# Title 45 — Insurance, Commissioner of

## Article 45-06 — Accident and Health Insurance

## Chapter 45-06-01.1 — Medicare Supplement Insurance Minimum Standards

Policies or Certificates Issued for Delivery Prior to January 1, 1992
or Certificates Issued for Delivery on or After January 1, 1992, and With an
Effective Date for Coverage Prior to June 1, 2010
or Certificates Issued for Delivery With an Effective Date for Coverage on or After
June 1, 2010
Supplement Benefit Plan Policies or Certificates Issued for Delivery on or After
January 1, 1992, and With an Effective Date for Coverage Prior to June 1, 2010
Supplement Benefit Plan Policies or Certificates Issued for Delivery With an
Effective Date for Coverage on or After June 1, 2010
Supplement Benefit Plan Policies or Certificates Issued for Delivery to Individuals
Newly Eligible for Medicare on or After January 1, 2020
Probationary Periods in Replacement Policies or Certificates
### § 45-06-01.1-01. Applicability and scope.

1. Except as otherwise specifically provided in sections 45-06-01.1-05, 45-06-01.1-10,
45-06-01.1-11, 45-06-01.1-14, and 45-06-01.1-19, this chapter applies to:
a. All Medicare supplement policies delivered or issued for delivery in this state on or after
the effective date of this rule; and
b. All certificates issued under group Medicare supplement policies which certificates have
been delivered or issued for delivery in this state.

2. This chapter does not apply to a policy or contract of one or more employers or labor
organizations, or of the trustees of a fund established by one or more employers or labor
organizations, or combination thereof, for employees or former employees, or a combination
thereof, or for members or former members, or a combination thereof, of the labor
organizations.
History: Effective January 1, 1992; amended effective July 8, 1997.
General Authority: NDCC 26.1-36.1-02(1)(2), 26.1-36.1-03
Law Implemented: NDCC 26.1-36.1
### § 45-06-01.1-02. Definitions.

For purposes of this chapter:
1. "1990 standardized Medicare supplement benefit plan", "1990 standardized benefit plan", or
"1990 plan" means a group or individual policy of Medicare supplement insurance issued on
or after January 1, 1992, and with an effective date for coverage prior to June 1, 2010, and
includes Medicare supplement insurance policies and certificates renewed on or after that
date which are not replaced by the issuer at the request of the insured.
2. "2010 standardized Medicare supplement benefit plan", "2010 standardized benefit plan" or
"2010 plan" means a group or individual policy of Medicare supplement insurance issued with
an effective date for coverage on or after June 1, 2010.
3. "Applicant" means:
a. In the case of an individual Medicare supplement policy, the person who seeks to
contract for insurance benefits; and
b. In the case of a group Medicare supplement policy, the proposed certificate holder.
4. "Bankruptcy" means when a Medicare advantage organization that is not an issuer has filed,
or has had filed against it, a petition for declaration of bankruptcy and has ceased doing
business in the state.
5. "Certificate" means any certificate delivered or issued for delivery in this state under a group
Medicare supplement policy.
6. "Certificate form" means the form on which the certificate is delivered or issued for delivery by
the issuer.
7. "Continuous period of creditable coverage" means the period during which an individual was
covered by creditable coverage, if during the period of the coverage the individual had no
breaks in coverage greater than sixty-three days.
8. a. "Creditable coverage" means, with respect to an individual, coverage of the individual
provided under any of the following:
(1) A group health plan;
(2) Health insurance coverage;
(3) Part A or part B of title XVIII of the Social Security Act (Medicare);
(4) Title XIX of the Social Security Act other than coverage consisting solely of benefits
under section 1928;

(6) A medical care program of the Indian health service or of a tribal organization;
(7) A state health benefits risk pool;
(8) A health plan offered under 5 U.S.C. 89 (federal employees health benefits
program);
(9) A public health plan as defined in federal regulations; and
(10) A health benefit plan under section 5(e) of the Peace Corps Act (22 U.S.C. 2504(e)).
b. "Creditable coverage" does not include one or more, or any combination of, the following:
(1) Coverage only for accident or disability income insurance, or any combination
thereof;
(2) Coverage issued as a supplement to liability insurance;
(3) Liability insurance, including general liability insurance and automobile liability
insurance;
(4) Workers' compensation or similar insurance;
(5) Automobile medical payment insurance;
(6) Credit-only insurance;
(7) Coverage for onsite medical clinics; and
(8) Other similar insurance coverage, specified in federal regulations under which
benefits for medical care are secondary or incidental to other insurance benefits.
c. "Creditable coverage" does not include the following benefits if they are provided under a
separate policy, certificate, or contract of insurance or are otherwise not an integral part
of the plan:
(1) Limited scope dental or vision benefits;
(2) Benefits for long-term care, nursing home care, home health care,
community-based care, or any combination thereof; and
(3) Such other similar, limited benefits as are specified in federal regulations.
d. "Creditable coverage" does not include the following benefits if offered as independent,
noncoordinated benefits:
(1) Coverage only for a specified disease or illness; and
(2) Hospital indemnity or other fixed indemnity insurance.
e. "Creditable coverage" does not include the following if it is offered as a separate policy,
certificate, or contract of insurance:
(1) Medicare supplement health insurance as defined under section 1882(g)(1) of the
Social Security Act;
(2) Coverage supplemental to the coverage provided under 10 U.S.C. 55; and
(3) Similar supplemental coverage provided to coverage under a group health plan.

9. "Employee welfare benefit plan" means a plan, fund, or program of employee benefits as
defined in 29 U.S.C. 1002 (Employee Retirement Income Security Act).
10. "Insolvency" means when an issuer, licensed to transact the business of insurance in this
state, is unable to pay its obligations when they are due, or when its admitted assets do not
exceed its liabilities plus the greater of:
a. Any capital and surplus required by law for its organization; or
b. The total par or stated value of its authorized and issued capital stock.
11. "Issuer" includes insurance companies, fraternal benefit societies, health care service plans,
health maintenance organizations, and any other entity delivering or issuing for delivery in this
state Medicare supplement policies or certificates.
12. "Medicare" means the Health Insurance for the Aged Act, title XVIII of the Social Security
Amendments of 1965, as then constituted or later amended.
13. "Medicare advantage plan" means a plan of coverage for health benefits under Medicare
part C as defined in 42 U.S.C. 1395w-28(b)(1), and includes:
a. Coordinated care plans which provide health care services, including health maintenance
organization plans, with or without a point-of-service option; plans offered by
provider-sponsored organizations; and preferred provider organization plans;
b. Medical savings account plans coupled with a contribution into a Medicare advantage
medical savings account; and
c. Medicare advantage private fee-for-service plans.
14. "Medicare supplement policy" means a group or individual policy of accident and sickness
insurance or a subscriber contract of hospital and medical service associations or health
maintenance organizations, other than a policy issued pursuant to a contract under section
1876 of the federal Social Security Act [42 U.S.C. 1395 et seq.] or an issued policy under the
demonstration project specified in 42 U.S.C. 1395ss(g)(1), which is advertised, marketed, or
designed primarily as a supplement to reimbursements under Medicare for the hospital,
medical, or surgical expenses of persons eligible for Medicare. "Medicare supplement policy"
does not include Medicare advantage plans established under Medicare part C, outpatient
prescription drug plans established under Medicare part D, or any health care prepayment
plan that provides benefits pursuant to an agreement under section 1833(a)(1)(A) of the
Social Security Act.
15. "Policy form" means the form on which the policy is delivered or issued for delivery by the
issuer.
16. "Prestandardized Medicare supplement benefit plan", "prestandardized benefit plan", or
"prestandardized plan" means a group or individual policy of Medicare supplement insurance
issued prior to January 1, 1992.
17. "Secretary" means the secretary of the United States department of health and human
services.
History: Effective January 1, 1992; amended effective August 27, 1998; December 1, 2001;
September 1, 2005; July 1, 2009.
General Authority: NDCC 26.1-36.1-02(1)(2), 26.1-36.1-03
Law Implemented: NDCC 26.1-36.1

### § 45-06-01.1-03. Policy definitions and terms.

No policy or certificate may be advertised, solicited, or issued for delivery in this state as a
Medicare supplement policy or certificate unless such policy or certificate contains definitions or terms
which conform to the requirements of this section.
1. "Accident", "accidental injury", or "accidental means" must be defined to employ "result"
language and may 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 may 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 do not include injuries for which benefits are
provided or available under any workers' compensation, employer's liability or similar law,
or motor vehicle no-fault plan, unless prohibited by law.
2. "Benefit period" or "Medicare benefit period" may not be defined more restrictively than as
defined in the Medicare program.
3. "Convalescent nursing home", "extended care facility", or "skilled nursing facility" may not be
defined more restrictively than as defined in the Medicare program.
4. "Health care expenses" means, for purposes of section 45-06-01.1-11, expenses of health
maintenance organizations associated with the delivery of health care services, which
expenses are analogous to incurred losses of insurers.
5. "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 not more restrictively
than as defined in the Medicare program.
6. "Medicare" must 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", or words of similar import.
7. "Medicare eligible expenses" means expenses of the kinds covered by Medicare parts A
and B, to the extent recognized as reasonable and medically necessary by Medicare.
8. "Physician" may not be defined more restrictively than as defined in the Medicare program.
9. "Sickness" may not be defined to be more restrictive than the following: "Sickness means
illness or disease of an insured person which first manifests itself 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.
History: Effective January 1, 1992; amended effective July 8, 1997; September 1, 2005.
General Authority: NDCC 26.1-36.1-02(1)(2), 26.1-36.1-03
Law Implemented: NDCC 26.1-36.1

### § 45-06-01.1-04. Policy provisions.

1. Except for permitted preexisting condition clauses as described in subdivision a of
subsection 1 of section 45-06-01.1-05, subdivision a of subsection 1 of section 45-06-01.1-06,
and subdivision a of subsection 1 of section 45-06-01.1-06.1, no policy or certificate may be
advertised, solicited, or issued for delivery in this state as a Medicare supplement policy if the
policy or certificate contains limitations or exclusions on coverage that are more restrictive
than those of Medicare.
2. No Medicare supplement policy or certificate may use waivers to exclude, limit, or reduce
coverage or benefits for specifically named or described preexisting diseases or physical
conditions.
3. No Medicare supplement policy or certificate in force in the state may contain benefits which
duplicate benefits provided by Medicare.
4. a. Subject to subdivisions d, e, and g of subsection 1 of section 45-06-01.1-05 and
subdivisions d and e of subsection 1 of section 45-06-01.1-06, a Medicare supplement
policy with benefits for outpatient prescription drugs in existence prior to January 1, 2006,
shall be renewed for current policyholders who do not enroll in part D at the option of the
policyholder.
b. A Medicare supplement policy with benefits for outpatient prescription drugs shall not be
issued after December 31, 2005.
c. After December 31, 2005, a Medicare supplement policy with benefits for outpatient
prescription drugs may not be renewed after the policyholder enrolls in Medicare part D
unless:
(1) The policy is modified to eliminate outpatient prescription coverage for expenses of
outpatient prescription drugs incurred after the effective date of the individual's
coverage under a Medicare part D plan; and
(2) Premiums are adjusted to reflect the elimination of outpatient prescription drug
coverage at the time of Medicare part D enrollment, accounting for any claims paid,
if applicable.
History: Effective January 1, 1992; amended effective July 8, 1997; September 1, 2005; July 1, 2009.
General Authority: NDCC 26.1-36.1-02(1)(2), 26.1-36.1-03
Law Implemented: NDCC 26.1-36.1-02
### § 45-06-01.1-05. Minimum benefit standards for prestandardized Medicare supplement benefit

plan policies or certificates issued for delivery prior to January 1, 1992.
No policy or certificate may be advertised, solicited, or issued for delivery in this state as a
Medicare supplement policy or certificate unless it meets or exceeds the following minimum standards.
These are minimum standards and do not preclude the inclusion of other provisions or benefits which
are not inconsistent with these standards:
1. General standards. The following standards apply to Medicare supplement policies and
certificates and are in addition to all other requirements of this rule:
a. A Medicare supplement policy or certificate may not exclude or limit benefits for losses
incurred more than six months from the effective date of coverage because it involved a
preexisting condition. The policy or certificate may 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 may not indemnify against losses resulting
from sickness on a different basis than losses resulting from accidents.
c. A Medicare supplement policy or certificate must 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.
Premiums may be modified to correspond with such changes.
d. A "noncancelable", "guaranteed renewable", or "noncancelable and guaranteed
renewable" Medicare supplement policy may not:
(1) 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
(2) Be canceled or nonrenewed by the issuer solely on the grounds of deterioration of
health.
e. (1) Except as authorized by the commissioner of this state, an issuer may neither
cancel nor nonrenew a Medicare supplement policy or certificate for any reason
other than nonpayment of premium or material misrepresentation.
(2) If a group Medicare supplement insurance policy is terminated by the group
policyholder and not replaced as provided in paragraph 4, the issuer must offer
certificate holders an individual Medicare supplement policy. The issuer must offer
the certificate holder at least the following choices:
(a) An individual Medicare supplement policy currently offered by the issuer having
comparable benefits to those contained in the terminated group Medicare
supplement policy; and
(b) An individual Medicare supplement policy which provides only such benefits as
are required to meet the minimum standards as defined in subsection 2 of
section 45-06-01.1-06.1.
(3) If membership in a group is terminated, the issuer must:
(a) Offer the certificate holder the conversion opportunities described in
paragraph 2; or
(b) At the option of the group policyholder, offer the certificate holder continuation
of coverage under the group policy.
(4) 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 must offer coverage to all persons covered under the old group
policy on its date of termination. Coverage under the new group policy may not
result in any exclusion for preexisting conditions that would have been covered
under the group policy being replaced.
f. Termination of a Medicare supplement policy or certificate must 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 predicated upon
the continuous total disability of the insured, limited to the duration of the policy benefit

period, if any, or to 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 subsection.
2. Minimum benefit standards.
a. Coverage of part A Medicare eligible expenses for hospitalization to the extent not
covered by Medicare from the sixty-first day through the ninetieth 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 three hundred sixty-five 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 coinsurance amount, 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 equal to the Medicare part B deductible (one
hundred dollars).
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.
History: Effective January 1, 1992; amended effective July 1, 1994; April 1, 1996; July 8, 1997;
September 1, 2005; July 1, 2009.
General Authority: NDCC 26.1-36.1-02(1)(2), 26.1-36.1-03
Law Implemented: NDCC 26.1-36.1-02
### § 45-06-01.1-06. Benefit standards for 1990 standardized Medicare supplement benefit plan

policies or certificates issued for delivery on or after January 1, 1992, and with an effective date
for coverage prior to June 1, 2010.
The following standards are applicable to all Medicare supplement policies or certificates delivered
or issued for delivery in this state on or after January 1, 1992, and with an effective date for coverage
prior to June 1, 2010. No policy or certificate may be advertised, solicited, delivered, or issued for
delivery in this state as a Medicare supplement policy or certificate unless it complies with these benefit
standards:
1. General standards. The following standards apply to Medicare supplement policies and
certificates and are in addition to all other requirements of this rule:

a. A Medicare supplement policy or certificate may not exclude or limit benefits for losses
incurred more than six months from the effective date of coverage because it involved a
preexisting condition. The policy or certificate may 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 may not indemnify against losses resulting
from sickness on a different basis than losses resulting from accidents.
c. A Medicare supplement policy or certificate must 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.
Premiums may be modified to correspond with such changes.
d. No Medicare supplement policy or certificate may 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.
e. Each Medicare supplement policy must be guaranteed renewable:
(1) The issuer may not cancel or nonrenew the policy solely on the ground of health
status of the individual.
(2) The issuer may not cancel or nonrenew the policy for any reason other than
nonpayment of premium or material misrepresentation.
(3) If the Medicare supplement policy is terminated by the group policyholder and is not
replaced as provided under paragraph 5, the issuer must offer certificate holders an
individual Medicare supplement policy which at the option of the certificate holder:
(a) Provides for continuation of the benefits contained in the group policy; or
(b) Provides for benefits that otherwise meet the requirements of this subsection.
(4) If an individual is a certificate holder in a group Medicare supplement policy and the
individual terminates membership in the group, the issuer must:
(a) Offer the certificate holder the conversion opportunity described in
paragraph 3; or
(b) At the option of the group policyholder, offer the certificate holder continuation
of coverage under the group policy.
(5) 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 must offer coverage to all persons covered under the old group
policy on its date of termination. Coverage under the new policy may not result in
any exclusion for preexisting conditions that would have been covered under the
group policy being replaced.
(6) 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 paragraph.

f. Termination of a Medicare supplement policy or certificate must 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.
g. (1) A Medicare supplement policy or certificate must provide that benefits and
premiums under the policy or certificate must be suspended at the request of the
policyholder or certificate holder for the period, not to exceed twenty-four months, in
which the policyholder or certificate holder has applied for and is determined to be
entitled to medical assistance under title XIX of the Social Security Act [42 U.S.C.
1396, et seq.], but only if the policyholder or certificate holder notifies the issuer of
the policy or certificate within ninety days after the date the individual becomes
entitled to assistance. Upon receipt of timely notice, the issuer shall return to the
policyholder or certificate holder that portion of the premium attributable to the
period of medical assistance eligibility, subject to adjustment for paid claims.
(2) If suspension occurs and if the policyholder or certificate holder loses entitlement to
medical assistance, the policy or certificate shall be automatically reinstituted,
effective as of the date of termination of entitlement if the policyholder or certificate
holder provides notice of loss of entitlement within ninety days after the date of loss
and pays the premium attributable to the period, effective as of the date of
termination of entitlement.
(3) Each Medicare supplement 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 or certificate holder loses coverage under the group
health plan, the policy shall be automatically reinstituted, effective as of the date of
loss of such coverage, if the policyholder provides notice of loss of coverage within
ninety days after the date of such loss and pays the premium due from that date.
(4) Reinstitution of coverage as described in paragraphs 2 and 3:
(a) May not provide for any waiting period with respect to treatment of preexisting
conditions;
(b) Must provide for resumption of coverage that is substantially equivalent to
coverage in effect before the date of suspension. If the suspended Medicare
supplement 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) Must provide for classification of premiums on terms at least as favorable to
the policyholder or certificate holder as the premium classification terms that
would have applied to the policyholder or certificate holder had the coverage
not been suspended.
h. If an issuer makes a written offer to the Medicare supplement policyholders or certificate
holders of one or more of its plans, to exchange during a specified period from the 1990
standardized plan as described in section 45-06-01.1-07 to a 2010 standardized plan as

described in section 45-06-01.1-07.1, the offer and subsequent exchange shall comply
with the following requirements:
(1) An issuer need not provide justification to the commissioner if the insured replaces a
1990 standardized policy or certificate with an issue age rated 2010 standardized
policy or certificate at the insured's original issue age and duration. If an insured's
policy or certificate to be replaced is priced on an issue age rate schedule at the
time of such offer, the rate charged to the insured for the new exchanged policy
shall recognize the policy reserve buildup, due to the prefunding inherent in the use
of an issue age rate basis, for the benefit of the insured. The method proposed to be
used by an issuer must be filed with the commissioner.
(2) The rating class of the new policy or certificate shall be the class closest to the
insured's class of the replaced coverage.
(3) An issuer may not apply new preexisting condition limitations or a new
incontestability period to the new policy for those benefits contained in the
exchanged 1990 standardized policy or certificate of the insured, but may apply
preexisting condition limitations of no more than six months to any added benefits
contained in the new 2010 standardized policy or certificate not contained in the
exchanged policy.
(4) The new policy or certificate shall be offered to all policyholders or certificate
holders within a given plan, except where the offer or issue would be in violation of
state or federal law.
2. Standards for basic core benefits common to benefit plans A through J. Every issuer
must make available a policy or certificate including only the following basic core package of
benefits to each prospective insured. An issuer may make available to prospective insureds
any of the other Medicare supplement insurance benefit plans in addition to the basic core
package, but not in lieu of it:
a. Coverage of part A Medicare-eligible expenses for hospitalization to the extent not
covered by Medicare from the sixty-first day through the ninetieth day in any Medicare
benefit period.
b. Coverage of part A Medicare-eligible expenses incurred for hospitalization to the extent
not covered by Medicare for each Medicare lifetime inpatient reserve day used.
c. Upon exhaustion of the Medicare hospital inpatient coverage including the lifetime
reserve days, coverage of one hundred percent of the Medicare part A eligible expenses
for hospitalization paid at the applicable prospective payment system rate, or other
appropriate Medicare standard of payment, subject to a lifetime maximum benefit of an
additional three hundred sixty-five days. The provider must accept the issuer's payment
as payment in full and may not bill the insured for any balance.
d. Coverage under Medicare parts A and 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.
e. Coverage for the coinsurance amount, 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
the Medicare part B deductible.
3. Standards for additional benefits. The following additional benefits must be included in
Medicare supplement benefit plans "B" through "J" only as provided by section 45-06-01.1-07:

