42 USC 1395 - Certification of medicare supplemental health insurance policies

1 So in original. Probably should be “subsection (l)”.

referred to as “Federal model standards”) for medicare supplemental policies to reflect the changes in law made by the Medicare Catastrophic Coverage Act of 1988, and subsection (g)(2)(A) shall be applied in a State, effective on and after the date specified in subparagraph (B), as if the reference to the Model Regulation adopted on

2 So in original. Probably should be followed by a comma.

(w), and (y).

3 So in original. Probably should be “meet”.

the requirements of this section.

4 So in original. Probably should be preceded by “the”.

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 group policy shall not result in any exclusion for preexisting conditions that would have been covered under the group policy being replaced.

5 See References in Text note below.

of the Public Health Service Act) of—

Editorial Notes

References in Text

Section 171(m) of the Social Security Act Amendments of 1994, referred to in subsecs. (d)(3)(A)(vi)(IV) and (r)(1), (2)(A), is section 171(m) of Puspan. L. 103–432, title I, Oct. 31, 1994, 108 Stat. 4452, which is set out as a note below.

Section 603(c) of the Social Security Amendments of 1983, referred to in subsec. (g)(1), is section 603(c) of Puspan. L. 98–21, title VI, Apr. 20, 1983, 97 Stat. 168, which was not classified to the Code, and was repealed by Puspan. L. 105–33, title IV, § 4803(d), Aug. 5, 1997, 111 Stat. 550, subject to transition provisions.

Section 2355 of the Deficit Reduction Act of 1984, referred to in subsec. (g)(1), is section 2355 of Puspan. L. 98–369, div. B, title III, July 18, 1984, 98 Stat. 1103, which is not classified to the Code.

Section 9412(span) of the Omnibus Budget Reconciliation Act of 1986, referred to in subsec. (g)(1), is section 9412(span) of Puspan. L. 99–509, title IX, Oct. 21, 1986, 100 Stat. 2062, which was not classified to the Code, and was repealed by Puspan. L. 105–33, title IV, § 4803(d), Aug. 5, 1997, 111 Stat. 550, subject to transition provisions.

The Medicare Catastrophic Coverage Act of 1988, referred to in subsecs. (k)(1)(A), (2)(A) and (l)(4)(A), is Puspan. L. 100–360, July 1, 1988, 102 Stat. 683. For complete classification of this Act to the Code, see Short Title of 1988 Amendment note set out under section 1305 of this title and Tables.

The Medicare Catastrophic Coverage Repeal Act of 1989, referred to in subsecs. (m)(1)(A), (2)(A) and (n)(2)(A), (5)(A), is Puspan. L. 101–234, Dec. 13, 1989, 103 Stat. 1979. For complete classification of this Act to the Code, see Short Title of 1989 Amendment note set out under section 1305 of this title and Tables.

The Omnibus Budget Reconciliation Act of 1990, referred to in subsec. (p)(1)(A)(iv), is Puspan. L. 101–508, Nov. 5, 1990, 104 Stat. 1388. For complete classification of this Act to the Code, see Tables.

Section 2701 of the Public Health Service Act, referred to in subsec. (s)(2)(D), is section 2701 of act July 1, 1944, which was classified to section 300gg of this title, was renumbered section 2704, effective for plan years beginning on or after Jan. 1, 2014, with certain exceptions, and amended, by Puspan. L. 111–148, title I, §§ 1201(2), 1563(c)(1), formerly § 1562(c)(1), title X, § 10107(span)(1), Mar. 23, 2010, 124 Stat. 154, 264, 911, and was transferred to section 300gg–3 of this title. A new section 2701 of act July 1, 1944, related to fair health insurance premiums, was added, effective for plan years beginning on or after Jan. 1, 2014, and amended, by Puspan. L. 111–148, title I, § 1201(4), title X, § 10103(a), Mar. 23, 2010, 124 Stat. 155, 892, and is classified to section 300gg of this title.

Paragraphs (2)(A), (B) and (3)(C)–(E) of section 1395u(span) of this title, referred to in subsec. (t)(3), were repealed by Puspan. L. 108–173, title IX, § 911(c)(3)(B)(i), (C)(iv), Dec. 8, 2003, 117 Stat. 2384.

The Medicare Prescription Drug, Improvement, and Modernization Act of 2003, referred to in subsec. (w)(1), is Puspan. L. 108–173, Dec. 8, 2003, 117 Stat. 2066. For complete classification of this Act to the Code, see Short Title of 2003 Amendment note set out under section 1305 of this title and Tables.

Section 264 of the Health Insurance Portability and Accountability Act of 1996, referred to in subsec. (x)(1)(C)(i), is section 264 of Puspan. L. 104–191, which is set out as a note under section 1320d–2 of this title.

Amendments

2015—Subsec. (z). Puspan. L. 114–10 added subsec. (z).

2010—Subsec. (o)(1). Puspan. L. 111–148, § 3210(span), substituted “(w), and (y)” for “, and (w)”.

Subsec. (y). Puspan. L. 111–148, § 3210(a), added subsec. (y).

2008—Subsec. (o)(4). Puspan. L. 110–233, § 104(span)(3), added par. (4).

Subsec. (o)(5). Puspan. L. 110–275 added par. (5).

Subsec. (s)(2)(E), (F). Puspan. L. 110–233, § 104(a), added subpars. (E) and (F).

Subsec. (x). Puspan. L. 110–233, § 104(span)(1), added subsec. (x).

Subsec. (x)(4). Puspan. L. 110–233, § 104(span)(2), added par. (4).

2007—Subsec. (r)(5). Puspan. L. 110–161 substituted “The Secretary may” for “(A) The Comptroller General shall periodically, not less often than once every 3 years,” and struck out “and to the Secretary” after “State involved” and subpar. (B) which read as follows: “The Secretary may independently perform such compliance audits.”

2003—Subsec. (d)(3)(A)(i)(II). Puspan. L. 108–173, § 736(e)(1), substituted “plan, a medicare supplemental policy” for “plan a medicare supplemental policy”.

Subsec. (d)(3)(B)(iii)(II). Puspan. L. 108–173, § 736(e)(2), substituted “to the best of the issuer’s or seller’s knowledge” for “to the best of the issuer or seller’s knowledge”.

Subsec. (g)(1). Puspan. L. 108–173, § 104(span)(2)(A), inserted “a prescription drug plan under part D or” after “but does not include”.

Subsec. (g)(2)(A). Puspan. L. 108–173, § 736(e)(3), substituted “medicare supplemental policies” for “medicare supplement policies”.

Subsec. (o)(1). Puspan. L. 108–173, § 104(span)(2)(B), substituted “subsections (p), (v), and (w)” for “subsection (p)”.

Subsec. (p)(2)(B). Puspan. L. 108–173, § 736(e)(4), substituted “; and” for “, and” at end.

Subsec. (s)(3)(A)(iii). Puspan. L. 108–173, § 736(e)(5), substituted “preexisting” for “pre-existing”.

