requiring emergency care or for symptoms of an unforeseen illness or condition requiring immediate attention; or
2. It was not reasonable to obtain the services through a network provider.
(Added to NAC by Comm’r of Insurance, eff. 5-13-96)
NAC 687B.366 Full payment required for covered services not available through network provider. (NRS 679B.130, 687B.430) A Medicare select policy or certificate must provide full payment for services covered under the policy that are not available through a network provider.
(Added to NAC by Comm’r of Insurance, eff. 5-13-96)
NAC 687B.368 Written disclosure of provisions, restrictions and limitations. (NRS 679B.130, 687B.430)
1. A Medicare select issuer shall disclose in writing the provisions, restrictions and limitations of the Medicare select policy or certificate to each applicant. The disclosure must include:
(a) An outline of coverage sufficient to permit the applicant to compare the coverage and premiums of the Medicare select policy or certificate with:
(1) Other policies or certificates to supplement Medicare offered by the Medicare select issuer; and
(2) Other Medicare select policies.
(b) A description of the primary care physicians, specialty physicians, hospitals and other network providers, including their addresses, phone numbers and hours of operation.
(c) A description of the provisions for a restricted network, including those provisions addressing payments for coinsurance and deductibles when providers other than network providers are utilized. 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.
(d) A description of coverage for emergency and urgently needed care and coverage for care provided outside the service area.
(e) A description of any limitations on referrals by network providers to persons other than network providers.
(f) A description of the policyholder’s or certificate holder’s rights to purchase other policies or certificates to supplement Medicare that the Medicare select issuer offers.
(g) A description of the program for quality assurance and the procedure for addressing grievances that the Medicare select issuer utilizes.
2. Before the sale of a Medicare select policy or certificate, a Medicare select issuer must obtain from the applicant a signed and dated form stating that the applicant has received the written disclosure required by subsection 1 and that the applicant understands the restrictions of the Medicare select policy or certificate.
(Added to NAC by Comm’r of Insurance, eff. 5-13-96; A by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit)
NAC 687B.370 Procedures for hearing complaints and resolving grievances. (NRS 679B.130, 687B.430)
1. A Medicare select issuer shall have written procedures for hearing complaints and resolving written grievances made by policyholders and certificate holders under a Medicare select policy or certificate. The procedures may include the utilization of arbitration if the Medicare select issuer and the policyholder or certificate holder or the policyholder’s or certificate holder’s spouse mutually agree to use it.
2. The procedure for addressing grievances must be described in all policies and certificates and in the outline of coverage provided to applicants for coverage pursuant to NAC 687B.368.
3. The Medicare select issuer shall provide detailed information to the policyholder or certificate holder at the time the policy or certificate is issued that describes how to file a grievance with the Medicare select issuer.
4. The Medicare select issuer shall begin evaluating a grievance filed with it within 10 working days after the filing date by transmitting the grievance to the person who has authority to investigate the issue fully and take corrective action to address it.
5. If a grievance is found to be valid, corrective action must commence within 48 hours after the determination or within 72 hours after the determination if a holiday occurs within the 48-hour period.
6. All concerned parties must be notified of the determination made with regard to the grievance.
7. The Medicare select issuer shall report to the Commissioner no later than March 31 of each year regarding its grievance procedure. The report must contain the number of grievances filed in the past year and a summary of the nature and resolution of those grievances.
(Added to NAC by Comm’r of Insurance, eff. 5-13-96)
NAC 687B.372 Availability of certain policies and certificates offered by Medicare select issuer. (NRS 679B.130, 687B.430)
1. A Medicare select issuer shall offer to each applicant for a Medicare select policy or certificate, at the time of initial purchase, the opportunity to purchase any policies or certificates to supplement Medicare that the Medicare select issuer offers.
2. Upon request by a policyholder or certificate holder, a Medicare select issuer shall make available the opportunity to purchase a different policy or certificate to supplement Medicare offered by the Medicare select issuer which has comparable or lesser benefits and which does not contain a provision for a restricted network. The Medicare select issuer shall make such policies or certificates available without requiring evidence of insurability if the person has been a policyholder or certificate holder for 6 months or more.
3. For the purposes of this section, a policy or certificate to supplement Medicare 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 subsection, a significant benefit means coverage for the Medicare Part A deductible, coverage for at-home recovery services or coverage for Medicare Part B excess charges.
