Certification of medicare supplemental health insurance policies

No medicare supplemental policy may be issued in a State on or after the date specified in subsection (p)(1)(C) unless— Any medicare supplemental policy issued in any State which the Secretary determines has established under State law a regulatory program that— provides that— The Secretary shall certify under this section any medicare supplemental policy, or continue certification of such a policy, only if he finds that such policy (or, with respect to paragraph (3) or the requirement described in subsection (s), the issuer of the policy)— where such a notice is received— It is unlawful for a person to sell or issue to an individual entitled to benefits under part A or enrolled under part B of this subchapter (including an individual electing a Medicare+Choice plan under section 1395w–21 of this title)— For purposes of this subparagraph, a health insurance policy (or a rider to an insurance contract which is not a health insurance policy) is not considered to “duplicate” health benefits under this subchapter or under another health insurance policy if it— The disclosure statement described in this clause for a type of policy is the statement specified under subparagraph (D) of this paragraph (as in effect before August 21, 1996) for that type of policy, as revised as follows: “THIS IS NOT MEDICARE SUPPLEMENT It is unlawful for a person to issue or sell a medicare supplemental policy to an individual entitled to benefits under part A or enrolled under part B, whether directly, through the mail, or otherwise, unless— The statement required by clause (i) shall be made on a form that— The Secretary shall— inform all individuals entitled to benefits under this subchapter (and, to the extent feasible, individuals about to become so entitled) of— The Secretary shall submit to the Congress no later than July 1, 1982, and periodically as may be appropriate thereafter (but not less often than once every 2 years), a report evaluating the effectiveness of the certification procedure and the criminal penalties established under this section, and shall include in such reports an analysis of— For purposes of this section: The State in which a policy is issued means— The Secretary shall prescribe such regulations as may be necessary for the effective, efficient, and equitable administration of the certification procedure established under this section. The Secretary shall first issue final regulations to implement the certification procedure established under subsection (a) not later than March 1, 1981. Nothing in this section shall be construed so as to affect the right of any State to regulate medicare supplemental policies which, under the provisions of this section, are considered to be issued in another State. Notwithstanding any other provision of this section (except as provided in subsections (l), (m), and (n))— Until the date specified in paragraph (3), in the case of a qualifying medicare supplemental policy described in paragraph (2) issued— In paragraph (1), the term “qualifying medicare supplemental policy” means a medicare supplemental policy— issued in a State which— The date specified in this paragraph is the earlier of— In the case of a State which the Secretary identifies as— In the case of a medicare supplemental policy in effect on January 1, 1989, and offered in a State which, as of such date— Notwithstanding any other provision of this section (except as provided in subsection (n))— Until the date specified in paragraph (4), in the case of a qualifying medicare supplemental policy described in paragraph (3) issued in a State— The transition provision described in this paragraph is— The date specified in this paragraph for a policy issued in a State is— In the case of a State which the Secretary identifies, in consultation with the Association, as— In the case of a medicare supplemental policy in effect on January 1, 1990, the policy shall not be deemed to meet the standards in subsection (c) unless each individual who is entitled to benefits under this subchapter and is a policyholder or certificate holder under such policy on such date is sent a notice in an appropriate form by not later than January 31, 1990, that explains— Except as provided in subparagraph (B), in the case of an individual who had in effect, as of December 31, 1988, a medicare supplemental policy with an insurer (as a policyholder or, in the case of a group policy, as a certificate holder) and the individual terminated coverage under such policy before December 13, 1989, no medicare supplemental policy of the insurer shall be deemed to meet the standards in subsection (c) unless the insurer— The requirements of this subsection are as follows: If, within 9 months after November 5, 1990, the National Association of Insurance Commissioners (in this subsection referred to as the “Association”) changes the revised NAIC Model Regulation (described in subsection (m)) to incorporate— In the case of a State which the Secretary identifies, in consultation with the Association, as— The benefits under the 1991 NAIC Model Regulation or 1991 Federal Regulation shall provide— The benefits under paragraph (2) shall, to the extent possible— For purposes of paragraph (2), the benefit packages described in this subparagraph are as follows: For purposes of subparagraph (A), a high deductible feature is one which— The amount specified in this subparagraph— The requirements of this subsection are as follows: Each medicare supplemental policy shall be guaranteed renewable and— If the medicare supplemental policy is terminated by the group policyholder and is not replaced as provided under paragraph (4), the issuer shall offer certificateholders an individual medicare supplemental policy which (at the option of the certificateholder)— If an individual is a certificateholder in a group medicare supplemental policy and the individual terminates membership in the group, the issuer shall— A medicare supplemental policy may not be issued or renewed (or otherwise provide coverage after the date described in subsection (p)(1)(C)) in any State unless— In the case of a policy issued during the 6-month period described in subparagraph (A) to an individual who is 65 years of age or older as of the date of issuance and who as of the date of the application for enrollment has a continuous period of creditable coverage (as defined in section 2701(c) 55 See References