Fill - Free fillable Commonwealth of Massachusetts Medicare Supplement Plan Form Filing PDF form

Medicare Supplement Plan (Rev 11/03/11) Page 1

CHECKLIST: MEDICARE SUPPLEMENT PLAN

FORM FILING

Pursuant to the Requirements of M.G.L. c. 176K and 211 CMR 71.00

• For each requirement, indicate the page number(s), and/or section(s), where the required

information is located.

• For items requiring company confirmation, place a checkmark (√) next to the requirement

acknowledging confirmation.

• If a requirement is not applicable, place “N/A” next to the requirement and explain, either within

the checklist or on a separate sheet, the legal basis under which the requirement does not apply

to the filed materials.

Carrier Name & NAIC #:

Product Name(s)

& Form #(s):

(Please attach a separate sheet if

necessary to identify all forms

submitted with the filing.)

$ 75 filing fee

remitted pursuant to

801 CMR 4.02(28)

$ 150 filing fee

remitted pursuant to

801 CMR 4.02(28)

Carrier Certification:

I __________________________ a duly authorized representative of

____________________________ certify that it is my good faith belief based on the review of this

checklist and submitted materials that the submitted materials comply with applicable Massachusetts

law.

FILINGS THAT DO NOT INCLUDE ALL APPLICABLE FULLY COMPLETED

CHECKLISTS WILL BE RETURNED AND NOT REVIEWED.

RESET

Medicare Supplement Plan (Rev 11/03/11) Page 2

FILING REQUIREMENTS 211 CMR 71.12(9)

________

All submissions shall be submitted in a form specified by the Commissioner, unless

granted a waiver from this requirement by the Division.

________

Each submission shall be accompanied by Massachusetts Division of Insurance Medicare

Supplement Checklist.

________

Each form submitted for final approval must be printed, be a printer's proof, or be in the

form in which it will be issued.

________

Each form shall display an identification code on the lower left-hand corner of the first

page.

________

The submission of a rider, application or endorsement shall specify the Policy or group of

Policies with which it will be used. The identification code of such Policy or group of

Policies shall be given together with, if possible, the approximate date of the original filing

to expedite review. If a new form makes reference to the provisions of a form previously

used that did not require filing or approval, it shall be accompanied by such previous form

for reference purposes.

________

Revisions shall not be made by rider, endorsement or amendment, except with prior

approval of the Commissioner. No such riders, endorsements or amendments shall be

submitted for approval unless the Issuer is notified in advance by the Commissioner that

revision by rider, endorsement or amendment is permissible.

________

All submitted material shall be filled in with appropriate hypothetical data.

________ Applications to be attached to Policy forms upon issue must be attached to such forms

upon submission. If such an application was previously filed and approved, the

approximate date of such approval must be noted, if possible. Policy outlines of coverage

prescribed in 211 CMR 71.13 must also be filed with the corresponding Policy forms, as

well as application forms and notices pursuant to 211 CMR 71.14.

________ The cover letter must state whether the form is new or replaces an approved or previously

filed form or forms.

________

If a form replaces a previously approved or filed form, the identification code of the

replaced form must be given and differences from the text of the replaced form must be

noted. Where an entire form has been rewritten to improve its readability, a general

description of changes is sufficient. Substantive changes shall be carefully noted.

________

If a form was previously disapproved, this fact must be set forth in the cover letter with the

reasons why the form is resubmitted.

Medicare Supplement Plan (Rev 11/03/11) Page 3

READABILITY STANDARDS 211 CMR 71.04 AND M.G.L. C. 175 §2B:

_________

Filing includes certification by company official that each form meets standards of

M.G.L. c. 175 §2B. The term "text" includes all printed matter except the name and

address of the insurer, name or title of the policy, captions and subcaptions, and schedule

pages and tables used in the policy. M.G.L. c. 175 §2B

___ Text of each form achieves minimum Flesch score of 50 as stated in

certification. (A statement to the effect that the score exceeds 50 is not

permitted.)

___ a. It is printed, except for tables, in not less than twelve-point type, one point

leaded.

