HF 1016

as introduced - 83rd Legislature (2003 - 2004) Posted on 12/15/2009 12:00am

  1.1                          A bill for an act 
  1.2             relating to insurance; regulating Medicare supplement 
  1.3             insurance; conforming state law to the minimum federal 
  1.4             standards; amending Minnesota Statutes 2002, sections 
  1.5             62A.31, subdivisions 1f, 1u; 62A.315; 62A.316. 
  1.6   BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA: 
  1.7      Section 1.  Minnesota Statutes 2002, section 62A.31, 
  1.8   subdivision 1f, is amended to read: 
  1.9      Subd. 1f.  [SUSPENSION BASED ON ENTITLEMENT TO MEDICAL 
  1.10  ASSISTANCE.] (a) The policy or certificate must provide that 
  1.11  benefits and premiums under the policy or certificate shall be 
  1.12  suspended for any period that may be provided by federal 
  1.13  regulation at the request of the policyholder or certificate 
  1.14  holder for the period, not to exceed 24 months, in which the 
  1.15  policyholder or certificate holder has applied for and is 
  1.16  determined to be entitled to medical assistance under title XIX 
  1.17  of the Social Security Act, but only if the policyholder or 
  1.18  certificate holder notifies the issuer of the policy or 
  1.19  certificate within 90 days after the date the individual becomes 
  1.20  entitled to this assistance. 
  1.21     (b) If suspension occurs and if the policyholder or 
  1.22  certificate holder loses entitlement to this medical assistance, 
  1.23  the policy or certificate shall be automatically reinstated, 
  1.24  effective as of the date of termination of this entitlement, if 
  1.25  the policyholder or certificate holder provides notice of loss 
  2.1   of the entitlement within 90 days after the date of the loss and 
  2.2   pays the premium attributable to the period, effective as of the 
  2.3   date of termination of entitlement. 
  2.4      (c) The policy must provide that upon reinstatement (1) 
  2.5   there is no additional waiting period with respect to treatment 
  2.6   of preexisting conditions, (2) coverage is provided which is 
  2.7   substantially equivalent to coverage in effect before the date 
  2.8   of the suspension, and (3) premiums are classified on terms that 
  2.9   are at least as favorable to the policyholder or certificate 
  2.10  holder as the premium classification terms that would have 
  2.11  applied to the policyholder or certificate holder had coverage 
  2.12  not been suspended. 
  2.13     Sec. 2.  Minnesota Statutes 2002, section 62A.31, 
  2.14  subdivision 1u, is amended to read: 
  2.15     Subd. 1u.  [GUARANTEED ISSUE FOR ELIGIBLE PERSONS.] (a)(1) 
  2.16  Eligible persons are those individuals described in paragraph 
  2.17  (b) who apply to enroll under the Medicare supplement policy not 
  2.18  later than 63 days after the date of the termination of 
  2.19  enrollment described in paragraph (b), seek to enroll under the 
  2.20  policy during the period specified in paragraph (c), and who 
  2.21  submit evidence of the date of termination or disenrollment with 
  2.22  the application for a Medicare supplement policy. 
  2.23     (2) With respect to eligible persons, an issuer shall not:  
  2.24  deny or condition the issuance or effectiveness of a Medicare 
  2.25  supplement policy described in paragraph (c) that is offered and 
  2.26  is available for issuance to new enrollees by the issuer; 