Subsec. (s)(3)(C)(ii). Puspan. L. 108–173, § 104(a)(2)(A), designated existing provisions as subcl. (I), substituted “Subject to subclause (II), only” for “Only”, and added subcl. (II).

Subsec. (s)(3)(C)(iii). Puspan. L. 108–173, § 104(a)(2)(B), inserted “and subject to subsection (v)(1)” after “subparagraph (B)(vi)”.

Subsec. (v). Puspan. L. 108–173, § 104(a)(1), added subsec. (v).

Subsec. (w). Puspan. L. 108–173, § 104(span)(1), added subsec. (w).

2000—Subsec. (s)(3)(A). Puspan. L. 106–554, § 1(a)(6) [title VI, § 618(a)(1)], in concluding provisions, substituted “seeks to enroll under the policy during the period specified in subparagraph (E)” for “, subject to subparagraph (E), seeks to enroll under the policy not later than 63 days after the date of the termination of enrollment described in such subparagraph”.

Subsec. (s)(3)(E). Puspan. L. 106–554, § 1(a)(6) [title VI, § 618(a)(2)], added subpar. (E) and struck out former subpar. (E) which read as follows:

“(E)(i) An individual described in subparagraph (B)(ii) may elect to apply subparagraph (A) by substituting, for the date of termination of enrollment, the date on which the individual was notified by the Medicare+Choice organization of the impending termination or discontinuance of the Medicare+Choice plan it offers in the area in which the individual resides, but only if the individual disenrolls from the plan as a result of such notification.

“(ii) In the case of an individual making such an election, the issuer involved shall accept the application of the individual submitted before the date of termination of enrollment, but the coverage under subparagraph (A) shall only become effective upon termination of coverage under the Medicare+Choice plan involved.”

Subsec. (s)(3)(F). Puspan. L. 106–554, § 1(a)(6) [title VI, § 618(span)], added subpar. (F).

1999—Subsec. (g)(1). Puspan. L. 106–113, § 1000(a)(6) [title III, § 321(k)(13)], struck out “or” after “; but does not include”.

Subsec. (q)(5)(C). Puspan. L. 106–170, § 205(a)(1), inserted “or paragraph (6)” after “this paragraph”.

Subsec. (q)(6). Puspan. L. 106–170, § 205(a)(2), added par. (6).

Subsec. (s)(2)(D). Puspan. L. 106–113, § 1000(a)(6) [title III, § 321(k)(14)], inserted “section” after “(as defined in” in introductory provisions.

Subsec. (s)(3)(A). Puspan. L. 106–113, § 1000(a)(6) [title V, § 501(a)(2)(A)], inserted “, subject to subparagraph (E),” after “in the case of an individual described in subparagraph (B) who” in concluding provisions.

Subsec. (s)(3)(B)(ii). Puspan. L. 106–113, § 1000(a)(6) [title V, § 536(a)(1)], inserted before period at end “or the individual is 65 years of age or older and is enrolled with a PACE provider under section 1395eee of this title, and there are circumstances that would permit the discontinuance of the individual’s enrollment with such provider under circumstances that are similar to the circumstances that would permit discontinuance of the individual’s election under the first sentence of such section if such individual were enrolled in a Medicare+Choice plan”.

Subsec. (s)(3)(B)(v)(II). Puspan. L. 106–113, § 1000(a)(6) [title V, § 536(a)(2)], inserted “any PACE provider under section 1395eee of this title,” after “demonstration project authority,”.

Subsec. (s)(3)(B)(vi). Puspan. L. 106–113, § 1000(a)(6) [title V, § 536(a)(3)], inserted “or in a PACE program under section 1395eee of this title” after “part C” and substituted “such plan or such program” for “such plan”.

Subsec. (s)(3)(E). Puspan. L. 106–113, § 1000(a)(6) [title V, § 501(a)(2)(B)], added subpar. (E).

1998—Subsec. (l)(6). Puspan. L. 105–362 struck out par. (6) which read as follows: “The Secretary shall report to the Congress in March 1989 and in July 1990 on actions States have taken in adopting standards equal to or more stringent than the NAIC Model Transition Regulation or the amended NAIC Model Regulation (or Federal model standards).”

1997—Subsec. (d)(3)(A)(i). Puspan. L. 105–33, § 4003(a)(1)(A), inserted “(including an individual electing a Medicare+Choice plan under section 1395w–21 of this title)” after “part B of this subchapter” in introductory provisions.

Subsec. (d)(3)(A)(i)(II). Puspan. L. 105–33, § 4003(a)(1)(B), inserted “in the case of an individual not electing a Medicare+Choice plan” after “(II)” and inserted “or in the case of an individual electing a Medicare+Choice plan, a medicare supplemental policy with knowledge that the policy duplicates health benefits to which the individual is otherwise entitled under the Medicare+ÐChoice plan or under another medicare supplemental policy” before comma at end.

Subsec. (d)(3)(A)(vi)(III). Puspan. L. 105–33, § 4031(c), inserted “, a policy described in clause (v),” after “Medicare supplemental policy”.

Subsec. (d)(3)(B)(i)(I). Puspan. L. 105–33, § 4003(a)(2), inserted “(including any Medicare+Choice plan)” after “health insurance policies”.

Subsec. (g)(1). Puspan. L. 105–33, § 4003(a)(3), inserted “or a Medicare+Choice plan or” after “does not include” the first place appearing.

Puspan. L. 105–33, § 4002(j)(2), struck out “, during the period beginning on the date specified in subsection (p)(1)(C) of this section and ending on December 31, 1995,” after “Omnibus Budget Reconciliation Act of 1986, or”.

Subsec. (p)(2)(C). Puspan. L. 105–33, § 4032(a)(1), inserted before period at end “plus the 2 plans described in paragraph (11)(A)”.

Subsec. (p)(11). Puspan. L. 105–33, § 4032(a)(2), added par. (11).

Subsec. (s)(2)(B). Puspan. L. 105–33, § 4031(span)(1), substituted “subparagraphs (C) and (D)” for “subparagraph (C)”.

Subsec. (s)(2)(D). Puspan. L. 105–33, § 4031(span)(2), added subpar. (D).

Subsec. (s)(3). Puspan. L. 105–33, § 4031(a)(3), added par. (3). Former par. (3) redesignated (4).

Puspan. L. 105–33, § 4031(a)(1), (2), substituted “requirements of this subsection” for “requirements of paragraphs (1) and (2)” and redesignated par. (3) as (4).

Subsec. (s)(4). Puspan. L. 105–33, § 4031(a)(2), redesignated par. (3) as (4).

Subsec. (u). Puspan. L. 105–33, § 4003(span), added subsec. (u).

1996—Subsec. (d)(3)(A)(iii). Puspan. L. 104–191, § 271(a)(1), substituted “clause (i)(II)” for “clause (i)”.

Subsec. (d)(3)(A)(iv) to (viii). Puspan. L. 104–191, § 271(a)(2), added cls. (iv) to (viii).

