Update to guidance on standardized Medigap policy

CMS recently issued guidance on a new standardized Medigap policy (Plan N) that will become effective June 1. Based on inquiries received from the provider community since the guidance was released, CMS has made several clarifying changes, which have resulted in the original guidance being replaced with the following.

Revised questions and answers regarding implementation of Medicare supplement Plan N co-payment, deductible, and coinsurance

Medicare supplement insurance plans and benefits have been updated in accordance with recent revisions to the Medicare Supplement Model Regulation and the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA). Section 9.1E (11) of the Model provides that new Medicare supplement Plan N will include a co-payment structure. As states and companies are working towards implementation of these new changes (which apply for policies with effective dates on or after June 1), a number of questions have surfaced regarding implementation of the new Plan N co-payment, deductible, and coinsurance requirements.

Plan N requirements

Section 9.1E (11) of NAIC Model Regulation 651 (as published in the Federal Register on April 24, 2009 (see page 18823) states:
“(11) Standardized Medicare supplement Plan N shall include only the following: The basic (core) benefit as defined in Section 8.1B of this regulation, plus one hundred percent (100%) of the Medicare Part A deductible, skilled nursing facility care, and medically necessary emergency care in a foreign country as defined in Sections 8.1C (1), (3) and (6) of this regulation, respectively, with co-payment s in the following amounts:
(a) the lesser of twenty dollars ($20) or the Medicare Part B coinsurance or co-payment for each covered health care provider office visit (including visits to medical specialists), and
(b) the lesser of fifty dollars ($50) or the Medicare Part B coinsurance or co-payment for each covered emergency room visit, however, this co-payment shall be waived if the insured is admitted to any hospital and the emergency visit is subsequently covered as a Medicare Part A expense.”
In order to ensure consistent implementation of this new standardized benefit Plan N, the Centers for Medicare and Medicaid Services (CMS) and the Senior Issues Task Force of the National Association of Insurance Commissioners (NAIC), have developed guidance. This information will also be provided to Medicare supplement carriers. References to CPT codes and Medicare procedures in this document have been reviewed by CMS, but are subject to change as Medicare rules and coding may change.