(Added to NAC by Comm’r of Insurance, eff. 5-13-96; A by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit)
NAC 687B.374 Provision for continuation of coverage; availability of policies to supplement Medicare as continuation of coverage. (NRS 679B.130, 687B.430)
1. Medicare select policies and certificates 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 NAC 687B.340 to 687B.376, inclusive, must be discontinued because the Medicare select program has not been reauthorized by Congress or because the statutory authority for the program has been substantially amended.
2. If the Secretary of Health and Human Services makes such a determination, each Medicare select issuer shall make available to each policyholder and certificate holder the opportunity to purchase any policy to supplement Medicare offered by the Medicare select issuer which has comparable or lesser benefits and which does not contain a provision for a restricted network. The Medicare select issuer shall make such policies and certificates available without requiring evidence of insurability.
3. For the purposes of this section, a policy to supplement Medicare 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 purpose of this subsection, a significant benefit means coverage for the Medicare Part A deductible, coverage for at-home recovery services or coverage for Part B excess charges.
(Added to NAC by Comm’r of Insurance, eff. 5-13-96; A by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit)
NAC 687B.376 Compliance with requests for data for evaluation of Medicare select program. (NRS 679B.130, 687B.430) A Medicare select issuer shall 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.
(Added to NAC by Comm’r of Insurance, eff. 5-13-96)
REQUIREMENTS FOR DELIVERY
NAC 687B.405 Delivery of certificates to policyholder of group insurance. (NRS 679B.130, 688B.110, 689B.090, 690A.070) All companies and all resident or nonresident agents or brokers doing group life insurance or group accident and health insurance business in Nevada must provide for delivery to the policyholder of the individual certificates required by NRS 688B.110, 689B.090 and 690A.070. Each company, agent and broker shall use his best efforts to see that policyholders distribute those certificates of insurance to all debtors, members or employees afforded coverage under the policy.
[Comm’r of Insurance, part M-5, eff. 5-13-72]—(Substituted in revision for NAC 687B.110)
NAC 687B.415 Delivery of other policies, memoranda or certificates of insurance. (NRS 679B.130)
1. Except for policies of group life or group accident and health insurance, all companies and all resident or nonresident agents and brokers shall deliver a copy of the policy or a memorandum or certificate of insurance to each insured person.
2. The memorandum or certificate of insurance must indicate the:
(a) Kind and amount of coverage;
(b) Term of the coverage;
(c) Amount of premium for each coverage provided; and
(d) Name and address of the company issuing the coverage.
3. For risks relating to a business, each insurer shall deliver the policy or memorandum or certificate of insurance to the insured within 90 days after the effective date of the policy.
[Comm’r of Insurance, part M-5, eff. 5-13-72]—(NAC A 10-30-85)—(Substituted in revision for NAC 687B.120)
CANCELLATION OF POLICIES
NAC 687B.520 Refunds to third parties. (NRS 679B.130)
1. All forms used by an agent broker, solicitor, company or any other person, partnership or corporation, for the purpose of obtaining authorization from an insured to cancel an existing insurance policy or policies, which authorize the payment of the unearned premium to anyone other than the insured, shall state in the heading or title of the form, in 14-point type or larger:
Authorization for Insurance Cancellation and Payment of Return Premium to a Third Party.
2. No form may be used for that purpose unless the title calls the attention of the insured to the fact that he is signing away his interest in the unearned premium to a third person.
[Comm’r of Insurance, PC-15, eff. 9-23-72]
NAC 687B.530 Notice to agent. (NRS 679B.130) Each insurer shall also provide a copy of the notice of cancellation of a policy to the agent who wrote the policy.
(Added to NAC by Comm’r of Insurance, eff. 10-30-85)
NOTICE OF TERMINATION TO EMPLOYEE LEASING COMPANIES
NAC 687B.550 Definitions. (NRS 679B.130) As used in NAC 687B.550 to 687B.564, inclusive, unless the context otherwise requires, the words and terms defined in NAC 687B.552 to 687B.560, inclusive, have the meanings ascribed to them in those sections.
(Added to NAC by Comm’r of Insurance by R025-04, 7-9-2004, eff. 8-1-2004)
NAC 687B.552 “Client company” defined. (NRS 679B.130) “Client company” has the meaning ascribed to it in NRS 616B.670.
(Added to NAC by Comm’r of Insurance by R025-04, 7-9-2004, eff. 8-1-2004)
NAC 687B.554 “Employee leasing company” defined. (NRS 679B.130) “Employee leasing company” has the meaning ascribed to it in NRS 616B.670.