Subsec. (d)(3)(C). Puspan. L. 104–191, § 271(span)(1), substituted “with respect to” for “with respect to (i)” and struck out before period at end “, (ii) the sale or issuance of a policy or plan described in subparagraph (A)(i)(I) (other than a medicare supplemental policy to an individual entitled to any medical assistance under subchapter XIX of this chapter) under which all the benefits are fully payable directly to or on behalf of the individual without regard to other health benefit coverage of the individual but only if (for policies sold or issued more than 60 days after the date the statements are published or promulgated under subparagraph (D)) there is disclosed in a prominent manner as part of (or together with) the application the applicable statement (specified under subparagraph (D)) of the extent to which benefits payable under the policy or plan duplicate benefits under this subchapter, or (iii) the sale or issuance of a policy or plan described in subparagraph (A)(i)(III) under which all the benefits are fully payable directly to or on behalf of the individual without regard to other health benefit coverage of the individual”.

Subsec. (d)(3)(D). Puspan. L. 104–191, § 271(span)(2), struck out subpar. (D) which provided for development of statements for various types of health insurance policies sold or issued to persons entitled to health benefits under this subchapter regarding extent to which benefits payable under those policies duplicate benefits under this subchapter.

1994—Subsec. (a)(2). Puspan. L. 103–432, § 171(c)(1)(B), in closing provisions substituted “on and after the effective date specified in subsection (p)(1)(C)” for “after the effective date of the NAIC or Federal standards with respect to the policy”.

Subsec. (a)(2)(A). Puspan. L. 103–432, § 171(c)(1)(A), substituted “1991 NAIC Model Regulation or 1991 Federal Regulation” for “NAIC standards or the Federal standards”.

Subsec. (span)(1). Puspan. L. 103–432, § 171(e)(2), substituted “subparagraph (F)” for “subsection (F)” in last sentence.

Puspan. L. 103–432, § 171(c)(4), substituted “the Secretary determines” for “the the Secretary determines” in introductory provisions.

Puspan. L. 103–432, § 171(c)(2), in last sentence substituted “Each report” for “The report”, “fail to meet the standards and requirements” for “fail to meet the standards”, “compliance, information regarding” for “compliance, and information regarding”, and “Commissioners may specify” for “Commissioners, may specify”.

Subsecs. (span)(1)(B), (c)(5). Puspan. L. 103–432, § 171(a)(1), made technical amendment to Puspan. L. 101–508, § 4351. See 1990 Amendment notes below.

Subsec. (d)(3)(A). Puspan. L. 103–432, § 171(d)(1)(D), struck out at end “This subsection shall not apply to such a seller until such date as the Secretary publishes a list of the standardized benefit packages that may be offered consistent with subsection (p) of this section.”

Puspan. L. 103–432, § 171(d)(1)(C), designated third sentence as cl. (iii), substituted “clause (i) with respect to the sale of a medicare supplemental policy” for “the previous sentence”, and struck out “and the statement under such subparagraph indicates on its face that the sale of the policy will not duplicate health benefits to which the individual is otherwise entitled” after “compliance with subparagraph (B)”.

Puspan. L. 103–432, § 171(d)(1)(B), designated second sentence as cl. (ii) and substituted “Whoever violates clause (i)” for “Whoever violates the previous sentence”.

Puspan. L. 103–432, § 171(d)(1)(A), designated first sentence as cl. (i) and amended it generally. Prior to amendment, first sentence read as follows: “It is unlawful for a person to sell or issue a health insurance policy to an individual entitled to benefits under part A of this subchapter or enrolled under part B of this subchapter, with knowledge that such policy duplicates health benefits to which such individual is otherwise entitled, other than benefits to which he is entitled under a requirement of State or Federal law (other than this subchapter or subchapter XIX of this chapter).”

Subsec. (d)(3)(B)(ii)(II). Puspan. L. 103–432, § 171(d)(2)(A), struck out “65 years of age or older” before “may be eligible”.

Subsec. (d)(3)(B)(iii)(I). Puspan. L. 103–432, § 171(d)(2)(B), (C), substituted “has a medicare supplemental policy” for “has another medicare supplemental policy” and “sale of a medicare supplemental policy” for “sale of such a policy”.

Subsec. (d)(3)(B)(iii)(II). Puspan. L. 103–432, § 171(d)(2)(D), substituted “has a medicare supplemental policy” for “has another policy”.

Subsec. (d)(3)(B)(iii)(III). Puspan. L. 103–432, § 171(d)(2)(E), amended subcl. (III) generally. Prior to amendment, subcl. (III) read as follows: “Subclause (I) also shall not apply if a State medicaid plan under subchapter XIX of this chapter pays the premiums for the policy, or pays less than an individual’s (who is described in section 1396d(p)(1) of this title) full liability for medicare cost sharing as defined in section 1396d(p)(3)(A) of this title.”

Subsec. (d)(3)(C). Puspan. L. 103–432, § 171(d)(3)(A), substituted “(i) the sale or issuance of a group policy” for “the selling of a group policy” and added cls. (ii) and (iii).

Subsec. (d)(3)(D). Puspan. L. 103–432, § 171(d)(3)(B), added subpar. (D).

Subsec. (d)(4)(D). Puspan. L. 103–432, § 171(k)(1), struck out before period at end “, if such policy expires not more than 12 months after the date on which the duplicate copy is mailed”.

Subsec. (d)(4)(E). Puspan. L. 103–432, § 171(k)(2), added subpar. (E).

Subsec. (f)(3). Puspan. L. 103–432, § 171(j)(2), added par. (3).

Subsec. (g)(1). Puspan. L. 103–432, § 171(f)(1), substituted “an eligible organization (as defined in section 1395mm(span) of this title) if the policy or plan provides benefits pursuant to a contract under section 1395mm of this title or an approved demonstration project described in section 603(c) of the Social Security Amendments of 1983, section 2355 of the Deficit Reduction Act of 1984, or section 9412(span) of the Omnibus Budget Reconciliation Act of 1986, or, during the period beginning on the date specified in subsection (p)(1)(C) of this section and ending on December 31, 1995, a policy or plan of an organization if the policy or plan provides benefits pursuant to an agreement under section 1395l(a)(1)(A) of this title” for “a health maintenance organization or other direct service organization which offers benefits under this subchapter, including such services under a contract under under section 1395mm of this title or an agreement under section 1395l of this title.”

Subsec. (g)(2)(B). Puspan. L. 103–432, § 171(c)(3), substituted “Secretary” for “Panel”.

Subsec. (o). Puspan. L. 103–432, § 171(a)(1), made technical amendment to Puspan. L. 101–508, § 4351. See 1990 Amendment note below.

Subsec. (p). Puspan. L. 103–432, § 171(a)(1), made technical amendment to Puspan. L. 101–508, § 4351. See 1990 Amendment note below.

