OAR 836-052-0134
Minimum Benefit Standards for Policies or Certificates Issued for Delivery Prior to July 1, 1992


(1)

A policy or certificate may not be advertised, solicited or issued for delivery in this state as a Medicare supplement policy or certificate unless it meets or exceeds the standards described in this rule. The standards described in this rule are minimum standards and do not preclude the inclusion of other provisions or benefits that are not inconsistent with the standards.

(2)

The following standards apply to Medicare supplement policies and certificates and are in addition to all other requirements of OAR 836-052-0103 (Purpose) to 836-052-0194 (Separability):

(a)

A Medicare supplement policy or certificate shall not exclude or limit benefits for losses insured more than six 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 months before the effective date of coverage;

(b)

A Medicare supplement policy or certificate shall not indemnify against losses resulting from sickness on a different basis than losses resulting from accidents;

(c)

A Medicare supplement policy or certificate shall provide that benefits designed to cover cost sharing amounts under Medicare will be changed automatically to coincide with any changes in the applicable Medicare deductible, copayment or coinsurance amounts and copayment percentage factors. Premiums may be modified to correspond with such changes. An insurer must justify any premium modification actuarially and must obtain approval from the Director before implementing the modification;

(d)

A “noncancelable,” “guaranteed renewable” or “noncancelable and guaranteed renewable” Medicare supplement policy shall not:

(A)

Provide for termination of coverage of a spouse solely because of the occurrence of an event specified for termination of coverage of the insured, other than the nonpayment of premium; or

(B)

Be canceled or nonrenewed by the issuer on the grounds of deterioration of health.

(e)

Intentionally left blank —Ed.

(A)

Except as authorized by the Director, an issuer shall neither cancel nor nonrenew a Medicare supplement policy or certificate for any reason other than nonpayment of premium or a material misrepresentation;

(B)

If a group Medicare supplement insurance policy is terminated by the group policyholder and not replaced as provided in paragraph (D) of this subsection, the issuer shall offer certificate holders an individual Medicare supplement policy. The issuer shall offer the certificate holder at least the following choices:
(i)
An individual Medicare supplement policy currently offered by the issuer having comparable benefits to those contained in the terminated group Medicare supplement policy; and
(ii)
An individual Medicare supplement policy that provides only such benefits as are required to meet the minimum standards as defined in OAR 836-052-0133 (Benefit Standards for 1990 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery on or After July 1, 1992 and with an Effective Date of Coverage Prior to June 1, 2010)(3).

(C)

If membership in a group is terminated, the issuer shall:
(i)
Offer the certificate holder the conversion opportunities described in paragraph (B) of this subsection; or
(ii)
At the option of the group policyholder, offer the certificate holder continuation of coverage under the group policy.

(D)

If a group Medicare supplement policy is replaced by another group Medicare supplement policy purchased by the same policyholder, the issuer of the replacement policy shall offer coverage to all persons covered under the old group policy on its date of termination. Coverage under the new group policy shall not result in any exclusion for preexisting conditions that would have been covered under the group policy being replaced;

(E)

This subsection does not prohibit rate increases otherwise authorized by law.

(f)

Termination of a Medicare supplement policy or certificate shall be without prejudice to any continuous loss that commenced while the policy was in force, but the extension of benefits beyond the period during which the policy was in force may be predicated upon the continuous total disability of the insured, limited to the duration of the policy benefit period, if any, or payment of the maximum benefits. Receipt of Medicare Part D benefits will not be considered in determining a continuous loss.

(g)

If a Medicare supplement policy eliminates an outpatient prescription drug benefit as a result of requirements imposed by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, the modified policy shall be deemed to satisfy the guaranteed renewal requirements of this section.

(3)

The following minimum benefit standards apply:

(a)

Coverage of Part A Medicare eligible expenses for hospitalization to the extent not covered by Medicare from the 61st day through the 90th day in any Medicare benefit period;

(b)

Coverage for either all or none of the Medicare Part A inpatient hospital deductible amount;

(c)

Coverage of Part A Medicare eligible expenses incurred as daily hospital charges during use of Medicare’s lifetime hospital inpatient reserve days;

(d)

Upon exhaustion of all Medicare hospital inpatient coverage, including the lifetime reserve days, coverage of ninety percent of all Medicare Part A eligible expenses for hospitalization not covered by Medicare, subject to a lifetime maximum benefit of an additional 365 days;

(e)

Coverage under Medicare Part A for the reasonable cost of the first three pints of blood (or equivalent quantities of packed red blood cells, as defined under federal regulations) unless replaced in accordance with federal regulations or already paid for under Part B;

(f)

Coverage for the co-insurance amount of Medicare eligible expenses under Part B regardless of hospital confinement, subject to a maximum calendar year out-of-pocket amount equal to the Medicare Part B deductible ($100);

(g)

Effective January 1, 1990, coverage under Medicare Part B for the reasonable cost of the first three pints of blood (or equivalent quantities of packed red blood cells, as defined under federal regulations), unless replaced in accordance with federal regulations or already paid for under Part A, subject to the Medicare deductible amount; and

(h)

Effective January 1, 1990, coverage for the coinsurance amount of Medicare eligible expenses for outpatient drugs used in immunosuppressive therapy, subject to the Medicare outpatient prescription drug deductible, if applicable.