___ b. The style, arrangement and overall appearance of the policy give no undue

prominence to any portion of the text of the policy and any endorsements or

riders;

___ c. It contains a table of contents or an alphabetical subject index;

___ d. The width of margins and ink to paper contrast do not interfere with the

readability of the form; and

___ e. The organization of the content of the policy and the summary of the policy

are conducive to understandability of the form.

_________

If insurer feels that any form is exempt from M.G.L. c. 175 §2B, state reason for

exemption in cover letter.

STANDARDS FOR POLICY DEFINITIONS 211 CMR 71.05:

_________

All definitions used in a Medicare Supplement Insurance Policy shall be compatible with

Medicare definitions and practice.

ALL MEDICARE SUPPLEMENT INSURANCE POLICIES SHALL INCLUDE A

DEFINITION FOR THE FOLLOWING TERMS:

_________

Accident, Accidental Injury, or Accidental Means shall be defined to employ "result"

language and shall not include words which establish an accidental means test or use

words such as "external, violent, visible wounds" or similar words of description or

characterization.

(a) The definition shall not be more restrictive than the following: "Injury or injuries for

which benefits are provided means accidental bodily injury sustained by the insured

person which is the direct result of an accident, independent of disease or bodily infirmity

or any other cause, and occurs while insurance coverage is in force."

(b) The definition may provide that injuries shall not include injuries for which benefits

are provided or available under any workers' compensation, employer's liability or similar

law, motor vehicle no-fault plan, or other motor vehicle insurance related plan, unless

prohibited by law.

_________

Benefit Period or Medicare Benefit Period shall not be defined more restrictively than

as defined in the Medicare program.

_________

Convalescent Nursing Home, Extended Care Facility, or Skilled Nursing Facility

shall not be defined more restrictively than as defined in the Medicare program. The

definition must take into account that there are Policy benefits for these providers'

services which are paid for only by the Medicare Supplement Insurance Policy and for

Medicare Supplement Plan (Rev 11/03/11) Page 4

which Medicare does not contribute payment.

_________

Hospital may be defined in relation to its status, facilities and available services or to

reflect its accreditation by the Joint Commission on Accreditation of Hospitals, but shall

not be defined more restrictively than as defined in the Medicare program. The definition

must take into account that there are Policy benefits for these providers' services which

are paid for only by the Medicare Supplement Insurance Policy and for which Medicare

does not contribute payment.

_________

Medicare shall be defined in the Policy and Certificate. Medicare may be substantially

defined as "The Health Insurance for the Aged Act, Title XVIII of the Social Security

Amendments of 1965 as Then Constituted or Later Amended, or "Title I, Part I of Public

Law 89-97, as Enacted by the Eighty-Ninth Congress of the United States of America and

popularly known as the Health Insurance for the Aged Act, as then constituted and any

later amendments or substitutes thereof."

_________

Medicare Eligible Expenses shall mean expenses of the kinds covered by Medicare

Parts A and B, to the extent recognized as reasonable and medically necessary by

Medicare.

_________

Physician shall not be defined more restrictively than as defined in the Medicare

program. The definition must take into account that there are Policy benefits for this

provider's services which are paid for only by the Medicare Supplement Insurance Policy

and for which Medicare does not contribute payment.

_________

Sickness shall not be defined more restrictively than the following:

Sickness means illness or disease of an insured person for which expenses are incurred

after the effective date of insurance and while the insurance is in force. The definition

may be further modified to exclude sicknesses or diseases for which benefits are provided

under any workers' compensation, occupational disease, employer's liability or similar

law.

POLICY LIMITATIONS 211 CMR 71.06:

_________

No Medicare Supplement Insurance Policy shall be advertised, solicited, issued,

renewed, delivered or issued for delivery which contains any waiting period or pre-

existing condition limitation or exclusion.

_________

No Medicare Supplement Insurance Policy shall contain limitations or exclusions on

coverage that are more restrictive than those of Medicare.

_________

Limitations on benefits shall be so labeled in a separate section of the Medicare

Supplement Insurance Policy as well as placed with the benefit provisions to which they

apply.