a. Medicare part A deductible: Coverage for all of the Medicare part A inpatient hospital
deductible amount per benefit period.
b. Skilled nursing facility care: Coverage for the actual billed charges up to the coinsurance
amount from the twenty-first day through the one hundredth day in a Medicare benefit
period for posthospital skilled nursing facility care eligible under Medicare part A.
c. Medicare part B deductible: Coverage for all of the Medicare part B deductible amount
per calendar year regardless of hospital confinement.
d. Eighty percent of the Medicare part B excess charges: Coverage for eighty percent of the
difference between the actual Medicare part B charge as billed, not to exceed any charge
limitation established by the Medicare program or state law, and the Medicare-approved
part B charge.
e. One hundred percent of the Medicare part B excess charges: Coverage for all of the
difference between the actual Medicare part B charge as billed, not to exceed any charge
limitation established by the Medicare program or state law, and the Medicare-approved
part B charge.
f. Basic outpatient prescription drug benefit: Coverage for fifty percent of outpatient
prescription drug charges, after a two hundred fifty dollar calendar year deductible, to a
maximum of one thousand two hundred fifty dollars in benefits received by the insured
per calendar year, to the extent not covered by Medicare. The outpatient prescription
drug benefit may be included for sale or issuance in a Medicare supplement policy until
January 1, 2006.
g. Extended outpatient prescription drug benefit: Coverage for fifty percent of outpatient
prescription drug charges, after a two hundred fifty dollar calendar year deductible to a
maximum of three thousand dollars in benefits received by the insured per calendar year,
to the extent not covered by Medicare. The outpatient prescription drug benefit may be
included for sale or issuance in a Medicare supplement policy until January 1, 2006.
h. Medically necessary emergency care in a foreign country: Coverage to the extent not
covered by Medicare for eighty percent of the billed charges for Medicare-eligible
expenses for medically necessary emergency hospital, physician, and medical care
received in a foreign country, which care would have been covered by Medicare if
provided in the United States and which care began during the first sixty consecutive
days of each trip outside the United States, subject to a calendar year deductible of two
hundred fifty dollars, and a lifetime maximum benefit of fifty thousand dollars. For
purposes of this benefit, "emergency care" means care needed immediately because of
an injury or an illness of sudden and unexpected onset.
i. (1) Preventive medical care benefit: Coverage for the following preventive health
services not covered by Medicare:
(a) An annual clinical preventive medical history and physical examination that
may include tests and services from subparagraph b and patient education to
address preventive health care measures.
(b) Preventive screening tests or preventive services, the selection and frequency
of which is determined to be medically appropriate by the attending physician.
(2) Reimbursement must be for the actual charges up to one hundred percent of the
Medicare-approved amount for each service, as if Medicare were to cover the
service as identified in American medical association current procedural terminology

codes, to a maximum of one hundred twenty dollars annually under this benefit.
This benefit may not include payment for any procedure covered by Medicare.
j. At-home recovery benefit: Coverage for services to provide short-term, at-home
assistance with activities of daily living for those recovering from an illness, injury, or
surgery.
(1) For purposes of this benefit, the following definitions apply:
(a) "Activities of daily living" includes, but is not limited to bathing, dressing,
personal hygiene, transferring, eating, ambulating, assistance with drugs that
are normally self-administered, and changing bandages or other dressings.
(b) "At-home recovery visit" means the period of a visit required to provide
at-home recovery care, without limit on the duration of the visit, except each
consecutive four hours in a twenty-four-hour period of services provided by a
care provider is one visit.
(c) "Care provider" means a duly qualified or licensed home health aide or
homemaker, personal care aide, or nurse provided through a licensed home
health care agency or referred by a licensed referral agency or licensed nurses
registry.
(d) "Home" means any place used by the insured as a place of residence,
provided that such place would qualify as a residence for home health care
services covered by Medicare. A hospital or skilled nursing facility may not be
considered the insured's place of residence.
(2) Coverage requirements and limitations.
(a) At-home recovery services provided must be primarily services which assist in
activities of daily living.
(b) The insured's attending physician must certify that the specific type and
frequency of at-home recovery services are necessary because of a condition
for which a home care plan of treatment was approved by Medicare.
(c) Coverage is limited to:
[1] No more than the number and type of at-home recovery visits certified as
necessary by the insured's attending physician. The total number of
at-home recovery visits may not exceed the number of
Medicare-approved home health care visits under a Medicare-approved
home care plan of treatment.
[2] The actual charges for each visit up to a maximum reimbursement of forty
dollars per visit.
[3] One thousand six hundred dollars per calendar year.
[4] Seven visits in any one week.
[5] Care furnished on a visiting basis in the insured's home.
[6] Services provided by a care provider as defined in this section.
[7] At-home recovery visits while the insured is covered under the policy or
certificate and not otherwise excluded.

[8] At-home recovery visits received during the period the insured is receiving
Medicare- approved home care services or no more than eight weeks
after the service date of the last Medicare-approved home health care
visit.
(3) Coverage is excluded for:
(a) Home care visits paid for by Medicare or other government programs; and
(b) Care provided by family members, unpaid volunteers, or providers who are not
care providers.
4. Standards for plans K and L.
a. Standardized Medicare supplement benefit plan K shall consist of the following:
(1) Coverage of one hundred percent of the part A hospital coinsurance amount for
each day used from the sixty-first through the ninetieth day in any Medicare benefit
period;
(2) Coverage of one hundred percent of the part A hospital coinsurance amount for
each Medicare lifetime inpatient reserve day used from the ninety-first through the
one hundred fiftieth day in any Medicare benefit period;
(3) Upon exhaustion of the Medicare hospital inpatient coverage, including the lifetime
reserve days, coverage of one hundred percent of the Medicare part A eligible
expenses for hospitalization paid at the applicable prospective payment system
rate, or other appropriate Medicare standard of payment, subject to a lifetime
maximum benefit of an additional three hundred sixty-five days. The provider shall
accept the issuer's payment as payment in full and may not bill the insured for any
balance;
(4) Medicare part A deductible: Coverage for fifty percent of the Medicare part A
inpatient hospital deductible amount per benefit period until the out-of-pocket
limitation is met as described in paragraph 10;
(5) Skilled nursing facility care: Coverage for fifty percent of the coinsurance amount for
each day used from the twenty-first day through the one hundredth day in a
Medicare benefit period for posthospital skilled nursing facility care eligible under
Medicare part A until the out-of-pocket limitation is met as described in
paragraph 10;
(6) Hospice care: Coverage for fifty percent of cost-sharing for all part A Medicare
eligible expenses and respite care until the out-of-pocket limitation is met as
described in paragraph 10;
(7) Coverage for fifty percent, under Medicare part A or B, of 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 until the out-of-pocket limitation is met as described in paragraph 10;
(8) Except for coverage provided in paragraph 9, coverage for fifty percent of the
cost-sharing otherwise applicable under Medicare part B after the policyholder pays
the part B deductible until the out-of-pocket limitation is met as described in
paragraph 10;

(9) Coverage of one hundred percent of the cost-sharing for Medicare part B preventive
services after the policyholder pays the part B deductible; and
(10) Coverage of one hundred percent of all cost-sharing under Medicare parts A and B
for the balance of the calendar year after the individual has reached the
out-of-pocket limitation on annual expenditures under Medicare parts A and B of
four thousand dollars in 2006, indexed each year by the appropriate inflation
adjustment specified by the secretary of the United States department of health and
human services.
b. Standardized Medicare supplement benefit plan L shall consist of the following:
(1) The benefits described in paragraphs 1, 2, 3, and 9 of subdivision a;
(2) The benefits described in paragraphs 4, 5, 6, 7, and 8 of subdivision a, but
substituting seventy-five percent for fifty percent; and
(3) The benefits described in paragraph 10 of subdivision a, but substituting two
thousand dollars for four thousand dollars.
History: Effective January 1, 1992; amended effective April 1, 1996; July 8, 1997; August 1, 2000;
December 1, 2001; September 1, 2005; July 1, 2009.
General Authority: NDCC 26.1-36.1-02(1)(2), 26.1-36.1-03
Law Implemented: NDCC 26.1-36.1-02
### § 45-06-01.1-06.1. Benefit standards for 2010 standardized Medicare supplement benefit plan

policies or certificates issued for delivery with an effective date for coverage on or after June 1,
2010.
The following standards are applicable to all Medicare supplement policies or certificates delivered
or issued for delivery in this state with an effective date for coverage on or after June 1, 2010. No policy
or certificate may be advertised, solicited, delivered, or issued for delivery in this state as a Medicare
supplement policy or certificate unless it complies with these benefit standards. No issuer may offer any
1990 standardized Medicare supplement benefit plan for sale on or after June 1, 2010. Benefit
standards applicable to Medicare supplement policies and certificates issued with an effective date for
coverage prior to June 1, 2010, remain subject to the requirements of sections 45-06-01.1-06 and
45-06-01.1-07.
1. General standards. The following standards apply to Medicare supplement policies and
certificates and are in addition to all other requirements of this chapter:
a. A Medicare supplement policy or certificate shall not exclude or limit benefits for losses
incurred more than six months from the effective date of coverage because it involved a
preexisting condition. The policy or certificate may 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.
Premiums may be modified to correspond with such changes.

d. No Medicare supplement policy or certificate 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.
e. Each Medicare supplement policy shall be guaranteed renewable.
(1) The issuer shall not cancel or nonrenew the policy solely on the ground of health
status of the individual.
(2) The issuer shall not cancel or nonrenew the policy for any reason other than
nonpayment of premium or material misrepresentation.
(3) If the Medicare supplement policy is terminated by the group policyholder and is not
replaced as provided under paragraph 5, the issuer shall offer certificate holders an
individual Medicare supplement policy which at the option of the certificate holder:
(a) Provides for continuation of the benefits contained in the group policy; or
(b) Provides for benefits that otherwise meet the requirements of this subsection.
(4) If an individual is a certificate holder in a group Medicare supplement policy and the
individual terminates membership in the group the issuer shall:
(a) Offer the certificate holder the conversion opportunity described in
paragraph 3; or
(b) At the option of the group policyholder, offer the certificate holder continuation
of coverage under the group policy.
(5) 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 policy shall not result in
any exclusion for preexisting conditions that would have been covered under the
group policy being replaced.
f. Termination of a Medicare supplement policy or certificate 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.
g. (1) A Medicare supplement policy or certificate shall provide that benefits and premiums
under the policy or certificate shall be suspended at the request of the policyholder
or certificate holder for the period not to exceed twenty-four months in which the
policyholder or certificate holder 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 or certificate holder notifies the issuer of the policy or certificate within
ninety days after the date the individual becomes entitled to assistance. Upon
receipt of timely notice, the issuer shall return to the policyholder or certificate holder
that portion of the premium attributable to the period of medical assistance eligibility
subject to adjustment for paid claims.
(2) If suspension occurs and if the policyholder or certificate holder loses entitlement to
medical assistance, the policy or certificate shall be automatically reinstituted
effective as of the date of termination of entitlement if the policyholder or certificate

holder provides notice of loss of entitlement within ninety days after the date of loss
and pays the premium attributable to the period, effective as of the date of
termination of entitlement.
(3) Each Medicare supplement 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 or certificate holder 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 ninety
days after the date of the loss and pays the premium attributable to the period,
effective as of the date of termination of enrollment in the group health plan.
(4) Reinstitution of coverages as described in paragraphs 2 and 3:
(a) Shall not provide for any waiting period with respect to treatment of preexisting
conditions;
(b) Shall provide for resumption of coverage that is substantially equivalent to
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 or certificate holder as the premium classification terms that
would have applied to the policyholder or certificate holder had the coverage
not been suspended.
2. Standards for basic benefits common to Medicare supplement insurance benefit plans A, B, C,
D, F, F with high deductible, G, M, and N. Every issuer of Medicare supplement insurance
benefit plans shall make available a policy or certificate including only the following basic core
package of benefits to each prospective insured. An issuer may make available to prospective
insureds any of the other Medicare supplement insurance benefit plans in addition to the basic
core package but not in lieu of it.
a. Coverage of part A Medicare-eligible expenses for hospitalization to the extent not
covered by Medicare from the sixty-first day through the ninetieth day in any Medicare
benefit period;
b. Coverage of part A Medicare-eligible expenses incurred for hospitalization to the extent
not covered by Medicare for each Medicare lifetime inpatient reserve day used;
c. Upon exhaustion of the Medicare hospital inpatient coverage, including the lifetime
reserve days coverage of one hundred percent of the Medicare part A eligible expenses
for hospitalization paid at the applicable prospective payment system rate or other
appropriate Medicare standard of payment subject to a lifetime maximum benefit of an
additional three hundred sixty-five days. The provider shall accept the issuer's payment
as payment in full and may not bill the insured for any balance;
d. Coverage under Medicare parts A and B for the reasonable cost of the first three pints of
blood or equivalent quantities of packed red blood cells, unless replaced in accordance
with federal regulations;
e. Coverage for the coinsurance amount, 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
the Medicare part B deductible; and

f. Hospice care. Coverage of cost-sharing for all part A Medicare eligible hospice care and
respite care expenses.
3. Standards for additional benefits. The following additional benefits shall be included in
Medicare supplement benefit plans B, C, D, F, F with high deductible, G, M, and N as provided
by section 45-06-01.1-07.1.
a. Medicare part A deductible. Coverage for one hundred percent of the Medicare part A
inpatient hospital deductible amount per benefit period.
b. Medicare part A deductible. Coverage for fifty percent of the Medicare part A inpatient
hospital deductible amount per benefit period.
c. Skilled nursing facility care. Coverage for the actual billed charges up to the coinsurance
amount from the twenty-first day through the one hundredth day in a Medicare benefit
period for posthospital skilled nursing facility care eligible under Medicare part A.
d. Medicare part B deductible. Coverage for one hundred percent of the Medicare part B
deductible amount per calendar year regardless of hospital confinement.
e. One hundred percent of the Medicare part B excess charges. Coverage for all of the
difference between the actual Medicare part B charges as billed, not to exceed any
charge limitation established by the Medicare program or state law, and the
Medicare-approved part B charge.
f. Medically necessary emergency care in a foreign country. Coverage to the extent not
covered by Medicare for eighty percent of the billed charges for Medicare-eligible
expenses for medically necessary emergency hospital, physician, and medical care
received in a foreign country, which care would have been covered by Medicare if
provided in the United States and which care began during the first sixty consecutive
days of each trip outside the United States, subject to a calendar year deductible of two
hundred fifty dollars, and a lifetime maximum benefit of fifty thousand dollars. For
purposes of this benefit, "emergency care" shall mean care needed immediately because
of an injury or an illness of sudden and unexpected onset.
History: Effective July 1, 2009; amended effective October 1, 2019.
General Authority: NDCC 26.1-36.1-02(1)(2), 26.1-36.1-03
Law Implemented: NDCC 26.1-36.1-02
### § 45-06-01.1-07. Standard Medicare supplement benefit plans for 1990 standardized Medicare

supplement benefit plan policies or certificates issued for delivery on or after January 1, 1992,
and with an effective date for coverage prior to June 1, 2010.
1. An issuer shall make available to each prospective policyholder and certificate holder a policy
form or certificate form containing only the basic core benefits, as defined in subsection 2 of
section 45-06-01.1-06.
2. No groups, packages, or combinations of Medicare supplement benefits other than those
listed in this section may be offered for sale in this state, except as may be permitted in
subsection 7 of this section and in section 45-06-01.1-08.
3. Benefit plans must be uniform in structure, language, designation, and format to the standard
benefit plans "A" through "L" listed in this section and conform to the definitions in section
benefit must be structured in accordance with the format provided in subsections 2 and 3 or 4
of section 45-06-01.1-06 and list the benefits in the order shown in this section. For purposes

of this section, "structure, language, and format" means style, arrangement, and overall
content of a benefit.
4. An issuer may use, in addition to the benefit plan designations required in subsection 3, other
designations to the extent permitted by law.
5. Makeup of benefit plans:
a. Standardized Medicare supplement benefit plan "A" is limited to the basic (core) benefits
common to all benefit plans, as defined in subsection 2 of section 45-06-01.1-06.
b. Standardized Medicare supplement benefit plan "B" may include only the following: The
core benefit as defined in subsection 2 of section 45-06-01.1-06, plus the Medicare
part A deductible as defined in subdivision a of subsection 3 of section 45-06-01.1-06.
c. Standardized Medicare supplement benefit plan "C" may include only the following: The
core benefit as defined in subsection 2 of section 45-06-01.1-06, plus the Medicare
part A deductible, skilled nursing facility care, Medicare part B deductible and medically
necessary emergency care in a foreign country as defined in subdivisions a, b, c, and h
of subsection 3 of section 45-06-01.1-06, respectively.
d. Standardized Medicare supplement benefit plan "D" may include only the following: The
core benefit as defined in subsection 2 of section 45-06-01.1-06, plus the Medicare
part A deductible, skilled nursing facility care, medically necessary emergency care in a
foreign country and the at-home recovery benefit as defined in subdivisions a, b, h, and j
of subsection 3 of section 45-06-01.1-06, respectively.
e. Standardized Medicare supplement benefit plan "E" may include only the following: The
core benefit as defined in subsection 2 of section 45-06-01.1-06, plus the Medicare
part A deductible, skilled nursing facility care, medically necessary emergency care in a
foreign country, and preventive medical care as defined in subdivisions a, b, h, and i of
subsection 3 of section 45-06-01.1-06, respectively.
f. Standardized Medicare supplement benefit plan "F" may include only the following: The
core benefit as defined in subsection 2 of section 45-06-01.1-06, plus the Medicare
part A deductible, the skilled nursing facility care, the Medicare part B deductible, one
hundred percent of the Medicare part B excess charges, and medically necessary
emergency care in a foreign country as defined in subdivisions a, b, c, e, and h of
subsection 3 of section 45-06-01.1-06, respectively.
g. Standardized Medicare supplement benefit high deductible plan "F" includes only the
following: one hundred percent of covered expenses following the payment of the annual
high deductible plan "F" deductible. The covered expenses include the core benefit as
defined in subsection 2 of section 45-06-01.1-06, plus the Medicare part A deductible,
skilled nursing facility care, the Medicare part B deductible, one hundred percent of the
Medicare part B excess charges, and medically necessary emergency care in a foreign
country as defined in subdivisions a, b, c, e, and h of subsection 3 of section
45-06-01.1-06, respectively. The annual high deductible plan "F" deductible consists of
out-of-pocket expenses, other than premiums, for services covered by the Medicare
supplement plan "F" policy, and are in addition to any other specific benefit deductibles.
The annual high deductible plan "F" deductible is one thousand five hundred dollars for
1998 and 1999 and must be based on the calendar year. It must be adjusted annually
thereafter by the secretary to reflect the change in the consumer price index for all urban
consumers for the twelve-month period ending with August of the preceding year and
rounded to the nearest multiple of ten dollars.

h. Standardized Medicare supplement benefit plan "G" may include only the following: The
core benefit as defined in subsection 2 of section 45-06-01.1-06, plus the Medicare
part A deductible, skilled nursing facility care, eighty percent of the Medicare part B
excess charges, medically necessary emergency care in a foreign country, and the
at-home recovery benefit as defined in subdivisions a, b, d, h, and j of subsection 3 of
section 45-06-01.1-06, respectively.
i. Standardized Medicare supplement benefit plan "H" may consist of only the following:
The core benefit as defined in subsection 2 of section 45-06-01.1-06, plus the Medicare
part A deductible, skilled nursing facility care, basic prescription drug benefit, and
medically necessary emergency care in a foreign country as defined in subdivisions a, b,
f, and h of subsection 3 of section 45-06-01.1-06, respectively. The outpatient
prescription drug benefit shall not be included in a Medicare supplement policy sold after
December 31, 2005.
j. Standardized Medicare supplement benefit plan "I" may consist of only the following: The
core benefit as defined in subsection 2 of section 45-06-01.1-06, plus the Medicare
part A deductible, skilled nursing facility care, one hundred percent of the Medicare
part B excess charges, basic prescription drug benefit, medically necessary emergency
care in a foreign country, and at-home recovery benefit as defined in subdivisions a, b, e,
f, h, and j of subsection 3 of section 45-06-01.1-06, respectively. The outpatient
prescription drug benefit shall not be included in a Medicare supplement policy sold after
December 31, 2005.
k. Standardized Medicare supplement benefit plan "J" may consist of only the following:
The core benefit as defined in subsection 2 of section 45-06-01.1-06, plus the Medicare
part A deductible, skilled nursing facility care, Medicare part B deductible, one hundred
percent of the Medicare part B excess charges, extended prescription drug benefit,
medically necessary emergency care in a foreign country, preventive medical care, and
at-home recovery benefit as defined in subdivisions a, b, c, e, g, h, i, and j of
subsection 3 of section 45-06-01.1-06, respectively. The outpatient prescription drug
benefit shall not be included in a Medicare supplement policy sold after December 31,
2005.
l. Standardized Medicare supplement benefit high deductible plan "J" consists of only the
following: one hundred percent of covered expenses following the payment of the annual
high deductible plan "J" deductible. The covered expenses include the core benefit as
defined in subsection 2 of section 45-06-01.1-06, plus the Medicare part A deductible,
skilled nursing facility care, Medicare part B deductible, one hundred percent of the
Medicare part B excess charges, extended outpatient prescription drug benefit, medically
necessary emergency care in a foreign country, preventive medical care benefit, and
at-home recovery benefit as defined in subdivisions a, b, c, e, g, h, i, and j of
subsection 3 of section 45-06-01.1-06, respectively. The annual high deductible plan "J"
deductible consists of out-of-pocket expenses, other than premiums, for services covered
by the Medicare supplement plan "J" policy, and are in addition to any other specific
benefit deductibles. The annual deductible is one thousand five hundred dollars for 1998
and 1999 and must be based on a calendar year. It must be adjusted annually thereafter
by the secretary to reflect the change in the consumer price index for all urban
consumers for the twelve-month period ending with August of the preceding year and
rounded to the nearest multiple of ten dollars. The outpatient prescription drug benefit
shall not be included in a Medicare supplement policy sold after December 31, 2005.
6. Makeup of two Medicare supplement plans mandated by the Medicare Prescription Drug
Improvement and Modernization Act of 2003:

a. Standardized Medicare supplement benefit plan "K" shall consist of only those benefits
described in subdivision a of subsection 4 of section 45-06-01.1-06.
b. Standardized Medicare supplement benefit plan "L" shall consist of only those benefits
described in subdivision b of subsection 4 of section 45-06-01.1-06.
7. New or innovative benefits: An issuer may, with the prior approval of the commissioner, offer
policies or certificates with new or innovative benefits in addition to the benefits provided in a
policy or certificate that otherwise complies with the applicable standards. The new or
innovative benefits may include benefits that are appropriate to Medicare supplement
insurance, new or innovative, not otherwise available, cost-effective, and offered in a manner
which is consistent with the goal of simplification of Medicare supplement policies. After
December 31, 2005, the innovative benefit shall not include an outpatient prescription drug
benefit.
History: Effective January 1, 1992; amended effective July 1, 1994; August 27, 1998; September 1,
2005; July 1, 2009.
General Authority: NDCC 26.1-36.1-02(1)(2), 26.1-36.1-03
Law Implemented: NDCC 26.1-36.1-02
### § 45-06-01.1-07.1. Standard Medicare supplement benefit plans for 2010 standardized

Medicare supplement benefit plan policies or certificates issued for delivery with an effective
date for coverage on or after June 1, 2010.
The following standards are applicable to all Medicare supplement policies or certificates delivered
or issued for delivery in this state with an effective date for coverage on or after June 1, 2010. No policy
or certificate may be advertised, solicited, delivered, or issued for delivery in this state as a Medicare
supplement policy or certificate unless it complies with these benefit plan standards. Benefit plan
standards applicable to Medicare supplement policies and certificates with an effective date for
coverage before June 1, 2010, remain subject to the requirements of sections 45-06-01.1-06 and
45-06-01.1-07.
1. a. An issuer shall make available to each prospective policyholder and certificate holder a
policy form or certificate form containing only the basic benefits, as defined in subsection
2 of section 45-06-01.1-06.1.
b. If an issuer makes available any of the additional benefits described in subsection 3 of
section 45-06-01.1-06.1, or offers standardized benefit plans K or L as described in
subdivisions h and i of subsection 5, then the issuer shall make available to each
prospective policyholder and certificate holder, in addition to a policy form or certificate
form with only the basic benefits as described in subdivision a, a policy form or certificate
form containing either standardized benefit plan C as described in subdivision c of
subsection 5 or standardized benefit plan F as described in subdivision e of subsection 5.
2. No groups, packages, or combinations of Medicare supplement benefits other than those
listed in this section shall be offered for sale in this state, except as may be permitted in
subsection 6 and section 45-06-01.1-08.
3. Benefit plans shall be uniform in structure, language, designation, and format to the standard
benefit plans listed in this subsection and conform to the definitions in section 45-06-01.1-02.
Each benefit shall be structured in accordance with the format provided in subsections 2 and 3
of section 45-06-01.1-06.1; or, in the case of plans K or L, in subdivisions h and i of subsection
5 and list the benefits in the order shown. For purposes of this section, "structure, language,
and format" means style, arrangement, and overall content of a benefit.