  2.27  discriminate in the pricing of such a Medicare supplement policy 
  2.28  because of health status, claims experience, receipt of health 
  2.29  care, medical condition, or age; or impose an exclusion of 
  2.30  benefits based upon a preexisting condition under such a 
  2.31  Medicare supplement policy. 
  2.32     (b) An eligible person is an individual described in any of 
  2.33  the following: 
  2.34     (1) the individual is enrolled under an employee welfare 
  2.35  benefit plan that provides health benefits that supplement the 
  2.36  benefits under Medicare; and the plan terminates, or the plan 
  3.1   ceases to provide all such supplemental health benefits to the 
  3.2   individual; 
  3.3      (2) the individual is enrolled with a Medicare+Choice 
  3.4   organization under a Medicare+Choice plan under Medicare part C, 
  3.5   and any of the following circumstances apply, or the individual 
  3.6   is 65 years of age or older and is enrolled with a Program of 
  3.7   All-Inclusive Care for the Elderly (PACE) provider under section 
  3.8   1894 of the federal Social Security Act, and there are 
  3.9   circumstances similar to those described in this clause that 
  3.10  would permit discontinuance of the individual's enrollment with 
  3.11  the provider if the individual were enrolled in a 
  3.12  Medicare+Choice plan: 
  3.13     (i) the organization's or plan's certification under 
  3.14  Medicare part C has been terminated or the organization has 
  3.15  terminated or otherwise discontinued providing the plan in the 
  3.16  area in which the individual resides; 
  3.17     (ii) the individual is no longer eligible to elect the plan 
  3.18  because of a change in the individual's place of residence or 
  3.19  other change in circumstances specified by the secretary, but 
  3.20  not including termination of the individual's enrollment on the 
  3.21  basis described in section 1851(g)(3)(B) of the federal Social 
  3.22  Security Act, United States Code, title 42, section 
  3.23  1395w-21(g)(3)(b) (where the individual has not paid premiums on 
  3.24  a timely basis or has engaged in disruptive behavior as 
  3.25  specified in standards under section 1856 of the federal Social 
  3.26  Security Act, United States Code, title 42, section 1395w-26), 
  3.27  or the plan is terminated for all individuals within a residence 
  3.28  area; 
  3.29     (iii) the individual demonstrates, in accordance with 
  3.30  guidelines established by the Secretary, that: 
  3.31     (A) the organization offering the plan substantially 
  3.32  violated a material provision of the organization's contract in 
  3.33  relation to the individual, including the failure to provide an 
  3.34  enrollee on a timely basis medically necessary care for which 
  3.35  benefits are available under the plan or the failure to provide 
  3.36  such covered care in accordance with applicable quality 
  4.1   standards; or 
  4.2      (B) the organization, or agent or other entity acting on 
  4.3   the organization's behalf, materially misrepresented the plan's 
  4.4   provisions in marketing the plan to the individual; or 
  4.5      (iv) the individual meets such other exceptional conditions 
  4.6   as the secretary may provide; 
  4.7      (3)(i) the individual is enrolled with: 
  4.8      (A) an eligible organization under a contract under section 
  4.9   1876 of the federal Social Security Act, United States Code, 
  4.10  title 42, section 1395mm (Medicare risk or cost); 
  4.11     (B) a similar organization operating under demonstration 
  4.12  project authority, effective for periods before April 1, 1999; 
  4.13     (C) an organization under an agreement under section 
  4.14  1833(a)(1)(A) of the federal Social Security Act, United States 
  4.15  Code, title 42, section 1395l(a)(1)(A) (health care prepayment 
  4.16  plan); or 
  4.17     (D) an organization under a Medicare Select policy under 
  4.18  section 62A.318 or the similar law of another state; and 
  4.19     (ii) the enrollment ceases under the same circumstances 
  4.20  that would permit discontinuance of an individual's election of 
  4.21  coverage under clause (2); 
  4.22     (4) the individual is enrolled under a Medicare supplement 
  4.23  policy, and the enrollment ceases because: 
  4.24     (i)(A) of the insolvency of the issuer or bankruptcy of the 
  4.25  nonissuer organization; or 
  4.26     (B) of other involuntary termination of coverage or 
  4.27  enrollment under the policy; 
  4.28     (ii) the issuer of the policy substantially violated a 
  4.29  material provision of the policy; or 
  4.30     (iii) the issuer, or an agent or other entity acting on the 
  4.31  issuer's behalf, materially misrepresented the policy's 
  4.32  provisions in marketing the policy to the individual; 
  4.33     (5)(i) the individual was enrolled under a Medicare 
  4.34  supplement policy and terminates that enrollment and 
  4.35  subsequently enrolls, for the first time, with any 
  4.36  Medicare+Choice organization under a Medicare+Choice plan under 
  5.1   Medicare part C; any eligible organization under a contract 
  5.2   under section 1876 of the federal Social Security Act, United 
  5.3   States Code, title 42, section 1395mm (Medicare risk or cost); 
  5.4   any similar organization operating under demonstration project 
  5.5   authority; an organization under an agreement under section 
  5.6   1833(a)(1)(A) of the federal Social Security Act, United States 
  5.7   Code, title 42, section 1395l(a)(1)(A) (health care prepayment 
  5.8   plan); any PACE provider under section 1894 of the federal 
  5.9   Social Security Act, or a Medicare Select policy under section 
  5.10  62A.318 or the similar law of another state; and 
  5.11     (ii) the subsequent enrollment under paragraph (a) item (i) 
  5.12  is terminated by the enrollee during any period within the first 
  5.13  12 months of such the subsequent enrollment during which the 
  5.14  enrollee is permitted to terminate the subsequent enrollment 
  5.15  under section 1851(e) of the federal Social Security Act; or 
  5.16     (6) the individual, upon first enrolling for benefits under 
  5.17  Medicare part B, enrolls in a Medicare+Choice plan under 
  5.18  Medicare part C, or with a PACE provider under section 1894 of 
  5.19  the federal Social Security Act, and disenrolls from the plan by 
  5.20  not later than 12 months after the effective date of enrollment. 