_________

No Medicare Supplement Insurance Policy shall contain benefits that duplicate benefits

provided by Medicare. No Medicare Supplement Insurance Policy offered or sold after

December 31, 2005 shall provide payment for drugs or biologicals eligible for coverage

under Medicare Part D.

Medicare Supplement Plan (Rev 11/03/11) Page 5

ELIGIBILITY 211 CMR 71.03

_________

Eligible Person: Any person who is eligible for Medicare Part A and B and is enrolled

in Medicare Part B regardless of age;

_________

provided, however, that Issuers and Health Maintenance Organizations are not required

to provide coverage to a person who is under the age of 65 and eligible for Medicare

coverage due solely to end-stage renal disease.

_________

provided, further, that nothing in 211 CMR 71.00 et seq. prevents an Issuer or an HMO

from providing coverage to a person who is under the age of 65 and is eligible for

Medicare coverage due solely to end-stage renal disease; and provided, further, that if

an Issuer or an HMO determines that it will provide coverage to people who are under

the age of 65 and eligible for Medicare coverage due solely to end-stage renal disease, it

shall do so in accordance with all of the provisions of 211 CMR 71.00 et seq.

_________

If a BBA Eligible Person also meets the requirements of being Initially Eligible for

Coverage, as defined in 211 CMR 71.03, the individual shall be entitled to guarantee

issue of all plans currently available from an Issuer as specified in 211 CMR 71.10(4),

including the time periods specified. See 211 CMR 71.10(13)(a) for the definition of a

BBA (the federal Balanced Budget Act or 1997 (P.L. 105-33) eligible person.

_________

If MMA Eligible Persons also meet the requirements of being Initially Eligible for

Coverage, as defined in 211 CMR 71.03, the individuals shall be entitled to guaranteed

coverage under all Policies currently available from an Issuer as specified in 211 CMR

71.10(4), including the time periods specified. See 211 CMR 71.10(14)(a) for the

definition of a MMA (federal Medicare Prescription Drug, Improvement, and

Modernization Act of 2003) Eligible Person.

RENEWABILITY 211 CMR 71.07:

_________

All Medicare Supplement Insurance Policies, including Alternate Innovative Benefit

Riders, shall contain a renewability provision as required by 211 CMR 71.07(1). Such

provision shall be appropriately captioned and shall appear on the first page of the

Policy and shall include any reservation by the Issuer of the right to change premiums.

MEDICARE SUPPLEMENT INSURANCE POLICIES SHALL COMPLY WITH THE

FOLLOWING REQUIREMENTS:

_________

The Issuer shall not cancel or nonrenew the Policy solely on the ground of the health

status of the individual.

_________

The Issuer shall not cancel or nonrenew the Policy, including an Alternate Innovative

Benefit Rider, for any reason other than nonpayment of premium or material

misrepresentation; provided that no Nonprofit Hospital Service Corporation or Medical

Service Corporation shall be required to continue the coverage of a Policyholder who

becomes a resident of a state other than Massachusetts.

_________

If the Medicare Supplement Insurance Policy is terminated by the group Policyholder

and is not replaced as provided under 211 CMR 71.07(3)(e), the Issuer shall offer

certificateholders an individual Medicare Supplement Insurance Policy which, at the

option of the certificateholder:

Medicare Supplement Plan (Rev 11/03/11) Page 6

1. Provides for continuation of the benefits contained in the group Policy; or

2. Provides for benefits that otherwise meet the requirements of 211 CMR

71.07(3).

_________

If an individual is a certificateholder in a group Medicare Supplement Insurance Policy

and the individual terminates membership in the group, the Issuer shall:

1. Offer the certificateholder the conversion opportunity described in 211

CMR 71.07(3)(c); or

2. At the option of the group Policyholder, offer the certificateholder

continuation of coverage under the group Policy.

_________

If a group Medicare Supplement Insurance Policy is replaced by another group

Medicare Supplement Insurance 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 Policy shall not

contain any waiting period or preexisting condition limitation or exclusion.

_________

Termination of a Medicare Supplement Insurance Policy shall be without prejudice to

any continuous loss which commenced while the Policy was in force, but the extension

of benefits beyond the period during which the Policy was in force may be conditioned

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.