(Added to NAC by Comm’r of Insurance by R025-04, 7-9-2004, eff. 8-1-2004)
NAC 687B.556 “Health maintenance organization” defined. (NRS 679B.130) “Health maintenance organization” has the meaning ascribed to it in NRS 695C.030.
(Added to NAC by Comm’r of Insurance by R025-04, 7-9-2004, eff. 8-1-2004)
NAC 687B.558 “Insurer” defined. (NRS 679B.130) “Insurer” has the meaning ascribed to it in NRS 679A.100.
(Added to NAC by Comm’r of Insurance by R025-04, 7-9-2004, eff. 8-1-2004)
NAC 687B.560 “Producer of insurance” defined. (NRS 679B.130) “Producer of insurance” has the meaning ascribed to it in NRS 679A.117.
(Added to NAC by Comm’r of Insurance by R025-04, 7-9-2004, eff. 8-1-2004)
NAC 687B.562 Disclosure of names and addresses of client companies; confidentiality. (NRS 679B.130, 687B.420)
1. Employee leasing companies applying for insurance coverage under chapter 688B, 689A, 689B, 689C, 695A, 695B, 695C, 695D or 695F of NRS shall submit the names and addresses of client companies to:
(a) Insurers or health maintenance organizations with their applications; and
(b) Producers of insurance.
2. Employee leasing companies shall update the names and addresses of client companies submitted pursuant to subsection 1 on the first business day of each month.
3. The information provided by employee leasing companies pursuant to subsections 1 and 2 is confidential.
(Added to NAC by Comm’r of Insurance by R025-04, 7-9-2004, eff. 8-1-2004)
NAC 687B.564 Notice of cancellation or failure to renew policy or contract. (NRS 679B.130, 687B.420)
1. An insurer or health maintenance organization shall not cancel or fail to renew a policy or contract issued to an employee leasing company pursuant to chapter 688B, 689A, 689B, 689C, 695A, 695B, 695C, 695D or 695F of NRS unless notice in writing of the termination is given to:
(a) The employee leasing company; and
(b) The client companies included on the current client company list.
2. As used in this section, “current client company list” means the most recent list of client companies provided by the employee leasing company pursuant to NAC 687B.562.
(Added to NAC by Comm’r of Insurance by R025-04, 7-9-2004, eff. 8-1-2004)
MISCELLANEOUS POLICIES
NAC 687B.610 Vendor single interest policies: Marking. (NRS 679B.130)
1. Each vendor single interest policy issued on a risk located in Nevada must have imprinted or stamped on the face in red, or have a red imprinted sticker on the face, with the following wording:
This policy provides SINGLE INTEREST insurance only—which protects the interest of the DEALER OR FINANCIAL INSTITUTIONS and not the purchaser.
2. The purchaser’s copy of the sales contract must have the same printing, stamp or sticker placed upon it in red.
3. If the original policy is retained by the vendor or mortgagee, the purchaser must be provided with a copy of the certificate of insurance which must be imprinted, stamped or marked as required by this section.
4. This section does not apply to life or accident and health insurance.
[Comm’r of Insurance, PC-1, eff. 9-23-72]
NAC 687B.620 Multiple line packages. (NRS 679B.130)
1. A multiple line package is an integrated policy which includes two or more of the following kinds of insurance:
(a) Fire and allied lines.
(b) Casualty.
(c) Surety.
(d) Inland marine.
2. Each multiple line package must be considered as a separate and complete insurance instrument, and must be so treated in all matters involving rating techniques, filing procedures, statistical reporting and statutory proceedings.
3. Any licensed rating organization which files a specific multiple line package assumes full responsibility for its filing.
[Comm’r of Insurance, PC-11, eff. 9-23-72]—(Substituted in revision for NAC 687B.410)
NAC 687B.630 Health policy, contract or plan that includes grace period for payment of premiums. (NRS 679B.130, 695B.280, 695D.100, 695F.300)
1. If an insurer issues a health insurance policy or contract, health care plan, health benefit plan or plan for dental care, whether individual, group or blanket, that includes a grace period:
(a) The insurer shall not require the payment of an additional premium for the grace period. If a premium is not paid by the end of the grace period, the contract of insurance terminates retroactively to the end of the day next preceding the grace period.