4. In addition to the benefit plan designations required in subsection 3, an issuer may use other
designations to the extent permitted by law.
5. Makeup of 2010 standardized benefit plans:
a. Standardized Medicare supplement benefit plan A shall include only the following: the
basic benefits as defined in subsection 2 of section 45-06-01.1-06.1.
b. Standardized Medicare supplement benefit plan B shall include only the following: the
basic benefit as defined in subsection 2 of section 45-06-01.1-06.1, plus one hundred
percent of the Medicare part A deductible as defined in subdivision a of subsection 3 of
section 45-06-01.1-06.1.
c. Standardized Medicare supplement benefit plan C shall include only the following: the
basic benefit as defined in subsection 2 of section 45-06-01.1-06.1, plus one hundred
percent of the Medicare part A deductible, skilled nursing facility care, one hundred
percent of the Medicare part B deductible, and medically necessary emergency care in a
foreign country as defined in subdivisions a, c, d, and f of subsection 3 of section
45-06-01.1-06.1, respectively.
d. Standardized Medicare supplement benefit plan D shall include only the following: the
basic benefit as defined in subsection 2 of section 45-06-01.1-06.1, plus one hundred
percent of the Medicare part A deductible, skilled nursing facility care, and medically
necessary emergency care in a foreign country as defined in subdivisions a, c, and f of
subsection 3 of section 45-06-01.1-06.1, respectively.
e. Standardized Medicare supplement plan F shall include only the following: the basic
benefit as defined in subsection 2 of section 45-06-01.1-06.1, plus one hundred percent
of the Medicare part A deductible, the skilled nursing facility care, one hundred percent of
the Medicare part B deductible, one hundred percent of the Medicare part B excess
charges, and medically necessary emergency care in a foreign country as defined in
subdivisions a, c, d, e, and f of subsection 3 of section 45-06-01.1-06.1, respectively.
f. Standardized Medicare supplement plan F with high deductible shall include only the
following: one hundred percent of covered expenses following the payment of the annual
deductible set forth in paragraph 2.
(1) The basic benefit as defined in subsection 2 of section 45-06-01.1-06.1, plus one
hundred percent of the Medicare part A deductible, skilled nursing facility care, one
hundred percent of the Medicare part B deductible, one hundred percent of the
Medicare part B excess charges, and medically necessary emergency care in a
foreign country as defined in subdivisions a, c, d, e, and f of subsection 3 of section
45-06-01.1-06.1, respectively.
(2) The annual deductible in plan F with high deductible shall consist of out-of-pocket
expenses, other than premiums, for services covered by plan F, and shall be in
addition to any other specific benefit deductibles. The basis for the deductible shall
be one thousand five hundred dollars and shall be adjusted annually from 1999 by
the secretary of the United States department of health and human services to
reflect the change in the consumer price index for all urban consumers for the
twelve-month period ending with August of the preceding year, and rounded to the
nearest multiple of ten dollars.
g. Standardized Medicare supplement benefit plan G shall include only the following: the
basic benefit as defined in subsection 2 of section 45-06-01.1-06.1, plus one hundred
percent of the Medicare part A deductible, skilled nursing facility care, one hundred

percent of the Medicare part B excess charges, and medically necessary emergency
care in a foreign country as defined in subdivisions a, c, e, and f of subsection 3 of
section 45-06-01.1-06.1, respectively. Effective January 1, 2020, the standardized benefit
plans described in subdivision d of subsection 1 of section 45-06-01.1-07.2 of this
regulation (Redesignated plan G high deductible) may be offered to any individual who
was eligible for Medicare prior to January 1, 2020.
h. Standardized Medicare supplement plan K is mandated by the Medicare Prescription
Drug Improvement and Modernization Act of 2003, and shall include only the following:
(1) Part A hospital coinsurance, sixty-first through ninetieth days. Coverage of one
hundred percent of the part A hospital coinsurance amount for each day used from
the sixty-first through the ninetieth day in any Medicare benefit period;
(2) Part A hospital coinsurance, ninety-first through one hundred fiftieth days. Coverage
of one hundred percent of the part A hospital coinsurance amount for each
Medicare lifetime inpatient reserve day used from the ninety-first through the one
hundred fiftieth day in any Medicare benefit period;
(3) Part A hospitalization after one hundred fifty days. Upon exhaustion of the Medicare
hospital inpatient coverage, including the lifetime reserve days, coverage of one
hundred percent of the Medicare part A eligible expenses for hospitalization paid at
the applicable prospective payment system rate, or other appropriate Medicare
standard of payment, subject to a lifetime maximum benefit of an additional three
hundred sixty-five days. The provider shall accept the issuer's payment as payment
in full and may not bill the insured for any balance;
(4) Medicare part A deductible. Coverage for fifty percent of the Medicare part A
inpatient hospital deductible amount per benefit period until the out-of-pocket
limitation is met as described in paragraph 10;
(5) Skilled nursing facility care. Coverage for fifty percent of the coinsurance amount for
each day used from the twenty-first day through the one hundredth day in a
Medicare benefit period for posthospital skilled nursing facility care eligible under
Medicare part A until the out-of-pocket limitation is met as described in
paragraph 10;
(6) Hospice care. Coverage for fifty percent of cost-sharing for all part A Medicare
eligible expenses and respite care until the out-of-pocket limitation is met as
described in paragraph 10;
(7) Blood. Coverage for fifty percent, under Medicare part A or B, of 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 until the out-of-pocket limitation is met as described in paragraph 10;
(8) Part B cost-sharing. Except for coverage provided in paragraph 9, coverage for fifty
percent of the cost-sharing otherwise applicable under Medicare part B after the
policyholder pays the part B deductible until the out-of-pocket limitation is met as
described in paragraph 10;
(9) Part B preventive services. Coverage of one hundred percent of the cost-sharing for
Medicare part B preventive services after the policyholder pays the part B
deductible; and
(10) Cost-sharing after out-of-pocket limits. Coverage of one hundred percent of all
cost-sharing under Medicare parts A and B for the balance of the calendar year after

the individual has reached the out-of-pocket limitation on annual expenditures under
Medicare parts A and B of four thousand dollars in 2006, indexed each year by the
appropriate inflation adjustment specified by the secretary of the United States
department of health and human services.
i. Standardized Medicare supplement plan L is mandated by the Medicare Prescription
Drug Improvement and Modernization Act of 2003, and shall include only the following:
(1) The benefits described in paragraphs 1, 2, 3, and 9 of subdivision h of subsection 5
of section 45-06-01.1-07.1;
(2) The benefit described in paragraphs 4, 5, 6, 7, and 8 of subdivision h of subsection
5 of section 45-06-01.1-07.1, but substituting seventy-five percent for fifty percent;
and
(3) The benefit described in paragraph 10 of subdivision h of subsection 5 of section
45-06-01.1-07.1, but substituting two thousand dollars for four thousand dollars.
j. Standardized Medicare supplement plan M shall include only the following: the basic
benefit as defined in subsection 2 of section 45-06-01.1-06.1, plus fifty percent of the
Medicare part A deductible, skilled nursing facility care, and medically necessary
emergency care in a foreign country as defined in subdivisions b, c, and f of subsection 3
of section 45-06-01.1-06.1, respectively.
k. Standardized Medicare supplement plan N shall include only the following: the basic
benefit as defined in subsection 2 of section 45-06-01.1-06.1, plus one hundred percent
of the Medicare part A deductible, skilled nursing facility care, and medically necessary
emergency care in a foreign country as defined in subdivisions a, c, and f of subsection 3
of section 45-06-01.1-06.1, respectively, with copayments in the following amounts:
(1) The lesser of twenty dollars or the Medicare part B coinsurance or copayment for
each covered health care provider office visit, including visits to medical specialists;
and
(2) The lesser of fifty dollars or the Medicare part B coinsurance or copayment for each
covered emergency room visit; however, this copayment shall be waived if the
insured is admitted to any hospital and the emergency visit is subsequently covered
as a Medicare part A expense.
6. New or innovative benefits. An issuer may, with the prior approval of the commissioner, offer
policies or certificates with new or innovative benefits, in addition to the standardized benefits
provided in a policy or certificate that otherwise complies with the applicable standards. The
new or innovative benefits shall include only benefits that are appropriate to Medicare
supplement insurance, are new or innovative, are not otherwise available, and are
cost-effective. Approval of new or innovative benefits must not adversely impact the goal of
Medicare supplement simplification. New or innovative benefits shall not include an outpatient
prescription drug benefit. New or innovative benefits shall not be used to change or reduce
benefits, including a change of any cost-sharing provision, in any standardized plan.
History: Effective July 1, 2009; amended effective October 1, 2019.
General Authority: NDCC 26.1-36.1-02(1)(2), 26.1-36.1-03
Law Implemented: NDCC 26.1-36.1-02

### § 45-06-01.1-07.2. 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.
The Medicare Access and CHIP Reauthorization Act of 2015 requires the following standards are
applicable to all Medicare supplement policies or certificates delivered or issued for delivery in this state
to individuals newly eligible for Medicare on or after January 1, 2020. No policy or certificate that
provides coverage of the Medicare part B deductible may be advertised, solicited, delivered or issued
for delivery in this state as a Medicare supplement policy or certificate to individuals newly eligible for
Medicare on or after January 1, 2020. All policies must comply with the following benefit standards.
Benefit plan standards applicable to Medicare supplement policies and certificates issued to individuals
eligible for Medicare before January 1, 2020, remain subject to the requirements of sections
45-06-01.1-06, 45-06-01.1-06.1, 45-06-01.1-07, and 45-06-01.1-07.1.
1. Benefit requirements. The standards and requirements of section 45-06-01.1-07.1 apply to all
Medicare supplement policies or certificates delivered or issued for delivery to individuals
newly eligible for Medicare on or after January 1, 2020, with the following exceptions:
a. Standardized Medicare supplement benefit plan C is redesignated as plan D and must
provide the benefits contained in subdivision c of subsection 5 of section 45-06-01.1-07.1
of this regulation but may not provide coverage for one hundred percent or any portion of
the Medicare part B deductible.
b. Standardized Medicare supplement benefit plan F is redesignated as plan G and must
provide the benefits contained in subdivision e of subsection 5 of section 45-06-01.1-07.1
of this regulation but may not provide coverage for one hundred percent or any portion of
the Medicare part B deductible.
c. Standardized Medicare supplement benefit places C, F, and F with high deductible may
not be offered to individuals newly eligible for Medicare on or after January 1, 2020.
d. Standardized Medicare supplement benefit plan F with high deductible is redesignated
as plan G with high deductible and must provide the benefits contained in subdivision f of
subsection 5 of section 45-06-01.1-07.1 of this regulation but may not provide coverage
for one hundred percent or any portion of the Medicare part B deductible; provided
further that, the Medicare part B deductible paid by the beneficiary shall be considered
an out-of-pocket expense in meeting the annual high deductible.
e. The reference to plans C or F contained in subdivision b of subsection 1 of section
2. Applicability to certain individuals. This section applies to only individuals newly eligible for
Medicare on or after January 1, 2020:
a. By reason of attaining age sixty-five on or after January 1, 2020; or
b. By reason of entitlement to benefits under part A pursuant to section 226(b) or 226A of
the Social Security Act, or who is deemed to be eligible for benefits under section 226(a)
of the Social Security Act on or after January 1, 2020.
3. Guaranteed issue for eligible persons. For purposes of subsection 5 of section
2020, any reference to a Medicare supplement policy C or F (including F with high deductible)
is deemed to be a reference to Medicare supplement policy D or G (including G with high
deductible), respectively, that meet the requirements of subsection 1.

4. Applicability to waivered states. In the case of a state described in section 1882(p)(6) of the
Social Security Act ("waivered" alternative simplification states) Medicare Access and CHIP
Reauthorization Act of 2015 prohibits the coverage of the Medicare part B deductible for any
Medicare supplement policy sold or issued to an individual that is newly eligible for Medicare
on or after January 1, 2020.
5. Offer of redesignated plans to individuals other than newly eligible. On or after January 1,
2020, the standardized benefit plans described in subdivision d of subsection 1 may be
offered to any individual who was eligible for Medicare prior to January 1, 2020, in addition to
the standardized plans described in subsection 5 of section 45-06-01.1-07.1 of this regulation.
History: Effective January 1, 2020.
General Authority: NDCC 26.1-36.1-02(1)(2), 26.1-36.1-03
Law Implemented: NDCC 26.1-36.1-02
### § 45-06-01.1-08. Medicare select policies and certificates.

1. a. This section applies to Medicare select policies and certificates, as defined in this
section.
b. No policy or certificate may be advertised as a Medicare select policy or certificate unless
it meets the requirements of this section.
2. For the purposes of this section:
a. "Complaint" means any dissatisfaction expressed by an individual concerning a Medicare
select issuer or its network providers.
b. "Grievance" means dissatisfaction expressed in writing by an individual insured under a
Medicare select policy or certificate with the administration, claims practices, or provision
of services concerning a Medicare select issuer or its network providers.
c. "Medicare select issuer" means an issuer offering, or seeking to offer, a Medicare select
policy or certificate.
d. "Medicare select policy" or "Medicare select certificate" mean respectively a Medicare
supplement policy or certificate that contains restricted network provisions.
e. "Network provider" means a provider of health care, or a group of providers of health
care, which has entered into a written agreement with the issuer to provide benefits
insured under a Medicare select policy.
f. "Restricted network provision" means any provision which conditions the payment of
benefits, in whole or in part, on the use of network providers.
g. "Service area" means the geographic area approved by the commissioner within which
an issuer is authorized to offer a Medicare select policy.
3. The commissioner may authorize an issuer to offer a Medicare select policy or certificate,
pursuant to this section and section 4358 of the Omnibus Budget Reconciliation Act of 1990
[Pub. L. 101-508; 104 Stat. 1388; 42 U.S.C. 1395ss(t)(1)] if the commissioner finds that the
issuer has satisfied all of the requirements of this regulation.
4. A Medicare select issuer may not issue a Medicare select policy or certificate in this state until
its plan of operation has been approved by the commissioner.

5. A Medicare select issuer must file a proposed plan of operation with the commissioner in a
format prescribed by the commissioner. The plan of operation must contain at least the
following information:
a. Evidence that all covered services that are subject to restricted network provisions are
available and accessible through network providers, including a demonstration that:
(1) Services can be provided by network providers with reasonable promptness with
respect to geographic location, hours of operation, and after-hour care. The hours of
operation and availability of after-hour care must reflect usual practice in the local
area. Geographic availability must reflect the usual travel times within the
community.
(2) The number of network providers in the service area is sufficient, with respect to
current and expected policyholders, either:
(a) To deliver adequately all services that are subject to a restricted network
provision; or
(b) To make appropriate referrals.
(3) There are written agreements with network providers describing specific
responsibilities.
(4) Emergency care is available twenty-four hours per day and seven days per week.
(5) In the case of covered services that are subject to a restricted network provision and
are provided on a prepaid basis, there are written agreements with network
providers prohibiting the providers from billing or otherwise seeking reimbursement
from or recourse against any individual insured under a Medicare select policy or
certificate. This paragraph does not apply to supplemental charges or coinsurance
amounts as stated in the Medicare select policy or certificate.
b. A statement or map providing a clear description of the service area.
c. A description of the grievance procedure to be utilized.
d. A description of the quality assurance program, including:
(1) The formal organizational structure;
(2) The written criteria for selection, retention, and removal of network providers; and
(3) The procedures for evaluating quality of care provided by network providers and the
process to initiate corrective action when warranted.
e. A list and description, by specialty, of the network providers.
f. Copies of the written information proposed to be used by the issuer to comply with
subsection 9.
g. Any other information requested by the commissioner.
6. a. A Medicare select issuer must file any proposed changes to the plan of operation, except
for changes to the list of network providers, with the commissioner prior to implementing
such changes. Such changes must be considered approved by the commissioner after
thirty days unless specifically disapproved.

b. An updated list of network providers must be filed with the commissioner at least
quarterly.
7. A Medicare select policy or certificate may not restrict payment for covered services provided
by non-network providers if:
a. The services are for symptoms requiring emergency care or are immediately required for
an unforeseen illness, injury, or a condition; and
b. It is not reasonable to obtain such services through a network provider.
8. A Medicare select policy or certificate must provide payment for full coverage under the policy
for covered services that are not available through network providers.
9. A Medicare select issuer must make full and fair disclosure in writing of the provisions,
restrictions, and limitations of the Medicare select policy or certificate to each applicant. This
disclosure must include at least the following:
a. An outline of coverage sufficient to permit the applicant to compare the coverage and
premiums of the Medicare select policy or certificate with:
(1) Other Medicare supplement policies or certificates offered by the issuer; and
(2) Other Medicare select policies or certificates.
b. A description (including address, telephone number, and hours of operation) of the
network providers, including primary care physicians, specialty physicians, hospitals, and
other providers.
c. A description of the restricted network provisions, including payments for coinsurance
and deductibles when providers other than network providers are utilized. Except to the
extent specified in the policy or certificate, expenses incurred when using out-of-network
providers do not count toward the out-of-pocket annual limit contained in plans K and L.
d. A description of coverage for emergency and urgently needed care and other
out-of-service area coverage.
e. A description of limitations on referrals to restricted network providers and to other
providers.
f. A description of the policyholder's rights to purchase any other Medicare supplement
policy or certificate otherwise offered by the issuer.
g. A description of the Medicare select issuer's quality assurance program and grievance
procedure.
10. Prior to the sale of a Medicare select policy or certificate, a Medicare select issuer must obtain
from the applicant a signed and dated form stating that the applicant has received the
information provided pursuant to subsection 9 and that the applicant understands the
restrictions of the Medicare select policy or certificate.
11. A Medicare select issuer must have and use procedures for hearing complaints and resolving
written grievances from the subscribers. Such procedures must be aimed at mutual
agreement for settlement and may include arbitration procedures.
a. The grievance procedure must be described in the policy and certificates and in the
outline of coverage.

b. At the time the policy or certificate is issued, the issuer must provide detailed information
to the policyholder describing how a grievance may be registered with the issuer.
c. Grievances must be considered in a timely manner and shall be transmitted to
appropriate decisionmakers who have authority to fully investigate the issue and take
corrective action.
d. If a grievance is found to be valid, corrective action must be taken promptly.
e. All concerned parties must be notified about the results of a grievance.
f. The issuer must report no later than each March thirty-first to the commissioner regarding
its grievance procedure. The report must be in a format prescribed by the commissioner
and must contain the number of grievances filed in the past year and a summary of the
subject, nature, and resolution of such grievances.
12. At the time of initial purchase, a Medicare select issuer must make available to each applicant
for a Medicare select policy or certificate the opportunity to purchase any Medicare
supplement policy or certificate otherwise offered by the issuer.
13. a. At the request of an individual insured under a Medicare select policy or certificate, a
Medicare select issuer must make available to the individual insured the opportunity to
purchase a Medicare supplement policy or certificate offered by the issuer which has
comparable or lesser benefits and which does not contain a restricted network provision.
The issuer must make the policies or certificates available without requiring evidence of
insurability after the Medicare select policy or certificate has been in force for six months.
b. For the purposes of this subsection, a Medicare supplement policy or certificate will be
considered to have comparable or lesser benefits unless it contains one or more
significant benefits not included in the Medicare select policy or certificate being
replaced. For the purposes of this paragraph, a significant benefit means coverage for
the Medicare part A deductible, coverage for at-home recovery services, or coverage for
Medicare part B excess charges.
14. Medicare select policies and certificates must provide for continuation of coverage in the event
the secretary of health and human services determines that Medicare select policies and
certificates issued pursuant to this section should be discontinued due to either the failure of
the Medicare select program to be reauthorized under law or its substantial amendment.
a. Each Medicare select issuer must make available to each individual insured under a
Medicare select policy or certificate the opportunity to purchase any Medicare
supplement policy or certificate offered by the issuer which has comparable or lesser
benefits and which does not contain a restricted network provision. The issuer must
make such policies and certificates available without requiring evidence of insurability.
b. For the purposes of this subsection, a Medicare supplement policy or certificate will be
considered to have comparable or lesser benefits unless it contains one or more
significant benefits not included in the Medicare select policy or certificate being
replaced. For the purposes of this paragraph, a significant benefit means coverage for
the Medicare part A deductible, coverage for at-home recovery services, or coverage for
part B excess charges.
15. A Medicare select issuer must comply with reasonable requests for data made by state or
federal agencies, including the United States department of health and human services, for
the purpose of evaluating the Medicare select program.
History: Effective January 1, 1992; amended effective July 8, 1997; September 1, 2005.