Subsec. (p)(1)(A). Puspan. L. 103–432, § 171(a)(2)(A), in introductory provisions, substituted “changes the revised NAIC Model Regulation (described in subsection (m)) to incorporate” for “promulgates”, and in closing provisions, struck out “(such limitations, language, definitions, format, and standards referred to collectively in this subsection as ‘NAIC standards’),” before “subsection (g)(2)(A)” and substituted “were a reference to the revised NAIC Model Regulation as changed under this subparagraph (such changed regulation referred to in this section as the ‘1991 NAIC Model Regulation’)” for “included a reference to the NAIC standards”.

Subsec. (p)(1)(B). Puspan. L. 103–432, § 171(a)(2)(B), substituted “make the changes in the revised NAIC Model Regulation” for “promulgate NAIC standards”, “a regulation” for “limitations, language, definitions, format, and standards described in clauses (i) through (iv) of such subparagraph (in this subsection referred to collectively as ‘Federal standards’)”, and “were a reference to the revised NAIC Model Regulation as changed by the Secretary under this subparagraph (such changed regulation referred to in this section as the ‘1991 Federal Regulation’)” for “included a reference to the Federal standards”.

Subsec. (p)(1)(C)(i). Puspan. L. 103–432, § 171(a)(2)(C), substituted “1991 NAIC Model Regulation or 1991 Federal Regulation” for “NAIC standards or the Federal standards”.

Subsec. (p)(1)(C)(ii)(I), (E). Puspan. L. 103–432, § 171(a)(2)(D), substituted “1991 NAIC Model Regulation or 1991 Federal Regulation” for “NAIC or Federal standards”.

Subsec. (p)(2). Puspan. L. 103–432, § 171(a)(2)(D), substituted “1991 NAIC Model Regulation or 1991 Federal Regulation” for “NAIC or Federal standards” in introductory provisions.

Subsec. (p)(2)(C). Puspan. L. 103–432, § 171(a)(2)(E), substituted “paragraph (4)(B)” for “paragraph (5)(B)”.

Subsec. (p)(4). Puspan. L. 103–432, § 171(a)(2)(G), substituted “applicable 1991 NAIC Model Regulation or 1991 Federal Regulation” for “applicable standards” wherever appearing.

Subsec. (p)(4)(A)(i). Puspan. L. 103–432, § 171(a)(2)(F), inserted “or paragraph (6)” after “subparagraph (B)”.

Subsec. (p)(6). Puspan. L. 103–432, § 171(a)(2)(H), substituted “described in clauses (i) through (iii) of paragraph (1)(A)” for “in regard to the limitation of benefits described in paragraph (4)”.

Subsec. (p)(7). Puspan. L. 103–432, § 171(a)(2)(I), substituted “policyholders” for “policyholder”.

Subsec. (p)(8). Puspan. L. 103–432, § 171(a)(2)(J), substituted “on and after the effective date specified in paragraph (1)(C) (but subject to paragraph (10)), in violation of the applicable 1991 NAIC Model Regulation or 1991 Federal Regulation insofar as such regulation relates to the requirements of subsection (o) or (q) or clause (i), (ii), or (iii) of paragraph (1)(A)” for “after the effective date of the NAIC or Federal standards with respect to the policy, in violation of the previous requirements of this subsection”.

Subsec. (p)(9)(B). Puspan. L. 103–432, § 171(a)(2)(D), substituted “1991 NAIC Model Regulation or 1991 Federal Regulation” for “NAIC or Federal standards”.

Subsec. (p)(9)(D). Puspan. L. 103–432, § 171(a)(2)(K), added subpar. (D).

Subsec. (p)(10). Puspan. L. 103–432, § 171(a)(2)(L), substituted “consistent with paragraph (1)(A)(i)” for “consistent with this subsection”.

Subsec. (q)(2). Puspan. L. 103–432, § 171(span)(1), substituted “paragraph (4)” for “paragraph (2)”.

Subsec. (q)(4). Puspan. L. 103–432, § 171(span)(2), substituted “issuer of the replacement policy” for “the succeeding issuer”.

Subsec. (q)(5)(A), (B). Puspan. L. 103–432, § 171(d)(4), made technical amendment to the reference to subchapter XIX of this chapter to correct reference to corresponding provision of original act.

Subsec. (r)(1). Puspan. L. 103–432, § 171(e)(1)(A), (E), in introductory provisions substituted “or renewed (or otherwise provide coverage after the date described in subsection (p)(1)(C))” for “or sold” and inserted at end of closing provisions “For the purpose of calculating the refund or credit required under paragraph (1)(B) for a policy issued before the date specified in subsection (p)(1)(C), the refund or credit calculation shall be based on the aggregate benefits provided and premiums collected under all such policies issued by an insurer in a State (separated as to individual and group policies) and shall be based only on aggregate benefits provided and premiums collected under such policies after the date specified in section 171(m)(4) of the Social Security Act Amendments of 1994.”

Subsec. (r)(1)(A). Puspan. L. 103–432, § 171(e)(1)(C), substituted “Commissioners)” for “Commissioners,”.

Puspan. L. 103–432, § 171(e)(1)(B), inserted “for periods after the effective date of these provisions” after “the policy can be expected”.

Subsec. (r)(1)(B). Puspan. L. 103–432, § 171(e)(1)(D), inserted before period at end “, treating policies of the same type as a single policy for each standard package”.

Subsec. (r)(2)(A). Puspan. L. 103–432, § 171(e)(1)(F)–(I), substituted “by standard package” for “by policy number” in first sentence and “until 12 months following issue” for “with respect to the first 2 years in which it is in effect” in second sentence, struck out “in order to apply paragraph (1)(B) to the first 2 years in which policies are effective” after “may be appropriate” in third sentence, and inserted at end “In the case of a policy issued before the date specified in subsection (p)(1)(C), paragraph (1)(B) shall not apply until 1 year after the date specified in section 171(m)(4) of the Social Security Act Amendments of 1994.”

Subsec. (r)(2)(C), (D). Puspan. L. 103–432, § 171(e)(1)(J), substituted “calendar year” for “policy year” wherever appearing.

Subsec. (r)(4). Puspan. L. 103–432, § 171(e)(1)(K), substituted “October” for “February”, “disallowance” for “disllowance”, “loss ratios” for “loss-ratios” in two places, and “loss ratio” for “loss-ratio”.

Subsec. (r)(6)(A). Puspan. L. 103–432, § 171(e)(1)(L), substituted “fails to provide refunds or credits as required in paragraph (1)(B)” for “issues a policy in violation of the loss ratio requirements of this subsection” and “policy issued for which such failure occurred” for “such violation”.

Subsec. (r)(6)(B). Puspan. L. 103–432, § 171(e)(1)(M), substituted “to the policyholder or, in the case of a group policy, to the certificate holder” for “to policyholders”.

Subsec. (s)(2)(A). Puspan. L. 103–432, § 171(g)(1), (2), substituted “in the case of an individual for whom an application is submitted prior to or” for “for which an application is submitted” and “as of the first day on which the individual is 65 years of age or older and is enrolled for benefits under part B” for “in which the individual (who is 65 years of age or older) first is enrolled for benefits under part B”.