(b) Except as otherwise provided in this paragraph, the insurer is not required to pay claims incurred during the grace period while a required premium remains unpaid and may seek reimbursement for any such claim erroneously paid during the grace period. The insurer is liable for any claims incurred during the grace period if the required premium payment is received during the grace period in accordance with the contract of insurance.
2. The Commissioner will, pursuant to NRS 687B.130, disapprove or withdraw the approval of any form used by an insurer which provides that, in lieu of requiring during the grace period the payment of a premium due, the insurer may deduct the premium due from the payment of a claim.
3. As used in this section:
(a) “Grace period” means the time after the date that a premium is due during which the premium can be paid without penalty to keep the policy in force.
(b) “Insurer” means any insurer that issues any health insurance policy or contract, health care plan, health benefit plan or plan for dental care, whether individual, group or blanket, and includes any:
(1) Insurance company;
(2) Carrier;
(3) Nonprofit corporation for hospital, medical or dental service;
(4) Health maintenance organization;
(5) Organization for dental care; or
(6) Prepaid limited health service organization.
(Added to NAC by Comm’r of Insurance by R009-02, eff. 5-23-2002; A by R009-02, 7-11-2002)
POLICIES THAT DUPLICATE BENEFITS PROVIDED UNDER MEDICARE
NAC 687B.700 Notice of duplication for policy which provides reimbursement upon both expense-incurred and fixed-indemnity basis. (NRS 679B.130)
1. An insurer that delivers or issues for delivery in this State a policy of health insurance which provides reimbursement upon both an expense-incurred and a fixed-indemnity basis and which provides benefits that are provided under Medicare shall provide notice to the insured that the policy contains certain benefits which are also provided under Medicare.
2. The notice must be:
(a) Printed on or attached to the first page of the application for the policy; and
(b) In not less than 12-point type and must not vary from the following form in terms of language or format:
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Important Notice to Persons on Medicare This Insurance Duplicates Some Medicare Benefits |
This is not Medicare Supplement Insurance
This insurance pays limited reimbursement for expenses if you meet the conditions listed in the policy. It also pays a fixed amount, regardless of your expenses, if you meet other policy conditions. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.
This insurance duplicates Medicare benefits when:
· any expenses or services covered by the policy are also covered by Medicare; or
· it pays the fixed dollar amount stated in the policy and Medicare covers the same event
Medicare generally pays for most or all of these expenses.
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
· hospitalization
· physician services
· hospice care
· outpatient prescription drugs if you are enrolled in Medicare Part D
· other approved items and services
|
Before You Buy This Insurance |
ü Check the coverage in all health insurance policies you already have.
ü For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, which is available from the insurance company.
ü For help in understanding your health insurance, contact the Commissioner of Insurance or the State Health Insurance Assistance Program (SHIP).
(Added to NAC by Comm’r of Insurance, eff. 5-13-96; A by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit)
NAC 687B.706 (NRS 679B.130)
1. An insurer that delivers or issues for delivery in this State an indemnity policy or other policy which provides reimbursement in a fixed dollar amount per day, excluding long-term care policies, and which provides benefits that are provided under Medicare shall provide notice to the insured that the policy contains certain benefits which are also provided under Medicare.
2. The notice must be:
(a) Printed or attached to the first page of the application for the policy; and
(b) In not less than 12-point type and must not vary from the following form in terms of language or format:
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Important Notice to Persons on Medicare This Insurance Duplicates Some Medicare Benefits |
This is not Medicare Supplement Insurance
This insurance pays a fixed dollar amount, regardless of your expenses, for each day you meet the policy conditions. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.
This insurance duplicates Medicare benefits when:
· any expenses or services covered by the policy are also covered by Medicare
Medicare generally pays for most or all of these expenses.
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
· hospitalization
· physician services
· outpatient prescription drugs if you are enrolled in Medicare Part D
· hospice
· other approved items and services
|
Before You Buy This Insurance |
ü Check the coverage in all health insurance policies you already have.
ü For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.
ü For help in understanding your health insurance, contact the Commissioner of Insurance or the State Health Insurance Assistance Program (SHIP).
(Added to NAC by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit)
NAC 687B.711 (NRS 679B.130)
1. An insurer that delivers or issues for delivery in this State a policy of health insurance which provides reimbursement in fixed dollar amounts for specified diseases or other specified impairments and which provides benefits that are provided under Medicare shall provide notice to the insured that the policy contains certain benefits which are also provided under Medicare.