General Authority: NDCC 26.1-36.1-02(1)(2), 26.1-36.1-03
Law Implemented: NDCC 26.1-36.1-02
### § 45-06-01.1-09. Open enrollment.

1. Any issuer may not deny or condition the issuance or effectiveness of any Medicare
supplement policy or certificate available for sale in this state, or discriminate in the pricing of
such a policy or certificate because of the health status, claims experience, receipt of health
care, or medical condition of an applicant in the case of an application for a policy or certificate
that is submitted prior to or during the six-month period beginning with the first day of the first
month in which an individual is both sixty-five years of age or older and is enrolled for benefits
under Medicare part B. Each Medicare supplement policy and certificate currently available
from an insurer must be made available to all applicants who qualify under this subsection
without regard to age.
2. a. If an applicant qualifies under subsection 1 and submits an application during the time
period referenced in subsection 1 and, as of the date of application, has had a
continuous period of creditable coverage of at least six months, the issuer may not
exclude benefits based on a preexisting condition.
b. If the applicant qualifies under subsection 1 and submits an application during the time
period referenced in subsection 1 and, as of the date of application, has had a
continuous period of creditable coverage that is less than six months, the issuer shall
reduce the period of any preexisting condition exclusion by the aggregate of the period of
creditable coverage applicable to the applicant as of the enrollment date. The secretary
shall specify the manner of the reduction under this subsection.
3. Except as provided in subsection 2 and sections 45-06-01.1-09.1 and 45-06-01.1-20,
subsection 1 may not be construed as preventing the exclusion of benefits under a policy,
during the first six months, based on a preexisting condition for which the policyholder or
certificate holder received treatment or was otherwise diagnosed during the six months before
the coverage became effective.
History: Effective January 1, 1992; amended effective July 8, 1997; August 27, 1998; September 1,
2005.
General Authority: NDCC 26.1-36.1-02(1)(2), 26.1-36.1-03
Law Implemented: NDCC 26.1-36.1-02
### § 45-06-01.1-09.1. Guaranteed issue for eligible persons.

1. Guaranteed issue.
a. Eligible persons are those individuals described in subsection 2 who seek to enroll under
the policy during the period specified in subsection 3, and who submit evidence of the
date of termination, disenrollment, or Medicare part D enrollment with the application for
a Medicare supplement policy.
b. With respect to eligible persons, an issuer may not deny or condition the issuance or
effectiveness of a Medicare supplement policy described in subsection 5 that is offered
and is available for issuance to new enrollees by the issuer, may not discriminate in the
pricing of such a Medicare supplement policy because of health status, claims
experience, receipt of health care, or medical condition, and may not impose an
exclusion of benefits based on a preexisting condition under such a Medicare
supplement policy.
2. Eligible persons. An eligible person is an individual described in any of the following
subdivisions:

a. The individual is enrolled under an employee welfare benefit plan that provides health
benefits that supplement the benefits under Medicare, and the plan terminates, or the
plan ceases to provide all such supplemental health benefits to the individual;
b. The individual is enrolled with a Medicare advantage organization under a Medicare
advantage plan under part C of Medicare, and any of the following circumstances apply,
or the individual is sixty-five years of age or older and is enrolled with a program of
all-inclusive care for the elderly provider under section 1894 of the Social Security Act,
and there are circumstances similar to those described below that would permit
discontinuance of the individual's enrollment with such provider if such individual were
enrolled in a Medicare advantage plan:
(1) The organization's or plan's certification has been terminated;
(2) The organization has terminated or otherwise discontinued providing the plan in the
area in which the individual resides;
(3) The individual is no longer eligible to elect the plan because of a change in the
individual's place of residence or other change in circumstances specified by the
secretary, but not including termination of the individual's enrollment on the basis
described in section 1851(g)(3)(B) of the federal Social Security Act, if the individual
has not paid premiums on a timely basis or has engaged in disruptive behavior as
specified in standards under section 1856, or the plan is terminated for all
individuals within a residence area;
(4) The individual demonstrates, in accordance with guidelines established by the
secretary, that:
(a) The organization offering the plan substantially violated a material provision of
the organization's contract under this part in relation to the individual, including
the failure to provide an enrollee on a timely basis medically necessary care for
which benefits are available under the plan or the failure to provide such
covered care in accordance with applicable quality standards; or
(b) The organization, or agent or other entity acting on the organization's behalf,
materially misrepresented the plan's provision in marketing the plan to the
individual; or
(5) The individual meets such other exceptional conditions as the secretary may
provide.
c. (1) The individual is enrolled with:
(a) An eligible organization operating under a contract under section 1876 of the
Social Security Act (Medicare cost);
(b) A similar organization operating under demonstration project authority, effective
for periods before April 1, 1999;
(c) An organization under an agreement under section 1833(a)(1)(A) of the Social
Security Act (health care prepayment plan); or
(d) An organization under a Medicare select policy; and
(2) The enrollment ceases under the same circumstances that would permit
discontinuance of an individual's election of coverage under subdivision b of
subsection 2;

d. The individual is enrolled under a Medicare supplement policy and the enrollment ceases
because:
(1) (a) Of the insolvency of the issuer or bankruptcy of the nonissuer organization; or
(b) Of other involuntary termination of coverage or enrollment under the policy;
(2) The issuer of the policy substantially violated a material provision of the policy; or
(3) The issuer, or an agent or other entity acting on the issuer's behalf, materially
misrepresented the policy's provisions in marketing the policy to the individual;
e. (1) The individual was enrolled under a Medicare supplement policy and terminates
enrollment and subsequently enrolls, for the first time, with any Medicare advantage
organization under a Medicare advantage plan under part C of Medicare, any
eligible organization under a contract under section 1876 of the Social Security Act
regarding Medicare cost, any similar organization operating under demonstration
project authority, any program of all-inclusive care for the elderly provider under
section 1894 of the Social Security Act, or a Medicare select policy; and
(2) The subsequent enrollment under paragraph 1 is terminated by the enrollee during
any period within the first twelve months of such subsequent enrollment, during
which the enrollee is permitted to terminate such subsequent enrollment under
section 1851(e) of the federal Social Security Act; or
f. The individual, upon first becoming eligible for benefits under part A of Medicare at age
sixty-five, enrolls in a Medicare advantage plan under part C of Medicare, or in a program
of all-inclusive care for the elderly provider under section 1894 of the Social Security Act,
and disenrolls from the plan or program by not later than twelve months after the
effective date of enrollment.
g. The individual enrolls in a Medicare part D plan during the initial enrollment period and, at
the time of enrollment in part D, was enrolled under a Medicare supplement policy that
covers outpatient prescription drugs and the individual terminates enrollment in the
Medicare supplement policy and submits evidence of enrollment in Medicare part D
along with the application for a policy described in subdivision d of subsection 5.
3. Guaranteed issue time periods.
a. In the case of an individual described in subdivision a of subsection 2, the guaranteed
issue period begins on the later of: (i) the date the individual receives a notice of
termination or cessation of all supplemental health benefits or, if such notice is not
received, notice that a claim has been denied because of a termination or cessation; or
(ii) the date that the applicable coverage terminates or ceases; and ends sixty-three days
thereafter;
b. In the case of an individual described in subdivision b, c, e, or f of subsection 2 whose
enrollment is terminated involuntarily, the guaranteed issue period begins on the date
that the individual receives a notice of termination and ends sixty-three days after the
date the applicable coverage is terminated;
c. In the case of an individual described in paragraph 1 of subdivision d of subsection 2, the
guaranteed issue period begins on the earlier of (i) the date that the individual receives a
notice of termination, a notice of the issuer's bankruptcy or insolvency, or other such
similar notice if any, and (ii) the date that the applicable coverage is terminated, and ends
on the date that is sixty-three days after the date the coverage is terminated;

d. In the case of an individual described in subdivision b, d, e, or f of subsection 2 who
disenrolls voluntarily, the guaranteed issue period begins on the date that is sixty days
before the effective date of the disenrollment and ends sixty-three days after the effective
date;
e. In the case of an individual described in subdivision g of subsection 2, the guaranteed
issue period begins on the date the individual receives notice pursuant to section 1882(v)
(2)(B) of the Social Security Act from the Medicare supplement issuer during the
sixty-day period immediately preceding the initial part D enrollment period and ends on
the date that is sixty-three days after the effective date of the individual's coverage under
Medicare part D; and
f. In the case of an individual described in subsection 2 but not described in the preceding
provisions of this subsection, the guaranteed issue period begins on the effective date of
disenrollment and ends on the date that is sixty-three days after the effective date.
4. Extended medigap access for interrupted trial periods.
a. In the case of an individual described in subdivision e of subsection 2, or deemed to be
so described pursuant to this paragraph, whose enrollment with an organization or
provider described in paragraph 1 of subdivision e of subsection 2 is involuntarily
terminated within the first twelve months of enrollment, and who, without an intervening
enrollment, enrolls with another such organization or provider, the subsequent enrollment
shall be deemed to be an initial enrollment described in subdivision e of subsection 2;
b. In the case of an individual described in subdivision f of subsection 2, or deemed to be so
described pursuant to this paragraph, whose enrollment with a plan or in a program
described in subdivision f of subsection 2 is involuntarily terminated within the first twelve
months of enrollment, and who, without an intervening enrollment, enrolls in another
such plan or program, the subsequent enrollment shall be deemed to be an initial
enrollment described in subdivision f of subsection 2; and
c. For purposes of subdivisions e and f of subsection 2, no enrollment of an individual with
an organization or provider described in paragraph 1 of subdivision e of subsection 2, or
with a plan or in a program described in subdivision f of subsection 2, may be deemed to
be an initial enrollment under this paragraph after the two-year period beginning on the
date on which the individual first enrolled with such an organization, provider, plan, or
program.
5. Products to which eligible persons are entitled. The Medicare supplement policy to which
eligible persons are entitled under:
a. Subdivisions a, b, c, and d of subsection 2 are a Medicare supplement policy that has a
benefit package classified as plan A, B, C, F (including F with a high deductible), K, or L
offered by any issuer.
b. (1) Subject to paragraph 2, subdivision e of subsection 2 is the same Medicare
supplement policy in which the individual was most recently previously enrolled, if
available from the same issuer, or, if not so available, a policy described in
subdivision a.
(2) After December 31, 2005, if the individual was most recently enrolled in a Medicare
supplement policy with an outpatient prescription drug benefit, a Medicare
supplement policy described in this paragraph is:
(a) The policy available from the same issuer but modified to remove outpatient
prescription drug coverage; or

(b) At the election of the policyholder, an A, B, C, F (including F with a high
deductible), K, or L policy that is offered by any issuer.
c. Subdivision f of subsection 2 includes any Medicare supplement policy offered by any
issuer.
d. Subdivision g of subsection 2 is a Medicare supplement policy that has a benefit package
classified as plan A, B, C, F (including F with a high deductible), K, or L, and that is
offered and is available for issuance to new enrollees by the same issuer that issued the
individual's Medicare supplement policy with outpatient prescription drug coverage.
6. Notification provisions.
a. At the time of an event described in subsection 2 because of which an individual loses
coverage or benefits due to the termination of a contract or agreement, policy, or plan,
the organization that terminates the contract or agreement, issuer terminating the policy,
or the administrator of the plan being terminated, respectively, shall notify the individual
of the individual's rights under this section, and of the obligations of the issuers of
Medicare supplement policies under subsection 1. Such notice shall be communicated
contemporaneously with the notification of termination.
b. At the time of an event described in subsection 2 because of which an individual ceases
enrollment under a contract or agreement, policy, or plan, the organization that offers the
contract or agreement, regardless of the basis for the cessation of enrollment, the issuer
offering the policy, or the administrator of the plan, respectively, shall notify the individual
of the individual's rights under this section, and of the obligations of issuers of Medicare
supplement policies under subsection 1. Such notice shall be communicated within ten
working days of the issuer receiving notification of disenrollment.
History: Effective August 27, 1998; amended effective December 1, 2001; September 1, 2005; July 1,
2009.
General Authority: NDCC 26.1-36.1-02, 26.1-36.1-03
Law Implemented: NDCC 26.1-36.1-02
### § 45-06-01.1-10. Standards for claims payment.

1. An issuer must 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 (Pub. L. 100-203;
101 Stat. 1330; 42 U.S.C. 1395ss(c)(3))] by:
a. 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;
b. Notifying the participating physician or supplier and the beneficiary of the payment
determination;
c. Paying the participating physician or supplier directly;
d. 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;
e. Paying user fees for claim notices that are transmitted electronically or otherwise; and

f. Providing to the secretary of health and human services, at least annually, a central
mailing address to which all claims may be sent by Medicare carriers.
2. Compliance with the requirements set forth in subsection 1 must be certified on the Medicare
supplement insurance experience reporting form.
History: Effective January 1, 1992.
General Authority: NDCC 26.1-36.1-02(1)(2), 26.1-36.1-03
Law Implemented: NDCC 26.1-36.1-02
### § 45-06-01.1-11. Loss ratio standards and refund or credit of premium.

1. Loss ratio standards.
a. (1) A Medicare supplement policy form or certificate form may not be delivered or
issued for delivery unless the policy form or certificate form can be expected, as
estimated for the entire period for which rates are computed to provide coverage, to
return to policyholders and certificate holders in the form of aggregate benefits (not
including anticipated refunds or credits) provided under the policy form or certificate
form:
(a) At least seventy-five percent of the aggregate amount of premiums earned in
the case of group policies; or
(b) At least sixty-five percent of the aggregate amount of premiums earned in the
case of individual policies;
(2) Calculated on the basis of incurred claims experience or incurred health care
expenses where coverage is provided by a health maintenance organization on a
service rather than reimbursement basis and earned premiums for such period and
in accordance with accepted actuarial principles and practices. Incurred health care
expenses when coverage is provided by a health maintenance organization shall
not include:
(a) Home office and overhead costs;
(b) Advertising costs;
(c) Commissions and other acquisition costs;
(d) Taxes;
(e) Capital costs;
(f) Administrative costs; and
(g) Claims processing costs.
b. All filings of rates and rating schedules must demonstrate that expected claims in relation
to premiums comply with the requirements of this section when combined with actual
experience to date. Filings of rate revisions must also demonstrate that the anticipated
loss ratio over the entire future period for which the revised rates are computed to
provide coverage can be expected to meet the appropriate loss ratio standards.
c. For purposes of applying subdivision a of subsection 1 of this section and subdivision c
of subsection 4 of section 45-06-01.1-12 only, policies issued as a result of solicitations of
individuals through the mails or by mass media advertising (including both print and
broadcast advertising) are deemed to be group policies.

d. For policies issued prior to January 1, 1992, expected claims in relation to premiums
must meet:
(1) The originally filed anticipated loss ratios when combined with the actual experience
since inception;
(2) The appropriate loss ratio requirements from subparagraphs a and b of paragraph 1
of subdivision a when combined with actual experience beginning with July 1, 1997,
to date; and
(3) The appropriate loss ratio requirement from subparagraphs a and b of paragraph 1
of subdivision a over the entire future period for which the rates are computed to
provide coverage.
2. Refund or credit calculation.
a. An issuer must collect and file with the commissioner by May thirty-first of each year the
data contained in the applicable reporting form contained in appendix A for each type in a
standard Medicare supplement benefit plan.
b. If on the basis of the experience as reported the benchmark ratio since inception (ratio 1)
exceeds the adjusted experience ratio since inception (ratio 3), then a refund or credit
calculation is required. The refund calculation must be done on a statewide basis for
each type in a standard Medicare supplement benefit plan. For purposes of the refund or
credit calculation, experience on policies issued within the reporting year must be
excluded.
c. For the purposes of this section, policies or certificates issued prior to January 1, 1992,
the issuer shall make the refund or credit calculation separately for all individual policies
(including all group policies subject to an individual loss ratio standard when issued)
combined and all other group policies combined for experience after July 1, 1997. The
first report is due by May 31, 1998.
d. A refund or credit may be made only when the benchmark loss ratio exceeds the
adjusted experience loss ratio and the amount to be refunded or credited exceeds a de
minimis level. The refund must include interest from the end of the calendar year to the
date of the refund or credit at a rate specified by the secretary of health and human
services, but in no event may it be less than the average rate of interest for thirteen-week
treasury notes. A refund or credit against premiums due must be made by September
thirtieth following the experience year upon which the refund or credit is based.
3. Annual filing of premium rates. An issuer of Medicare supplement policies and certificates
issued before or after the effective date of this chapter must file annually its rates, rating
schedule, and supporting documentation including ratios of incurred losses to earned
premiums by policy duration for approval by the commissioner in accordance with the filing
requirements and procedures prescribed by the commissioner. The supporting documentation
must also demonstrate in accordance with actuarial standards of practice using reasonable
assumptions that the appropriate loss ratio standards can be expected to be met over the
entire period for which rates are computed. The demonstration must exclude active life
reserves. An expected third-year loss ratio which is greater than or equal to the applicable
percentage must be demonstrated for policies or certificates in force less than three years.
As soon as practicable, but prior to the effective date of enhancements in Medicare benefits,
every issuer of Medicare supplement policies or certificates in this state must file with the
commissioner, in accordance with the applicable filing procedures of this state:

a. (1) Appropriate premium adjustments necessary to produce loss ratios as anticipated
for the current premium for the applicable policies or certificates. The supporting
documents as necessary to justify the adjustment must accompany the filing.
(2) An issuer must make premium adjustments necessary to produce an expected loss
ratio under the policy or certificate to conform to minimum loss ratio standards for
Medicare supplement policies and which are expected to result in a loss ratio at
least as great as that originally anticipated in the rates used to produce current
premiums by the issuer for the Medicare supplement policies or certificates. No
premium adjustment which would modify the loss ratio experience under the policy
other than the adjustments described herein may be made with respect to a policy
at any time other than upon its renewal date or anniversary date.
(3) If an issuer fails to make premium adjustments acceptable to the commissioner, the
commissioner may order premium adjustments, refunds, or premium credits
deemed necessary to achieve the loss ratio required by this section.
b. Any appropriate riders, endorsements, or policy forms needed to accomplish the
Medicare supplement policy or certificate modifications necessary to eliminate benefit
duplications with Medicare. The riders, endorsements, or policy forms must provide a
clear description of the Medicare supplement benefits provided by the policy or
certificate.
4. Public hearings. The commissioner may conduct a public hearing to gather information
concerning a request by an issuer for an increase in a rate for a policy form or certificate form
issued before or after the effective date of this chapter if the experience of the form for the
previous reporting period is not in compliance with the applicable loss ratio standard. The
determination of compliance is made without consideration of any refund or credit for such
reporting period. Public notice of the hearing may be furnished in a manner deemed
appropriate by the commissioner.
History: Effective January 1, 1992; amended effective July 8, 1997; September 1, 2005.
General Authority: NDCC 26.1-36.1-02(1)(2), 26.1-36.1-03
Law Implemented: NDCC 26.1-36.1-04
### § 45-06-01.1-12. Filing and approval of policies and certificates and premium rates.