_________ A Medicare Supplement Insurance Policy shall provide that benefits and premiums

under the Policy shall be suspended at the request of the Policyholder for the period

(not to exceed 24 months unless the Issuer permits a longer period of suspension) in

which the Policyholder has applied for and is determined to be entitled to medical

assistance under Title XIX of the Social Security Act, but only if the Policyholder

notifies the Issuer of such Policy within 90 days after the date the individual becomes

entitled to such assistance.

_________

If suspension occurs and if the Policyholder loses entitlement to medical assistance, the

Policy shall be automatically reinstituted (effective as of the date of termination of

such entitlement) if the Policyholder provides notice of loss of entitlement within 90

days after the date of loss and pays the premium attributable to the period, effective as

of the date of termination of entitlement.

_________

Each Medicare Supplement Insurance 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 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 within 90 days after the date of the

loss.

Medicare Supplement Plan (Rev 11/03/11) Page 7

_________

Reinstitution of such coverages as described in 211 CMR 71.07(3)(g)3. and 4.:

a. Shall not provide for any waiting period with respect to treatment of preexisting

conditions;

b. Shall provide for coverage which is substantially equivalent to coverage in

effect before the date of such suspension. If the suspended Medicare

Supplement Insurance Policy provided coverage for outpatient prescription

drugs, reinstitution of the Policy for Medicare Part D enrollees shall be without

coverage for outpatient prescription drugs and shall otherwise provide

substantially equivalent coverage to the coverage in effect before the date of

suspension; and

c. Shall provide for classification of premiums on terms at least as favorable to

the Policyholder as the premium classification terms that would have applied to

the Policyholder had the coverage not been suspended.

Policy Benefit Standards 211 CMR 71.08:

A Medicare Supplement Insurance Policy shall not be advertised, solicited, delivered, issued, issued for

delivery or renewed unless the Policy meets the following requirements:

_________ A Medicare Supplement Insurance Policy shall not indemnify against losses resulting

from sickness on a different basis than losses resulting from accidents.

Any Medicare Supplement Insurance Policy 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 amount and copayment percentage factors

_________

and any Medicare Supplement Insurance Policy issued to be effective on or

after January 1, 2006 shall provide that benefits will be changed automatically

to coincide with any changes required under Massachusetts law regarding

mandated benefits;

_________

premiums may be modified to correspond with such changes, if approved by

the Commissioner in accordance with statutory and regulatory requirements;

provided, however, that such Policy shall provide that the Insured agrees to the

change of benefits and premiums based on changes required under

Massachusetts law regarding mandated benefits;

_________

and provided, further, that, except as otherwise required by law, all Medicare

Supplement Insurance Policies originally issued to be effective prior to January

1, 2006 shall maintain any Guaranteed Renewable fixed drug deductible and

the same benefits covered in the original Policy

_________ No Medicare Supplement Insurance Policy shall 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.

Medicare Supplement Plan (Rev 11/03/11) Page 8

_________

Each Medicare Supplement Insurance Policy shall be Guaranteed Renewable in

accordance with the provisions of 211 CMR 71.07.

_________

No Medicare Supplement Insurance Policy issued to be effective on or before

December 31, 2005, which provides coverage for prescription drugs, shall exclude

coverage of any such drug for the treatment of cancer or HIV/AIDS on the ground that

the off-label use of the drug has not been approved by the United States Food and Drug

Administration for that indication; provided, however, that such drug is recognized for

treatment of such indication in one of the standard reference compendia; or in the

medical literature, as those terms are defined in M.G.L. c. 175, § 47O, or by the

Commissioner under the provisions of M.G.L. c. 175, § 47P.

