Review Requirements Checklist Medicare Supplements Form Filing for

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					Office of Product Regulation                 Ohio Department of Insurance
Services
                                                         Ted Strickland – Governor
50 W. Town Street, Suite
                                                         Mary Jo Hudson – Director
300
Columbus, OH 43215
(614) 644-2644                  Review Requirements Checklist Medicare
(614) 728-5238 Fax
www.ohioinsurance.gov          Supplements Form Filing for Prior Approval

Filing form checklists are not all inclusive and only function as guides. Checklists are summaries, and are not intended as
a Department directive nor a technical legal interpretation. Although efforts are made to ensure that checklists are
accurate, they are subject to change without prior notification.

Line of Business:                            Lines of Insurance:                     Codes:
Medicare Supplement Insurance

Medicare Advantage                          Individual                               MS03I.000
Medicare Select                             Individual                               MS04I.001, MS04I.002, MS04I.003, MS04I.004
                                                                                     MS04I.005, MS04I.006, MS04I.007, MS04I.008
                                                                                     MS04I.009, MS04I.010, MS04I.011, MS04I.012
Medicare Standard                           Individual                               MS05I.001, MS05I.002, MS05I.003, MS05I.004
                                                                                     MS05I.005, MS05I.006, MS05I.007, MS05I.008
                                                                                     MS05I.009, MS05I.010, MS051.011, MS05I.012

Medicare Advantage                          Group                                    MS03G.000
Medicare Select                             Group                                    MS04G.001, MS04G.002, MS04G.003,
                                                                                     MS04G.004, MS04G.005, MS04G.006,
                                                                                     MS04G.007, MS04G.008, MS04G.009,
                                                                                     MS04G.010, MS04G.011, MS04G.012

Medicare Standard                           Group                                    MS05G.001, MS05G.002, MS05G.003,
                                                                                     MS05G.004, MS05G.005, MS05G.006,
                                                                                     MS05G.007, MS05G.008, MS05G.009,
                                                                                     MS05G.010, MS05G.011, MS05G.012

ORC references Ohio Revised Code
OAC references Ohio Administrative Code




Review Requirements                     Reference                  Comments
Definitions                             ORC 3923.33                    “Applicant” means the person who seeks to contract for
                                                                   individual insurance benefits or the proposed certificate holder
                                                                   for group insurance benefits.
                                                                      “Certificate” means a group policy certificate delivered or
                                                                   issued in Ohio.
                                                                      “Certificate form,” means a group policy form on which the
                                                                   certificate is delivered or issued.
                                                                      “Direct response insurance policy” means policy or
                                                                   certificate marketed without an insurance agent.
                                                                      “Issuer” includes insurance companies, fraternal benefit,
                                                                   HICs, etc., delivering or issuing policies or certificates in Ohio.
                                                                       “Medicare” means the “Health Insurance for the Aged Act”
                                                                   Title XVIII of the Social Security Amendment of 1965.




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INS9111 (Rev. 07/27/2007)                                                                                                    Page 1 of 5
Ohio Department of Insurance                                          Review Requirements Checklist Medicare Supplements Form Filing
                                                                                                                   for Prior Approval