in Text note below. of the Public Health Service Act) of— Nothing in subparagraph (E) or in subparagraphs (A) or (B) of subsection (x)(2) shall be construed to limit the ability of an issuer of a medicare supplemental policy from, to the extent otherwise permitted under this subchapter— The issuer of a medicare supplemental policy— An individual described in this subparagraph is an individual described in any of the following clauses: The individual is enrolled under a medicare supplemental policy under this section and such enrollment ceases because— The individual— For purposes of subparagraph (A), the time period specified in this subparagraph is— Subject to clause (ii), for purposes of this paragraph— If a medicare supplemental policy meets the 1991 NAIC Model Regulation or 1991 Federal Regulation and otherwise complies with the requirements of this section except that benefits under the policy are restricted to items and services furnished by certain entities (or reduced benefits are provided when items or services are furnished by other entities), the policy shall nevertheless be treated as meeting those standards if— If the Secretary determines that an issuer of a policy approved under paragraph (1)— A policy described in this subparagraph is any of the following: A policy of insurance to which substantially all of the coverage relates to— Notwithstanding any other provision of law, on or after January 1, 2006, a medigap Rx policy (as defined in paragraph (6)(A)) may not be sold, issued, or renewed under this section— Subparagraph (A)(ii) shall not apply to the renewal of a medigap Rx policy that was issued before January 1, 2006. Nothing in this subsection shall be construed as preventing the offering on and after January 1, 2006, of “H”, “I”, and “J” policies described in paragraph (2)(D)(i) if the benefit packages are modified in accordance with paragraph (2)(C). In the case of an individual who is covered under a medigap Rx policy and enrolls under a part D plan— before the end of the initial part D enrollment period, the individual may— No medicare supplemental policy of an issuer shall be deemed to meet the standards in subsection (c) unless the issuer provides written notice (in accordance with standards of the Secretary established in consultation with the National Association of Insurance Commissioners) during the 60-day period immediately preceding the initial part D enrollment period, to each individual who is a policyholder or certificate holder of a medigap Rx policy (at the most recent available address of that individual) of the following: If the individual enrolls in a plan under part D during the initial enrollment period under section 1395w–101(b)(2)(A) of this title, the individual has the option of— If the individual does not enroll in a plan under part D during such period, the individual may continue enrollment in the individual’s current plan without change, but— The policy modification described in this subparagraph is the elimination of prescription coverage for expenses of prescription drugs incurred after the effective date of the individual’s coverage under a part D plan and the appropriate adjustment of premiums to reflect such elimination of coverage. No medicare supplemental policy of an issuer shall be deemed to meet the standards in subsection (c) unless the issuer— Any reference to a benefit package classified as “H”, “I”, or “J” (including the benefit package classified as “J” with a high deductible feature, as described in subsection (p)(11)) under the standards established under subsection (p)(2) shall be construed as including a reference to such a package as modified under subparagraph (C) and such packages as modified shall not be counted as a separate benefit package under such subsection. Except for the modification provided under subparagraph (C), the waivers previously in effect under subsection (p)(2) shall continue in effect. The issuer of a medicare supplemental policy— An individual described in this subparagraph with respect to the issuer of a medicare supplemental policy is an individual who— For purposes of applying this paragraph in the case of a State that provides for offering of benefit packages other than under the classification referred to in subparagraph (A)(i), the references to benefit packages in such subparagraph are deemed references to comparable benefit packages offered in such State. The penalties described in subsection (d)(3)(A)(ii) shall apply with respect to a violation of paragraph (1)(A). The provisions of paragraph (4) of subsection (s) shall apply with respect to the requirements of paragraph (3) in the same manner as they apply to the requirements of such subsection. Any provision in this section or in a medicare supplemental policy relating to guaranteed renewability of coverage shall be deemed to have been met with respect to a part D enrollee through the continuation of the policy subject to modification under paragraph (2)(C) or the offering of a substitute policy under paragraph (3). The previous sentence shall not be construed to affect the guaranteed renewability of such a modified or substitute policy. For purposes of this subsection: The term “medigap Rx policy” means a medicare supplemental policy— The term “part D enrollee” means an individual who is enrolled in a part D plan. The term “part D plan” means a prescription drug plan or an MA–PD plan (as defined for purposes of part D). The term “initial part D enrollment period” means the initial enrollment period described in section 1395w–101(b)(2)(A) of this title. The Secretary shall request the National Association of Insurance Commissioners to review and revise the standards for benefit packages under subsection (p)(1), taking into account the changes in benefits resulting from enactment of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 and to otherwise update standards to reflect other changes in law included in such Act. Such revision shall incorporate the inclusion of the 2 benefit packages described in paragraph (2). Such revisions shall be made consistent with the rules applicable under subsection (p)(1)(E) with the reference to the “1991 NAIC Model Regulation” deemed a reference to the NAIC Model Regulation as published in the Federal Register on December 4, 1998, and as subsequently updated by the National Association of Insurance Commissioners to reflect previous changes in law (and subsection (v)) and