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Medicare Supplement Checklist.xls

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					  Medicare Supplement

COMPANY NAME:

NAIC Code (#####):

                                                                                                                                     Electronic Communication Requested
FEIN (#########):


    REVIEW
 REQUIREMENTS       REFERENCE                                              COMMENTS                                                         REFERENCE
TYPE of FILING: MEDICARE SUPPLEMENT                                                                                                    FORM/PAGE/PARAGRAPH
FORMS - Standardized Medicare Supplements
                                    Effective August 1, 2005
                                    (a) The North Carolina Department of Insurance incorporates by reference,
                                    including subsequent amendments and editions, the National Association of
                                    Insurance Commissioners Medicare Supplement Insurance Minimum Standards
                                    Model Act, Model No. 651. Copies of this Act may be obtained from: The National
                                    Association of Insurance Commissioners, 2301 McGee Street, Kansas City, MO
                                    64108-1662; the North Carolina Department of Insurance, Life & Health Division,
                                    1201 Mail Service Center, Raleigh, NC 27699-1201; and from the Department of
                                    Insurance web page: http://www.ncdoi.com/.(b) Section 7 of Model No. 651 shall
                                    apply to policies or certificates issued for delivery in North Carolina before January
                                    1, 1992.

                     T11 NCAC           (c) Section 8 of Model No. 651 shall apply to policies or certificates issued for
                     12.0843            delivery in North Carolina on or after January 1, 1992.

                                        (d) For purposes of this rule, Section 8A(7)(c) of Model No. 651 shall read as
                                        follows:

                                        Each Medicare supplement policy shall provide that benefits and premiums under
                                        the policy shall be suspended (for any period that may be provided by federal
                                        regulation) at the request of the policyholder if the policyholder is entitled to benefits
                                        under Section 226(b) of the Social Security Act and is covered under a group health
                                        plan (as defined in Section 1862(b)(1)(A)(v) of the Social Security Act). If
                                        suspension occurs and if the policyholder or certificate holder loses coverage under
                                        the group health plan, the policy shall be automatically reinstituted (effective as of
                                        the date of loss of coverage) if the policyholder provides notice of loss of coverage

                                        Effective July 1, 2006, any insurer, as defined by G.S. 58-1-5(3), that files with the
                                        Commissioner for review or approval product forms of life, annuity, accident and
                     T11 NCAC           health, multiple employer welfare arrangements or managed care provider contract
                     12.0329            forms and supporting documents, or premium rates, shall comply with this rule.
  Medicare Supplement

    REVIEW
 REQUIREMENTS          REFERENCE                                            COMMENTS                                                   REFERENCE
TYPE of FILING: MEDICARE SUPPLEMENT                                                                                               FORM/PAGE/PARAGRAPH
                                      Applications that contain the Acronyms AIDS or HIV must also contain a definition of
                    T11 NCAC
                                      such abbreviations. The Life and Health Division will accept as a valid definition the
                    12.0324
                                      full and proper phrase for which the acronym stands.
                                      Must include on the cover, first or insert page a statement that the policy (certificate)
                                      is a legal contract between the policy owner and the insurer and the statement,
                    NCGS 58-38-20
                                      printed in larger or other contrasting type or color, "READ YOUR POLICY
                                      (CERTIFICATE) CAREFULLY."
                    NCGS 58-38-
                                      An index of major provisions in the certificate and policy is required.
                    20(2)
                                      Individual rate revisions shall be approved by the Commissioner prior to
                    NCGS 58-51-95(f) implementation. Approved rates shall be guaranteed for a period of not less than 12
                                      months and preceded by a written 45 day notice.
General Information - Medicare Supplements

NAIC Model 651 or                        Termination of a Medicare supplement policy or certificate shall be without prejudice
                  Section 7.                                                                                                            XXXXX
subsequent Model                         to any continuous loss that commenced while the policy was in force.


                     NCGS 58-54-         No policy in force shall contain benefits that duplicate benefits provided by
                                                                                                                                        XXXXX
                     10(a)               Medicare.

                                         Effective 10/1/2001, all Medicare supplement issuers must make Plans A, C and J
                     NCGS 58-54-45       available to the disabled population during the 6 month period beginning with the              XXXXX
                                         first month of enrollment in Medicare Part B.
General Information - Medicare Supplements
                                      Include a cover letter, or the NAIC Adopted Uniform Transmittal Document in lieu
                    T11 NCAC          thereof, that:
                                                                                                                                        XXXXX
                    12.0329(1)        (a)        Includes the name and address of the submitting company.


                     T11 NCAC            (b)       States the company issuing the form.                                                 XXXXX
                     12.0329(1)


                     T11 NCAC            (c)        Includes the toll-free telephone number and valid electronic e-mail address
                                                                                                                                        XXXXX
                     12.0329(1)          of the filer.