Subsec. (s)(2)(B). Puspan. L. 103–432, § 171(g)(3), substituted “before the policy became effective” for “before it became effective”.

Subsec. (t)(1). Puspan. L. 103–432, § 171(h)(1)(A), (B), substituted “If a medicare supplemental policy meets the 1991 NAIC Model Regulation or 1991 Federal Regulation” for “If a policy meets the NAIC Model Standards”.

Subsec. (t)(1)(A). Puspan. L. 103–432, § 171(h)(1)(C), inserted “or agreements” after “contracts”.

Subsec. (t)(1)(E)(i), (F). Puspan. L. 103–432, § 171(h)(1)(D), substituted “standards in the 1991 NAIC Model Regulation or 1991 Federal Regulation” for “NAIC standards”.

Subsec. (t)(2). Puspan. L. 103–432, § 171(h)(1)(E), inserted “the issuer” before “is subject to a civil money penalty” in concluding provisions.

1990—Puspan. L. 101–508, § 4353(a)(1), struck out “Voluntary” at beginning of section catchline.

Subsec. (a). Puspan. L. 101–508, § 4353(a)(2), designated existing provisions as par. (1) and added par. (2).

Puspan. L. 101–508, § 4207(k)(1), formerly § 4027(k)(1), as renumbered by Puspan. L. 103–432, § 160(d)(4), struck out “(k)(4),” after “subsections (k)(3),” in third sentence.

Subsec. (span)(1). Puspan. L. 101–508, § 4353(c)(5), inserted at end “The report required under subsection (F) shall include information on loss ratios of policies sold in the State, frequency and types of instances in which policies approved by the State fail to meet the standards of this paragraph, actions taken by the State to bring such policies into compliance, and information regarding State programs implementing consumer protection provisions, and such further information as the Secretary in consultation with the National Association of Insurance Commissioners, may specify.”

Puspan. L. 101–508, § 4353(span)(1), (2), substituted “the Secretary” for “Supplemental Health Insurance Panel (established under paragraph (2))” in introductory provisions and for “the Panel” in concluding provisions.

Puspan. L. 101–508, § 4207(k)(1), formerly § 4027(k)(1), as renumbered by Puspan. L. 103–432, § 160(d)(4), which directed the amendment of third sentence of par. (1) by striking out “(k)(4),” was executed by making the deletion after “subsections (k)(3),” in concluding provisions to reflect the probable intent of Congress.

Subsec. (span)(1)(A). Puspan. L. 101–508, § 4358(span)(2)(A), inserted before semicolon at end “, except as otherwise provided by subparagraph (H)”.

Puspan. L. 101–508, § 4353(span)(3), inserted “and enforcement” after “application”.

Subsec. (span)(1)(B). Puspan. L. 101–508, § 4351(1), formerly § 4351(a)(1), as renumbered and amended by Puspan. L. 103–432, § 171(a)(1), substituted “through (5)” for “through (4)”.

Subsec. (span)(1)(C). Puspan. L. 101–508, § 4355(span), substituted for semicolon at end “, and that a copy of each such policy, the most recent premium for each such policy, and a listing of the ratio of benefits provided to premiums collected for the most recent 3-year period for each such policy issued or sold in the State is maintained and made available to interested persons;”.

Subsec. (span)(1)(D). Puspan. L. 101–508, § 4353(span)(3), inserted “and enforcement” after “application”.

Subsec. (span)(1)(F). Puspan. L. 101–508, § 4353(c)(1)–(3), added subpar. (F).

Subsec. (span)(1)(G). Puspan. L. 101–508, § 4355(c), which directed amendment of par. (1) by adding at the end thereof a new subpar. (G), was executed by adding the new subpar. (G) immediately after subpar. (F) to reflect the probable intent of Congress.

Subsec. (span)(1)(H). Puspan. L. 101–508, § 4358(span)(2)(B)–(D), added subpar. (H).

Subsec. (span)(2). Puspan. L. 101–508, § 4353(span)(4), amended par. (2) generally. Prior to amendment, par. (2) read as follows:

“(A) There is hereby established a panel (hereinafter in this section referred to as the ‘Panel’) to be known as the Supplemental Health Insurance Panel. The Panel shall consist of the Secretary, who shall serve as the Chairman, and four State commissioners or superintendents of insurance, who shall be appointed by the Secretary and serve at his pleasure. Such members shall first be appointed not later than December 31, 1980.

“(B) A majority of the members of the Panel shall constitute a quorum, but a lesser number may conduct hearings.

“(C) The Secretary shall provide such technical, secretarial, clerical, and other assistance as the Panel may require.

“(D) There are authorized to be appropriated such sums as may be necessary to carry out this paragraph.

“(E) Members of the Panel shall be allowed, while away from their homes or regular places of business in the performance of services for the Panel, travel expenses (including per diem in lieu of subsistence) in the same manner as persons employed intermittently in the Government service are allowed expenses under section 5703 of title 5.”

Subsec. (c). Puspan. L. 101–508, § 4357(a)(1), inserted “or the requirement described in subsection (s)” after “paragraph (3)” in introductory provisions.

Puspan. L. 101–508, § 4355(a)(2), struck out at end “For purposes of paragraph (2), policies issued as a result of solicitations of individuals through the mails or by mass media advertising (including both print and broadcast advertising) shall be deemed to be individual policies.”

Subsec. (c)(1). Puspan. L. 101–508, § 4358(span)(1), inserted before semicolon at end “(except as otherwise provided by subsection (t))”.

Subsec. (c)(2). Puspan. L. 101–508, § 4355(a)(1), amended par. (2) generally. Prior to amendment, par. (2) read as follows: “can be expected (as estimated for the entire period for which rates are computed to provide coverage, on the basis of incurred claims experience and earned premiums for such period and in accordance with accepted actuarial principles and practices) to return to policyholders in the form of aggregate benefits provided under the policy, at least 75 percent of the aggregate amount of premiums collected in the case of group policies and at least 60 percent of the aggregate amount of premiums collected in the case of individual policies;”.

Subsec. (c)(5). Puspan. L. 101–508, § 4351(2), formerly § 4351(a)(2), as renumbered and amended by Puspan. L. 103–432, § 171(a)(1), added par. (5).

Subsec. (d)(3)(A). Puspan. L. 101–508, § 4354(a)(1), substituted “It is unlawful for a person to sell or issue” for “Whoever knowingly sells”, “duplicates health benefits” for “substantially duplicates health benefits”, “. Whoever violates the previous sentence shall be fined” for “, shall be fined”, “(other than this subchapter or subchapter XIX of this chapter)” for “(other than this subchapter)”, and “$25,000 (or $15,000 in the case of a person other than the issuer of the policy)” for “$5,000” and inserted at end “A seller (who is not the issuer of a health insurance policy) shall not be considered to violate the previous sentence if the policy is sold in compliance with subparagraph (B) and the statement under such subparagraph indicates on its face that the sale of the policy will not duplicate health benefits to which the individual is otherwise entitled. This subsection shall not apply to such a seller until such date as the Secretary publishes a list of the standardized benefit packages that may be offered consistent with subsection (p) of this section.”

