| Contact Person: | Illinois Division of Insurance | 320 West Washington Street | ||
| Cindy Colonius | Review Requirements Checklist | Springfield, IL 62767-0001 | ||
| 217-782-4572 | ||||
| Cindy.Colonius@Illinois.gov |
Effective 10/31/08 |
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| Line(s) of | Filing | Line(s) of | Filing | |
| Business | Code(s) | Insurance | Code(s) | |
Individual and Group Medicare Supplement |
MSO1
|
Individual and Group Medicare Supplement Policies |
MSO1.000
|
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| Illinois Insurance Code Link | Illinois Compiled Statutes Online | |||
| Illinois Administrative Code Link | Administrative Regulations Online | |||
| Product Coding Matrix | Product Coding Matrix | |||
| REVIEW REQUIREMENTS | REFERENCE |
DESCRIPTION OF REVIEWSTANDARDS REQUIREMENTS |
LOCATION OF STANDARD IN FILING |
| NOTE: These brief summaries do not include all requirements of all laws, regulations, bulletins, or requirements, so review actual law, regulation, bulletin, or requirement for details to ensure that forms are fully compliant before filing with the Department of Insurance. | |||
| FORM FILING REQUIREMENTS | REFERENCE | DESCRIPTION OF REVIEW STANDARDS REQUIREMENTS | LOCATION OF STANDARD IN FILING |
| Uniform Transmittal Document (Etrans) | 50 IL Adm Code 916 | Form filings must now be submitted either by SERFF or CD-ROM. Please visit
the Division's web site for the Universal Transmittal Document (Etrans)
by clicking this link. Scroll down to "Universal Transmittal Document Software (Etrans)" |
|
| Review Requirements Checklist | Go to Review Requirements Checklists on DOI web site. See next column | Each filing must include a completed Review Requirements Checklist that must contain a completed “Location of Standard in Filing” column for each required element of the filing. Please indicate the proper page # and form # for each entry. The checklists may be found at this link. |
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| Cover Letter and Letter of Submission | 50 IL Adm. Code 1405.20 (e) |
In addition to referencing any previously approved form number(s) as required by 50 IL Adm. Code 1405.20(e), those references must also include the filing number and SERFF tracking number (if applicable and available) for the referenced forms. Letters of submission must generally describe the intent and use of the form being filed and, if applicable, how it will be used with any previously approved form(s). |
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| Outline of Coverage | 50 IL Adm. Code 2007.80 b) | An Outline of Coverage must be submitted with a uniform transmittal document and contain a unique filing number. | |
| Form Filing Requirements | 50 IL Adm. Code 2007.80 c) | Insurers may not file more than one filing of a policy or certificate for each Standard Medicare Supplement Plan. | |
| Rates | 50 IL Adm. Code 2008.81 | Rates must be submitted with a uniform transmittal document and contain a unique filing number. The cover letter must disclose the previously approved policy(s) form numbers and filing numbers as well as approval date for the previously approved filings to which the new rate filing applies. |
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Under Age 65 Rate Requirements |
215 ILCS 5/363(6)(c) Bulletin 2008-02 |
Insurers must file a new rate schedule which clearly shows that the under age 65 rates do not exceed the highest rate they charge to anyone over 65. |
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| Annual Filing of Premium Rates | 50 IL Adm. Code 2008.80 c) | Rates must be filed annually. |
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| Advertising Filing Requirements | 50 IL Adm. Code 2008.90 h) | Insurers are required to file their Medicare Supplement advertising with an informational transmittal and diskette. Each advertisement must be related to a policy form or forms on the transmittal. The cover letter must disclose the previously approved policy(s) form numbers and filing numbers as well as approval date for the previously approved filings to which the new rate filing applies. |
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| GENERAL REQUIREMENTS FOR ALL FILINGS | REFERENCE | DESCRIPTION OF REVIEW STANDARDS REQUIREMENTS | |
| Entire Contract | 215 ILCS 5/357.2 215 ILCS 5/367(2)(a) |
The policy, including the application and any amendments and riders, constitutes the entire contract of insurance and no change is valid unless approved by an executive officer of the company and unless such approval be endorsed hereon or attached hereto. | |
| Time Limit on Certain Defenses | 215 ILCS 5/357.3 215 ILCS 5/367(2) |
A policy is incontestable two years from the date of issue except for fraudulent misstatements made by the applicant on the application. | |
| Timely Payment of Claims | 215 ILCS 5/357.1 215 ILCS 5/357.9 |
Claims must be paid within 30 days following receipt of written due proof of loss. | |
| Timely Payment of Health Care Services | 215 ILCS 5/368a |
