Chapter 29

22 GCA BUSINESS REGULATIONS CH. 29 MEDICAL CARE INSURANCE 1 CHAPTER 29 MEDICAL CARE INSURANCE NOTE: Medical Care Insurance (§§ 43700-43709) was enacted as Chapter VII of Title XXXIX of the Government Code. Compiler has changed sections numbers because there already exists a Chapter 7. § 29101. Definitions. § 29102. Applicability and Scope. § 29103. Standards for Policy Provisions and Author ity to Promulgate Regulations. § 29104. Loss Ratio Standards. § 29105. Disclosure Standards. § 29106. Notice of Free Examination. § 29107. Filing Requirements for Advertising. § 29108. Administrative Procedures. § 29109. Penalties. § 29110. Severability. § 29101. Definitions. (a) Applicant means: (1) In the case of an individual Medicare supplemen t policy, the person who seeks to contract for insurance benefits , and (2) In the case of a group Medicare supplement poli cy, the proposed certificate holder. (b) Certificate means, for the purposes of this Chapter, any certi ficate delivered or issued for delivery in Guam under a gr oup Medicare supplement policy. (c) Certificate Form means, the form on which the certificate is delivered or issued for delivery by the issuer.

te delivered or issued for delivery in Guam under a gr oup Medicare supplement policy. (c) Certificate Form means, the form on which the certificate is delivered or issued for delivery by the issuer. (d) Insurer includes insurance companies, fraternal benefit so cieties, health care service plans, health maintenance organ izations, and any other entity delivering or issuing for delivery in Guam M edicare supplement policies or certificates. (e) Medicare means the AHealth Insurance for the Aged Act, @ Title XVIII of the Social Security Amendments of 1965, as then constituted or later amended. COL922201722 GCA BUSINESS REGULATIONS CH. 29 MEDICAL CARE INSURANCE 2 (f) Medicare Supplement Policy means a group of individual policy of accident and sickness insurance or a subscriber con tract of hospital and medical service associations or health maintenance organizations, other than a policy issued pursuant to contract under Section 1876 or Section 1833 of the Federal Social Security Act (42 U.S.C. Section 1395 et. seq.), or an issued policy under a demonstration project authori zed pursuant to amendments to the Federal Social Security Act, whic h is advertised, marketed or designed

(42 U.S.C. Section 1395 et. seq.), or an issued policy under a demonstration project authori zed pursuant to amendments to the Federal Social Security Act, whic h is advertised, marketed or designed primarily as a supplement to r eimbursements under Medicare for the hospital, medical or surgical expe nses of persons eligible for Medicare. (g) Policy Form means the form on which the policy is delivered or issued for delivery by the issuer. SOURCE: GC § 43900; added by P.L. 21-123:1 (July 20, 1992) § 29102. Applicability and Scope. (a) Except as otherwise specifically provided in § 29104, this Chapter shall apply to: (1) all Medicare supplement policies delivered or i ssued for delivery in Guam on or after the effective date her eof, and (2) All certificates issued under group Medicare su pplement policies, which certificates have been delivered or issued for delivery in Guam. (b) This Chapter shall not apply to a policy of one (1) or more employers or labor organizations, or of the trustee s of a fund established by one (1) or more employers or labor organizations, o r combination thereof, for employees or former employees or a combination thereof, or for members or former

the trustee s of a fund established by one (1) or more employers or labor organizations, o r combination thereof, for employees or former employees or a combination thereof, or for members or former members, or a combination thereof, of the labor organization. (c) The provisions of this Chapter are not intended to prohibit or apply to insurance policies or health care benefit plans, including group conversion policies, provided to Medicare eligible persons whi ch policies are not marketed or held to be Medicare supplement policies or benefit plans. (d) Except for those offered by a fraternal benefit society, all health care insurance service plans, health insurance subs cription contracts, policies, certificates or supplement plans issued p ursuant to this Chapter shall be subject to the provisions of 22 GCA Chapter 18, Article 11, relative to health care insurance for the coverage for autis m spectrum disorder. COL922201722 GCA BUSINESS REGULATIONS CH. 29 MEDICAL CARE INSURANCE 3 SOURCE: GC § 43901; added by P.L. 21-123:1 (July 20, 1992). Subsection (d) added by P.L. 34-006:5 (May 10, 2017).