  5.21     (c)(1) In the case of an individual described in paragraph 
  5.22  (b), clause (1), the guaranteed issue period begins on the date 
  5.23  the individual receives a notice of termination or cessation of 
  5.24  all supplemental health benefits or, if a notice is not 
  5.25  received, notice that a claim has been denied because of a 
  5.26  termination or cessation, and ends 63 days after the date of the 
  5.27  applicable notice. 
  5.28     (2) In the case of an individual described in paragraph 
  5.29  (b), clause (2), (3), (5), or (6), whose enrollment is 
  5.30  terminated involuntarily, the guaranteed issue period begins on 
  5.31  the date that the individual receives a notice of termination 
  5.32  and ends 63 days after the date the applicable coverage is 
  5.33  terminated. 
  5.34     (3) In the case of an individual described in paragraph 
  5.35  (b), clause (4)(i), the guaranteed issue period begins on the 
  5.36  earlier of: (i) the date that the individual receives a notice 
  6.1   of termination, a notice of the issurer's bankruptcy or 
  6.2   insolvency, or other such similar notice if any; and (ii) the 
  6.3   date that the applicable coverage is terminated, and ends on the 
  6.4   date that is 63 days after the date the coverage is terminated. 
  6.5      (4) In the case of an individual described in paragraph 
  6.6   (b), clause (2), (4), (5), or (6), who disenrolls voluntarily, 
  6.7   the guaranteed issue period begins on the date that is 60 days 
  6.8   before the effective date of the disenrollment and ends on the 
  6.9   date that is 63 days after the effective date. 
  6.10     (5) In the case of an individual described in paragraph (b) 
  6.11  but not described in this paragraph, the guaranteed issue period 
  6.12  begins on the effective date of disenrollment and ends on the 
  6.13  date that is 63 days after the effective date. 
  6.14     (d)(1) In the case of an individual described in paragraph 
  6.15  (b), clause (5), or deemed to be so described, pursuant to this 
  6.16  paragraph, whose enrollment with an organization or provider 
  6.17  described in paragraph (b), clause (5)(i), is involuntarily 
  6.18  terminated within the first 12 months of enrollment, and who, 
  6.19  without an intervening enrollment, enrolls with another such 
  6.20  organization or provider, the subsequent enrollment is deemed to 
  6.21  be an initial enrollment described in paragraph (b), clause (5). 
  6.22     (2) In the case of an individual described in paragraph 
  6.23  (b), clause (6), or deemed to be so described, pursuant to this 
  6.24  paragraph, whose enrollment with a plan or in a program 
  6.25  described in paragraph (b), clause (6), is involuntarily 
  6.26  terminated within the first 12 months of enrollment, and who, 
  6.27  without an intervening enrollment, enrolls in another such plan 
  6.28  or program, the subsequent enrollment is deemed to be an initial 
  6.29  enrollment described in paragraph (b), clause (6). 
  6.30     (3) For purposes of paragraph (b), clauses (5) and (6), no 
  6.31  enrollment of an individual with an organization or provider 
  6.32  described in paragraph (b), clause (5)(i), or with a plan or in 
  6.33  a program described in paragraph (b), clause (6), may be deemed 
  6.34  to be an initial enrollment under this paragraph after the 
  6.35  two-year period beginning on the date on which the individual 
  6.36  first enrolled with the organization, provider, plan, or program.