Periodic payments must be made within 60 days of insured's selection of a provider or effective date of selection, whichever is later. In case of retrospective enrollment only 30 days after notice by employer to insurer. Subsequent payments must be in monthly periodic cycle. Penalty payment of 9% per year. Payments other than periodic must be made within 30 days after receipt of due proof of loss. Same penalty provisions. |
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| Proof of Loss | 215 ILCS 5/357.1 215 ILCS 5/357.8 |
Written proofs of loss should be submitted to the company within 90 days of loss. | |
| Reinstatement | 215 ILCS 5/357.1 215 ILCS 5/357.5 |
A policy may be reinstated with or without an application as provided. | |
| Spousal Conversion | 215 ILCS 5/356d | Policies of accident and health must contain a conversion provision, made available without evidence of insurability, for dependent spouses upon a valid judgment of dissolution of the marriage if such application is made within 60 days following the date of judgment. | |
| REQUIRED DISCLOSURE PROVISIONS | |||
| Required Disclosure Provisions | 50 IL Adm. Code 2008.90 | Insurers would benefit greatly by reading this entire Section. | |
| Renewability and Continuation | 50 IL Adm. Code 2008.70 a) 4) B) | The coverage may not be canceled or nonrenewed by the issuer solely on the grounds of deteriorating health. | |
| Riders/Endorsements | 50 IL Adm. Code 2008.90 a) 2) | The insured must agree in writing to policy or endorsements that reduce or eliminate benefits after coverage is in force or at the time of reinstatement. | |
| Usual and Customary | 50 IL Adm. Code 2008.90 a) 3) | Policies may not provide benefit payments based on standards described as "usual and customary", "reasonable and customary" or terms similar in nature. | |
| Pre-existing Limitations | 50 IL Adm. Code 2008.90
a) 4) 215 ILCS 5/363(5) |
Policies containing pre-existing condition limitations provisions must be placed in a separate paragraph and be labeled as "Preexisting Condition Limitations".A Medicare Supplement policy or certificate may not deny a claim for losses incurred more than 6 months from the effective date of coverage. | |
| Free Look | 50 IL Adm. Code
2008.90 a) 5) 215 ILCS 5/363(4) |
Policies must contain a 30-day free look provision. | |
| Guide to Health Insurance for People with Medicare | 50 IL Adm. Code 2008.90
a) 6) 215 ILCS 5/363a (6)(c) |
Issuers of Medicare Supplement policies that provide benefits on an expense incurred or indemnity basis must provide applicants with a Guide to Health Insurance for People with Medicare that has been approved by the Director. | |
| Application Forms | 50 IL Adm. Code 2008.100 a) | Application forms must include a replacement question. | |
| Identification Cards | 50 IL. Adm. Code 2008.90 b) | Identification cards provided to the policyholder(s) must reflect the name of the issuer rather than a corporate name and must also identify which plan of coverage is being provided to the policyholder. | |
| Policy Checklist | 50 IL Adm. Code 2008.90
c) and Appendix
A 215 ILCS 5/363a(3)(f) |
A policy checklist is required. | |
| Outline of Coverage | 50 IL Adm. Code 2008.90
f) and Appendix B
215 ILCS 5/363a(6)(a)(b) |
An outline of coverage is required. It must indicate all the plans and corresponding premium rates the insurer has available in Illinois. The cover letter must disclose the previously approved policy(s) form numbers and filing numbers as well as approval date for the previously approved filings to which the new rate filing applies. |
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| STANDARDIZED MEDICARE SUPPLEMENT PLANS (A-L) | |||
| Plan A | 50 IL. Adm. Code 2008.71b) and c) and Appendix C | Core benefits (benefits for the 61st-90th day; benefits for 91st-150th day; Part A hospital benefits, full coverage of an additional 365 days per lifetime upon exhaustion; Part B coinsurance or co-payment; First 3 pints of blood each calendar year.) | |
| Plan B | 50 IL Adm. Code 2008.71b) and c) and Appendix D | Core benefits as set forth in Plan A as well as Medicare Part A deductible. | |
| Plan C | 50 IL Adm. Code 2008.71 b) and c) and Appendix E | Core Benefits (Plan A) and Medicare Parts A and B deductibles; foreign travel emergency benefit, skilled nursing coinsurance. | |
| Plan D | 50 IL Adm. Code 2008.71 b) and c) and Appendix F | Core Benefits (Plan A) and Medicare Part A deductible; foreign travel emergency benefit, skilled nursing coinsurance; and at home recovery benefit. | |
| Plan E | 50 IL Adm. Code 2008.71 b) and c) and Appendix G | Core Benefits (Plan A) and Medicare Part A deductible; skilled nursing coinsurance; foreign travel emergency benefit; preventive care benefit. | |
| Plan F | 50 IL Adm. Code 2008.71 b) and c) and Appendix H | Core Benefits (Plan A) and Medicare Parts A and B deductibles; Part B Excess (100%); skilled nursing coinsurance benefit; foreign travel emergency benefit. May also have a high deductible option. | |