Subsec. (d)(3)(B). Puspan. L. 101–508, § 4354(a)(2), amended subpar. (B) generally. Prior to amendment, subpar. (B) read as follows: “For purposes of this paragraph, benefits which are payable to or on behalf of an individual without regard to other health benefit coverage of such individual, shall not be considered as duplicative.”

Subsec. (d)(4)(B). Puspan. L. 101–508, § 4353(d)(1), struck out at end “For purposes of this paragraph, a medicare supplemental policy shall be deemed to be approved by the commissioner or superintendent of insurance of a State if—

“(i) the policy has been certified by the Secretary pursuant to subsection (c) of this section or was issued in a State with an approved regulatory program (as defined in subsection (g)(2)(B) of this section);

“(ii) the policy has been approved by the commissioners or superintendents of insurance in States in which more than 30 percent of such policies are sold; or

“(iii) the State has in effect a law which the commissioner or superintendent of insurance of the State has determined gives him the authority to review, and to approve, or effectively bar from sale in the State, such policy;

except that such a policy shall not be deemed to be approved by a State commissioner or superintendent of insurance if the State notifies the Secretary that such policy has been submitted for approval to the State and has been specifically disapproved by such State after providing appropriate notice and opportunity for hearing pursuant to the procedures (if any) of the State.”

Subsec. (g)(1). Puspan. L. 101–508, § 4356(a), inserted before period at end of first sentence “and does not include a policy or plan of a health maintenance organization or other direct service organization which offers benefits under this subchapter, including such services under a contract under under section 1395mm of this title or an agreement under section 1395l of this title”.

Subsecs. (o), (p). Puspan. L. 101–508, § 4351(3), formerly § 4351(a)(3), as renumbered and amended by Puspan. L. 103–432, § 171(a)(1), added subsecs. (o) and (p).

Subsec. (q). Puspan. L. 101–508, § 4352, added subsec. (q).

Subsec. (q)(5). Puspan. L. 101–508, § 4354(span), added par. (5).

Subsec. (r). Puspan. L. 101–508, § 4355(a)(3), added subsec. (r).

Subsec. (s). Puspan. L. 101–508, § 4357(a)(2), added subsec. (s).

Subsec. (t). Puspan. L. 101–508, § 4358(a), added subsec. (t).

1989—Subsecs. (a), (span)(1). Puspan. L. 101–234, § 203(a)(1)(A), substituted “subsections (k)(3), (k)(4), (m), and (n)” for “subsection (k)(3)”.

Subsec. (k)(1)(A). Puspan. L. 101–234, § 203(a)(1)(B)(i), inserted “except as provided in subsection (m),” before “subsection (g)(2)(A)”.

Subsec. (k)(3). Puspan. L. 101–234, § 203(a)(1)(B)(ii), substituted “subsections (l), (m), and (n)” for “subsection (l)”.

Subsecs. (m), (n). Puspan. L. 101–234, § 203(a)(1)(C), added subsecs. (m) and (n).

1988—Subsec. (a). Puspan. L. 100–360, § 221(d)(1), substituted “Subject to subsection (k)(3), such” for “Such”.

Subsec. (span)(1). Puspan. L. 100–360, § 221(d)(2), substituted “(subject to subsection (k)(3), for so long as” for “(for so long as” in concluding provisions.

Subsec. (span)(1)(B). Puspan. L. 100–360, § 221(a)(1), substituted “through (4)” for “and (3)”.

Subsec. (span)(1)(C). Puspan. L. 100–360, § 221(span)(2), (3), added subpar. (C). Former subpar. (C) redesignated (D).

Puspan. L. 100–360, § 221(span)(1), substituted “(A), (B), and (C)” for “(A) and (B)”.

Subsec. (span)(1)(D), (E). Puspan. L. 100–360, § 221(span)(2), redesignated former subpars. (C) and (D) as (D) and (E), respectively.

Subsec. (span)(2)(A). Puspan. L. 100–360, § 221(f), substituted “appointed by the Secretary” for “appointed by the President”.

Subsec. (span)(3). Puspan. L. 100–360, § 221(e), added par. (3).

Subsec. (c). Puspan. L. 100–360, § 411(i)(1)(B), added Puspan. L. 100–203, § 4081(span)(2)(A), see 1987 Amendment note below.

Subsec. (c)(3). Puspan. L. 100–360, § 411(i)(1)(B), redesignated Puspan. L. 100–203, § 4081(span)(2)(B)–(D), see 1987 Amendment note below.

Subsec. (c)(3)(A). Puspan. L. 100–360, § 411(i)(1)(C)(i), substituted “claim form” for “claims form” in two places and “such notice” for “such claims form”.

Subsec. (c)(3)(B)(i). Puspan. L. 100–360, § 411(i)(1)(C)(ii), inserted “under the policy” after “payment determination”.

Subsec. (c)(3)(B)(ii). Puspan. L. 100–360, § 411(i)(1)(C)(iii), substituted “payment covered by such policy” for “appropriate payment”.

Subsec. (c)(4). Puspan. L. 100–360, § 221(a)(2), added par. (4).

Subsec. (d). Puspan. L. 100–360, § 428(span)(1), substituted “shall be fined under title 18 or imprisoned not more than 5 years, or both, and, in addition to or in lieu of such a criminal penalty, is subject to a civil money penalty of not to exceed $5,000 for each such prohibited act” for “shall be guilty of a felony and upon conviction thereof shall be fined not more than $25,000 or imprisoned for not more than 5 years, or both” in pars. (1), (2), (3)(A), and (4)(A).

Subsec. (d)(5). Puspan. L. 100–360, § 428(span)(2), added par. (5).

Subsec. (e). Puspan. L. 100–360, § 221(c), designated existing provision as par. (1) and added pars. (2) and (3).

Subsecs. (k), (l). Puspan. L. 100–360, § 221(d)(3), added subsecs. (k) and (l).

1987—Subsec. (span)(1)(B). Puspan. L. 100–203, § 4081(span)(1)(A), amended subpar. (B) generally. Prior to amendment, subpar. (B) read as follows: “includes a requirement equal to or more stringent than the requirement described in subsection (c)(2) of this section; and”.

Subsec. (span)(1)(D). Puspan. L. 100–203, § 4081(span)(1)(B), (C), added subpar. (D).

Subsec. (c). Puspan. L. 100–203, § 4081(span)(2)(A), as added by Puspan. L. 100–360, § 411(i)(1)(B), inserted “(or, with respect to paragraph (3), the issuer of the policy)” in introductory provisions.

Subsec. (c)(3). Puspan. L. 100–203, § 4081(span)(2)(B)–(D), formerly § 4081(span)(2), as redesignated by Puspan. L. 100–360, § 411(i)(1)(B), added par. (3).