  7.1      (e) The Medicare supplement policy to which eligible 
  7.2   persons are entitled under: 
  7.3      (1) paragraph (b), clauses (1) to (4), is any Medicare 
  7.4   supplement policy that has a benefit package consisting of the 
  7.5   basic Medicare supplement plan described in section 62A.316, 
  7.6   paragraph (a), plus any combination of the three optional riders 
  7.7   described in section 62A.316, paragraph (b), clauses (1) to (3), 
  7.8   offered by any issuer; 
  7.9      (2) paragraph (b), clause (5), is the same Medicare 
  7.10  supplement policy in which the individual was most recently 
  7.11  previously enrolled, if available from the same issuer, or, if 
  7.12  not so available, any policy described in clause (1) offered by 
  7.13  any issuer; 
  7.14     (3) paragraph (b), clause (6), shall include any Medicare 
  7.15  supplement policy offered by any issuer. 
  7.16     (d) (f)(1) At the time of an event described in paragraph 
  7.17  (b), because of which an individual loses coverage or benefits 
  7.18  due to the termination of a contract or agreement, policy, or 
  7.19  plan, the organization that terminates the contract or 
  7.20  agreement, the issuer terminating the policy, or the 
  7.21  administrator of the plan being terminated, respectively, shall 
  7.22  notify the individual of the individual's rights under this 
  7.23  subdivision, and of the obligations of issuers of Medicare 
  7.24  supplement policies under paragraph (a).  The notice must be 
  7.25  communicated contemporaneously with the notification of 
  7.26  termination. 
  7.27     (2) At the time of an event described in paragraph (b), 
  7.28  because of which an individual ceases enrollment under a 
  7.29  contract or agreement, policy, or plan, the organization that 
  7.30  offers the contract or agreement, regardless of the basis for 
  7.31  the cessation of enrollment, the issuer offering the policy, or 
  7.32  the administrator of the plan, respectively, shall notify the 
  7.33  individual of the individual's rights under this subdivision, 
  7.34  and of the obligations of issuers of Medicare supplement 
  7.35  policies under paragraph (a).  The notice must be communicated 
  7.36  within ten working days of the issuer receiving notification of 
  8.1   disenrollment.  
  8.2      (e) (g) Reference in this subdivision to a situation in 
  8.3   which, or to a basis upon which, an individual's coverage has 
  8.4   been terminated does not provide authority under the laws of 
  8.5   this state for the termination in that situation or upon that 
  8.6   basis. 
  8.7      (f) (h) An individual's rights under this subdivision are 
  8.8   in addition to, and do not modify or limit, the individual's 
  8.9   rights under subdivision 1h. 
  8.10     Sec. 3.  Minnesota Statutes 2002, section 62A.315, is 
  8.11  amended to read: 
  8.12     62A.315 [EXTENDED BASIC MEDICARE SUPPLEMENT PLAN; 