1. An issuer may not deliver or issue for delivery a policy or certificate to a resident of this state
unless the policy form or certificate form has been filed with and approved by the
commissioner in accordance with filing requirements and procedures prescribed by the
commissioner.
2. An issuer shall file any riders or amendments to policy or certificate forms to delete outpatient
prescription drug benefits as required by the Medicare Prescription Drug Improvement and
Modernization Act of 2003 only with the commissioner in the state in which the policy or
certificate was issued.
3. An issuer may not use or change premium rates for a Medicare supplement policy or
certificate unless the rates, rating schedule, and supporting documentation have been filed
with and approved by the commissioner in accordance with the filing requirements and
procedures prescribed by the commissioner.
4. a. Except as provided in subdivision b of this subsection, an issuer may not file for approval
more than one form of a policy or certificate of each type for each standard Medicare
supplement benefit plan.

b. An issuer may offer, with the approval of the commissioner, up to four additional policy
forms or certificate forms of the same type for the same standard Medicare supplement
benefit plan, one for each of the following cases:
(1) The inclusion of new or innovative benefits.
(2) The addition of either direct response or agent marketing methods.
(3) The addition of either guaranteed issue or underwritten coverage.
(4) The offering of coverage to individuals eligible for Medicare by reason of disability.
c. For the purposes of this section, a "type" means an individual policy, a group policy, an
individual Medicare select policy, or a group Medicare select policy.
5. a. Except as provided in paragraph 1, an issuer must continue to make available for
purchase any policy form or certificate form issued after the effective date of this
regulation that has been approved by the commissioner. A policy form or certificate form
may not be considered to be available for purchase unless the issuer has actively offered
it for sale in the previous twelve months.
(1) An issuer may discontinue the availability of a policy form or certificate form if the
issuer provides to the commissioner in writing its decision at least thirty days prior to
discontinuing the availability of the form of the policy or certificate. After receipt of
the notice by the commissioner, the issuer may no longer offer for sale the policy
form or certificate form in this state.
(2) An issuer that discontinues the availability of a policy form or certificate form
pursuant to paragraph 1 may not file for approval a new policy form or certificate
form of the same type for the same standard Medicare supplement benefit plan as
the discontinued form for a period of five years after the issuer provides notice to the
commissioner of the discontinuance. The period of discontinuance may be reduced
if the commissioner determines that a shorter period is appropriate.
b. The sale or other transfer of Medicare supplement business to another issuer is
considered a discontinuance for the purposes of this subsection.
c. A change in the rating structure or methodology is considered a discontinuance under
subdivision a unless the issuer complies with the following requirements:
(1) The issuer provides an actuarial memorandum, in a form and manner prescribed by
the commissioner, describing the manner in which the revised rating methodology
and resultant rates differ from the existing rating methodology and existing rates.
(2) The issuer does not subsequently put into effect a change of rates or rating factors
that would cause the percentage differential between the discontinued and
subsequent rates as described in the actuarial memorandum to change. The
commissioner may approve a change to the differential which is in the public
interest.
6. a. Except as provided in subdivision b, the experience of all policy forms or certificate forms
of the same type in a standard Medicare supplement benefit plan must be combined for
purposes of the refund or credit calculation prescribed in section 45-06-01.1-11.
b. Forms assumed under an assumption reinsurance agreement may not be combined with
the experience of other forms for purposes of the refund or credit calculation.

History: Effective January 1, 1992; amended effective July 1, 1994; September 1, 2005.
General Authority: NDCC 26.1-36.1-02(1)(2), 26.1-36.1-03
Law Implemented: NDCC 26.1-36.1-02
### § 45-06-01.1-13. Permitted compensation arrangements.

1. An issuer or other entity must provide level commissions or other compensation to an agent or
other representative for the sale of a Medicare supplement policy or certificate for the year of
issuance and no fewer than five renewal years.
2. No issuer or other entity may provide compensation to its agents or other producers and no
agent or producer may receive compensation greater than the renewal compensation payable
by the replacing issuer on renewal policies or certificates if an existing policy or certificate is
replaced.
3. For purposes of this section, "compensation" includes pecuniary or nonpecuniary
remuneration of any kind relating to the sale or renewal of the policy or certificate including,
but not limited to, bonuses, gifts, prizes, awards, and finders fees.
4. This section does not apply to an issuer or other entity that provides a one-time commission or
other compensation provided the amount paid to an agent or other representative for the sale
of a Medicare supplement insurance policy or certificate does not exceed twenty-five dollars.
This payment is in lieu of level commissions.
History: Effective January 1, 1992; amended effective January 6, 1992.
General Authority: NDCC 26.1-36.1-02(1)(2)
Law Implemented: NDCC 26.1-36.1-03
### § 45-06-01.1-14. Required disclosure provisions.

1. General rules.
a. Medicare supplement policies and certificates must include a renewal or continuation
provision. The language or specifications of the provision must be consistent with the
type of contract issued. Such provision must be appropriately captioned and must appear
on the first page of the policy, and must include any reservation by the issuer of the right
to change premiums and any automatic renewal premium increases based on the
policyholder's age.
b. 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 policy, or is required to reduce or eliminate benefits to avoid duplication of
Medicare benefits, all riders or endorsements added to a Medicare supplement policy
after date of issue or at reinstatement or renewal which reduce or eliminate benefits or
coverage in the policy must require a signed acceptance by the insured. After the date of
policy or certificate issue, any rider or endorsement which increases benefits or coverage
with a concomitant increase in premium during the policy term must be agreed to in
writing signed by the insured, unless the benefits are required by the minimum standards
for Medicare supplement policies, or if the increased benefits or coverage is required by
law. When a separate additional premium is charged for benefits provided in connection
with riders or endorsements, the premium charge must be set forth in the policy.
c. Medicare supplement policies or certificates may not provide for the payment of benefits
based on standards described as "usual and customary", "reasonable and customary", or
words of similar import.

d. If a Medicare supplement policy or certificate contains any limitations with respect to
preexisting conditions, such limitations must appear as a separate paragraph of the
policy and be labeled as "preexisting condition limitations".
e. Medicare supplement policies and certificates must have a notice prominently printed on
the first page of the policy or certificate or attached thereto stating in substance that the
policyholder or certificate holder has the right to return the policy or certificate within thirty
days of its delivery and to have the premium refunded if, after examination of the policy
or certificate, the insured person is not satisfied for any reason.
f. (1) Issuers of accident and sickness policies or certificates which provide hospital or
medical expense coverage on an expense incurred or indemnity basis to persons
eligible for Medicare must provide to those applicants a guide to health insurance
for people with Medicare in the form developed jointly by the national association of
insurance commissioners and the centers for Medicare and Medicaid services and
in a type size no smaller than twelve-point type. Delivery of the guide must be made
whether or not such policies or certificates are advertised, solicited, or issued as
Medicare supplement policies or certificates as defined in this regulation. Except in
the case of direct response issuers, delivery of the guide must be made to the
applicant at the time of application and acknowledgment of receipt of the guide must
be obtained by the insurer. Direct response issuers must deliver the guide to the
applicant upon request but not later than at the time the policy is delivered.
(2) For the purposes of this section, "form" means the language, format, type size, type
proportional spacing, bold character, and line spacing.
2. Notice requirements.
a. As soon as practicable, but no later than thirty days prior to the annual effective date of
any Medicare benefit changes, an issuer must notify its policyholders and certificate
holders of modifications it has made to Medicare supplement insurance policies or
certificates in a format acceptable to the commissioner. The notice must:
(1) Include a description of revisions to the Medicare program and a description of each
modification made to the coverage provided under the Medicare supplement policy
or certificate; and
(2) Inform each policyholder or certificate holder as to when any premium adjustment is
to be made due to changes in Medicare.
b. The notice of benefit modifications and any premium adjustments must be in outline form
and in clear and simple terms so as to facilitate comprehension.
c. Such notices may not contain or be accompanied by any solicitation.
3. Medicare Prescription Drug Improvement and Modernization Act of 2003 notice
requirements. Issuers must comply with any notice requirements of the Medicare Prescription
Drug Improvement and Modernization Act of 2003.
4. Outline of coverage requirements for Medicare supplement policies.
a. Issuers must provide an outline of coverage to all applicants at the time application is
presented to the prospective applicant and, except for direct response policies, must
obtain an acknowledgment of receipt of the outline from the applicant; and
b. If an outline of coverage is provided at the time of application and the Medicare
supplement policy or certificate is issued on a basis which would require revision of the

outline, a substitute outline of coverage properly describing the policy or certificate must
accompany such policy or certificate when it is delivered and contain the following
statement, in no less than twelve-point type, immediately above the company name:
"NOTICE: Read this outline of coverage carefully. It is not identical to the outline of
coverage provided upon application and the coverage originally applied for has not been
issued."
c. The outline of coverage provided to applicants pursuant to this section consists of four
parts: a cover page, premium information, disclosure pages, and charts displaying the
features of each benefit plan offered by the issuer. The outline of coverage must be in the
language and format prescribed below in no less than twelve-point type. All plans must
be shown on the cover page, and the plans that are offered by the issuer must be
prominently identified. Premium information for plans that are offered must be shown on
the cover page or immediately following the cover page and must be prominently
displayed. The premium and mode must be stated for all plans that are offered to the
prospective applicant. All possible premiums for the prospective applicant must be
illustrated.
d. The following items must be included in the outline of coverage in the order prescribed
below:

Benefit Chart of Medicare Supplement Plans Sold for Effective Dates on or After June 1, 2010
This chart shows the benefits included in each of the standard Medicare supplement plans. Every
company must make Plan A available. Some plans may not be available in your state.
Basic Benefits:
• Hospitalization - Part A coinsurance plus coverage for 365 additional days after Medicare benefits
end.
• Medical Expenses - Part B coinsurance (generally 20 percent of Medicare- approved expenses) or
copayments for hospital outpatient services. Plans K, L, and N require insureds to pay a portion of Part
B coinsurance or copayments.
• Blood - First three pints of blood each year.
• Hospice - Part A coinsurance.

Basic, Basic, Basic, Basic, Basic, including Basic, Hospitalization Hospitalization Basic, Basic, including
including including including including 100% including and preventive and preventive including 100% 100% Part B
100% 100% 100% 100% Part B 100% care paid at care paid at Part B coinsurance,
Part B Part B Part B Part B coinsurance Part B 100%; other 100%; other coinsurance except up to $20
coinsurance coinsurance coinsurance coinsurance coinsurance basic benefits basic benefits copayment for
paid at 50% paid at 75% office visit, and up
to $50 copayment
for ER
Skilled Skilled Skilled Nursing Skilled 50% Skilled 75% Skilled Skilled Nursing Skilled
Nursing Nursing Facility Nursing Nursing Facility Nursing Facility Facility Nursing
Facility Facility Coinsurance Facility Coinsurance Coinsurance Coinsurance Facility
Coinsurance Coinsurance Coinsurance Coinsurance
Part A Part A Part A Part A Part A 50% Part A 75% Part A 50% Part A Part A Deductible
Deductible Deductible Deductible Deductible Deductible Deductible Deductible Deductible
Part B Part B
Deductible Deductible
Part B Excess Part B Excess
(100%) (100%)
Foreign Travel Foreign Travel Foreign Travel Foreign Travel Foreign Travel Foreign
Emergency Emergency Emergency Emergency Emergency Travel Emergency
*Plan F also has an option called a high deductible Plan F. This high deductible plan pays the Out-of-pocket Out-of-pocket
same benefits as Plan F after one has paid a calendar year [$2,240] deductible. Benefits from limit [$5,240]; limit [$2,620];
high deductible Plan F will not begin until out-of-pocket expenses exceed [$2,240]. Out-of-pocket paid at 100% paid at 100%
expenses for this deductible are expenses that would ordinarily be paid by the policy. These after limit after limit
expenses include the Medicare deductibles for Part A and Part B, but do not include the plan's reached reached
separate foreign travel emergency deductible.

PREMIUM INFORMATION [Boldface Type]
We [insert issuer's name] can only raise your premium if we raise the premium for all policies like yours
in this State. [If the premium is based on the increasing age of the insured, include information
specifying when premiums will change.]
DISCLOSURES [Boldface Type]
Use this outline to compare benefits and premiums among policies.
This outline shows benefits and premiums of policies sold for effective dates on or after June 1,
2010. Policies sold for effective dates prior to June 1, 2010, have different benefits and
premiums. Plans E, H, I, and J are no longer available for sale. [This paragraph shall not appear
after June 1, 2011.]
READ YOUR POLICY VERY CAREFULLY [Boldface Type]
This is only an outline describing your policy's most important features. The policy is your insurance
contract. You must read the policy itself to understand all of the rights and duties of both you and your
insurance company.
RIGHT TO RETURN POLICY [Boldface Type]
If you find that you are not satisfied with your policy, you may return it to [insert issuer's address]. If you
send the policy back to us within 30 days after you receive it, we will treat the policy as if it had never
been issued and return all of your payments.
POLICY REPLACEMENT [Boldface Type]
If you are replacing another health insurance policy, do NOT cancel it until you have actually received
your new policy and are sure you want to keep it.
NOTICE [Boldface Type]
This policy may not fully cover all of your medical costs.
[for agents:]
Neither [insert company's name] nor its agents are connected with Medicare.
[for direct response:]
[insert company's name] is not connected with Medicare.
This outline of coverage does not give all the details of Medicare coverage. Contact your local Social
Security Office or consult Medicare and You for more details.
COMPLETE ANSWERS ARE VERY IMPORTANT [Boldface Type]
When you fill out the application for the new policy, be sure to answer truthfully and completely all
questions about your medical and health history. The company may cancel your policy and refuse to
pay any claims if you leave out or falsify important medical information. [If the policy or certificate is
guaranteed issue, this paragraph need not appear.]
Review the application carefully before you sign it. Be certain that all information has been properly
recorded.
[Include for each plan prominently identified in the cover page, a chart showing the services, Medicare
payments, plan payments and insured payments for each plan, using the same language, in the same
order, using uniform layout and format as shown in the charts below. No more than four plans may be

shown on one chart. For purposes of illustration, charts for each plan are included in this regulation. An
issuer may use additional benefit plan designations on these charts pursuant to subsection 4 of Section
45-06-01.1-07.1.]
[Include an explanation of any innovative benefits on the cover page and in the chart, in a manner
approved by the commissioner.]
Benefit Chart of Medicare Supplement Plans Sold On or After January 1, 2020
This chart shows the benefits included in each of the standard Medicare supplement plans. Some plans
may not be available. Only applicants first eligible for Medicare before 2020 may purchase plans C, F,
and high deductible F.
Note: A  means one hundred percent of the benefits is paid.
Medicare First
Eligible Before
Benefits Plans Available to All Applicants 2020 Only
Medicare part A          
coinsurance and
hospital coverage
(up to an additional
365 days after
Medicare benefits
are used up)
Medicare part B     50% 75%    
coinsurance or Copays
copayment apply3
Blood (first three     50% 75%    
pints)
Part A hospice care 50% 75%    
coinsurance or
copayment
Skilled nursing 50% 75%    
facility coinsurance
Medicare part A 50% 75% 50%   
deductible
Medicare part B  
deductible
Medicare part B  
excess charges
Foreign travel      
emergency (up to
plan limits)
Out-of-pocket limit [$5,240]2 [$2,620]2
in [2018]2
1Plans F and G also have a high deductible option which require first paying a plan deductible of
[$2,240] before the plan begins to pay. Once the plan deductible is met, the plan pays one hundred
percent of covered services for the rest of the calendar year. High deductible plan G does not cover the
Medicare part B deductible. However, high deductible plans F and G count your payment of the
Medicare part B deductible toward meeting the plan deductible.

2Plans K and L pay one hundred percent of covered services for the rest of the calendar year once you
meet the out-of-pocket yearly limit.
3Plan N pays one hundred percent of the part B coinsurance, except for a copayment of up to $20 for
some office visits and up to a $50 copayment for emergency room visits that do not result in an
inpatient admission.
* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after
you have been out of the hospital and have not received skilled care in any other facility for 60 days in
a row.
Semiprivate room and board,
general nursing and
miscellaneous services and
supplies
First 60 days All but [$1,340] $0 [$1,340] (Part A deductible)
61st thru 90th day All but [$335] a day [$335] a day $0
91st day and after:
--While using 60 lifetime All but [$670] a day [$670] a day $0
reserve days
--Once lifetime reserve days
are used:
--Additional 365 days $0 100% of Medicare-eligible $0**
expenses
--Beyond the additional $0 $0 All costs
365 days
You must meet Medicare's
requirements, including having
been in a hospital for at least
3 days and entered a
Medicare-approved facility
Within 30 days after leaving
the hospital
First 20 days All approved amounts $0 $0
21st thru 100th day All but [$167.50] a day $0 Up to [$167.50] a day
101st day and after $0 $0 All costs
First 3 pints $0 3 pints $0
Additional amounts 100% $0 $0
You must meet Medicare's All but very limited Medicare $0
requirements, including a copayment/coinsurance for copayment/coinsurance

doctor's certification of outpatient drugs and
terminal illness. inpatient respite care
** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place
of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days
as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for
the balance based on any difference between its billed charges and the amount Medicare would have
paid.

* Once you have been billed [$183] of Medicare-approved amounts for covered services (which are
noted with an asterisk), your Part B deductible will have been met for the calendar year.
HOSPITAL TREATMENT, such
as physician's services,
inpatient and outpatient
medical and surgical services
and supplies, physical and
speech therapy, diagnostic
tests, durable medical
equipment,
First [$183] of $0 $0 [$183] (Part B deductible)
Medicare-approved
amounts*
Remainder of Generally 80% Generally 20% $0
Medicare-approved
amounts
Part B Excess Charges $0 $0 All costs
(Above Medicare-approved
amounts)
First 3 pints $0 All costs $0
Next [$183] of $0 $0 [$183] (Part B deductible)
Medicare-approved amounts*
Remainder of 80% 20% $0
Medicare-approved amounts

--Medically necessary skilled 100% $0 $0
care services and medical
supplies
--Durable medical equipment
First [$183] of $0 $0 [$183] (Part B deductible)
Medicare-approved
amounts*
Remainder of 80% 20% $0
Medicare-approved
amounts

* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after
you have been out of the hospital and have not received skilled care in any other facility for 60 days in
a row.
Semiprivate room and board, general
nursing and miscellaneous services and
supplies
First 60 days All but [$1,340] [$1,340] (Part A $0
deductible)
61st thru 90th day All but [$335] a day [$335] a day $0
91st day and after:
--While using 60 lifetime reserve days All but [$670] a day [$670] a day $0
--Once lifetime reserve days are used:
--Additional 365 days $0 100% of $0**
Medicare-eligible
expenses
--Beyond the additional 365 days $0 $0 All costs
You must meet Medicare's requirements,
including having been in a hospital for at
least 3 days and entered a
Medicare-approved facility within 30 days
after leaving the hospital
First 20 days All approved amounts $0 $0
21st thru 100th day All but [$167.50] a day $0 Up to [$167.50] a day
101st day and after $0 $0 All costs
First 3 pints $0 3 pints $0
Additional amounts 100% $0 $0
You must meet Medicare's requirements, All but very limited Medicare copayment/ $0
including a doctor's certification of terminal copayment/ coinsurance
illness. coinsurance for
outpatient drugs and
inpatient respite care
** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place
of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days
as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for
the balance based on any difference between its billed charges and the amount Medicare would have
paid.

* Once you have been billed [$183] of Medicare-approved amounts for covered services (which are
noted with an asterisk), your Part B deductible will have been met for the calendar year.
HOSPITAL TREATMENT, such
as physician's services,
inpatient and outpatient
medical and surgical services
and supplies, physical and
speech therapy, diagnostic
tests, durable medical
equipment,
First [$183] of $0 $0 [$183] (Part B deductible)
Medicare-approved
amounts*
Remainder of Generally 80% Generally 20% $0
Medicare-approved
amounts
Part B Excess Charges $0 $0 All costs
(Above Medicare-approved
amounts)
First 3 pints $0 All costs $0
Next [$183] of $0 $0 [$183] (Part B deductible)
Medicare-approved amounts*
Remainder of 80% 20% $0
Medicare-approved amounts

--Medically necessary skilled 100% $0 $0
care services and medical
supplies
--Durable medical equipment
First [$183] of $0 $0 [$183] (Part B deductible)
Medicare-approved
amounts*
Remainder of 80% 20% $0
Medicare-approved
amounts

* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after
you have been out of the hospital and have not received skilled care in any other facility for 60 days in
a row.
Semiprivate room and board, general
nursing and miscellaneous services and
supplies
First 60 days All but [$1,340] [$1,340] (Part A $0
deductible)
61st thru 90th day All but [$335] a day [$335] a day $0
91st day and after:
--While using 60 lifetime reserve days All but [$670] a day [$670] a day $0
--Once lifetime reserve days are used:
--Additional 365 days $0 100% of $0**
Medicare-eligible
expenses
--Beyond the additional 365 days $0 $0 All costs
You must meet Medicare's requirements,
including having been in a hospital for at
least 3 days and entered a
Medicare-approved facility within 30 days
after leaving the hospital
First 20 days All approved amounts $0 $0
21st thru 100th day All but [$167.50] a day Up to [$167.50] a day $0
101st day and after $0 $0 All costs
First 3 pints $0 3 pints $0
Additional amounts 100% $0 $0
You must meet Medicare's requirements, All but very limited $0
including a doctor's certification of terminal copayment/ Medicare copayment/
illness. coinsurance for coinsurance
outpatient drugs and
inpatient respite care
** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place
of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days
as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for
the balance based on any difference between its billed charges and the amount Medicare would have
paid.