                     T11 NCAC            (d)       Provides a unique identifying form number of each form submitted and its
                                                                                                                                        XXXXX
                     12.0329(1)          descriptive title.
  Medicare Supplement

    REVIEW
 REQUIREMENTS       REFERENCE                                             COMMENTS                                                   REFERENCE
TYPE of FILING: MEDICARE SUPPLEMENT                                                                                             FORM/PAGE/PARAGRAPH

                  T11 NCAC
                                     (e)       Indicates whether the form is new or a form revision.                                  XXXXX
                  12.0329(1)


                  T11 NCAC
                                     (f)      Identifies, for any revised forms, the form being replaced by its form                  XXXXX
                  12.0329(1)
                                     number, assigned tracking number, and approval date.


                  NCGS 58-38-
                                     A certified Flesch Scale readability analysis and test score of at least 50 is required.         XXXXX
                  30(b)(1)


                                     No action at law or in equity may be brought to recover on the policy prior to
                  NCGS 58-51-        expiration of 60 days after written proof of loss has been furnished. No such action
                                                                                                                                      XXXXX
                  15(a)(11)          may be brought after the expiration of 3 years after the time written proof of loss is
                                     required to be furnished.
RATES

NAIC Model 651 or                    The actuarial memorandum must stated the anticipated minimum loss ratio. In the
                  Section 14.A.
subsequent Model                     case of individual policies the minimum is 65% and in group 75% policies.



                  Section 17.D.(3)   Premium rates must be listed in the outline of coverage.


General Information - Medicare Supplement RATES
                                     Refund or Credit Calculation reports must be filed annually by May 31 to the
NAIC Model 651 or                    Commissioner. Reporting form shall be in the format prescribed by the NAIC in
                  Section 14.                                                                                                         XXXXX
subsequent Model                     Appendix A of the Model Regulation to Implement the NAIC Medicare Supplement
                                     Insurance Minimum Standards Model Act.


                                     Annual filing of premium rates, rating schedule and supporting documentation,
                  Section 15.                                                                                                         XXXXX
                                     including ratios of incurred losses to earned premiums by policy duration.


                  Section 15. &    Shall not use or change premium rates unless rates, rating schedule and supporting
                                                                                                                                      XXXXX
                  NCGS 58-51-95(f) documentation have been filed with and approved by the Commissioner.
  Medicare Supplement

    REVIEW
 REQUIREMENTS       REFERENCE                                            COMMENTS                                                   REFERENCE
TYPE of FILING: MEDICARE SUPPLEMENT                                                                                            FORM/PAGE/PARAGRAPH
                                      A change in the rating structure or methodology shall be considered a
                                     discontinuance under Paragraph (d) of this Rule unless the issuer complies with the
                                     following requirements:
                                     (1) The issuer provides an actuarial memorandum, in a form and manner prescribed
                                     by the Commissioner, describing the manner in which the revised rating
                  Section 15.        methodology and resultant rates differ from the existing rating methodology and                 XXXXX
                                     resultant rates.
                                     (2) The issuer does not subsequently put into effect a change of rates or rating
                                     factors that would cause the percentage differential between the discontinued and
                                     subsequent rates as described in the actuarial memorandum to change. The
                                     Commissioner may approve a change to the differential that is in the public interest.

                                   Medicare supplement plans developed under an attained age methodology must
                                   disclose that attained age rating means the premium increases with age; an
                                   illustration over a period of 10 years which reflects the increase in premium due to
                  NCGS 58-54-25(f)                                                                                                   XXXXX
                                   age must be included; a statement at issue age policies do not increase with age;
                                   and, a statement that the applicant should compare issue age policies and attained
                                   age policies.

                                      The same form number cannot be used more than once. You may however amend
                  NCGS 58-51-
                                     the form number with a suffix or revision date so that it will be distinguishable from          XXXXX
                  5(a)(6)
                                     the originally approved version.
APPLICATIONS - Medicare Supplements
NAIC Model 651 or                    Issuer shall provide an outline of coverage to each applicant at the time of
                  Section 17.
subsequent Model                     application and obtain an acknowledgment of receipt.

                                     It is necessary that the application contain statements and questions as stated in
                  Section 18.
                                     the Administrative Code.
                                     The Application Heading: "To The Best Of Your Knowledge" must comply as stated
                  Section 18.
                                     by Administrative Code.
                                     The replacement notice shall be provided in substantially the format reflected and in
                  Section 18.
                                     no less than 12-point type.
               NCGS 58-39-           The application disclosure authorization must specify the length of time (maximum
               35(7)                 30 months) the authorization remains valid.
MEDICARE SELECT FORMS
                                     A Medicare Select policy or certificate shall not restrict payment for covered services
NAIC Model 651 or                    provided by non-network providers if: (1) The services are for symptoms requiring
                  Section 10.
subsequent Model                     emergency care or are immediately required for an unforeseen illness, injury or a
                                     condition; and (2) it is not feasible to obtain services through a network provider.
  Medicare Supplement

    REVIEW
 REQUIREMENTS       REFERENCE                                                 COMMENTS                                                   REFERENCE
TYPE of FILING: MEDICARE SUPPLEMENT                                                                                                 FORM/PAGE/PARAGRAPH

                                        A Medicare Select policy or certificate shall provide payment for full coverage under
                    Section 10.
                                        the policy for covered services that are not available through network providers.