Source: Rule 836-052-0134 — Minimum Benefit Standards for Policies or Certificates Issued for Delivery Prior to July 1, 1992, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=836-052-0134.

836–052–0103
Purpose
836–052–0107
Authority
836–052–0114
Applicability and Scope
836–052–0119
Definitions
836–052–0124
Policy Definitions and Terms
836–052–0129
Policy Provisions
836–052–0132
Benefit Standards for 2010 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery with an Effective Date of Coverage on or After June 1, 2010
836–052–0133
Benefit Standards for 1990 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery on or After July 1, 1992 and with an Effective Date of Coverage Prior to June 1, 2010
836–052–0134
Minimum Benefit Standards for Policies or Certificates Issued for Delivery Prior to July 1, 1992
836–052–0136
Standard Medicare Supplement Benefit Plans for 1990 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery on or After July 1, 1992 and with an Effective Date of Coverage Prior to June 1, 2010
836–052–0138
Open Enrollment
836–052–0139
Medicare Select Policies and Certificates
836–052–0140
Standards for Claims Payment
836–052–0141
Standard Medicare Supplement Benefit Plans for 2010 Standardized Medicare Supplement Benefit Plan Policies or Certificates with an Effective Date of Coverage on or After June 1, 2010
836–052–0142
Guaranteed Issue for Eligible Persons
836–052–0143
Annual Opportunity to Select Another Medicare Supplement Policy or Certificate
836–052–0144
Standard Medicare Supplement Benefit Plans for 2020 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery to Individuals Newly Eligible for Medicare on or after January 1, 2020.
836–052–0145
Loss Ratio Standards and Refund or Credit of Premium
836–052–0151
Filing and Approval of Policies and Certificates and Premium Rates
836–052–0156
Permitted Compensation Arrangements
836–052–0160
Required Disclosure Provisions
836–052–0165
Requirements for Application Forms, Replacement Coverage
836–052–0170
Filing Requirements for Advertising
836–052–0175
Standards for Marketing
836–052–0180
Appropriateness of Recommended Purchase and Excessive Insurance
836–052–0185
Reporting of Multiple Policies
836–052–0190
Prohibition Against Preexisting Conditions, Waiting Periods, Elimination Periods and Probationary Periods in Replacement Policies and Certificates
836–052–0192
Prohibition Against Use of Genetic Information and Requests for Genetic Testing
836–052–0194
Separability
836–052–0225
Durational Limits for Health Maintenance Organizations
836–052–0230
Provider Services Limits for Insurers and Health Care Contractors
836–052–0500
Statutory Authority
836–052–0508
Definitions
836–052–0516
Policy Definitions
836–052–0526
Policy Practices and Provisions
836–052–0531
Long Term Care Insurance Partnership Program
836–052–0546
Required Policy Provisions
836–052–0556
Required Disclosure of Rating Practices to Consumers
836–052–0566
Initial Rate Filing Requirements
836–052–0576
Prohibition Against Post-Claims Underwriting, Applications
836–052–0586
Minimum Standards for Home Health and Community Care Benefits in Long-Term Care Insurance Policies
836–052–0596
Standards for Covered Services
836–052–0606
Use and Definition of “Home” or Similar Wording
836–052–0616
Requirement to Offer Inflation Protection
836–052–0626
Requirements for Application Forms and Replacement Coverage
836–052–0636
Reporting Requirements
836–052–0637
Annual Rate Certification Requirements
836–052–0639
Training for Insurance Producers
836–052–0646
Benefits Provided Through Advancement of Life Insurance Proceeds
836–052–0656
Reserve Standards
836–052–0666
Loss Ratio
836–052–0676
Premium Rate Schedule Increases
836–052–0680
Premium Rate Schedule Increases for Policies Subject to Loss Ratio Limits Related to Original Filings
836–052–0686
Filing Requirements for Out-of-State Group Policies
836–052–0696
Filing Requirements for Advertising
836–052–0706
Standards for Marketing
836–052–0716
Disclosure Statement
836–052–0726
Suitability
836–052–0736
Prohibition Against Preexisting Conditions, Waiting Periods and Probationary Periods in Replacement Policies and Certificates
836–052–0738
Availability of New Services or Providers
836–052–0740
Right to Reduce Coverage and Lower Premiums
836–052–0746
Nonforfeiture Benefit Requirement
836–052–0756
Standards for Benefit Triggers
836–052–0766
Additional Standards for Benefit Triggers for Qualified Long-Term Care Insurance Contracts
836–052–0768
Appealing An Insurer’s Determination That The Benefit Trigger Is Not Met
836–052–0770
Prompt Payment of Clean Claims
836–052–0776
Standard Format Outline of Coverage
836–052–0786
Requirement to Deliver Shopper’s Guide
836–052–0790
Disclosure of Benefits Paid
836–052–0800
Purpose
836–052–0810
Replacement Upon Termination
836–052–0840
Termination of Coverage
836–052–0850
Multiple Employer Trusts
836–052–0860
Form of Notice to Group Policyholder
836–052–1000
Prosthetic and Orthotic Devices
Last Updated

Jun. 8, 2021

Rule 836-052-0134’s source at or​.us