* Once you have been billed [$183] of Medicare-approved amounts for covered services (which are
noted with an asterisk), your Part B deductible will have been met for the calendar year.
such as physician's services, inpatient and
outpatient medical and surgical services
and supplies, physical and speech therapy,
diagnostic tests, durable medical
equipment,
First [$183] of Medicare-approved $0 [$183] (Part B $0
amounts* deductible)
Remainder of Medicare-approved Generally 80% Generally 20% $0
amounts
Part B Excess Charges (Above $0 $0 All costs
Medicare-approved amounts)
First 3 pints $0 All costs $0
Next [$183] of Medicare-approved amounts* $0 [$183] (Part B $0
deductible)
Remainder of Medicare-approved amounts 80% 20% $0

--Medically necessary skilled care services 100% $0 $0
and medical supplies
--Durable medical equipment
First [$183] of Medicare-approved $0 [$183] (Part B $0
amounts* deductible)
Remainder of Medicare-approved 80% 20% $0
amounts

Medically necessary emergency care
services beginning during the first 60 days of
each trip outside the USA
First $250 each calendar year $0 $0 $250
Remainder of charges $0 80% to a lifetime 20% and amounts over
maximum benefit of the $50,000 lifetime
$50,000 maximum

* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after
you have been out of the hospital and have not received skilled care in any other facility for 60 days in
a row.
Semiprivate room and board, general
nursing and miscellaneous services and
supplies
First 60 days All but [$1,340] [$1,340] (Part A $0
deductible)
61st thru 90th day All but [$335] a day [$335] a day $0
91st day and after:
--While using 60 lifetime reserve days All but [$670] a day [$670] a day $0
--Once lifetime reserve days are used:
--Additional 365 days $0 100% of $0**
Medicare-eligible
expenses
--Beyond the additional 365 days $0 $0 All costs
You must meet Medicare's requirements,
including having been in a hospital for at
least 3 days and entered a
Medicare-approved facility within 30 days
after leaving the hospital
First 20 days All approved amounts $0 $0
21st thru 100th day All but [$167.50] a day Up to [$167.50] a day $0
101st day and after $0 $0 All costs
First 3 pints $0 3 pints $0
Additional amounts 100% $0 $0
You must meet Medicare's requirements, All but very limited Medicare copayment/ $0
including a doctor's certification of terminal copayment/ coinsurance
illness. coinsurance for
outpatient drugs and
inpatient respite care
** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place
of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days
as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for
the balance based on any difference between its billed charges and the amount Medicare would have
paid.

* Once you have been billed [$183] of Medicare-approved amounts for covered services (which are
noted with an asterisk), your Part B deductible will have been met for the calendar year.
TREATMENT, such as
physician's services, inpatient
and outpatient medical and
surgical services and supplies,
physical and speech therapy,
diagnostic tests, durable
medical equipment,
First [$183] of $0 $0 [$183] (Part B deductible)
Medicare-approved
amounts*
Remainder of Generally 80% Generally 20% $0
Medicare-approved
amounts
Part B Excess Charges $0 $0 All costs
(Above
Medicare-approved
amounts)
First 3 pints $0 All costs $0
Next [$183] of $0 $0 [$183] (Part B deductible)
Medicare-approved amounts*
Remainder of 80% 20% $0
Medicare-approved amounts
--Medically necessary skilled care services 100% $0 $0
and medical supplies
--Durable medical equipment
First [$183] of Medicare-approved $0 $0 [$183] (Part B
amounts* deductible)
Remainder of Medicare-approved amounts 80% 20% $0

Medically necessary emergency care services
beginning during the first 60 days of each trip
outside the USA
First $250 each calendar year $0 $0 $250
Remainder of charges $0 80% to a lifetime 20% and amounts over
maximum benefit of the $50,000 lifetime
$50,000 maximum

PLAN F or HIGH DEDUCTIBLE PLAN F
* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after
you have been out of the hospital and have not received skilled care in any other facility for 60 days in
a row.
[** This high deductible plan pays the same benefits as Plan F after one has paid a calendar
year [$2,240] deductible. Benefits from the high deductible plan F will not begin until
out-of-pocket expenses are [$2,240]. Out-of-pocket expenses for this deductible are expenses
that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A
and Part B, but does not include the plan's separate foreign travel emergency deductible.]
Semiprivate room and board, general nursing and
miscellaneous services and supplies
First 60 days All but [$1,340] [$1,340] (Part A $0
deductible)
61st thru 90th day All but [$335] a day [$335] a day $0
91st day and after:
While using 60 lifetime reserve days All but [$670] a day [$670] a day $0
Once lifetime reserve days are used:
Additional 365 days $0 100% of $0***
Medicare-eligible
expenses
Beyond the additional 365 days $0 $0 All costs
You must meet Medicare's requirements,
including having been in a hospital for at least
3 days and entered a Medicare-approved facility
within 30 days after leaving the hospital
First 20 days All approved amounts $0 $0
21st thru 100th day All but [$167.50] a day Up to [$167.50] a day $0
101st day and after $0 $0 All costs
First 3 pints $0 3 pints $0
Additional amounts 100% $0 $0
You must meet Medicare's requirements, All but very limited Medicare copayment/ $0
including a doctor's certification of terminal illness. copayment/ coinsurance
coinsurance for
outpatient drugs and
inpatient respite care
*** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the
place of Medicare and will pay whatever amount Medicare would have paid for up to an additional

365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from
billing you for the balance based on any difference between its billed charges and the amount Medicare
would have paid.

PLAN F or HIGH DEDUCTIBLE PLAN F
* Once you have been billed [$183] of Medicare-approved amounts for covered services (which are
noted with an asterisk), your Part B deductible will have been met for the calendar year.
[** This high deductible plan pays the same or offers the same benefits as Plan F after one has
paid a calendar year [$2,240] deductible. Benefits from the high deductible plan F will not begin
until out-of-pocket expenses are [$2,240]. Out-of-pocket expenses for this deductible are
expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for
Part A and Part B, but does not include the plan's separate foreign travel emergency
deductible.]
[$2,240] [$2,240]
TREATMENT, such as
physician's services, inpatient
and outpatient medical and
surgical services and supplies,
physical and speech therapy,
diagnostic tests, durable medical
equipment,
First [$183] of $0 [$183] (Part B deductible) $0
Medicare-approved
amounts*
Remainder of Generally 80% Generally 20% $0
Medicare-approved amounts
Part B Excess Charges $0 100% $0
(Above Medicare-approved
amounts)
First 3 pints $0 All costs $0
Next [$183] of $0 [$183] (Part B deductible) $0
Medicare-approved amounts*
Remainder of 80% 20% $0
Medicare-approved amounts

PLAN F or HIGH DEDUCTIBLE PLAN F
[$2,240] [$2,240]
--Medically necessary skilled care 100% $0 $0
services and medical supplies
--Durable medical equipment
First [$183] of Medicare-approved $0 [$183] (Part B $0
amounts* deductible)
Remainder of Medicare-approved 80% 20% $0
amounts

PLAN G or HIGH DEDUCTIBLE PLAN G
* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after
you have been out of the hospital and have not received skilled care in any other facility for 60 days in
a row.
[** This high deductible plan pays the same benefits as Plan G after one has paid a calendar year
[$2,240] deductible. Benefits from the high deductible Plan G will not begin until out-of-pocket expenses
are [$2,240]. Out-of-pocket expenses for this deductible include expenses for the Medicare Part B
deductible, and expenses that would ordinarily be paid by the policy. This does not include the plan's
separate foreign travel emergency deductible.]
Semiprivate room and board, general nursing
and miscellaneous services and supplies
First 60 days All but [$1,340] [$1,340] (Part A $0
deductible)
61st thru 90th day All but [$335] a day [$335] a day $0
91st day and after:
--While using 60 lifetime reserve days All but [$670] a day [$670] a day $0
--Once lifetime reserve days are used:
--Additional 365 days $0 100% of $0***
Medicare-eligible
expenses
--Beyond the additional 365 days $0 $0 All costs
You must meet Medicare's requirements,
including having been in a hospital for at least
3 days and entered a Medicare-approved
facility within 30 days after leaving the hospital
First 20 days All approved amounts $0 $0
21st thru 100th day All but [$167.50] a day Up to [$167.50] a day $0
101st day and after $0 $0 All costs
First 3 pints $0 3 pints $0
Additional amounts 100% $0 $0
You must meet Medicare's requirements, All but very limited Medicare copayment/ $0
including a doctor's certification of terminal copayment/ coinsurance
illness. coinsurance for
outpatient drugs and
inpatient respite care
*** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the
place of Medicare and will pay whatever amount Medicare would have paid for up to an additional
365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from

billing you for the balance based on any difference between its billed charges and the amount Medicare
would have paid.

PLAN G or HIGH DEDUCIBLE PLAN G
* Once you have been billed [$183] of Medicare-approved amounts for covered services (which are
noted with an asterisk), your Part B deductible will have been met for the calendar year.
[** This high deductible plan pays the same benefits as Plan G after one has paid a calendar year
[$2,240] deductible. Benefits from the high deductible Plan G will not begin until out-of-pocket expenses
are [$2,240]. Out-of-pocket expenses for this deductible include expenses for the Medicare Part B
deductible, and expenses that would ordinarily be paid by the policy. This does not include the plan's
separate foreign travel emergency deductible.]
HOSPITAL TREATMENT, such
as physician's services,
inpatient and outpatient
medical and surgical services
and supplies, physical and
speech therapy, diagnostic
tests, durable medical
equipment
First [$183] of $0 $0 [$183] (Part B deductible)
Medicare-approved
amounts*
Remainder of Generally 80% Generally 20% $0
Medicare-approved
amounts
Part B Excess Charges $0 100% $0
(Above Medicare-approved
amounts)
First 3 pints $0 All costs $0
Next [$183] of $0 $0 [$183] (unless Part B
Medicare-approved amounts* deductible has been met)
Remainder of 80% 20% $0
Medicare-approved amounts

PLAN G or HIGH DEDUCTIBLE PLAN G
--Medically necessary skilled care 100% $0 $0
services and medical supplies
--Durable medical equipment
First [$183] of Medicare-approved $0 $0 [$183] (unless Part B
amounts* deductible has been met)
Remainder of Medicare-approved 80% 20% $0
amounts
PLAN G or HIGH DEDUCTIBLE PLAN G
Medically necessary emergency care
services beginning during the first
60 days of each trip outside the USA
First $250 each calendar year $0 $0 $250
Remainder of charges $0 80% to a lifetime maximum 20% and amounts over the
benefit of $50,000 $50,000 lifetime maximum

* You will pay half the cost-sharing of some covered services until you reach the annual out-of-pocket
limit of [$5,240] each calendar year. The amounts that count toward your annual limit are noted with
diamonds (♦) in the chart below. Once you reach the annual limit, the plan pays 100% of your Medicare
copayment and coinsurance for the rest of the calendar year. However, this limit does NOT include
charges from your provider that exceed Medicare-approved amounts (these are called "Excess
Charges") and you will be responsible for paying this difference in the amount charged by your
provider and the amount paid by Medicare for the item or service.
** A benefit period begins on the first day you receive service as an inpatient in a hospital and ends
after you have been out of the hospital and have not received skilled care in any other facility for
60 days in a row.
Semiprivate room and board,
general nursing and miscellaneous
services and supplies
First 60 days All but [$1,340] [$670] (50% of Part A [$670] (50% of Part A
deductible) deductible)♦
61st thru 90th day All but [$335] a day [$335] a day $0
91st day and after:
--While using 60 lifetime All but [$670] a day
reserve days
--Once lifetime reserve days [$670] a day $0
are used:
--Additional 365 days $0 100% of Medicare-eligible $0***
expenses
--Beyond the additional $0 $0 All costs
365 days
You must meet Medicare's
requirements, including having
been in a hospital for at least
3 days and entered a
Medicare-approved facility within
30 days after leaving the hospital
First 20 days All approved amounts $0 $0
21st thru 100th day All but [$167.50] a day Up to [$83.75] a day Up to [$183.75] a day♦
101st day and after $0 $0 All costs
First 3 pints $0 50% 50%♦
Additional amounts 100% $0 $0
You must meet Medicare's All but very limited 50% of 50% of Medicare
requirements, including a doctor's copayment/coinsurance copayment/coinsurance copayment/coinsurance♦
certification of terminal illness. for outpatient drugs and
inpatient respite care

*** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the
place of Medicare and will pay whatever amount Medicare would have paid for up to an additional
365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from
billing you for the balance based on any difference between its billed charges and the amount Medicare
would have paid.

**** Once you have been billed [$183] of Medicare-approved amounts for covered services (which are
noted with an asterisk), your Part B deductible will have been met for the calendar year.
TREATMENT, such as
physician's services, inpatient
and outpatient medical and
surgical services and supplies,
physical and speech therapy,
diagnostic tests, durable
medical equipment,
First [$183] of $0 $0 [$183] (Part B
Medicare-approved deductible)****♦
amounts****
Preventive benefits for Generally 75% or more of Remainder of All costs above
Medicare-covered services Medicare-approved Medicare-approved amounts Medicare-approved amounts
amounts
Remainder of Generally 80% Generally 10% Generally 10%♦
Medicare-approved
amounts
Part B Excess Charges $0 $0 All costs (and they do not
(Above Medicare-approved count toward annual
amounts) out-of-pocket limit of
[$5,240])*
First 3 pints $0 50% 50%♦
Next [$183] of $0 $0 [$183] (Part B
Medicare-approved deductible)****♦
amounts****
Remainder of Generally 80% Generally 10% Generally 10%♦
Medicare-approved amounts
* This plan limits your annual out-of-pocket payments for Medicare-approved amounts to [$5,240] per
year. However, this limit does NOT include charges from your provider that exceed
Medicare-approved amounts (these are called "Excess Charges") and you will be responsible
for paying this difference in the amount charged by your provider and the amount paid by
Medicare for the item or service.

--Medically necessary skilled care 100% $0 $0
services and medical supplies
--Durable medical equipment
First [$183] of Medicare-approved $0 $0 [$183] (Part B
amounts***** deductible)♦
Remainder of Medicare-approved 80% 10% 10%♦
amounts
***** Medicare benefits are subject to change. Please consult the latest Guide to Health Insurance for
People with Medicare.

* You will pay one-fourth of the cost-sharing of some covered services until you reach the annual
out-of-pocket limit of [$2,620] each calendar year. The amounts that count toward your annual limit are
noted with diamonds (♦) in the chart below. Once you reach the annual limit, the plan pays 100% of
your Medicare copayment and coinsurance for the rest of the calendar year. However, this limit does
NOT include charges from your provider that exceed Medicare-approved amounts (these are
called "Excess Charges") and you will be responsible for paying this difference in the amount
charged by your provider and the amount paid by Medicare for the item or service.
** A benefit period begins on the first day you receive service as an inpatient in a hospital and ends
after you have been out of the hospital and have not received skilled care in any other facility for
60 days in a row.
Semiprivate room and board,
general nursing and miscellaneous
services and supplies
First 60 days All but [$1,340] [$1,005] (75% of Part A [$335] (25% of Part A
deductible) deductible)♦
61st thru 90th day All but [$335] a day [$335] a day $0
91st day and after:
--While using 60 lifetime All but [$670] a day [$670] a day $0
reserve days
--Once lifetime reserve days are
used:
--Additional 365 days $0 100% of Medicare-eligible $0***
expenses
--Beyond the additional $0 $0 All costs
365 days
You must meet Medicare's
requirements, including having
been in a hospital for at least
3 days and entered a
Medicare-approved facility within
30 days after leaving the hospital
First 20 days All approved amounts $0 $0
21st thru 100th day All but [$167.50] a day Up to [$125.63] a day Up to [$41.88] a day♦
101st day and after $0 $0 All costs
First 3 pints $0 75% 25%♦
Additional amounts 100% $0 $0
You must meet Medicare's All but very limited 75% of 25% of
requirements, including a doctor's copayment/coinsurance copayment/coinsurance copayment/coinsurance♦
certification of terminal illness. for outpatient drugs and
inpatient respite care

*** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the
place of Medicare and will pay whatever amount Medicare would have paid for up to an additional
365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from
billing you for the balance based on any difference between its billed charges and the amount Medicare
would have paid.

**** Once you have been billed [$183] of Medicare-approved amounts for covered services (which are
noted with an asterisk), your Part B deductible will have been met for the calendar year.
HOSPITAL TREATMENT, such
as physician's services,
inpatient and outpatient
medical and surgical services
and supplies, physical and
speech therapy, diagnostic
tests, durable medical
equipment,
First [$183] of $0 $0 [$183] (Part B
Medicare-approved deductible)****♦
amounts****
Preventive benefits for Generally 75% or more of Remainder of All costs above
Medicare-covered services Medicare-approved amounts Medicare-approved amounts Medicare-approved amounts
Remainder of Generally 80% Generally 15% Generally 5%♦
Medicare-approved
amounts
Part B Excess Charges $0 $0 All costs (and they do not
(Above Medicare-approved count toward annual
amounts) out-of-pocket limit of
[$2,620])*
First 3 pints $0 75% 25%♦
Next [$183] of $0 $0 [$183] (Part B deductible)♦
Medicare-approved
amounts****
Remainder of Generally 80% Generally 15% Generally 5%♦
Medicare-approved amounts
* This plan limits your annual out-of-pocket payments for Medicare-approved amounts to [$2,620] per
year. However, this limit does NOT include charges from your provider that exceed
Medicare-approved amounts (these are called "Excess Charges") and you will be responsible
for paying this difference in the amount charged by your provider and the amount paid by
Medicare for the item or service.

--Medically necessary skilled care 100% $0 $0
services and medical supplies
--Durable medical equipment
First [$183] of Medicare-approved $0 $0 [$183] (Part B
amounts***** deductible)♦
Remainder of Medicare-approved 80% 15% 5%♦
amounts
***** Medicare benefits are subject to change. Please consult the latest Guide to Health Insurance for
People with Medicare.

* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after
you have been out of the hospital and have not received skilled care in any other facility for 60 days in
a row.
Semiprivate room and board,
general nursing and
miscellaneous services and
supplies
First 60 days All but [$1,340] [$670] (50% of Part A [$670] (50% of Part A
deductible) deductible)
61st thru 90th day All but [$335] a day [$335] a day $0
91st day and after:
--While using 60 lifetime All but [$670] a day [$670] a day $0
reserve days
--Once lifetime reserve days
are used:
--Additional 365 days $0 100% of Medicare-eligible $0**
expenses
--Beyond the additional $0 $0 All costs
365 days
You must meet Medicare's
requirements, including having
been in a hospital for at least
3 days and entered a
Medicare-approved facility within
30 days after leaving the hospital
First 20 days All approved amounts $0 $0
21st thru 100th day All but [$167.50] a day Up to [$167.50] a day $0
101st day and after $0 $0 All costs
First 3 pints $0 3 pints $0
Additional amounts 100% $0 $0
You must meet Medicare's All but very limited Medicare $0
requirements, including a doctor's copayment/coinsurance for copayment/coinsurance
certification of terminal illness. outpatient drugs and
inpatient respite care
** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place
of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days
as provided in the policy's "Core Benefits". During this time the hospital is prohibited from billing you for
the balance based on any difference between its billed charges and the amount Medicare would have
paid.

* Once you have been billed [$183] of Medicare-approved amounts for covered services (which are
noted with an asterisk), your Part B deductible will have been met for the calendar year.
HOSPITAL TREATMENT, such
as physician's services,
inpatient and outpatient
medical and surgical services
and supplies, physical and
speech therapy, diagnostic
tests, durable medical
equipment
First [$183] of $0 $0 [$183] (Part B deductible)
Medicare-approved
amounts*
Remainder of Generally 80% Generally 20% $0
Medicare-approved
amounts
Part B Excess Charges $0 $0 All costs
(Above Medicare-approved
amounts)
First 3 pints $0 All costs $0
Next [$183] of $0 $0 [$183] (Part B deductible)
Medicare-approved amounts*
Remainder of 80% 20% $0
Medicare-approved amounts

Medically necessary skilled care
services and medical supplies
--Durable medical equipment 100% $0 $0
First [$183] of Medicare-approved $0 $0 [$183] (Part B deductible)
amounts*
Remainder of Medicare-approved 80% 20% $0
amounts
Medically necessary emergency care services
beginning during the first 60 days of each trip
outside the USA
First $250 each calendar year $0 $0 $250
Remainder of charges $0 80% to a lifetime 20% and amounts over
maximum benefit of the $50,000 lifetime
$50,000 maximum

* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after
you have been out of the hospital and have not received skilled care in any other facility for 60 days in
a row.
Semiprivate room and board,
general nursing and
miscellaneous services and
supplies
First 60 days All but [$1,340] [$1,340] (Part A deductible) $0
61st thru 90th day All but [$335] a day [$335] a day $0
91st day and after:
--While using 60 lifetime All but [$670] a day [$670] a day $0
reserve days
--Once lifetime reserve days
are used:
--Additional 365 days $0 100% of Medicare-eligible $0**
expenses
--Beyond the additional $0 $0 All costs
365 days
You must meet Medicare's
requirements, including having
been in a hospital for at least
3 days and entered a
Medicare-approved facility within
30 days after leaving the hospital
First 20 days All approved amounts $0 $0
21st thru 100th day All but [$167.50] a day Up to [$167.50] a day $0
101st day and after $0 $0 All costs
First 3 pints $0 3 pints $0
Additional amounts 100% $0 $0
You must meet Medicare's All but very limited Medicare 0%
requirements, including a doctor's copayment/coinsurance for copayment/coinsurance
certification of terminal illness. outpatient drugs and
inpatient respite care
** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the
place of Medicare and will pay whatever amount Medicare would have paid for up to an additional
365 days as provided in the policy's "Core Benefits". During this time the hospital is prohibited from
billing you for the balance based on any difference between its billed charges and the amount Medicare
would have paid.