_________

An Issuer of a Medicare Supplement Insurance Policy shall refund the unearned

portion of any premium paid on a quarterly, semi-annual or annual basis upon the

death of a Policyholder. An Issuer of a Medicare Supplement Insurance Policy may

refund the unearned portion of any premium paid on a quarterly, semi-annual or annual

basis in the case of cancellation by the Policyholder for reasons other than death. When

calculating all such refunds, an Issuer of a Medicare Supplement Insurance Policy shall

convert the billing mode from annual, semi-annual, or quarterly to monthly as of the

date of death or cancellation by the Policyholder for reasons other than death and

refund the premium paid less the sum of the monthly premiums earned to that point or

use a refund methodology submitted to and approved by the Commissioner. All

Medicare Supplement Issuers shall notify applicants regarding premium refunds in the

required outline of coverage as set forth in 211 CMR 71.13(2)(c)2. Nothing in 211

CMR 71.08(1)(h) shall affect the rights of a Policyholder to return the Policy within 30

days of its delivery and receive a premium refund pursuant to 211 CMR 71.13 (1)(e).

STANDARDS FOR CLAIMS PAYMENT 211 CMR 71.11 AND M.G.L.C.175 §110

An Issuer of Medicare Supplement Insurance shall comply with section 1882(c)(3) of the Social Security

Act (as enacted by section 4081(b)(2)(C) of the Omnibus Budget Reconciliation Act of 1987 (OBRA)

1987, Pub. L. No. 100-203) by:

_________

Accepting a notice from a Medicare carrier on dually assigned claims submitted by

participating physicians and suppliers as a claim for benefits in place of any other

claim form otherwise required and making a payment determination on the basis of

the information contained in that notice.

_________ Notifying the participating physician or supplier and the beneficiary of the payment

Determination.

_________

Paying the participating physician or supplier directly.

_________

Furnishing, at the time of enrollment, each enrollee with a card listing the Policy

name, number and a central mailing address to which notices from a Medicare carrier

may be sent.

Medicare Supplement Plan (Rev 11/03/11) Page 9

_________

Within forty-five days from . . . receipt of notice [of a claim by a claimant] if payment

is not made the insurer shall notify t

he claimant in writing specifying the reasons for

the nonpayment or whatever further documentation is necessary for payment of said

claim within the terms of the policy. If the insurer fails to comply with the provisions

of this paragraph, said insurer shall pay, in addition to any benefits which inure to

such claimant or provider, interest on such benefits, which shall accrue beginning

forty-five days after the insurer's receipt of notice of claim at the rate of one and one-

half percent per month, not to exceed eighteen percent per year. The provisions of this

paragraph relating to interest payments shall not apply to a claim which an insurer is

investigating because of suspected fraud.

REQUIRED DISCLOSURE PROVISIONS 211 CMR 71.13

_______

Except for riders or endorsements by which the Issuer effectuates a request made in

writing by the Insured, exercises a specifically reserved right under a Medicare

Supplement Insurance Policy, or is required to reduce or eliminate benefits to avoid

duplication of Medicare benefits, all riders or endorsements added to a Medicare

Supplement Insurance Policy after date of issue or at reinstatement or renewal which

reduce or eliminate benefits or coverage in the Policy shall require a signed acceptance by

the Insured. After the date of Policy issue, any rider or endorsement which increases

benefits or coverage with a concomitant increase in premium during the Policy term shall

be agreed to in writing signed by the Insured, unless the benefits are required by the

minimum standards for Medicare Supplement Insurance Policies, or if the increased

benefits or coverage is required by law. Where a separate additional premium is charged

for benefits provided in connection with riders or endorsements, the premium charge shall

be set forth in the Policy.

_______

Each Policy shall have a notice prominently printed on the first page of the Policy or

attached thereto stating in substance that the Policyholder shall have the right to return the

Policy within 30 days of its delivery and to have the premium refunded if, after

examination of the Policy, the insured person is not satisfied for any reason.

________

Each Policy shall not provide for the payment of benefits based on standards described as

usual and customary," "reasonable and customary," or words of similar import.