Definitions                             ORC 3923.33                 “Medicare supplement policy” means a group or individual
                                                                 policy of sickness and accident insurance or HICs or others,
                                                                 which is advertised, marketed, or designed as a supplemental
                                                                 to medicare for reimbursement of hospital, medical, or surgical
                                                                 expenses.
                                                                    “Policy form” means the form, which a policy is delivered or
                                                                 issued by issuer.
Purpose                                 OAC 3901-1-41(A)         This rule provides the reasonable standardization of terms and
                                                                 benefits; to facilitate public understanding and comparison; to
                                                                 eliminate provisions, which may mislead the purchaser or
                                                                 settlements of claims; and to provide full disclosures to persons
                                                                 eligible.
Authority, Applicability and Scope      OAC 3901-1-41(C)         This applies to individual and group medicare supplement
                                                                 policies and certificates delivered or issued in Ohio, except as
                                                                 otherwise specifically noted.
Medicare Supplement Rule                OAC 3901-1-41 (D)           “Applicant” means a person who seeks to contract for
Definitions                                                      individual insurance benefits, and the proposed certificate
                                                                 holder for group benefits.
                                                                     “Bankruptcy” means a “Medicare+Choice organization that
                                                                 is not an issuer has filed/had filed a petition of bankruptcy and
                                                                 ceased doing business in Ohio.
                                                                   “Certificate” means any certificate delivered or issued in
                                                                 Ohio under a group medicare supplement policy.
                                                                    “Certificate form” means the form on which the certificate is
                                                                 delivered or issued by the issuer.
                                                                    “Continuous period of creditable coverage” means the
                                                                 period during which an individual was covered by creditable
                                                                 coverage, with no break in coverage greater than sixty-three
                                                                 (63) days.
                                                                    “Creditable coverage” means coverage of the individual
                                                                 provided under any of the following: a group health plan; health
                                                                 insurance coverage; social security/medicare; social
                                                                 security/medicaid; CHAMPUS; medical care program of the
                                                                 Indian health services or a tribal organization; state health
                                                                 benefit risk pool, FEHBP; public health plan; peace corps act.
                                                                     “Creditable coverage” shall not include; accident or disability
                                                                 income insurance; supplement to liability; liability, general
                                                                 liability; automobile liability insurance; worker’s compensation;
                                                                 automobile medical payment or credit only insurance; coverage
                                                                 for on-site medical clinics or other similar coverage, which
                                                                 benefits for medical care is secondary to other insurance
                                                                 benefits.
                                                                    Shall not include benefits if they are provided under a
                                                                 separate policy, certificate, or contract of insurance; Limited
                                                                 scope dental or vision; long-term care, nursing home, home
                                                                 health, community based care.
                                                                    Shall not include benefits if offered as independent, non-
                                                                 coordinated benefits; specified disease or illness coverage;
                                                                 hospital indemnity or fixed indemnity insurance.

                               Accredited by the National Association of Insurance Commissioners (NAIC)
INS9111 (Rev. 07/27/2007)                                                                                                 Page 2 of 5
Ohio Department of Insurance                                           Review Requirements Checklist Medicare Supplements Form Filing
                                                                                                                    for Prior Approval




Medicare Supplement Rule                 OAC 3901-1-41 (D)           Shall not include if offered as a separate policy, certificate
Definitions                                                       or contract: Medicare supplemental health insurance.
                                                                     “Employee welfare benefit plan”: means a plan, fund or
                                                                  program of employee benefits (ERISA).
                                                                      “Insolvency or Insolvent” means an insurer is unable to pay
                                                                  its obligations when due, or its admitted assets do not exceed
                                                                  its liabilities plus as further stipulated in the rule at sub item (8).
Required policy definitions and          OAC 3901-1-41 (E)        Includes definitions for “accident”, “benefit period”,
terms                                                             “convalescent nursing home”, “health care expenses”,
                                                                  “Medicare”, “Medicare-eligible expenses”, “physician”,
                                                                  “sickness”.
Application of provisions and            ORC 3923.331             Includes exemptions.
standards
Prohibited policy provisions             ORC 3923.332             Includes permitted pre-existing conditions limitation standard –
                                                                  grants authority to Superintendent of Insurance to adopt
                                                                  applicable rules and standards.
Reasonable premium for benefits          ORC 3923.333             Grants authority to Superintendent of Insurance to establish
provided                                                          minimum standards for loss ratios.
Outline of coverage/disclosures          ORC 3923.334             Mandated format and content, minimum 12-point type size
                                                                  entire outline.
Outline of coverage                      OAC 3901-1-41 (Q)
                                         (3), Appendix C
Right to return for refund               ORC 3923.335             Right to return for refund within 30 days of delivery.
Prior approval of advertising            ORC 3923.336             Grants to Superintendent prior approval authority of any
                                                                  Medicare supplement insurance advertising used in Ohio.
Solicitation and sale                    OAC 3901-1-35            Defines unfair or deceptive acts.
Standardization of coverage              OAC 3901-1-41 (H)        Benefit standards for policies or certificates issued on and after
                                                                  May 1, 1992.
Policy provisions                        OAC 3901-1-41 (F)        No policy or certificate may be advertised, solicited, issued as
                                                                  a medicare supplement policy if it contains limitations or
                                                                  exclusions more restrictive than those of medicare.
Minimum benefits prior to May 1,         OAC 3901-1-41 (G)        Includes minimum benefit requirements prior to required
1992                                                              standardized Plans A through J.
Benefit standards for policies           OAC 3901-1-41 (H)        Includes core benefit language and additional benefits
delivered after May 1, 1992                                       language applicable to respective Plans A through J.
Standard Medicare supplement             OAC 3901-1-41 (I)        Benefit plans shall be uniform in structure, language,
benefit plans                                                     designation and format to the standard A through J plans.
                                                                  Structure, language and format means style, arrangement and
                                                                  overall content of a benefit.
Medicare Select policies and             OAC 3901-1-41 (J)        Includes requirements for Medicare Select insurance and other
certificates                                                      related filing requirements distinct to Medicare Select.
Open enrollment                          OAC 3901-1-41 (K)        Includes requirements applicable to open enrollment applicants
                                                                  for Medicare supplement insurance.
Guaranteed issue for eligible            OAC 3901-1-41 (L)        Definition of eligible persons at (L)(2).
persons


