Tennessee Code Annotated

Title 56: Insurance

Chapter 7: Policies and Policyholders

Part 14: Medicare Supplement Insurance

TCA 56-7-1453: Contents of policies and certificates -- Duplicate benefits -- Preexisting conditions -- Rules and regulations. -- [Amended effective January 1, 2011. See the Compiler's Notes.]

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

(b)  Notwithstanding any other law to the contrary, a medicare supplement policy or certificate shall not exclude or limit benefits for losses incurred more than six (6) months from the effective date of coverage because it involved a preexisting condition. The policy or certificate shall not define a preexisting condition more restrictively than a condition for which medical advice was given or treatment was recommended by or received from a physician within six (6) months before the effective date of coverage.

(c)   The commissioner shall promulgate reasonable rules and regulations to establish specific standards for policy provisions of medicare supplement policies and certificates. The standards shall be in addition to and in accordance with applicable laws of this state, including chapter 26 of this title. No requirement of this title relating to minimum required policy benefits, other than the minimum standards contained in §§ 56-7-1451, 56-7-1452, this section and §§ 56-7-1454 — 56-7-1459, shall apply to medicare supplement policies and certificates. The standards may cover, but are not limited to:

     (1)  Terms of renewability;

     (2)  Initial and subsequent conditions of eligibility;

     (3)  Nonduplication of coverage;

     (4)  Probationary periods;

     (5)   Benefits limitations, exceptions and reductions;

     (6)  Elimination periods;

     (7)  Requirements for replacement;

     (8)  Recurrent conditions; and

     (9)  Definitions of terms.

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

(e)  The commissioner may promulgate, from time to time, reasonable rules and regulations necessary to conform medicare supplement policies and certificates to the requirements of federal law and regulations promulgated under federal law, including, but not limited to:

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

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

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

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

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

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

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

[Effective January 1, 2011. See the Compiler's Notes.]

(g)  (1)  (A)  Insurers offering medicare supplement policies and certificates in this state to persons sixty-five (65) years of age or older shall also offer medicare supplement policies to persons in this state who are under sixty-five (65) years of age and eligible for and enrolled in medicare by reason of disability or end stage renal disease. Except as otherwise provided in this section, all benefits, protections, policies, and procedures that apply to persons sixty-five (65) years of age or older shall also apply to persons that are eligible for and enrolled in medicare by reason of disability or end stage renal disease.

          (B)  Individuals who are under sixty-five (65) years of age and eligible for medicare by reason of disability or end stage renal disease may enroll in a medicare supplement policy at any time authorized or required by the federal government, or within six (6) months after:

                (i)  Enrolling in medicare part B, or by January 1, 2011, whichever is later;

                (ii)  The date of the notice that such person has been retroactively enrolled in medicare part B due to a retroactive eligibility decision made by the social security administration;

                (iii)  No longer having access to alternative forms of health insurance coverage such as accident and sickness policies, employer- sponsored group health coverage or medicare advantage plans due to termination or cancellation of such coverage because of the individual's employment status, or an action by a health insurer or employer that is unrelated to the individual's status, conduct or failure to pay premiums; or

                (iv)  Being involuntarily disenrolled from Title XIX (medicaid) or Title XXI (state children's health insurance program) of the Social Security Act.

          (C)  Premium rates for medicare supplement policies and certificates issued pursuant to this subsection (g) may differ between persons who qualify for medicare who are sixty-five (65) years of age or older and those who qualify for medicare by reason of disability or end stage renal disease and who are younger than sixty-five (65) years of age; provided, however, that such differences in premium rates are pursuant to rate schedules that are based on sound actuarial principles and are reasonable in relation to the benefits provided.

     (2)  Upon the expiration of five (5) years from May 27, 2010, the department of commerce and insurance shall conduct a study for the purpose of determining the appropriateness of separate premium rating for populations under sixty-five (65) years of age and such study, at a minimum, shall evaluate whether continued separate premium rating is justified in comparison to any negative rating impact or increased cost in premium that would occur to the medicare supplement insurance population taken as a whole if such separate premium rating were not allowed. The cost of any such study shall be borne by the department within the existing resources of the department at the time of the study.

History: [Acts 1992, ch. 735, § 3; 2010, ch. 978, §§ 1, 2.]