________

Each Policy shall have a specification page and shall provide the following information:

1. The Policy number;

2. The name of the Insured;

3. The effective date, assuming the premium for the Policy has been paid on or

before that date;

4. A listing of the premium or premiums payable and the periods to which they apply.

________

No misleading Policy names shall be used. A carrier's Policy name shall not misrepresent

the extent of benefits actually provided. Carriers shall not use the name "Medicare

Supplement," "Medigap" or similar terms except to describe a Policy that complies with

211 CMR 71.00.

Medicare Supplement Plan (Rev 11/03/11) Page 10

MEDICARE SUPPLEMENT CORE POLICY 211 CMR 71.90

A Medicare Supplement Core Insurance Policy shall provide the following coverage and shall not

provide any additional benefits:

________

The following Medicare Part A eligible expenses:

(a) To the extent not covered by Medicare, benefits for hospitalization for the first 90 days

per benefit period less the Medicare Part A deductible, plus 60 lifetime reserve days, then

an additional lifetime maximum of 365 days paid at the applicable prospective payment

system rate or other appropriate Medicare standard of payment. The provider shall accept

the Issuer’s payment as payment in full and may not bill the insured for any balance. Such

benefits shall include treatment for biologically-based mental disorders and charges for

the first three pints of blood.

(b) To the extent not covered by Medicare, for biologically-based mental disorders, stays

in a licensed mental hospital, less Part A deductibles; for other mental disorders benefits,

stays in a licensed mental hospital for at least 60 days per calendar year less days covered

by Medicare or already covered by the plan in that calendar year for other mental

disorders, less Part A deductibles.

________

The following Medicare Part B eligible expenses: To the extent not covered by Medicare,

the Medicare Part B coinsurance or in the case of hospital outpatient department services

paid under a prospective payment system, the copayment amount, of Medicare eligible

expenses under Part B regardless of hospital confinement, subject to a maximum calendar

year out-of pocket amount equivalent to the Medicare Part B deductible [$100]. This

includes all costs for the first three pints of blood.

________

Services rendered for the treatment of mental disorders on an outpatient basis:

a. For biologically-based mental disorders:

1. By a provider covered by Medicare, the benefit described in 211 CMR 71.90(2).

2. By a provider not covered by Medicare, coverage for all medically necessary visits.

b. For other mental health disorders:

1. By a provider covered by Medicare, the benefit described in 211 CMR 71.90(2).

2. By a provider not covered by Medicare, a minimum of 24 medically necessary

visits per 12-month period, less any visits already covered under 211 CMR

71.90(3)(a)(1), in the 12-month period. As required by M.G.L. c. 175, § 47B(i);

M.G.L. c. 176A, § 8A(i); M.G.L. c. 176B §4A(i), psychopharmacological services

and neuropsychological assessment services shall be treated as a medical benefit

and shall be covered as described in 211 CMR 71.90(2). The benefit described in

211 CMR 71.90(3) is subject to 211 CMR 71.06(4).

________

Enteral formulas medically necessary for the treatment of malabsorption caused by

Crohn's disease, ulcerative colitis, gastroesophageal reflux, gastrointestinal motility,

chronic intestinal pseudo-obstruction, as required by M.G.L. c. 175, § 47I; M.G.L. c.

176A, § 8L; and M.G.L. c. 176B, § 4K, less any Medicare payments.

________ Enteral formulas medically necessary for the treatment of inherited diseases of amino

acids and organic acids as required by M.G.L. c. 175, § 47I; M.G.L. c. 176A, § 8L; and

M.G.L. c. 176B, § 4K, less any Medicare payments. Coverage for inherited disease of

Medicare Supplement Plan (Rev 11/03/11) Page 11

amino acids and organic acids shall include food products modified to be low protein in

an amount not to exceed $5,000 annually for any Insured individual.

________

Where applicable, as required under M.G.L. c. 175, § 47G, as amended from time to time,

pap smear tests and mammograms not covered by Medicare.

________

Bone marrow transplants or transplants for certain patients with breast cancer as required

by M.G.L. c. 175, § 47M; M.G.L. c. 176A, § 8O (as added by St. 1993, c. 458, § 2); and

M.G.L. c. 176B, § 4O not covered by Medicare. The benefit described in 211 CMR

71.90(6) is subject to 211 CMR 71.06(4).

________

At the option of the Issuer, and if approved by the Commissioner, the New or Innovative

Benefits outlined in 211 CMR 71.09(1) or (5). Such New or Innovative Benefits may be

offered within the Policy or as an optional Alternate Innovative Benefit Rider to the

Medicare Supplement Core Insurance Policy.