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Ohio Department of Insurance                                          Review Requirements Checklist Medicare Supplements Form Filing
                                                                                                                   for Prior Approval




Standards for claims payment            OAC 3901-1-41 (M)        Issuer shall comply with the Social Security Act. Accept claims
                                                                 for benefits from participating physicians; notify payment
                                                                 determination; pay the physician. Furnish enrollment cards
                                                                 with policy name, number and mailing address of the insurer.
                                                                 Provide Health and Human Services with the central mailing
                                                                 address annually.
Loss ratio standards and refund or      OAC 3901-1-41 (N)        Includes minimum loss ratio for group and for individual
credit of premium                                                policies; and requirements for refund or credit calculation.
                                                                 Appendix A
Filing and approval of policies and     OAC 3901-1-41 (O)        Includes prior approval of premium rate filings for individual
rates                                                            policies and group policies, annual rate filing required, prior
                                                                 approval any change in filed premium rates, 30 days deemer,
                                                                 etc.
Permitted compensation                  OAC 3901-1-41 (P)        Includes requirements for level of first year commission or
arrangements                                                     other compensation in relation to second year; subsequent
                                                                 (renewal) year commission or other compensation.
Required disclosure provisions          OAC 3901-1-41 (Q)        Includes annual disclosure to policy/certificate holders required
                                        (2), Appendix F          30 days prior to annual effective date of any Medicare benefit
                                                                 changes, format requirements.
                                                                 Includes required first page notice for non-medicare
                                        OAC 3901-1-41(Q)
                                                                 supplement policies and additional required disclosure per
                                        (4), Appendix G
                                                                 applicable statement in Appendix G to be given to person
                                                                 eligible for Medicare as part of or together with application for
                                                                 specified non-medicare supplement policy/certificate.
Application forms:                      OAC 3901-1-41            Includes questions and statements required to be in application
                                        (R), Appendix D          or supplement to application.
                                        OAC 3901-1-41(R),        Includes mandated format, time of delivery requirements,
Replacement coverage
                                        Appendix E               minimum 12 point type-size.
                                        ORC 3999.21              Required fraud notice.
                                        ORC 3901.45              No insurer shall inquire into sexual orientation/AIDS.
                                        OAC 3901-1-49            Aids testing consent form.
                                        ORC 3901.49              Genetic testing.
Filing requirements for advertising     OAC 3901-1-41 (S)        Prior approval is required for advertisement whether written or
                                                                 electronic media for each medicare supplement policy.
Standards for marketing                 OAC 3901-1-41 (T)        Issuer is responsible for establishing specified marketing
                                                                 procedures. Includes mandated first page policy certificate
                                                                 disclosure and specifies prohibited acts/practices.
Appropriateness of recommended          OAC 3901-1-41 (U)        Specifies agent responsibilities regarding sale of replacement
purchase and excessive                                           policy/certificate and prohibits sale of duplicate Medicare
insurance                                                        supplement policy to a person.
Prohibitions against pre-existing       OAC 3901-1-41            Requires credit of any waiting/elimination and probationary
conditions, waiting periods,            (W)                      periods satisfied under replaced policy if in effect less than six
elimination periods, and                                         months, otherwise, all time periods waived for
probationary periods in                                          policies/certificates in effect six or more months.
replacement policies




                               Accredited by the National Association of Insurance Commissioners (NAIC)
INS9111 (Rev. 07/27/2007)                                                                                                 Page 4 of 5
Ohio Department of Insurance                                           Review Requirements Checklist Medicare Supplements Form Filing
                                                                                                                    for Prior Approval



Standardized health claim form           ORC 3902.21–             Specifies required claim forms issuers must accept.
                                         3902.23; OAC
                                         3901–1-59
Unfair health claim practices            OAC 3901-1-60            Include minimum requirements applicable to claims
                                                                  investigation and disposition.
Flesch Reading Ease Minimum              ORC 3902.01-             Minimum score 40; certification signed by officer of issuer
Standards                                3902.08                  required.




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INS9111 (Rev. 07/27/2007)                                                                                                  Page 5 of 5