  8.13  COVERAGE.] 
  8.14     The extended basic Medicare supplement plan must have a 
  8.15  level of coverage so that it will be certified as a qualified 
  8.16  plan pursuant to section 62E.07, and will provide: 
  8.17     (1) coverage for all of the Medicare part A inpatient 
  8.18  hospital deductible and coinsurance amounts, and 100 percent of 
  8.19  all Medicare part A eligible expenses for hospitalization not 
  8.20  covered by Medicare; 
  8.21     (2) coverage for the daily copayment amount of Medicare 
  8.22  part A eligible expenses for the calendar year incurred for 
  8.23  skilled nursing facility care; 
  8.24     (3) coverage for the copayment coinsurance amount or in the 
  8.25  case of hospital outpatient department services paid under a 
  8.26  prospective payment system, the co-payment amount, of Medicare 
  8.27  eligible expenses under Medicare part B regardless of hospital 
  8.28  confinement, and the Medicare part B deductible amount; 
  8.29     (4) 80 percent of the usual and customary hospital and 
  8.30  medical expenses and supplies described in section 62E.06, 
  8.31  subdivision 1, not to exceed any charge limitation established 
  8.32  by the Medicare program or state law, the usual and customary 
  8.33  hospital and medical expenses and supplies, described in section 
  8.34  62E.06, subdivision 1, while in a foreign country, and 
  8.35  prescription drug expenses, not covered by Medicare; 
  8.36     (5) coverage for the reasonable cost of the first three 
  9.1   pints of blood, or equivalent quantities of packed red blood 
  9.2   cells as defined under federal regulations under Medicare parts 
  9.3   A and B, unless replaced in accordance with federal regulations; 
  9.4      (6) 100 percent of the cost of immunizations and routine 
  9.5   screening procedures for cancer, including mammograms and pap 
  9.6   smears; 
  9.7      (7) preventive medical care benefit:  coverage for the 
  9.8   following preventive health services: 
  9.9      (i) an annual clinical preventive medical history and 
  9.10  physical examination that may include tests and services from 
  9.11  clause (ii) and patient education to address preventive health 
  9.12  care measures; 
  9.13     (ii) any one or a combination of the following preventive 
  9.14  screening tests or preventive services, the frequency of which 
  9.15  is considered medically appropriate: 
  9.16     (A) fecal occult blood test and/or digital rectal 
  9.17  examination; 
  9.18     (B) dipstick urinalysis for hematuria, bacteriuria, and 
  9.19  proteinuria; 
  9.20     (C) pure tone (air only) hearing screening test 
  9.21  administered or ordered by a physician; 
  9.22     (D) serum cholesterol screening every five years; 
  9.23     (E) thyroid function test; 
  9.24     (F) diabetes screening; 
  9.25     (iii) any other tests or preventive measures determined 
  9.26  appropriate by the attending physician.  
  9.27     Reimbursement shall be for the actual charges up to 100 
  9.28  percent of the Medicare-approved amount for each service as if 
  9.29  Medicare were to cover the service as identified in American 
  9.30  Medical Association current procedural terminology (AMA CPT) 
  9.31  codes to a maximum of $120 annually under this benefit.  This 
  9.32  benefit shall not include payment for any procedure covered by 
  9.33  Medicare; 
  9.34     (8) at-home recovery benefit:  coverage for services to 
  9.35  provide short-term at-home assistance with activities of daily 
  9.36  living for those recovering from an illness, injury, or surgery: 
 10.1      (i) for purposes of this benefit, the following definitions 
 10.2   shall apply: 
 10.3      (A) "activities of daily living" include, but are not 
 10.4   limited to, bathing, dressing, personal hygiene, transferring, 
 10.5   eating, ambulating, assistance with drugs that are normally 
 10.6   self-administered, and changing bandages or other dressings; 
 10.7      (B) "care provider" means a duly qualified or licensed home 
 10.8   health aide/homemaker, personal care aide, or nurse provided 
 10.9   through a licensed home health care agency or referred by a 
 10.10  licensed referral agency or licensed nurses registry; 
 10.11     (C) "home" means a place used by the insured as a place of 
 10.12  residence, provided that the place would qualify as a residence 
 10.13  for home health care services covered by Medicare.  A hospital 
 10.14  or skilled nursing facility shall not be considered the 
 10.15  insured's place of residence; 
 10.16     (D) "at-home recovery visit" means the period of a visit 
 10.17  required to provide at-home recovery care, without limit on the 
 10.18  duration of the visit, except each consecutive four hours in a 
 10.19  24-hour period of services provided by a care provider is one 
 10.20  visit; 
 10.21     (ii) coverage requirements and limitations: 
 10.22     (A) at-home recovery services provided must be primarily 
 10.23  services that assist in activities of daily living; 
 10.24     (B) the insured's attending physician must certify that the 
 10.25  specific type and frequency of at-home recovery services are 
 10.26  necessary because of a condition for which a home care plan of 
 10.27  treatment was approved by Medicare; 
 10.28     (C) coverage is limited to: 
 10.29     (I) no more than the number and type of at-home recovery 
 10.30  visits certified as medically necessary by the insured's 
 10.31  attending physician.  The total number of at-home recovery 
 10.32  visits shall not exceed the number of Medicare-approved home 
 10.33  health care visits under a Medicare-approved home care plan of 
 10.34  treatment; 
 10.35     (II) the actual charges for each visit up to a maximum 
 10.36  reimbursement of $40 per visit; 
 11.1      (III) $1,600 per calendar year; 
 11.2      (IV) seven visits in any one week; 
 11.3      (V) care furnished on a visiting basis in the insured's 
 11.4   home; 
 11.5      (VI) services provided by a care provider as defined in 
 11.6   this section; 
 11.7      (VII) at-home recovery visits while the insured is covered 
 11.8   under the policy or certificate and not otherwise excluded; 
 11.9      (VIII) at-home recovery visits received during the period 
 11.10  the insured is receiving Medicare-approved home care services or 
 11.11  no more than eight weeks after the service date of the last 
 11.12  Medicare-approved home health care visit; 
 11.13     (iii) coverage is excluded for: 
 11.14     (A) home care visits paid for by Medicare or other 
 11.15  government programs; and 
 11.16     (B) care provided by family members, unpaid volunteers, or 
 11.17  providers who are not care providers. 