                                        A Medicare Select issuer shall make full and fair disclosure in writing of the
                                        provisions, restrictions, and limitations of the Medicare Select policy or certificate to
                    Section 10.
                                        each applicant. The disclosure shall include items (1) through (7) as detailed in the
                                        Rule.

                                        A Medicare Select issuer shall have and use the procedures detailed for hearing
                                        complaints and resolving written grievances from the subscribers, which procedures
                    Section 10.
                                        shall be aimed at mutual agreement for settlement and may include arbitration
                                        procedures.

                                        The grievance procedure shall be described in the policy and certificates and in the
                    Section 10.
                                        outline of coverage.

Medicare Select - General Information

NAIC Model 651 or                       A Medicare Select issuer shall not issue a Medicare Select policy or certificate until
                  Section 10.                                                                                                             XXXXX
subsequent Model                        its plan of operation has been approved by the Commissioner.

                                        The plan of operation shall contain at least the following information: Evidence that
                                        all covered services that are subject to restricted network provisions are available
                    Section 10.                                                                                                           XXXXX
                                        and accessible through network providers, including a demonstration to satisfy T11
                                        NCAC 20.0300.

                                        Plan of operation must contain a statement or map providing a clear description of
                    Section 10.                                                                                                           XXXXX
                                        the services area.


                                        Plan of operation must contain a description of the grievance procedure to be
                    Section 10.                                                                                                           XXXXX
                                        utilized.
                                        Plan of operation must contain a description of the quality assurance program,
                                        including: the formal organizational structure; the written criteria for selection,
                    Section 10.         retention and removal of network providers; the procedures for evaluating quality of              XXXXX
                                        care provided by network providers, and the process to initiate corrective action
                                        when warranted.
                                        Plan of operation will contain a list and description, by specialty, of the network
                    Section 10.                                                                                                           XXXXX
                                        providers.
  Medicare Supplement

    REVIEW
 REQUIREMENTS       REFERENCE                                               COMMENTS                                                 REFERENCE
TYPE of FILING: MEDICARE SUPPLEMENT                                                                                             FORM/PAGE/PARAGRAPH
                                       Plan of operation will contain copies of the written information proposed to be used
                    Section 10.                                                                                                       XXXXX
                                       by the issuer to comply with Paragraph (i) of this Rule.

                                       At the time the policy or certificate is issued, the issuer shall provide detailed
                    Section 10.        information to the policyholder describing how a grievance may be registered with              XXXXX
                                       the issuer.
                                       Grievances shall be considered in a timely manner and shall be transmitted to
                    Section 10.        appropriate decision-makers who have authority to fully investigate the issue and              XXXXX
                                       take corrective action.
               Section 10.       If a grievance is found to be valid, corrective action shall be taken promptly.                      XXXXX
               Section 10.       All concerned parties shall be notified about the results of a grievance                             XXXXX
ADVERTISEMENTS - General Medicare Supplement Information

NAIC Model 651 or                      Every issuer shall comply with NCGS 58-54-35 before it uses any advertising in
                  Section 19.                                                                                                         XXXXX
subsequent Model                       North Carolina.

                    T11 NCAC
                                       Advertising form must disclose the name of the actual insurance carrier.                       XXXXX
                    12.0529
                                       The same form number cannot be used more than once. You may however amend
                    NCGS 58-51-
                                       the form number with a suffix or revision date so that it will be distinguishable from         XXXXX
                    5(a)(6)
                                       the originally approved version.
REPORTING - General Medicare Supplement Information

NAIC Model 651 or                      On or before May 1st of each year, the issuer must file experience data on each
                  Section 14.                                                                                                         XXXXX
subsequent Model                       plan type to verify whether or not the required benchmark loss ratio is being met.

                                       On or before March 1st of each year, the issuer must report (on each individual
                    Section 22.                                                                                                       XXXXX
                                       resident of this state) whether or not more than one supplement is in force.
                    T11 NCAC           All issuers must report annually the number of written complaints or inquires
                                                                                                                                      XXXXX
                    12.0548            received from policyholders who are eligible for Medicare.

                                       An issuer of Medicare Select shall report no later than each March 31st regarding its
                    Section 10.        grievance procedure. The report shall contain the number of grievances filed in the            XXXXX
                                       past year and a summary of the subject, nature and resolution of such grievances.
 Medicare Supplement

    REVIEW
 REQUIREMENTS       REFERENCE                                                COMMENTS                                                                      REFERENCE
TYPE of FILING: MEDICARE SUPPLEMENT                                                                                                                   FORM/PAGE/PARAGRAPH


                                A detailed reason or explanation as to why a requirement is not
                               applicable must be provided on a separate page for those
                               requirements referenced by N/A


                               I, the filer, acknowledge that I have prepared the submitted form(s) in
                               accordance with the checklist and to the best of my knowledge this file
                               is in substantial compliance with all of the above listed reference
                               point’s.




                               Signature of Filer                                                                                              Date


                               The Life and Health Division checklist is intended to expedite the Departments overall review time of new
                               form filings. The checklist serves as a basic guide to assist the Industry in preparation of new form filings
                               prior to submission. The checklist is not a substitute for Departmental review. All forms must comply with
                               State Insurance Law.

				
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