ctrum disorder. COL922201722 GCA BUSINESS REGULATIONS CH. 29 MEDICAL CARE INSURANCE 3 SOURCE: GC § 43901; added by P.L. 21-123:1 (July 20, 1992). Subsection (d) added by P.L. 34-006:5 (May 10, 2017). 2017 NOTE: Internal reference in subsection (d) altered to ref lect the change in codification. Pursuant to P.L. 34-006:7 (May 10, 2017), insurance coverage requirements shall be in effect regardless of any repeal or change in pro visions of the Affordable Care Act. § 29103. Standards for Policy Provisions and Author ity to Promulgate Regulations. (a) No Medicare supplement policy or certificate in force in Guam shall contain benefits that duplicate benefits provided b y Medicare. (b) Notwithstanding any other provision of law, a M edicare supplement policy or certificate shall not exclude or limit be nefits for loss incurred more than six (6) months from the effective date of cove rage because it involved a preexisting condition more restrictively than a con dition for which medical advice was given or treatment was recommended by or received from a physician within six (6) months before the effectiv e date of coverage.

tion more restrictively than a con dition for which medical advice was given or treatment was recommended by or received from a physician within six (6) months before the effectiv e date of coverage. (c) The Commissioner shall adopt reasonable regulat ions to establish specific standards for policy provisions of Medicar e supplement policies and certificates. Such standards shall be in addition t o and in accordance with applicable laws of Guam. No requirement of the Insu rance Code relating to minimum required policy benefits, other than the mi nimum standards contained in this Chapter, shall apply to Medicare supplement policies and certificates. The standards may cover, but not be l imited to: (1) Terms of renewability; (2) Initial and subsequent conditions of eligibilit y; (3) Non-duplication of coverage; (4) Probationary periods; (5) Benefit limitations, exceptions and reductions; (6) Elimination periods; (7) Requirements for replacement; (8) Recurrent conditions; and (9) Definitions of terms. (d) The Commissioner shall adopt reasonable regulat ions to establish COL922201722 GCA BUSINESS REGULATIONS CH.

) Requirements for replacement; (8) Recurrent conditions; and (9) Definitions of terms. (d) The Commissioner shall adopt reasonable regulat ions to establish COL922201722 GCA BUSINESS REGULATIONS CH. 29 MEDICAL CARE INSURANCE 4 minimum standards for benefits, claims payment, mar keting practices and compensation arrangements and reporting practices, for Medicare supplement policies and certificates. (e) The Commissioner may adopt from time to time su ch reasonable regulations as are necessary to conform Medicare su pplement policies and certificates to the requirements of Federal law and regulations promulgated thereunder, including but not limited to: (1) Requiring refunds or credits if the policies ar e certificates do not meet loss ratio requirements; (2) Establishing a uniform methodology for calculat ing and reporting loss ratios; (3) Assuring public access to policies, premiums an d loss ratio information of issuers of Medicare supplement insur ance. (4) Establishing a process for approving or disappr oving policy forms and certificate forms and proposed premium in creases; (5) Establishing a policy for holding public hearin gs prior to approval of premium increases; and (6)

r approving or disappr oving policy forms and certificate forms and proposed premium in creases; (5) Establishing a policy for holding public hearin gs prior to approval of premium increases; and (6) Establishing standards for Medicare Select poli cies and certificates. (f) The Commissioner may adopt reasonable regulatio ns that specify prohibited policy provisions not otherwise specific ally authorized by statute which, in the opinion of the commissioner, are unju st, unfair or unfairly discriminatory to any person insured or proposed to be insured under a Medicare supplement policy or certificate. SOURCE: GC § 43902.; added by P.L. 21-123:1 (July 20, 1992) . § 29104. Loss Ratio Standards. Medicare supplement policies shall return to policy holders benefits which are reasonable in relation to the premium cha rged. The commissioner shall issue reasonable regulations to establish min imum standards for loss ratios of Medicare supplement policies 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 in accordance with accep ted

rience, or incurred health care expenses where coverage is provided by a health maintenance organization on a service rather than reimbursement basis, and earned premiums in accordance with accep ted actuarial principles and practices. COL922201722 GCA BUSINESS REGULATIONS CH. 29 MEDICAL CARE INSURANCE 5 SOURCE: GC § 43903; added by P.L. 21-123:1 (July 20, 1992). § 29105. Disclosure Standards. (a) In order to provide for full and fair disclosur e in the sale of Medicare supplement policies, no Medicare supplemen t policy or certificate shall be delivered in Guam unless an outline of cov erage is delivered to the applicant at the time application is made. (b) The Commissioner shall prescribe the format and content of the outline of coverage required by subsection (a) of t his section. For purposes of this section, format means style, arrangements and overall appearance, including such items as the size, color and promine nce of type and arrangement of text and captions. Such outline of c overage shall include: (1) A description of the principal benefits and cov erage provided in the policy; (2) A statement of the renewal provisions, includin g any reservation by the issuer of a