* Once you have been billed [$183] of Medicare-approved amounts for covered services (which are
noted with an asterisk), your Part B deductible will have been met for the calendar year.
HOSPITAL TREATMENT, such
as physician's services,
inpatient and outpatient
medical and surgical services
and supplies, physical and
speech therapy, diagnostic
tests, durable medical
equipment
First [$183] of $0 $0 [$183] (Part B deductible)
Medicare-approved
amounts*
Remainder of Generally 80% Balance, other than up to Up to [$20] per office visit
Medicare-approved [$20] per office visit and up to and up to [$50] per
amounts [$50] per emergency room emergency room visit. The
visit. The copayment of up to copayment of up to [$50] is
[$50] is waived if the insured waived if the insured is
is admitted to any hospital admitted to any hospital and
and the emergency visit is the emergency visit is
covered as a Medicare Part A covered as a Medicare Part A
expense. expense.
Part B Excess Charges $0 $0 All costs
(Above Medicare-approved
amounts)
First 3 pints $0 All costs $0
Next [$183] of $0 $0 [$183] (Part B deductible)
Medicare-approved amounts*
Remainder of 80% 20% $0
Medicare-approved amounts

Medically necessary skilled care
services and medical supplies
--Durable medical equipment 100% $0 $0
First [$183] of Medicare-approved $0 $0 [$183] (Part B deductible)
amounts*
Remainder of Medicare-approved 80% 20% $0
amounts
Medically necessary emergency care services
beginning during the first 60 days of each trip
outside the USA
First $250 each calendar year $0 $0 $250
Remainder of charges $0 80% to a lifetime 20% and amounts over
maximum benefit of the $50,000 lifetime
$50,000 maximum
5. Notice regarding policies or certificates that are not Medicare supplement policies.
a. Any accident and sickness insurance policy or certificate, other than a Medicare
supplement policy; a policy issued pursuant to a contract under section 1876 of the
Social Security Act [42 U.S.C. 1395 et seq.]; disability income policy; or other policy
identified in subsection 2 of section 45-06-01.1-01, issued for delivery in this state to
persons eligible for Medicare, must notify insureds under the policy that the policy is not
a Medicare supplement policy or certificate. The notice must either be printed or attached
to the first page of the outline of coverage delivered to insureds under the policy, or if no
outline of coverage is delivered, to the first page of the policy, or certificate delivered to
insureds. The notice must be in no less than twelve-point type and must contain the
following language:
CONTRACT]. If you are eligible for Medicare, review the Guide to Health Insurance for
People with Medicare available from the company."
b. Applications provided to persons eligible for Medicare for the health insurance policies for
certificates described in subdivision a must disclose, using the applicable statement in
appendix C, the extent to which the policy duplicates Medicare. The disclosure statement
must be provided as a part of, or together with, the application for the policy or certificate.

History: Effective January 1, 1992; amended effective August 1, 1992; July 1, 1994; April 1, 1996;
July 1, 1998; August 27, 1998; December 1, 2001; September 1, 2005; July 1, 2009; January 1, 2020.
General Authority: NDCC 26.1-36.1-03, 26.1-36.1-05
Law Implemented: NDCC 26.1-36.1-05
### § 45-06-01.1-15. Requirements for application forms and replacement coverage.

1. Application forms must include the following questions designed to elicit information as to
whether, as of the date of the application, the applicant currently has Medicare supplement,
Medicare advantage, Medicaid coverage, or other health insurance policy or certificate in
force or whether a Medicare supplement policy or certificate is intended to replace any other
accident and sickness policy or certificate presently in force. A supplementary application or
other form to be signed by the applicant and agent containing such questions and statements
may be used.
[Statements]
1. You do not need more than one Medicare supplement policy.
2. If you purchase this policy, you may want to evaluate your existing health coverage
and decide if you need multiple coverages.
3. You may be eligible for benefits under Medicaid and may not need a Medicare
supplement policy.
4. If, after purchasing this policy, you become eligible for Medicaid, the benefits and
premiums under your Medicare supplement policy can be suspended, if requested,
during your entitlement to benefits under Medicaid for 24 months. You must request
this suspension within 90 days of becoming eligible for Medicaid. If you are no
longer entitled to Medicaid, your suspended Medicare supplement policy (or, if that
is no longer available, a substantially equivalent policy) will be reinstituted if
requested within 90 days of losing Medicaid eligibility. If the Medicare supplement
policy provided coverage for outpatient prescription drugs and you enrolled in
Medicare Part D while your policy was suspended, the reinstituted policy will not
have outpatient prescription drug coverage, but will otherwise be substantially
equivalent to your coverage before the date of the suspension.
5. If you are eligible for, and have enrolled in a Medicare supplement policy by reason
of disability and you later become covered by an employer or union-based group
health plan, the benefits and premiums under your Medicare supplement policy can
be suspended, if requested, while you are covered under the employer or
union-based group health plan. If you suspend your Medicare supplement policy
under these circumstances, and later lose your employer or union-based group
health plan, your suspended Medicare supplement policy (or, if that is no longer
available, a substantially equivalent policy) will be reinstituted if requested within
90 days of losing your employer or union-based group health plan. If the Medicare
supplement policy provided coverage for outpatient prescription drugs and you
enrolled in Medicare Part D while your policy was suspended, the reinstituted policy
will not have outpatient prescription drug coverage, but will otherwise be
substantially equivalent to your coverage before the date of the suspension.
6. Counseling services may be available in your state to provide advice concerning
your purchase of Medicare supplement insurance and concerning medical
assistance through the state medical assistance program, including benefits as a
qualified Medicare beneficiary (QMB) and a special low-income Medicare
beneficiary (SLMB).

[Questions]
If you lost or are losing other health insurance coverage and received a notice from your prior insurer
saying you were eligible for guaranteed issue of a Medicare supplement insurance policy, or that you
had certain rights to buy such a policy, you may be guaranteed acceptance in one or more of our
Medicare supplement plans. Please include a copy of the notice from your prior insurer with your
application. PLEASE ANSWER ALL QUESTIONS.
[Please mark Yes or No below with an "X"]
To the best of your knowledge,
1. a. Did you turn age 65 in the last 6 months?
Yes _____________ No _____________
b. Did you enroll in Medicare Part B in the last 6 months?
Yes _____________ No _____________
c. If yes, what is the effective date? _____________
2. Are you covered for medical assistance through the state Medicaid program?
[NOTE TO APPLICANT: If you are participating in a "Spend-Down Program" and have not met
your "Share of Cost," please answer NO to this question.]
Yes _____________ No _____________
If yes,
a. Will Medicaid pay your premiums for this Medicare supplement policy?
Yes _____________ No _____________
b. Do you receive any benefits from Medicaid OTHER THAN payments toward your
Medicare Part B premium?
Yes _____________ No _____________
3. a. If you had coverage from any Medicare plan other than original Medicare within the past
63 days (for example, a Medicare Advantage plan, or a Medicare HMO or PPO), fill in
your start and end dates below. If you are still covered under this plan, leave "END"
blank.
b. If you are still covered under the Medicare plan, do you intend to replace your current
coverage with this new Medicare supplement policy?
Yes _____________ No _____________
c. Was this your first time in this type of Medicare plan?
Yes _____________ No _____________
d. Did you drop a Medicare supplement policy to enroll in the Medicare plan?
Yes _____________ No _____________

4. a. Do you have another Medicare supplement policy in force?
Yes _____________ No _____________
b. If so, with what company, and what plan do you have [optional for Direct Mailers]?
______________________________________
c. If so, do you intend to replace your current Medicare supplement policy with this policy?
Yes _____________ No _____________
5. Have you had coverage under any other health insurance within the past 63 days? (For
example, an employer, union, or individual plan)
Yes _____________ No _____________
a. If so, with what company and what kind of policy?
______________________________________
______________________________________
______________________________________
______________________________________
b. What are your dates of coverage under the other policy?
If you are still covered under the other policy, leave "END" blank.
2. Agents shall list any other health insurance policies they have sold to the applicant.
a. List policies sold which are still in force.
b. List policies sold in the past five years which are no longer in force.
3. In the case of a direct response issuer, a copy of the application or supplemental form, signed
by the applicant, and acknowledged by the insurer, must be returned to the applicant by the
insurer upon delivery of the policy.
4. Upon determining that a sale will involve replacement of Medicare supplement coverage, any
issuer, other than a direct response issuer, or its agent, must furnish the applicant, prior to
issuance or delivery of the Medicare supplement policy or certificate, a notice regarding
replacement of Medicare supplement coverage. One copy of the notice signed by the
applicant and the agent, except where the coverage is sold without an agent, must be
provided to the applicant and an additional signed copy must be retained by the issuer. A
direct response issuer must deliver to the applicant at the time of the issuance of the policy
the notice regarding replacement of Medicare supplement coverage.
5. The notice required by subsection 4 for an issuer must be provided in substantially the
following form in no less than twelve-point type:
[Insurance company's name and address]

According to [your application] [information you have furnished], you intend to terminate existing
Medicare supplement or Medicare Advantage insurance and replace it with a policy to be issued by
[Company Name] Insurance Company. Your new policy will provide thirty (30) days within which you
may decide without cost whether you desire to keep the policy.
You should review this new coverage carefully. Compare it with all accident and sickness coverage you
now have. If, after due consideration, you find that purchase of this Medicare supplement coverage is a
wise decision, you should terminate your present Medicare supplement or Medicare Advantage
coverage. You should evaluate the need for other accident and sickness coverage you have that may
duplicate this policy.
I have reviewed your current medical or health insurance coverage. To the best of my knowledge, this
Medicare supplement policy will not duplicate your existing Medicare supplement or, if applicable,
Medicare Advantage coverage because you intend to terminate your existing Medicare supplement
coverage or leave your Medicare Advantage plan. The replacement policy is being purchased for the
following reason (check one):
Additional benefits.
No change in benefits, but
lower premiums.
Fewer benefits and lower
premiums.
My plan has outpatient
prescription drug coverage and
I am enrolling in Part D.
Disenrollment from a Medicare
Advantage plan. Please explain
reason for disenrollment
[Optional only for Direct
Mailers].
Other. (please specify)
1. Note: If the issuer of the Medicare supplement policy being applied for does not, or is
otherwise prohibited from imposing preexisting condition limitations, please skip to
statement 2 below. Health conditions which you may presently have (preexisting
conditions) may not be immediately or fully covered under the new policy. This could
result in denial or delay of a claim for benefits under the new policy, whereas a similar
claim might have been payable under your present policy.

2. State law provides that your replacement policy or certificate may not contain new
preexisting conditions, waiting periods, elimination periods, or probationary periods. The
insurer will waive any time periods applicable to preexisting conditions, waiting periods,
elimination periods, or probationary periods in the new policy (or coverage) for similar
benefits to the extent such time was spent (depleted) under the original policy.
3. If you still wish to terminate your present policy and replace it with new coverage, be
certain to truthfully and completely answer all questions on the application concerning
your medical and health history. Failure to include all material medical information on an
application may provide a basis for the company to deny any future claims and to refund
your premium as though your policy had never been in force. After the application has
been completed and before you sign it, review it carefully to be certain that all information
has been properly recorded. [If the policy or certificate is guaranteed issue, this
paragraph need not appear.]
Do not cancel your present policy until you have received your new policy and are sure that you want to
keep it.
(Signature of Agent, Broker or Other Representative)*
[Typed Name and Address of Issuer, Agent or Broker]
(Applicant's Signature)
(Date)
*Signature not required for direct response sales.
6. Paragraphs 1 and 2 of the replacement notice (applicable to preexisting conditions) may be
deleted by an issuer if the replacement does not involve application of a new preexisting
condition limitation.
History: Effective January 1, 1992; amended effective July 1, 1994; April 1, 1996; July 8, 1997;
September 1, 2005.
General Authority: NDCC 26.1-36.1-03
Law Implemented: NDCC 26.1-36.1-02, 26.1-36.1-05
### § 45-06-01.1-16. Filing requirements for advertising.

An issuer must provide a copy of any Medicare supplement advertisement intended for use in this
state whether through written, radio, or television medium to the insurance commissioner of this state
for review or approval by the commissioner to the extent it may be required under state law.
History: Effective January 1, 1992.
General Authority: NDCC 26.1-36.1-03
Law Implemented: NDCC 26.1-36.1-07

### § 45-06-01.1-17. Standards for marketing.

1. An issuer, directly or through its producers, must:
a. Establish marketing procedures to assure that any comparison of policies by its agents or
other producers will be fair and accurate.
b. Establish marketing procedures to assure excessive insurance is not sold or issued.
c. Display prominently by type, stamp, or other appropriate means on the first page of the
policy the following:
"Notice to buyer: This policy may not cover all of your medical expenses."
d. Inquire and otherwise make every reasonable effort to identify whether a prospective
applicant or enrollee for Medicare supplement insurance already has accident and
sickness insurance and the types and amounts of any such insurance.
e. Establish auditable procedures for verifying compliance with this subsection.
2. In addition to the practices prohibited in North Dakota Century Code chapter 26.1-04, the
following acts and practices are prohibited:
a. Twisting. Knowingly making any misleading representation or incomplete or fraudulent
comparison of any insurance policies or insurers for the purpose of inducing, or tending
to induce, any person to lapse, forfeit, surrender, terminate, retain, pledge, assign,
borrow on, or convert any insurance policy or to take out a policy of insurance with
another insurer.
b. High pressure tactics. Employing any method of marketing having the effect of or tending
to induce the purchase of insurance through force, fright, threat, whether explicit or
implied, or undue pressure to purchase or recommend the purchase of insurance.
c. Cold lead advertising. Making use directly or indirectly of any method of marketing which
fails to disclose in a conspicuous manner that a purpose of the method of marketing is
solicitation of insurance and that contact will be made by an insurance agent or
insurance company.
3. The terms "Medicare supplement", "medigap", "Medicare wraparound", and words of similar
import may not be used unless the policy is issued in compliance with this chapter.
History: Effective January 1, 1992.
General Authority: NDCC 26.1-36.1-02(1)(2), 26.1-36.1-03
Law Implemented: NDCC 26.1-36.1-02
### § 45-06-01.1-18. Appropriateness of recommended purchase and excessive insurance.

1. In recommending the purchase or replacement of any Medicare supplement policy or
certificate an agent shall make reasonable efforts to determine the appropriateness of a
recommended purchase or replacement.
2. Any sale of a Medicare supplement policy or certificate that will provide an individual more
than one Medicare supplement policy or certificate is prohibited.
3. An issuer shall not issue a Medicare supplement policy or certificate to an individual enrolled
in Medicare part C unless the effective date of the coverage is after the termination date of the
individual's part C coverage.

History: Effective January 1, 1992; amended effective September 1, 2005.
General Authority: NDCC 26.1-36.1-02(1)(2), 26.1-36.1-03
Law Implemented: NDCC 26.1-36.1-02
### § 45-06-01.1-19. Reporting of multiple policies.

1. On or before March first of each year, an issuer must report the following information for every
individual resident of this state for which the issuer has in force more than one Medicare
supplement policy or certificate:
a. Policy and certificate number.
b. Date of issuance.
2. The items set forth above must be grouped by individual policyholder.
History: Effective January 1, 1992.
General Authority: NDCC 26.1-36.1-02(1)(2), 26.1-36.1-03
Law Implemented: NDCC 26.1-36.1-02
### § 45-06-01.1-20. Prohibition against preexisting conditions, waiting periods, elimination

periods, and probationary periods in replacement policies or certificates.
1. If a Medicare supplement policy or certificate replaces another Medicare supplement policy or
certificate, the replacing issuer must waive any time periods applicable to preexisting
conditions, waiting periods, elimination periods, and probationary periods in the new Medicare
supplement policy or certificate for similar benefits to the extent such time was spent under
the original policy.
2. If a Medicare supplement policy or certificate replaces another Medicare supplement policy or
certificate which has been in effect for at least six months, the replacing policy may not
provide any time period applicable to preexisting conditions, waiting periods, elimination
periods, and probationary periods for benefits similar to those contained in the original policy
or certificate.
History: Effective January 1, 1992; amended effective September 1, 2005.
General Authority: NDCC 26.1-36.1-02(1)(2), 26.1-36.1-03
Law Implemented: NDCC 26.1-36.1-02
### § 45-06-01.1-20.1. Prohibition against use of genetic information and requests for genetic

testing.
This section applies to all policies with policy years beginning on or after May 21, 2009.
1. An issuer of a Medicare supplement policy or certificate shall not:
a. Deny or condition the issuance or effectiveness of the policy or certificate, including the
imposition of any exclusion of benefits under the policy based on a preexisting condition,
on the basis of the genetic information with respect to such individual; and
b. Discriminate in the pricing of the policy or certificate, including the adjustment of premium
rates, of an individual on the basis of the genetic information with respect to such
individual.
2. Nothing in subsection a shall be construed to limit the ability of an issuer, to the extent
otherwise permitted by law, from:

a. Denying or conditioning the issuance or effectiveness of the policy or certificate or
increasing the premium for a group based on the manifestation of a disease or disorder
of an insured or applicant; or
b. Increasing the premium for any policy issued to an individual based on the manifestation
of a disease or disorder of an individual who is covered under the policy. In such case,
the manifestation of a disease or disorder in one individual cannot also be used as
genetic information about other group members and to further increase the premium for
the group.
3. An issuer of a Medicare supplement policy or certificate shall not request or require an
individual or a family member of such individual to undergo a genetic test.
4. Subsection 3 shall not be construed to preclude an issuer of a Medicare supplement policy or
certificate from obtaining and using the results of a genetic test in making a determination
regarding payment (as defined for the purposes of applying the regulations promulgated under
part C of title XI and section 264 of the Health Insurance Portability and Accountability Act of
1996, as may be revised from time to time) and consistent with subsection 1.
5. For purposes of carrying out subsection 4, an issuer of a Medicare supplement policy or
certificate may request only the minimum amount of information necessary to accomplish the
intended purpose.
6. Notwithstanding subsection 3, an issuer of a Medicare supplement policy may request, but not
require, that an individual or a family member of such individual undergo a genetic test if each
of the following conditions is met:
a. The request is made pursuant to research that complies with part 46 of title 45, Code of
Federal Regulations, or equivalent federal regulations, and any applicable state or local
law or regulations for the protection of human subjects in research.
b. The issuer clearly indicates to each individual, or in the case of a minor child, to the legal
guardian of such child, to whom the request is made that:
(1) Compliance with the request is voluntary; and
(2) Noncompliance will have no effect on enrollment status or premium or contribution
amounts.
c. No genetic information collected or acquired under this subsection shall be used for
underwriting, determination of eligibility to enroll or maintain enrollment status, premium
rates, or the issuance, renewal, or replacement of a policy or certificate.
d. The issuer notifies the secretary in writing that the issuer is conducting activities pursuant
to the exception provided for under this subsection, including a description of the
activities conducted.
e. The issuer complies with such other conditions as the secretary may by regulation
require for activities conducted under this subsection.
7. An issuer of a Medicare supplement policy or certificate shall not request, require, or purchase
genetic information for underwriting purposes.
8. An issuer of a Medicare supplement policy or certificate shall not request, require, or purchase
genetic information with respect to any individual prior to such individual's enrollment under
the policy in connection with such enrollment.

9. If an issuer of a Medicare supplement policy or certificate obtains genetic information
incidental to the requesting, requiring, or purchasing of other information concerning any
individual, such request, requirement, or purchase shall not be considered a violation of
subsection 8 if such request, requirement, or purchase is not in violation of subsection 7.
10. For the purposes of this section only:
a. "Family member" means, with respect to an individual, any other individual who is a
first-degree, second-degree, third-degree, or fourth-degree relative of such individual.
b. "Genetic information" means, with respect to any individual, information about such
individual's genetic tests, the genetic tests of family members of such individual, and the
manifestation of a disease or disorder in family members of such individual. Such term
includes, with respect to any individual, any request for, or receipt of, genetic services, or
participation in clinical research which includes genetic services, by such individual or
any family member of such individual. Any reference to genetic information concerning
an individual or family member of an individual who is a pregnant woman, includes
genetic information of any fetus carried by such pregnant woman, or with respect to an
individual or family member utilizing reproductive technology, includes genetic
information of any embryo legally held by an individual or family member. The term
"genetic information" does not include information about the sex or age of any individual.
c. "Genetic services" means a genetic test, genetic counseling (including obtaining,
interpreting, or assessing genetic information), or genetic education.
d. "Genetic test" means an analysis of human DNA, RNA, chromosomes, proteins, or
metabolites, that detect genotypes, mutations, or chromosomal changes. The term
"genetic test" does not mean an analysis of proteins or metabolites that does not detect
genotypes, mutations, or chromosomal changes; or an analysis of proteins or
metabolites that is directly related to a manifested disease, disorder, or pathological
condition that could reasonably be detected by a health care professional with
appropriate training and expertise in the field of medicine involved.
e. "Issuer of a Medicare supplement policy or certificate" includes third-party administrator,
or other person acting for or on behalf of such issuer.
f. "Underwriting purposes" means:
(1) Rules for, or determination of, eligibility (including enrollment and continued
eligibility) for benefits under the policy;
(2) The computation of premium or contribution amounts under the policy;
(3) The application of any preexisting condition exclusion under the policy; and
(4) Other activities related to the creation, renewal, or replacement of a contract of
health insurance or health benefits.
History: Effective July 1, 2009.
General Authority: NDCC 26.1-36.1-02(1)(20), 26.1-36.1-03
Law Implemented: NDCC 26.1-36.1-02
### § 45-06-01.1-21. Separability.

If any provision of this chapter or the application thereof to any person or circumstance is for any
reason held to be invalid, the remainder of the chapter and the application of such provision to other
persons or circumstances may not be affected thereby.

History: Effective January 1, 1992.
General Authority: NDCC 26.1-36.1-03
Law Implemented: NDCC 26.1-36.1
### § 45-06-01.1-22. Effective date.

Repealed effective October 1, 2019.