________ Licensed hospice care services to terminally ill patients with a life expectancy of six

months or less, as set forth and regulated by M.G.L. c. 111, § 57D and as authorized by a

duly licensed physician as required by M.G.L. c. 175, § 47Q (as added by St. 1994, c. 284,

§ 2); M.G.L. c. 176A, § 8P (as added by St. 1994, c. 284, § 3); and M.G.L. c. 176B, § 4Q

(as added by St. 1994, c. 284, § 4).

________

Expenses incurred in the medically necessary diagnosis and treatment of speech, hearing

and language disorders individuals licensed as speech-language pathologists or

audiologists under M.G.L. c. 112, as required by M.G.L. c. 175, § 47U (as added by St.

2000, c. 345, § 2); M.G.L. c. 176A, § 8U (as added by St. 2000, c. 345, § 3); and M.G.L.

c. 176B, § 4U (as added by St. 2000, c. 345, § 4).

________

Hormone replacement therapy services for peri and post menopausal women and

outpatient contraceptive services under the same terms and conditions as for such other

outpatient services. Outpatient contraceptive services shall mean consultations,

examinations, procedures and medical services provided on an outpatient basis and related

to the use of all contraceptive methods to prevent pregnancy that have been approved by

the United States Food and Drug Administration, as required by M.G.L. c. 175, § 47W(a)

(as added by St. 2002, c. 49, §1); M.G.L. c. 176A, § 8W(a) (as added by St. 2002, c. 49,

§2); M.G.L. c. 176B, § 4W(a) (as added by St. 2002, c. 49, §3); and/or M.G.L. c.176G, §

4O(a) (as added by St. 2002, c. 49, § 4). The benefit described in 211 CMR 71.90(12) is

subject to 211 CMR 71.06(4).

________ According to M.G.L. c. 175 §47AA, M.G.L. c. 176A §8DD M.G.L. c. 176B §4DD fully

insured health plans issued or renewed by health insurance carriers on and after

January 1, 2011 must provide benefits for the diagnosis and treatment of ASD on a

nondiscriminatory basis to all residents of Massachusetts and to all insureds having a

principal place of employment in Massachusetts. [refer to above-noted statutes for a

complete description of the mandate]

Medicare Supplement Plan (Rev 11/03/11) Page 12

MEDICARE SUPPLEMENT 1 211 CMR 71.91

A Medicare Supplement 1 Insurance Policy shall provide the following coverage and shall not provide

any additional benefits:

________

The following Medicare Part A eligible expenses:

(a) To the extent not covered by Medicare, benefits for hospitalization for the first 90 days

per benefit period, plus 60 lifetime reserve days, then an additional lifetime maximum of

365 days paid at the applicable prospective payment system or other appropriate Medicare

standard of payment. The provider shall accept the Issuer’s payment as payment in full

and may not bill the insured for any balance. Such benefits shall include treatment for

biologically-based mental disorders and charges for the first three pints of blood.

(b) To the extent not covered by Medicare, for biologically-based mental disorders, stays

in a licensed mental hospital; for other mental disorders benefits, stays in a licensed

mental hospital for a minimum of 120 days per benefit period (at least 60 days per

calendar year) less days covered by Medicare or already covered by the plan in that

calendar year for other mental disorders.

the extent not covered by Medicare, and $10 per day for the l01st through the 365th day

per benefit period, provided the stay otherwise meets Medicare requirements. Benefits for

services in all skilled nursing facilities shall be available for a combined maximum of 365

days per benefit period.

________ Services in a skilled nursing facility not certified by Medicare at $8 per day for 365 days

per benefit period, provided the admission otherwise meets Medicare requirements.

Benefits for services in all skilled nursing facilities shall be available for a combined

maximum of 365 days per benefit period.

________

The following Medicare Part B eligible expenses: To the extent not covered by Medicare,

the Medicare Part B deductible and coinsurance or in the case of hospital outpatient

department services paid under a prospective payment system, the copayment amount for

Medicare Part B eligible expenses regardless of hospital confinement. This includes all

costs for the first three pints of blood.