of c overage shall include: (1) A description of the principal benefits and cov erage provided in the policy; (2) A statement of the renewal provisions, includin g any reservation by the issuer of a right to change prem iums; and disclosure of the existence of any automatic renewal premium i ncreases based on the policyholder =s age. (3) A statement that the outline of coverage is a s ummary of the policy issued or applied for and that the policy sh ould be consulted to determine governing contractual provisions. (c) The Commissioner may prescribe by regulation a standard form and the contents of an informational brochure for perso ns eligible for Medicare, which is intended to improve the buyer =s ability to select the most appropriate coverage and improve the buyer =s understanding of Medicare. (1) Except in the case of direct response insurance policies, the commissioner may require by regulation that the inf ormational brochure be provided to any prospective insured eligible for Medicare concurrently with delivery of the outline of covera ge. (2) With respect to direct response insurance polic ies, the commissioner may require by regulation that the pre scribed brochure be

r Medicare concurrently with delivery of the outline of covera ge. (2) With respect to direct response insurance polic ies, the commissioner may require by regulation that the pre scribed brochure be provided upon request to any prospective insured el igible for Medicare, but in no event later than the time of policy deliv ery. (d) The Commissioner may adopt regulations for capt ions or notice requirements determined to be in the public interes t and designed to inform prospective insured that particular insurance cover ages are not Medicare COL922201722 GCA BUSINESS REGULATIONS CH. 29 MEDICAL CARE INSURANCE 6 supplement coverages, for all accident and sickness insurance policies sold to persons eligible for Medicare by reason of age, other than: (1) Medicare supplement policies; (2) Disability income policies; (3) Basic, catastrophic or major medical expense po licies; or (4) Single premium, nonrenewable policies. (e) The commissioner may adopt reasonable regulatio ns to govern the full and fair disclosure of the information in conn ection with the replacement of accident and sickness policies, subscriber contr acts or certificates by persons eligible for Medicare.

o govern the full and fair disclosure of the information in conn ection with the replacement of accident and sickness policies, subscriber contr acts or certificates by persons eligible for Medicare. SOURCE: GC § 43904; added by P.L. 21-123:1 (July 20, 1992). 2017 NOTE: Subitem designations added in subsection (c) purs uant to the authority of 1 GCA § 1606. § 29106. Notice of Free Examination. Medicare supplement policies and certificates shall have a notice prominently printed on the first page of the policy or certificate or attached thereto stating in substance that the applicant sha ll have the right to return the policy or certificate within thirty (30) days o f its delivery and to have the premium refunded if, after examination of the polic y or certificate, the applicant is not satisfied for any reasons. Any ref und made pursuant to this section shall be paid directly to the applicant by the issuer in a timely manner. SOURCE: GC § 43905; added by P.L. 21-123:1 (July 20, 1992). § 29107. Filing Requirements for Advertising. Every issuer of Medicare supplement insurance polic ies or certificates in Guam shall provide a copy of any Medicare supple ment advertisement intended

. § 29107. Filing Requirements for Advertising. Every issuer of Medicare supplement insurance polic ies or certificates in Guam shall provide a copy of any Medicare supple ment advertisement intended for use in Guam whether through written, r adio, or television medium to the commissioner for review or approval b y the Commissioner to the extent it may be required under law. SOURCE: GC § 43906; added by P.L. 21-123:1 (July 20, 1992). § 29108. Administrative Procedures. Regulations adopted pursuant to '12212, Chapter 12 relating to the adoption and promulgation of rules and regulations. COL922201722 GCA BUSINESS REGULATIONS CH. 29 MEDICAL CARE INSURANCE 7 SOURCE: GC § 43907; added by P.L. 21-123:1 (July 20, 1992). § 29109. Penalties. In addition to any other applicable penalties for v iolations of the Insurance Code, the commissioner may require issuer s violating any provision of this Chapter or regulations promulgate d pursuant to this Chapter to cease marketing any Medicare supplement policy o r certificate in Guam which is related directly or indirectly to a violat ion or may require such issuer to take such actions as are necessary to com ply with the provisions of this

pplement policy o r certificate in Guam which is related directly or indirectly to a violat ion or may require such issuer to take such actions as are necessary to com ply with the provisions of this Chapter or both. SOURCE: GC § 43908; added by P.L. 21-123:1 (July 20, 1992). § 29110. Severability. If any provision of this Chapter or the application thereof to any person or circumstances is for any reason held to be inval id, the remainder of the Chapter and the application of such provision to ot her persons or circumstances shall not be affected thereby. SOURCE: GC § 43909; added by P.L. 21-123:1 (July 20, 1992). ---------- COL9222017 COL9222017