Subsec. (d)(1). Puspan. L. 100–93 substituted “knowingly and willfully” for “knowingly or willfully”.

Statutory Notes and Related Subsidiaries

Change of Name

References to Medicare+Choice deemed to refer to Medicare Advantage or MA, subject to an appropriate transition provided by the Secretary of Health and Human Services in the use of those terms, see section 201 of Puspan. L. 108–173, set out as a note under section 1395w–21 of this title.

Committee on Interstate and Foreign Commerce of House of Representatives changed to Committee on Energy and Commerce of House of Representatives immediately prior to noon on Jan. 3, 1981, by House Resolution No. 549, Ninety-sixth Congress, Mar. 25, 1980. Committee on Energy and Commerce of House of Representatives treated as referring to Committee on Commerce of House of Representatives by section 1(a) of Puspan. L. 104–14, set out as a note preceding section 21 of Title 2, The Congress. Committee on Commerce of House of Representatives changed to Committee on Energy and Commerce of House of Representatives, and jurisdiction over matters relating to securities and exchanges and insurance generally transferred to Committee on Financial Services of House of Representatives by House Resolution No. 5, One Hundred Seventh Congress, Jan. 3, 2001.

Effective Date of 2008 Amendment

Puspan. L. 110–233, title I, § 104(c), May 21, 2008, 122 Stat. 903, provided that: “The amendments made by this section [amending this section] shall apply with respect to an issuer of a medicare supplemental policy for policy years beginning on or after the date that is 1 year after the date of enactment of this Act [May 21, 2008].”

Effective Date of 1999 Amendments

Puspan. L. 106–170, title II, § 205(span), Dec. 17, 1999, 113 Stat. 1900, provided that: “The amendments made by subsection (a) [amending this section] apply with respect to requests made after the date of the enactment of this Act [Dec. 17, 1999].”

Amendment by section 1000(a)(6) [title III, § 321(k)(13), (14)] of Puspan. L. 106–113 effective as if included in the enactment of the Balanced Budget Act of 1997, Puspan. L. 105–33, except as otherwise provided, see section 1000(a)(6) [title III, § 321(m)] of Puspan. L. 106–113, set out as a note under section 1395d of this title.

Amendment by section 1000(a)(6) [title V, § 501(a)(2)] of Puspan. L. 106–113 applicable to notices of impending terminations or discontinuances made on or after Nov. 29, 1999, see section 1000(a)(6) [title V, § 501(d)(1)] of Puspan. L. 106–113, set out as a note under section 1395w–21 of this title.

Puspan. L. 106–113, div. B, § 1000(a)(6) [title V, § 536(span)], Nov. 29, 1999, 113 Stat. 1536, 1501A–391, provided that: “The amendments made by this section [amending this section] shall apply to terminations or discontinuances made on or after the date of the enactment of this Act [Nov. 29, 1999].”

Effective Date of 1997 Amendment

Puspan. L. 105–33, title IV, § 4002(j)(2), Aug. 5, 1997, 111 Stat. 330, provided that the amendment made by that section is effective Jan. 1, 1999.

Puspan. L. 105–33, title IV, § 4031(d), Aug. 5, 1997, 111 Stat. 357, provided that:

“(1)Guaranteed issue.—The amendment made by subsection (a) [amending this section] shall take effect on July 1, 1998.

“(2)Limit on preexisting condition exclusions.—The amendment made by subsection (span) [amending this section] shall apply to policies issued on or after July 1, 1998.

“(3)Conforming amendment.—The amendment made by subsection (c) [amending this section] shall be effective as if included in the enactment of the Health Insurance Portability and Accountability Act of 1996 [Puspan. L. 104–191].”

Puspan. L. 105–33, title IV, § 4032(span), Aug. 5, 1997, 111 Stat. 359, provided that:

“(1)In general.—The amendments made by subsection (a) [amending this section] shall take effect the date of the enactment of this Act [Aug. 5, 1997].

“(2)Transition.—The provisions of section 4031(e) [set out as a note below] shall apply with respect to this section in the same manner as they apply to section 4031 [amending this section and enacting provisions set out as notes below].”

Effective Date of 1996 Amendment

Puspan. L. 104–191, title II, § 271(d), Aug. 21, 1996, 110 Stat. 2036, provided that:

“(1) Except as provided in this subsection, the amendment made by subsection (a) [amending this section] shall be effective as if included in the enactment of section 4354 of the Omnibus Budget Reconciliation Act of 1990 [Puspan. L. 101–508].

“(2)

(A) Clause (vi) of section 1882(d)(3)(A) of the Social Security Act [42 U.S.C. 1395ss(d)(3)(A)(vi)], as added by subsection (a), shall only apply to individuals applying for—

“(i) a health insurance policy described in section 1882(d)(3)(A)(iv) of such Act (as added by subsection (a)), after the date of the enactment of this Act [Aug. 21, 1996], or

“(ii) another health insurance policy after the end of the 30-day period beginning on the date of the enactment of this Act.

“(B) A seller or issuer of a health insurance policy may substitute, for the disclosure statement described in clause (vii) of such section, the statement specified under section 1882(d)(3)(D) of the Social Security Act (as in effect before the date of the enactment of this Act), without the revision specified in such clause.”

Effective Date of 1994 Amendment

Puspan. L. 103–432, title I, § 171(l), Oct. 31, 1994, 108 Stat. 4451, provided that: “The amendments made by this section [amending this section and sections 1320c–3, 1395span–2, and 1395span–4 of this title, repealing section 1395zz of this title, and enacting and amending provisions set out as notes below] shall be effective as if included in the enactment of OBRA–1990 [Puspan. L. 101–508]; except that—

“(1) the amendments made by subsection (d)(1) [amending this section] shall take effect on the date of the enactment of this Act [Oct. 31, 1994], but no penalty shall be imposed under section 1882(d)(3)(A) of the Social Security Act [42 U.S.C. 1395ss(d)(3)(A)] (for an action occurring after the effective date of the amendments made by section 4354 of OBRA–1990 [see section 4354(c) of Puspan. L. 101–508, set out as an Effective Date of 1990 Amendment note below] and before the date of the enactment of this Act) with respect to the sale or issuance of a policy which is not unlawful under section 1882(d)(3)(A)(i)(II) of the Social Security Act [42 U.S.C. 1395ss(d)(3)(A)(i)(II)] (as amended by this section);

“(2) the amendments made by subsection (d)(2)(A) [amending this section] and by subparagraphs (A), (B), and (E) of subsection (e)(1) [amending this section] shall be effective on the date specified in subsection (m)(4) [set out as a note below]; and

“(3) the amendment made by subsection (g)(2) [amending this section] shall take effect on January 1, 1995, and shall apply to individuals who attain 65 years of age or older on or after the effective date of section 1882(s)(2) of the Social Security Act [42 U.S.C. 1395ss(s)(2), for effective date see section 4357(span) of Puspan. L. 101–508, set out as an Effective Date of 1990 Amendment note below] (and, in the case of individuals who attained 65 years of age after such effective date and before January 1, 1995, and who were not covered under such section before January 1, 1995, the 6-month period specified in that section shall begin January 1, 1995).”