2. The notice must be:
(a) Printed on or attached to the first page of the application for the policy; and
(b) In not less than 12-point type and must not vary from the following form in terms of language or format:
|
Important Notice to Persons on Medicare This Insurance Duplicates Some Medicare Benefits |
This is not Medicare Supplement Insurance
This insurance pays a fixed amount, regardless of your expenses, if you meet the policy conditions, for one of the specific diseases or health conditions named in the policy. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.
This insurance duplicates Medicare benefits because Medicare generally pays for most of the expenses for the diagnosis and treatment of the specific conditions or diagnoses named in the policy.
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
· hospitalization
· physician services
· hospice
· outpatient prescription drugs if you are enrolled in Medicare Part D
· other approved items and services
|
Before You Buy This Insurance |
ü Check the coverage in all health insurance policies you already have.
ü For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.
ü For help in understanding your health insurance, contact the Commissioner of Insurance or the State Health Insurance Assistance Program (SHIP).
(Added to NAC by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit)
NAC 687B.716 (NRS 679B.130)
1. An insurer that delivers or issues for delivery in this State a policy of health insurance which provides reimbursement for expenses incurred for an accidental injury only and which provides benefits that are provided under Medicare shall provide notice to the insured that the policy contains benefits which are also provided under Medicare.
2. The notice must be:
(a) Printed or attached to the first page of the application for the policy; and
(b) In not less than 12-point type and must not vary from the following form in terms of language or format:
|
Important Notice to Persons on Medicare This Insurance Duplicates Some Medicare Benefits |
This is not Medicare Supplement Insurance
This insurance provides limited benefits, if you meet the policy conditions, for hospital or medical expenses that result from accidental injury. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.
This insurance duplicates Medicare benefits when it pays:
· hospital or medical expenses up to the maximum stated in the policy
Medicare generally pays for most or all of these expenses.
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
· hospitalization
· physician services
· outpatient prescription drugs if you are enrolled in Medicare Part D
· other approved items and services
|
Before You Buy This Insurance |
ü Check the coverage in all health insurance policies you already have.
ü For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.
ü For help in understanding your health insurance, contact the Commissioner of Insurance or the State Health Insurance Assistance Program (SHIP).
(Added to NAC by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit)
NAC 687B.720 Notice of duplication for policy which provides reimbursement for expenses incurred for specified diseases and other specified impairments. (NRS 679B.130)
1. An insurer that delivers or issues for delivery in this State a policy of health insurance which provides reimbursement for expenses incurred for specified diseases and other specified impairments and which provides benefits that are provided under Medicare shall provide notice to the insured that the policy contains certain benefits which are also provided under Medicare.
2. The notice must be:
(a) Printed on or attached to the first page of the application for the policy; and
(b) In not less than 12-point type and must not vary from the following form in terms of language or format:
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Important Notice to Persons on Medicare This Insurance Duplicates Some Medicare Benefits |
This is not Medicare Supplement Insurance
This insurance provides limited benefits, if you meet the policy conditions, for hospital or medical expenses only when you are treated for one of the specific diseases or health conditions listed in the policy. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.
This insurance duplicates Medicare benefits when it pays:
· hospital or medical expenses up to the maximum stated in the policy
Medicare generally pays for most or all of these expenses.
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
· hospitalization
· physician services
· hospice
· outpatient prescription drugs if you are enrolled in Medicare Part D
· other approved items and services
|
Before You Buy This Insurance |
ü Check the coverage in all health insurance policies you already have.
ü For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.
ü For help in understanding your health insurance, contact the Commissioner of Insurance or the State Health Insurance Assistance Program (SHIP).
(Added to NAC by Comm’r of Insurance, eff. 5-13-96; A by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit)
NAC 687B.725 Notice of duplication for policy which provides reimbursement for expenses incurred for specified limited services. (NRS 679B.130)
1. An insurer that delivers or issues for delivery in this State a policy of health insurance which provides reimbursement for expenses incurred for specified limited services and which provides benefits that are provided under Medicare shall provide notice to the insured that the policy contains certain benefits which are also provided under Medicare.
2. The notice must be:
(a) Printed on or attached to the first page of the application for the policy; and
(b) In not less than 12-point type and must not vary from the following form in terms of language or format:
|
Important Notice to Persons on Medicare This Insurance Duplicates Some Medicare Benefits |
This is not Medicare Supplement Insurance
This insurance provides limited benefits, if you meet the policy conditions, for expenses relating to the specific services listed in the policy. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.