 11.18     Sec. 4.  Minnesota Statutes 2002, section 62A.316, is 
 11.19  amended to read: 
 11.20     62A.316 [BASIC MEDICARE SUPPLEMENT PLAN; COVERAGE.] 
 11.21     (a) The basic Medicare supplement plan must have a level of 
 11.22  coverage that will provide: 
 11.23     (1) coverage for all of the Medicare part A inpatient 
 11.24  hospital coinsurance amounts, and 100 percent of all Medicare 
 11.25  part A eligible expenses for hospitalization not covered by 
 11.26  Medicare, after satisfying the Medicare part A deductible; 
 11.27     (2) coverage for the daily copayment amount of Medicare 
 11.28  part A eligible expenses for the calendar year incurred for 
 11.29  skilled nursing facility care; 
 11.30     (3) coverage for the copayment coinsurance amount, or in 
 11.31  the case of outpatient department services paid under a 
 11.32  prospective payment system, the co-payment amount, of Medicare 
 11.33  eligible expenses under Medicare part B regardless of hospital 
 11.34  confinement, subject to the Medicare part B deductible amount; 
 11.35     (4) 80 percent of the hospital and medical expenses and 
 11.36  supplies incurred during travel outside the United States as a 
 12.1   result of a medical emergency; 
 12.2      (5) coverage for the reasonable cost of the first three 
 12.3   pints of blood, or equivalent quantities of packed red blood 
 12.4   cells as defined under federal regulations under Medicare parts 
 12.5   A and B, unless replaced in accordance with federal regulations; 
 12.6      (6) 100 percent of the cost of immunizations and routine 
 12.7   screening procedures for cancer screening including mammograms 
 12.8   and pap smears; and 
 12.9      (7) 80 percent of coverage for all physician prescribed 
 12.10  medically appropriate and necessary equipment and supplies used 
 12.11  in the management and treatment of diabetes.  Coverage must 
 12.12  include persons with gestational, type I, or type II diabetes. 
 12.13     (b) Only the following optional benefit riders may be added 
 12.14  to this plan: 
 12.15     (1) coverage for all of the Medicare part A inpatient 
 12.16  hospital deductible amount; 
 12.17     (2) a minimum of 80 percent of eligible medical expenses 
 12.18  and supplies not covered by Medicare part B, not to exceed any 
 12.19  charge limitation established by the Medicare program or state 
 12.20  law; 
 12.21     (3) coverage for all of the Medicare part B annual 
 12.22  deductible; 
 12.23     (4) coverage for at least 50 percent, or the equivalent of 
 12.24  50 percent, of usual and customary prescription drug expenses; 
 12.25     (5) coverage for the following preventive health services: 
 12.26     (i) an annual clinical preventive medical history and 
 12.27  physical examination that may include tests and services from 
 12.28  clause (ii) and patient education to address preventive health 
 12.29  care measures; 
 12.30     (ii) any one or a combination of the following preventive 
 12.31  screening tests or preventive services, the frequency of which 
 12.32  is considered medically appropriate: 
 12.33     (A) fecal occult blood test and/or digital rectal 
 12.34  examination; 
 12.35     (B) dipstick urinalysis for hematuria, bacteriuria, and 
 12.36  proteinuria; 
 13.1      (C) pure tone (air only) hearing screening test, 
 13.2   administered or ordered by a physician; 
 13.3      (D) serum cholesterol screening every five years; 
 13.4      (E) thyroid function test; 
 13.5      (F) diabetes screening; 
 13.6      (iii) any other tests or preventive measures determined 
 13.7   appropriate by the attending physician. 