________

Services rendered for the treatment of mental disorders on an outpatient basis:

a. For biologically-based mental disorders:

1. By a provider covered by Medicare, the benefit described in 211 CMR 71.90(2).

2. By a provider not covered by Medicare, coverage for all medically necessary visits.

b. For other mental health disorders:

1. By a provider covered by Medicare, the benefit described in 211 CMR 71.90(2).

2. By a provider not covered by Medicare, a minimum of 24 medically necessary

visits per 12-month period, less any visits already covered under 211 CMR

71.90(3)(a)(1), in the 12-month period. As required by M.G.L. c. 175, § 47B(i);

M.G.L. c. 176A, § 8A(i); M.G.L. c. 176B §4A(i), psychopharmacological services

and neuropsychological assessment services shall be treated as a medical benefit

and shall be covered as described in 211 CMR 71.90(2). The benefit described in

211 CMR 71.90(3) is subject to 211 CMR 71.06(4).

Medicare Supplement Plan (Rev 11/03/11) Page 13

________

Enteral formulas medically necessary for the treatment of malabsorption caused by

Crohn's disease, ulcerative colitis, gastroesophageal reflux, gastrointestinal motility,

chronic intestinal pseudo-obstruction, as required by M.G.L. c. 175, § 47I; M.G.L. c.

176A, § 8L; and M.G.L. c. 176B, § 4K, less any Medicare payments.

________

Enteral formulas medically necessary for the treatment of inherited diseases of amino

acids and organic acids as required by M.G.L. c. 175, § 47I; M.G.L. c. 176A, § 8L; and

M.G.L. c. 176B, § 4K, less any Medicare payments. Coverage for inherited disease of

amino acids and organic acids shall include food products modified to be low protein in

an amount not to exceed $5,000 annually for any Insured individual.

________

The Medicare daily skilled nursing facility coinsurance for Christian Science Sanatorium

nursing services up to 30 days per benefit period.

________ For those traveling outside the United States, and its territories, coverage for the same

services and the same level of payment as is provided within the United States by the

combination of Medicare Part A and Part B and the Medicare Supplement 1 Insurance

Policy less any Medicare payments.

________

Where applicable, as required under M.G.L. c. 175, § 47G, as amended from time to time,

pap smear tests and mammograms not covered by Medicare.

________

Non-Medicare covered services rendered by a dentist during a Medicare-eligible

admission for those services.

________

Bone marrow transplants or transplants for certain patients with breast cancer as required

by M.G.L. c. 175, § 47M; M.G.L. c. 176A, § 8O (as added by St. 1993, c. 458, § 2); and

M.G.L. c. 176B, § 4O not covered by Medicare. The benefit described in 211 CMR

71.90(6) is subject to 211 CMR 71.06(4).

________

At the option of the Issuer, and if approved by the Commissioner, the New or Innovative

Benefits outlined in 211 CMR 71.09(1) or (5). Such New or Innovative Benefits may be

offered within the Policy or as an optional Alternate Innovative Benefit Rider to the

Medicare Supplement Core Insurance Policy.

________

Licensed hospice care services to terminally ill patients with a life expectancy of six

months or less, as set forth and regulated by M.G.L. c. 111, § 57D and as authorized by a

duly licensed physician as required by M.G.L. c. 175, § 47Q (as added by St. 1994, c. 284,

§ 2); M.G.L. c. 176A, § 8P (as added by St. 1994, c. 284, § 3); and M.G.L. c. 176B, § 4Q

(as added by St. 1994, c. 284, § 4).

________

Expenses incurred in the medically necessary diagnosis and treatment of speech, hearing

and language disorders individuals licensed as speech-language pathologists or

audiologists under M.G.L. c. 112, as required by M.G.L. c. 175, § 47U (as added by St.

2000, c. 345, § 2); M.G.L. c. 176A, § 8U (as added by St. 2000, c. 345, § 3); and M.G.L.

c. 176B, § 4U (as added by St. 2000, c. 345, § 4).

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