This insurance duplicates Medicare benefits when:
· any of the services covered by the policy are also covered by Medicare
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
· hospitalization
· physician services
· outpatient prescription drugs if you are enrolled in Medicare Part D
· other approved items and services
|
Before You Buy This Insurance |
ü Check the coverage in all health insurance policies you already have.
ü For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.
ü For help in understanding your health insurance, contact the Commissioner of Insurance or the State Health Insurance Assistance Program (SHIP).
(Added to NAC by Comm’r of Insurance, eff. 5-13-96; A by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit)
NAC 687B.730 Notice of duplication for policy not described in NAC 687B.700 to 687B.725, inclusive. (NRS 679B.130)
1. An insurer that delivers or issues for delivery in this State a policy of health insurance, other than a policy of insurance described in NAC 687B.700 to 687B.725, inclusive, and which provides benefits that are provided under Medicare shall provide notice to the insured that the policy contains certain benefits which are also provided under Medicare.
2. The notice must be:
(a) Printed on or attached to the first page of the application for the policy; and
(b) In not less than 12-point type and must not vary from the following form in terms of language or format:
|
Important Notice to Persons on Medicare This Insurance Duplicates Some Medicare Benefits |
This is not Medicare Supplement Insurance
This insurance provides limited benefits if you meet the conditions listed in the policy. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement Insurance.
This insurance duplicates Medicare benefits when it pays:
· the benefits stated in the policy and coverage for the same event is provided by Medicare
Medicare generally pays for most or all of these expenses.
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
· hospitalization
· physician services
· hospice
· outpatient prescription drugs if you are enrolled in Medicare Part D
· other approved items and services
|
Before You Buy This Insurance |
ü Check the coverage in all health insurance policies you already have.
ü For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.
ü For help in understanding your health insurance, contact the Commissioner of Insurance or the State Health Insurance Assistance Program (SHIP).
(Added to NAC by Comm’r of Insurance, eff. 5-13-96; A by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit)
NAC 687B.735 Payment of benefits that are covered under other policies. (NRS 679B.130) A policy of health insurance described in NAC 687B.700, 687B.720, 687B.725 or 687B.730 which provides benefits that are provided under Medicare may not be delivered or issued for delivery in this State unless the policy includes a provision that specifically states that the benefits under the policy will be provided without regard to any other policy or coverage of health insurance, including Medicare.
(Added to NAC by Comm’r of Insurance, eff. 5-13-96; A by R110-98, 2-23-99)
POLICIES OF LIABILITY INSURANCE
NAC 687B.800 Policy sold by short-term lessor of motor vehicle: Deemed primary coverage; filing requirements. (NRS 679B.130) A policy of liability insurance that is sold by a short-term lessor of a motor vehicle to a short-term lessee of a motor vehicle:
1. Shall be deemed to provide primary coverage, and any other policy of liability insurance shall be deemed to provide excess coverage; and
2. Must be filed with the Commissioner as a policy of insurance for personal risk in the manner set forth in chapter 686B of NRS.
(Added to NAC by Comm’r of Insurance by R151-99, eff. 1-28-2000)
POLICIES OF MOTOR VEHICLE INSURANCE
NAC 687B.850 Chargeable accidents: Restrictions on authority of insurer; filing and use of definition. (NRS 679B.130, 687B.385)
1. An insurer shall not cancel, refuse to renew or increase the premium charge for the liability coverage under a policy of motor vehicle insurance upon renewal of the policy of motor vehicle insurance because of an accident that is not a chargeable accident.
2. Each insurer shall file with the Division its definition of a “chargeable accident” and shall use the filed definition. The insurer’s definition of a “chargeable accident” may include only those accidents for which the insured is 50 percent or more at fault.
3. Each filing of a rate for a policy of motor vehicle insurance submitted to the Division must define a “chargeable accident” in terms of a monetary amount of damage.
4. An insurer may not define a claim made under the comprehensive portion of a policy of motor vehicle insurance as a chargeable accident in order to increase the premium for the policy or to cancel the policy, but the insurer may use a series of such claims to discontinue comprehensive coverage or to offer a higher deductible for comprehensive coverage upon the renewal of the policy.
(Added to NAC by Comm’r of Insurance by R100-06, eff. 12-7-2006)