the reference to “date of enactment of this subsection” deemed a reference to December 8, 2003. To the extent practicable, such revision shall provide for the implementation of revised standards for benefit packages as of January 1, 2006. The benefit packages described in this paragraph are the following (notwithstanding any other provision of this section relating to a core benefit package): A benefit package consisting of the following: A benefit package consisting of the benefit package described in subparagraph (A), except as follows: An issuer of a medicare supplemental policy shall not request or require an individual or a family member of such individual to undergo a genetic test. Subparagraph (A) shall not be construed to limit the authority of a health care professional who is providing health care services to an individual to request that such individual undergo a genetic test. Nothing in subparagraph (A) shall be construed to preclude an issuer of a medicare supplemental policy from obtaining and using the results of a genetic test in making a determination regarding payment (as such term is defined for the purposes of applying the regulations promulgated by the Secretary under part C of subchapter XI and section 264 of the Health Insurance Portability and Accountability Act of 1996, as may be revised from time to time) consistent with subsection (s)(2)(E). For purposes of clause (i), an issuer of a medicare supplemental policy may request only the minimum amount of information necessary to accomplish the intended purpose. Notwithstanding subparagraph (A), an issuer of a medicare supplemental policy may request, but not require, that an individual or a family member of such individual undergo a genetic test if each of the following conditions is met: The issuer clearly indicates to each individual, or in the case of a minor child, to the legal guardian of such child, to whom the request is made that— An issuer of a medicare supplemental policy shall not request, require, or purchase genetic information for underwriting purposes (as defined in paragraph (3)). An issuer of a medicare supplemental policy shall not request, require, or purchase genetic information with respect to any individual prior to such individual’s enrollment under the policy in connection with such enrollment. If an issuer of a medicare supplemental policy obtains genetic information incidental to the requesting, requiring, or purchasing of other information concerning any individual, such request, requirement, or purchase shall not be considered a violation of subparagraph (B) if such request, requirement, or purchase is not in violation of subparagraph (A). In this subsection: The term “family member” means with respect to an individual, any other individual who is a first-degree, second-degree, third-degree, or fourth-degree relative of such individual. The term “genetic information” means, with respect to any individual, information about— Such term includes, with respect to any individual, any request for, or receipt of, genetic services, or participation in clinical research which includes genetic services, by such individual or any family member of such individual. The term “genetic information” shall not include information about the sex or age of any individual. The term “genetic test” means an analysis of human DNA, RNA, chromosomes, proteins, or metabolites, that detects genotypes, mutations, or chromosomal changes. The term “genetic test” does not mean— The term “genetic services” means— The term “underwriting purposes” means, with respect to a medicare supplemental policy— The term “issuer of a medicare supplemental policy” includes a third-party administrator or other person acting for or on behalf of such issuer. Any reference in this section to genetic information concerning an individual or family member of an individual shall— The Secretary shall request the National Association of Insurance Commissioners to review and revise the standards for benefit packages described in paragraph (2) under subsection (p)(1), to otherwise update standards to include requirements for nominal cost sharing to encourage the use of appropriate physicians’ services under part B. Such revisions shall be based on evidence published in peer-reviewed journals or current examples used by integrated delivery systems and made consistent with the rules applicable under subsection (p)(1)(E) with the reference to the “1991 NAIC Model Regulation” deemed a reference to the NAIC Model Regulation as published in the Federal Register on December 4, 1998, and as subsequently updated by the National Association of Insurance Commissioners to reflect previous changes in law and the reference to “date of enactment of this subsection” deemed a reference to March 23, 2010. To the extent practicable, such revision shall provide for the implementation of revised standards for benefit packages as of January 1, 2015. The benefit packages described in this paragraph are benefit packages classified as “C” and “F”. Notwithstanding any other provision of this section, on or after January 1, 2020, a medicare supplemental policy that provides coverage of the part B deductible, including any such policy (or rider to such a policy) issued under a waiver granted under subsection (p)(6), may not be sold or issued to a newly eligible Medicare beneficiary. In this subsection, the term “newly eligible Medicare beneficiary” means an individual who is neither of the following: In the case of a State described in subsection (p)(6), nothing in this section shall be construed as preventing the State from modifying its alternative simplification program under such subsection so as to eliminate the coverage of the part B deductible for any medical supplemental policy sold or issued under such program to a newly eligible Medicare beneficiary on or after January 1, 2020. In the case of a newly eligible Medicare beneficiary, except as the Secretary may otherwise provide, any reference in this section to a medicare supplemental policy which has a benefit package classified as “C” or “F” shall be deemed, as of January 1, 2020, to be a reference to a medicare supplemental policy which has a benefit package classified as “D” or “G”, respectively. The penalties described in clause (ii) of subsection (d)(3)(A) shall apply with respect to a violation of paragraph (1) in the same manner as it applies to a violation of clause (i) of such subsection.