| Plan G | 50 IL Adm. Code 2008.71 b) and c) and Appendix I | Core Benefits (Plan A) and Medicare Part A deductible; skilled nursing coinsurance; Part B Excess (80%); foreign travel emergency benefit; and at home recovery benefit. | |
| Plan H | 50 IL Adm. Code 2008.71 b) and c) and Appendix J | Core Benefits (Plan A) and Medicare Part A deductible; skilled nursing coinsurance; foreign travel emergency benefit; basic drug benefit ($1, 250). | |
| Plan I | 50 IL Adm. Code 2008.71 b) and c) and Appendix K | Core Benefits (Plan A) and Medicare Part A deductible; skilled nursing coinsurance; Part B Excess (100%); foreign travel emergency benefit; at home recovery benefit; and basic drug benefit ($1,250). | |
| Plan J | 50 IL Adm. Code 2008.71 b) and c) and Appendix L | Core Benefits (Plan A) and Medicare Parts A and B deductibles; Part B Excess (100%); skilled nursing coinsurance benefit; foreign travel emergency benefit; at home recovery; extended drugs ($3,000); and preventative care benefit. May also have a high deductible option. | |
| Plan K | 50 IL Adm. Code 2008.71 d) 1) and Appendix M | Must fully cover the cost sharing for Part B preventive services, the Part A hospital co-insurance and an additional 365 days of hospital coverage. It must also cover 50% of the Part A and Part B blood deductibles, the Part B co-insurance, the skilled nursing facility co-insurance, the cost sharing associated with the hospice benefit, and the Part A hospital deductible. Additionally, it must cover 100% of all cost sharing under Medicare Parts A and B for the rest of the calendar year once a beneficiary reaches an out-of-pocket limit of $4000 in 2006. The outpatient prescription drug benefit shall not be included in a Medicare supplement policy sold after December 31, 2005. | |
| Plan L | 50 IL Adm. Code 2008.71 d) 2) Appendix N | Must fully cover the cost sharing for Part B preventive services, the Part A hospital co-insurance and an additional 365 days of hospital coverage. It must also cover 75% of the Part A and Part B blood deductibles, the Part B co-insurance, the skilled nursing facility co-insurance, the cost sharing associated with the hospice benefit, and the Part A hospital deductible. Additionally, it must cover 100% of all cost sharing under Medicare Parts A and B for the rest of the calendar year once a beneficiary reaches an out-of-pocket limit of $2000 in 2006. |
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| MEDICARE SELECT POLICIES | |||
| Plan of Operation | 50 IL. Adm. Code Part 2008.73 e) | A Plan of Operation must be submitted for the network and must be submitted with an informational transmittal sheet. | |
| Emergency Care | 50 IL. Adm. Code Part 2008.73 e) 1) D) | Emergency Care must be available 24 hours a day and 7 days a week. | |
| List of Network Providers | 50 IL. Adm. Code Part 2008.73 e) 5) | A list of the network providers must be submitted and an updated list filed at least quarterly. | |
| Covered Services | 50 IL. Adm. Code Part 2008.73 h) | Services not available in-network must be covered in full under a Medicare Select Policy or certificate. | |
| Outline of Coverage | 50 IL. Adm. Code Part 2008.73 i) | Outlines of coverage for Medicare Select policies must be sufficient to compare the coverage and premiums with other Medicare Supplement policies offered by the insurer or policies or certificates issued by other insurers. | |
| Grievances/Complaints | 50 IL. Adm. Code Part 2008.73 k) | The Medicare Select policy or certificate must set forth the grievance procedure describing how a grievance may be registered with the issuer. | |
| GENERAL INFORMATION | |||
| Discretionary Authority | 215 ILCS 5/143(1) 50 IL Adm. Code 2001.3 |
Insurers are not permitted to place discretionary authority language in contracts of accident and health. | |
| Use of SSN on ID Cards |
The focus of HB 4712 is on any card required for an individual to access products or services, while SB 2545 is more limited in that it just focuses on insurance cards. HB 4712 prevents a person from:
Insurers are required to comply with both provisions. |
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| Medicare Supplement Eligibility Under 65 | 215 ILCS 5/363(6) | This provision offers guidelines for insurers issuing coverage to individuals under age 65 who become eligible due to disability. | |
| MMA Notice Requirements | 50 IL Adm. Code 2008.90 e) | Insurers must comply with any notice requirements of the Medicare Prescription Drug, Improvement and Modernization Act of 2003. | |
| DEPARTMENT POSITIONS | |||
| One Filing Only for Each Standard Medicare Supplement Benefit Plan | 215 ILCS 5/143(1) | Insurers may not file more than one form of a policy or certificate for each type of Standard Medicare Supplement Benefit Plan. | |
| HIV/AIDS Questions on Application | 215 ILCS 5/143(1) | Questions designed to elicit information regarding AIDS, ARC and HIV must be specifically related to the testing, diagnosis or treatment done by a physician or an appropriately licensed clinical professional acting within the scope of his/her license. |