 13.8      Reimbursement shall be for the actual charges up to 100 
 13.9   percent of the Medicare-approved amount for each service, as if 
 13.10  Medicare were to cover the service as identified in American 
 13.11  Medical Association current procedural terminology (AMA CPT) 
 13.12  codes, to a maximum of $120 annually under this benefit.  This 
 13.13  benefit shall not include payment for a procedure covered by 
 13.14  Medicare; 
 13.15     (6) coverage for services to provide short-term at-home 
 13.16  assistance with activities of daily living for those recovering 
 13.17  from an illness, injury, or surgery: 
 13.18     (i) For purposes of this benefit, the following definitions 
 13.19  apply: 
 13.20     (A) "activities of daily living" include, but are not 
 13.21  limited to, bathing, dressing, personal hygiene, transferring, 
 13.22  eating, ambulating, assistance with drugs that are normally 
 13.23  self-administered, and changing bandages or other dressings; 
 13.24     (B) "care provider" means a duly qualified or licensed home 
 13.25  health aide/homemaker, personal care aid, or nurse provided 
 13.26  through a licensed home health care agency or referred by a 
 13.27  licensed referral agency or licensed nurses registry; 
 13.28     (C) "home" means a place used by the insured as a place of 
 13.29  residence, provided that the place would qualify as a residence 
 13.30  for home health care services covered by Medicare.  A hospital 
 13.31  or skilled nursing facility shall not be considered the 
 13.32  insured's place of residence; 
 13.33     (D) "at-home recovery visit" means the period of a visit 
 13.34  required to provide at-home recovery care, without limit on the 
 13.35  duration of the visit, except each consecutive four hours in a 
 13.36  24-hour period of services provided by a care provider is one 
 14.1   visit; 
 14.2      (ii) Coverage requirements and limitations: 
 14.3      (A) at-home recovery services provided must be primarily 
 14.4   services that assist in activities of daily living; 
 14.5      (B) the insured's attending physician must certify that the 
 14.6   specific type and frequency of at-home recovery services are 
 14.7   necessary because of a condition for which a home care plan of 
 14.8   treatment was approved by Medicare; 
 14.9      (C) coverage is limited to: 
 14.10     (I) no more than the number and type of at-home recovery 
 14.11  visits certified as necessary by the insured's attending 
 14.12  physician.  The total number of at-home recovery visits shall 
 14.13  not exceed the number of Medicare-approved home care visits 
 14.14  under a Medicare-approved home care plan of treatment; 
 14.15     (II) the actual charges for each visit up to a maximum 
 14.16  reimbursement of $40 per visit; 
 14.17     (III) $1,600 per calendar year; 
 14.18     (IV) seven visits in any one week; 
 14.19     (V) care furnished on a visiting basis in the insured's 
 14.20  home; 
 14.21     (VI) services provided by a care provider as defined in 
 14.22  this section; 
 14.23     (VII) at-home recovery visits while the insured is covered 
 14.24  under the policy or certificate and not otherwise excluded; 
 14.25     (VIII) at-home recovery visits received during the period 
 14.26  the insured is receiving Medicare-approved home care services or 
 14.27  no more than eight weeks after the service date of the last 
 14.28  Medicare-approved home health care visit; 
 14.29     (iii) Coverage is excluded for: 
 14.30     (A) home care visits paid for by Medicare or other 
 14.31  government programs; and 
 14.32     (B) care provided by family members, unpaid volunteers, or 
 14.33  providers who are not care providers; 
 14.34     (7) coverage for at least 50 percent, or the equivalent of 
 14.35  50 percent, of usual and customary prescription drug expenses to 
 14.36  a maximum of $1,200 paid by the issuer annually under this 
 15.1   benefit.  An issuer of Medicare supplement insurance policies 
 15.2   that elects to offer this benefit rider shall also make 
 15.3   available coverage that contains the rider specified in clause 
 15.4   (4).