For the State of Company Name
NAIC Group Code NAIC Company Code
Address Person Completing Exhibit
Title Telephone Number
(a) (b)
Line Earned Premium3 Incurred Claims4
1. Current Year's Experience
a. Total (all policy years)
b. Current year's issues5
c. Net (for reporting purposes = 1a-1b)
2. Past Years' Experience (all policy years)
3. Total Experience
(Net Current Year + Past Year)
4. Refunds Last Year (Excluding Interest)
5. Previous Since Inception (Excluding Interest)
6. Refunds Since Inception (Excluding Interest)
7. Benchmark Ratio Since Inception (see worksheet for Ratio 1)
8. Experienced Ratio Since Inception (Ratio 2)
Total Actual Incurred Claims (line 3, col . b)
Total Earned Prem. (line 3, col. a) - Refunds Since Inception (line 6)
9. Life Years Exposed Since Inception
If the Experienced Ratio is less than the Benchmark Ratio, and there are more than
500 life years exposure, then proceed to calculation of refund.
10. Tolerance Permitted (obtained from credibility table)
Medicare Supplement Credibility Table
Life Years Exposed
Since Inception Tolerance
10,000+ 0.0%
5,000-9,999 5.0%

2,500-4,999 7.5%
1,000-2,499 10.0%
500-999 15.0%
If less than 500, no credibility.
______________________________
1 Individual, Group, Individual Medicare Select, or Group Medicare Select Only.
2 "SMSBP" = Standardized Medicare Supplement Benefit Plan - Use "P" for prestandardized
plans.
3 Includes Modal Loadings and Fees Charged.
4 Excludes Active Life Reserves.
5 This is to be used as "Issue Year Earned Premium" for Year 1 of next year's "Worksheet for
Calculation of Benchmark Ratios".

For the State of Company Name
NAIC Group Code NAIC Company Code
Address Person Completing Exhibit
Title Telephone Number
11. Adjustment to Incurred Claims for Credibility
Ratio 3 = Ratio 2 + Tolerance
If Ratio 3 is more than Benchmark Ratio (Ratio 1), a refund or credit to premium is not required. If
Ratio 3 is less than the Benchmark Ratio, then proceed.
12. Adjusted Incurred Claims
[Total Earned Premiums (line 3, col. a)-Refunds Since Inception (line 6)] x Ratio 3
(line 11)
13. Refund =
Total Earned Premiums (line 3, col. a)-Refunds Since Inception (line 6)-[Adjusted
Incurred Claims (line 12)/Benchmark Ratio (Ratio 1)]
If the amount on line 13 is less than .005 times the annualized premium in force as of December 31 of
the reporting year, then no refund is made. Otherwise, the amount on line 13 is to be refunded or
credited, and a description of the refund or credit against premiums to be used must be attached to this
form.
I certify that the above information and calculations are true and accurate to the best of my knowledge
and belief.
Signature
Name - Please Type
Title - Please Type
Date

For the State of Company Name
NAIC Group Code NAIC Company Code
Address Person Completing Exhibit
Title Telephone Number
(a)3 (b)4 (c) (d) (e) (f) (g) (h) (i) (j) (o)5
Earned Cumulative Cumulative Policy Year
Year Premium Factor (b)x(c) Loss Ratio (d)x(e) Factor (b)x(g) Loss Ratio (h)x(i) Loss Ratio
1 2.770 0.507 0.000 0.000 0.46
2 4.175 0.567 0.000 0.000 0.63
3 4.175 0.567 1.194 0.759 0.75
4 4.175 0.567 2.245 0.771 0.77
5 4.175 0.567 3.170 0.782 0.80
6 4.175 0.567 3.998 0.792 0.82
7 4.175 0.567 4.754 0.802 0.84
8 4.175 0.567 5.445 0.811 0.87
9 4.175 0.567 6.075 0.818 0.88
10 4.175 0.567 6.650 0.824 0.88
11 4.175 0.567 7.176 0.828 0.88

(a)3 (b)4 (c) (d) (e) (f) (g) (h) (i) (j) (o)5
Earned Cumulative Cumulative Policy Year
Year Premium Factor (b)x(c) Loss Ratio (d)x(e) Factor (b)x(g) Loss Ratio (h)x(i) Loss Ratio
12 4.175 0.567 7.655 0.831 0.88
13 4.175 0.567 8.093 0.834 0.89
14 4.175 0.567 8.493 0.837 0.89
15+6 4.175 0.567 8.684 0.838 0.89
Total: (k): (l): (m): (n):
Benchmark Ratio Since Inception: (l + n)/(k + m): __________________________
1Individual, Group, Individual Medicare Select, or Group Medicare Select Only.
2"SMSBP" = Standardized Medicare Supplement Benefit Plan - Use "P" for prestandardized plans.
3Year 1 is the current calendar year - 1. Year 2 is the current calendar year - 2 (etc.) (Example: If the current year is 1991, then: Year 1 is
1990; Year 2 is 1989, etc.).
4For the calendar year on the appropriate line in column (a), the premium earned during that year for policies issued in that year.
5These loss ratios are not explicitly used in computing the benchmark loss ratios. They are the loss ratios, on a policy year basis, which
result in the cumulative loss ratios displayed on this worksheet. They are shown here for informational purposes only.
6To include the earned premium for all years prior to as well as the 15th year prior to the current year.

For the State of Company Name
NAIC Group Code NAIC Company Code
Address Person Completing Exhibit
Title Telephone Number
(a)3 (b)4 (c) (d) (e) (f) (g) (h) (i) (j) (o)5
Earned Cumulative Cumulative Policy Year
Year Premium Factor (b)x(c) Loss Ratio (d)x(e) Factor (b)x(g) Loss Ratio (h)x(i) Loss Ratio
1 2.770 0.442 0.000 0.000 0.40
2 4.175 0.493 0.000 0.000 0.55
3 4.175 0.493 1.194 0.659 0.65
4 4.175 0.493 2.245 0.669 0.67
5 4.175 0.493 3.170 0.678 0.69
6 4.175 0.493 3.998 0.686 0.71
7 4.175 0.493 4.754 0.695 0.73
8 4.175 0.493 5.445 0.702 0.75
9 4.175 0.493 6.075 0.708 0.76
10 4.175 0.493 6.650 0.713 0.76
11 4.175 0.493 7.176 0.717 0.76

(a)3 (b)4 (c) (d) (e) (f) (g) (h) (i) (j) (o)5
Earned Cumulative Cumulative Policy Year
Year Premium Factor (b)x(c) Loss Ratio (d)x(e) Factor (b)x(g) Loss Ratio (h)x(i) Loss Ratio
12 4.175 0.493 7.655 0.720 0.77
13 4.175 0.493 8.093 0.723 0.77
14 4.175 0.493 8.493 0.725 0.77
15+6 4.175 0.493 8.684 0.725 0.77
Total: (k): (l): (m): (n):
Benchmark Ratio Since Inception: (l + n)/(k + m): __________________________
1Individual, Group, Individual Medicare Select, or Group Medicare Select Only.
2"SMSBP" = Standardized Medicare Supplement Benefit Plan - Use "P" for prestandardized plans.
3Year 1 is the current calendar year - 1. Year 2 is the current calendar year - 2 (etc.) (Example: If the current year is 1991, then: Year 1 is
1990; Year 2 is 1989, etc.).
4For the calendar year on the appropriate line in column (a), the premium earned during that year for policies issued in that year.
5These loss ratios are not explicitly used in computing the benchmark loss ratios. They are the loss ratios, on a policy year basis, which
result in the cumulative loss ratios displayed on this worksheet. They are shown here for informational purposes only.
6To include the earned premium for all years prior to as well as the 15th year prior to the current year.

Company Name:
Address:
Telephone Number:
Due March 1, annually
The purpose of this form is to report the following information on each resident of this state who has in force more than one Medicare
supplement policy or certificate. The information is to be grouped by individual policyholder.
Policy and Certificate # Date of Issuance
Signature

Name and Title (please type)
Date

Instructions for Use of the Disclosure Statements for
Health Insurance Policies Sold to Medicare Beneficiaries
That Duplicate Medicare
1. Section 1882 (d) of the federal Social Security Act [42 U.S.C. 1395ss] prohibits the sale of a health insurance policy (the term policy
includes certificate) to Medicare beneficiaries that duplicates Medicare benefits unless it will pay benefits without regard to a
beneficiary's other health coverage and it includes the prescribed disclosure statement on or together with the application for the
policy.
2. All types of health insurance policies that duplicate Medicare shall include one of the attached disclosure statements, according to
the particular policy type involved, on the application or together with the application. The disclosure statement may not vary from
the attached statements in terms of language or format (type size, type proportional spacing, bold character, line spacing, and usage
of boxes around text).
3. State and federal law prohibits insurers from selling a Medicare supplement policy to a person that already has a Medicare
supplement policy except as a replacement policy.
4. Property/casualty and life insurance policies are not considered health insurance.
5. Disability income policies are not considered to provide benefits that duplicate Medicare.
6. Long-term care insurance policies that coordinate with Medicare and other health insurance are not considered to provide benefits
that duplicate Medicare.
7. The federal law does not preempt state laws that are more stringent than the federal requirements.
8. The federal law does not preempt existing state form filing requirements.
9. Section 1882 of the federal Social Security Act was amended in Subsection (d)(3)(A) to allow for alternative disclosure statements.
The disclosure statements already in Appendix C remain. Carriers may use either disclosure statement with the requisite insurance
product. However, carriers should use either the original disclosure statements or the alternative disclosure statements and not use
both simultaneously.

[Original disclosure statement for policies that provide benefits for expenses incurred for an accidental injury only.]
This is not Medicare Supplement Insurance
This insurance provides limited benefits, if you meet the policy conditions, for hospital or medical expenses that result from accidental
injury. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.
This insurance duplicates Medicare benefits when it pays:
• hospital or medical expenses up to the maximum stated in the policy
Medicare generally pays for most or all of these expenses.
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
• hospitalization
• physician services
• [outpatient prescription drugs if you are enrolled in Medicare Part D]
• other approved items and services
Before You Buy This Insurance
√ Check the coverage in all health insurance policies you already have.
√ For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with
Medicare, available from the insurance company.
√ For help in understanding your health insurance, contact your state insurance department or state [health] insurance [assistance]
program [SHIP].

[Original disclosure statement for policies that provide benefits for specified limited services.]
This is not Medicare Supplement Insurance
This insurance provides limited benefits, if you meet the policy conditions, for expenses relating to the specific services listed in the policy. It
does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.
This insurance duplicates Medicare benefits when:
• any of the services covered by the policy are also covered by Medicare
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
• hospitalization
• physician services
• [outpatient prescription drugs if you are enrolled in Medicare Part D]
• other approved items and services
Before You Buy This Insurance
√ Check the coverage in all health insurance policies you already have.
√ For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with
Medicare, available from the insurance company.
√ For help in understanding your health insurance, contact your state insurance department or state [health] insurance [assistance]
program [SHIP].

[Original disclosure statement for policies that reimburse expenses incurred for specified diseases or other specified impairments. This
includes expense-incurred cancer, specified disease and other types of health insurance policies that limit reimbursement to named
medical conditions.]
This is not Medicare Supplement Insurance
This insurance provides limited benefits, if you meet the policy conditions, for hospital or medical expenses only when you are treated for
one of the specific diseases or health conditions listed in the policy. It does not pay your Medicare deductibles or coinsurance and is not a
substitute for Medicare Supplement insurance.
This insurance duplicates Medicare benefits when it pays:
• hospital or medical expenses up to the maximum stated in the policy
Medicare generally pays for most or all of these expenses.
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
• hospitalization
• physician services
• hospice
• [outpatient prescription drugs if you are enrolled in Medicare Part D]
• other approved items and services
Before You Buy This Insurance
√ Check the coverage in all health insurance policies you already have.
√ For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with
Medicare, available from the insurance company.
√ For help in understanding your health insurance, contact your state insurance department or state [health] insurance [assistance]
program [SHIP].

[Original disclosure statement for policies that pay fixed dollar amounts for specified diseases or other specified impairments. This includes
cancer, specified disease, and other health insurance policies that pay a scheduled benefit or specific payment based on diagnosis of the
conditions named in the policy.]
This is not Medicare Supplement Insurance
This insurance pays a fixed amount, regardless of your expenses, if you meet the policy conditions, for one of the specific diseases or
health conditions named in the policy. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare
Supplement insurance.
This insurance duplicates Medicare benefits because Medicare generally pays for most of the expenses for the diagnosis and
treatment of the specific conditions or diagnoses named in the policy.
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
• hospitalization
• physician services
• hospice
• [outpatient prescription drugs if you are enrolled in Medicare Part D]
• other approved items and services
Before You Buy This Insurance
√ Check the coverage in all health insurance policies you already have.
√ For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with
Medicare, available from the insurance company.
√ For help in understanding your health insurance, contact your state insurance department or state [health] insurance [assistance]
program [SHIP].

[Original disclosure statement for indemnity policies and other policies that pay a fixed dollar amount per day, excluding long-term care
policies.]
This is not Medicare Supplement Insurance
This insurance pays a fixed dollar amount, regardless of your expenses, for each day you meet the policy conditions. It does not pay your
Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.
This insurance duplicates Medicare benefits when:
• any expenses or services covered by the policy are also covered by Medicare
Medicare generally pays for most or all of these expenses.
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
• hospitalization
• physician services
• hospice
• [outpatient prescription drugs if you are enrolled in Medicare Part D]
• other approved items and services
Before You Buy This Insurance
√ Check the coverage in all health insurance policies you already have.
√ For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with
Medicare, available from the insurance company.
√ For help in understanding your health insurance, contact your state insurance department or state [health] insurance [assistance]
program [SHIP].

[Original disclosure statement for policies that provide benefits upon both an expense-incurred and fixed indemnity basis.]
This is not Medicare Supplement Insurance
This insurance pays limited reimbursement for expenses if you meet the conditions listed in the policy. It also pays a fixed amount,
regardless of your expenses, if you meet other policy conditions. It does not pay your Medicare deductibles or coinsurance and is not a
substitute for Medicare Supplement insurance.
This insurance duplicates Medicare benefits when:
• any expenses or services covered by the policy are also covered by Medicare; or
• it pays the fixed dollar amount stated in the policy and Medicare covers the same event
Medicare generally pays for most or all of these expenses.
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
• hospitalization
• physician services
• hospice care
• [outpatient prescription drugs if you are enrolled in Medicare Part D]
• other approved items and services
Before You Buy This Insurance
√ Check the coverage in all health insurance policies you already have.
√ For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with
Medicare, available from the insurance company.
√ For help in understanding your health insurance, contact your state insurance department or state [health] insurance [assistance]
program [SHIP].

[Original disclosure statement for other health insurance policies not specifically identified in the preceding statements.]
This is not Medicare Supplement Insurance
This insurance provides limited benefits if you meet the conditions listed in the policy. It does not pay your Medicare deductibles or
coinsurance and is not a substitute for Medicare Supplement insurance.
This insurance duplicates Medicare benefits when it pays:
• the benefits stated in the policy and coverage for the same event is provided by Medicare
Medicare generally pays for most or all of these expenses.
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
• hospitalization
• physician services
• hospice
• [outpatient prescription drugs if you are enrolled in Medicare Part D]
• other approved items and services
Before You Buy This Insurance
√ Check the coverage in all health insurance policies you already have.
√ For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with
Medicare, available from the insurance company.
√ For help in understanding your health insurance, contact your state insurance department or state [health] insurance [assistance]
program [SHIP].

[Alternative disclosure statement for policies that provide benefits for expenses incurred for an accidental injury only.]
Some health care services paid for by Medicare may also trigger the payment of benefits from this policy.
This insurance provides limited benefits, if you meet the policy conditions, for hospital or medical expenses that result from accidental
injury. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.
Medicare generally pays for most or all of these expenses.
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
• hospitalization
• physician services
• [outpatient prescription drugs if you are enrolled in Medicare Part D]
• other approved items and services
This policy must pay benefits without regard to other health benefit coverage to which you may be entitled under Medicare or
other insurance.
Before You Buy This Insurance
√ Check the coverage in all health insurance policies you already have.
√ For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with
Medicare, available from the insurance company.
√ For help in understanding your health insurance, contact your state insurance department or state [health] insurance [assistance]
program [SHIP].

[Alternative disclosure statement for policies that provide benefits for specified limited services.]
Some health care services paid for by Medicare may also trigger the payment of benefits under this policy.
This insurance provides limited benefits, if you meet the policy conditions, for expenses relating to the specific services listed in the policy. It
does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
• hospitalization
• physician services
• [outpatient prescription drugs if you are enrolled in Medicare Part D]
• other approved items and services
This policy must pay benefits without regard to other health benefit coverage to which you may be entitled under Medicare or
other insurance.
Before You Buy This Insurance
√ Check the coverage in all health insurance policies you already have.
√ For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with
Medicare, available from the insurance company.
√ For help in understanding your health insurance, contact your state insurance department or state [health] insurance [assistance]
program [SHIP].

[Alternative disclosure statement for policies that reimburse expenses incurred for specified diseases or other specified impairments. This
includes expense-incurred cancer, specified disease and other types of health insurance policies that limit reimbursement to named
medical conditions.]
Some health care services paid for by Medicare may also trigger the payment of benefits from this policy. Medicare generally
pays for most or all of these expenses.
This insurance provides limited benefits, if you meet the policy conditions, for hospital or medical expenses only when you are treated for
one of the specific diseases or health conditions listed in the policy. It does not pay your Medicare deductibles or coinsurance and is not a
substitute for Medicare Supplement insurance.
Medicare generally pays for most or all of these expenses.
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
• hospitalization
• physician services
• hospice
• [outpatient prescription drugs if you are enrolled in Medicare Part D]
• other approved items and services
This policy must pay benefits without regard to other health benefit coverage to which you may be entitled under Medicare or
other insurance.
Before You Buy This Insurance
√ Check the coverage in all health insurance policies you already have.
√ For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with
Medicare, available from the insurance company.
√ For help in understanding your health insurance, contact your state insurance department or state [health] insurance [assistance]
program [SHIP].

[Alternative disclosure statement for policies that pay fixed dollar amounts for specified diseases or other specified impairments. This
includes cancer, specified disease, and other health insurance policies that pay a scheduled benefit or specific payment based on
diagnosis of the conditions named in the policy.]
Some health care services paid for by Medicare may also trigger the payment of benefits from this policy.
This insurance pays a fixed amount, regardless of your expenses, if you meet the policy conditions, for one of the specific diseases or
health conditions named in the policy. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare
Supplement insurance.
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
• hospitalization
• physician services
• hospice
• [outpatient prescription drugs if you are enrolled in Medicare Part D]
• other approved items and services
This policy must pay benefits without regard to other health benefit coverage to which you may be entitled under Medicare or
other insurance.
Before You Buy This Insurance
√ Check the coverage in all health insurance policies you already have.
√ For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with
Medicare, available from the insurance company.
√ For help in understanding your health insurance, contact your state insurance department or state [health] insurance [assistance]
program [SHIP].

[Alternative disclosure statement for indemnity policies and other policies that pay a fixed dollar amount per day, excluding long-term care
policies.]
Some health care services paid for by Medicare may also trigger the payment of benefits from this policy.
This insurance pays a fixed dollar amount, regardless of your expenses, for each day you meet the policy conditions. It does not pay your
Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.
Medicare generally pays for most or all of these expenses.
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
• hospitalization
• physician services
• hospice
• [outpatient prescription drugs if you are enrolled in Medicare Part D]
• other approved items and services
This policy must pay benefits without regard to other health benefit coverage to which you may be entitled under Medicare or
other insurance.
Before You Buy This Insurance
√ Check the coverage in all health insurance policies you already have.
√ For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with
Medicare, available from the insurance company.
√ For help in understanding your health insurance, contact your state insurance department or state [health] insurance [assistance]
program [SHIP].

[Alternative disclosure statement for policies that provide benefits upon both an expense-incurred and fixed indemnity basis.]
Some health care services paid for by Medicare may also trigger the payment of benefits from this policy.
This insurance pays limited reimbursement for expenses if you meet the conditions listed in the policy. It also pays a fixed amount,
regardless of your expenses, if you meet other policy conditions. It does not pay your Medicare deductibles or coinsurance and is not a
substitute for Medicare Supplement insurance.
Medicare generally pays for most or all of these expenses.
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
• hospitalization
• physician services
• hospice care
• [outpatient prescription drugs if you are enrolled in Medicare Part D]
• other approved items and services
This policy must pay benefits without regard to other health benefit coverage to which you may be entitled under Medicare or
other insurance.
Before You Buy This Insurance
√ Check the coverage in all health insurance policies you already have.
√ For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with
Medicare, available from the insurance company.
√ For help in understanding your health insurance, contact your state insurance department or state [health] insurance [assistance]
program [SHIP].

[Alternative disclosure statement for other health insurance policies not specifically identified in the preceding statements.]
Some health care services paid for by Medicare may also trigger the payment of benefits from this policy.
This insurance provides limited benefits if you meet the conditions listed in the policy. It does not pay your Medicare deductibles or
coinsurance and is not a substitute for Medicare Supplement insurance.
Medicare generally pays for most or all of these expenses.
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
• hospitalization
• physician services
• hospice
• [outpatient prescription drugs if you are enrolled in Medicare Part D]
• other approved items and services
This policy must pay benefits without regard to other health benefit coverage to which you may be entitled under Medicare or
other insurance.
Before You Buy This Insurance
√ Check the coverage in all health insurance policies you already have.
√ For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with
Medicare, available from the insurance company.
√ For help in understanding your health insurance, contact your state insurance department or state [health] insurance [assistance]
program [SHIP].