Effective Date of 1990 Amendment

Puspan. L. 101–508, title IV, § 4353(d)(2), Nov. 5, 1990, 104 Stat. 1388–130, provided that: “The amendment made by paragraph (1) [amending this section] shall apply to policies mailed, or caused to be mailed, on and after July 1, 1991.”

Puspan. L. 101–508, title IV, § 4354(c), Nov. 5, 1990, 104 Stat. 1388–132, provided that: “The amendments made by this section [amending this section] shall apply to policies issued or sold more than 1 year after the date of the enactment of this Act [Nov. 5, 1990].”

Puspan. L. 101–508, title IV, § 4355(d), Nov. 5, 1990, 104 Stat. 1388–134, as amended by Puspan. L. 103–432, title I, § 171(e)(3), Oct. 31, 1994, 108 Stat. 4449, provided that: “The amendments made by this section [amending this section] shall apply to policies issued or renewed (or otherwise providing coverage after the date described in section 1882(p)(1)(C) of the Social Security Act [42 U.S.C. 1395ss(p)(1)(C)]) on or after the date specified in section 1882(p)(1)(C) of the Social Security Act.”

Puspan. L. 101–508, title IV, § 4356(span), Nov. 5, 1990, 104 Stat. 1388–134, as amended by Puspan. L. 103–432, title I, § 171(f)(2), Oct. 31, 1994, 108 Stat. 4449, provided that: “The amendment made by subsection (a) [amending this section] shall take effect on the date specified in section 1882(p)(1)(C) of the Social Security Act [42 U.S.C. 1395ss(p)(1)(C)].”

Puspan. L. 101–508, title IV, § 4357(span), Nov. 5, 1990, 104 Stat. 1388–135, provided that: “The amendments made by subsection (a) [amending this section] shall take effect 1 year after the date of the enactment of this Act [Nov. 5, 1990].”

Amendment by section 4358(a), (span)(1), (2) of Puspan. L. 101–508 only applicable in 15 States (as determined by Secretary of Health and Human Services) and such other States as elect such amendment to apply to them, and during the 6½-year period beginning with 1992, with such amendment to remain in effect beyond the 6½-year period unless the Secretary makes certain determinations, see section 4358(c) of Puspan. L. 101–508, as amended, set out as a note under section 1320c–3 of this title.

Effective Date of 1989 Amendment

Puspan. L. 101–234, title II, § 203(e), Dec. 13, 1989, 103 Stat. 1985, provided that: “The provisions of this section [amending this section, enacting provisions set out as notes under sections 1395span–2 and 1395mm of this title, and amending provisions set out as a note under this section] shall take effect January 1, 1990, except that the amendment made by subsection (d) [amending provisions set out as an Effective Date of 1988 Amendment note under this section] shall be effective as if included in the enactment of MCCA [Puspan. L. 100–360].”

Effective Date of 1988 Amendment

Puspan. L. 100–360, title II, § 221(g), July 1, 1988, 102 Stat. 746, as amended by Puspan. L. 100–485, title VI, § 608(d)(12), Oct. 13, 1988, 102 Stat. 2415; Puspan. L. 101–234, title II, § 203(d), Dec. 13, 1989, 103 Stat. 1985, provided that:

“(1) Except as provided in paragraphs (2) and (3), the amendments made by this section [amending this section] shall take effect on the date of the enactment of this Act [July 1, 1988].

“(2) The amendments made by subsections (a) and (span) [amending this section] shall become effective on the date specified in subsection (k)(1)(B) or (k)(2)(B) of section 1882 of the Social Security Act [42 U.S.C. 1395ss(k)(1)(B), (2)(B)] (as added by subsection (d) of this section).

“(3) The amendment made by subsection (e) [amending this section] shall apply to medicare supplemental policies as of January 1, 1989, with respect to advertising used on or after such date.

“(4) The Secretary of Health and Human Services shall provide for the reappointment of members to the Supplemental Health Insurance Panel (under section 1882(span)(2) of the Social Security Act [42 U.S.C. 1395ss(span)(2)]) by not later than 90 days after the date of the enactment of this Act [July 1, 1988].”

Except as specifically provided in section 411 of Puspan. L. 100–360, amendment by section 411(i)(1)(B), (C) of Puspan. L. 100–360, as it relates to a provision in the Omnibus Budget Reconciliation Act of 1987, Puspan. L. 100–203, effective as if included in the enactment of that provision in Puspan. L. 100–203, see section 411(a) of Puspan. L. 100–360, set out as a Reference to OBRA; Effective Date note under section 106 of Title 1, General Provisions.

Amendment by section 428(span) of Puspan. L. 100–360 effective July 1, 1988, and applicable only with respect to violations occurring on or after such date, see section 428(c) of Puspan. L. 100–360, set out as an Effective Date note under section 1320span–10 of this title.

Effective Date of 1987 Amendment

Puspan. L. 100–203, title IV, § 4081(c)(2), Dec. 22, 1987, 101 Stat. 1330–128, as amended by Puspan. L. 100–360, title IV, § 411(i)(1)(D), (E), July 1, 1988, 102 Stat. 788; Puspan. L. 100–485, title VI, § 608(d)(24)(A), Oct. 13, 1988, 102 Stat. 2421, provided that:

“(A) The amendments made by subsection (span) [amending this section] shall apply to medicare supplemental policies as of January 1, 1989 (or, if applicable, the date established under subparagraph (B)).

“(B) In the case of a State which the Secretary of Health and Human Services identifies as—

“(i) requiring State legislation (other than legislation appropriating funds) in order for medicare supplemental policies to be changed to meet the requirements of section 1882(c)(3) of the Social Security Act [42 U.S.C. 1395ss(c)(3)], and

“(ii) having a legislature which is not scheduled to meet in 1988 in a legislative session in which such legislation may be considered or which has not enacted such legislation before July 1, 1988,

the date specified in this subparagraph is the first day of the first calendar quarter beginning after the close of the first legislative session of the State legislature that begins on or after January 1, 1989, and in which legislation described in clause (i) may be considered.”

Amendment by Puspan. L. 100–93 effective at end of fourteen-day period beginning Aug. 18, 1987, and inapplicable to administrative proceedings commenced before end of such period, see section 15(a) of Puspan. L. 100–93, set out as a note under section 1320a–7 of this title.

Effective Date

Puspan. L. 96–265, title V, § 507(span), June 9, 1980, 94 Stat. 481, provided that: “The amendment made by this section [enacting this section] shall become effective on the date of the enactment of this Act [June 9, 1980], except that the provisions of paragraph (4) of section 1882(d) of the Social Security Act [42 U.S.C. 1395ss(d)(4)] (as added by this section) shall become effective on July 1, 1982.”

Rule of Construction

Puspan. L. 108–173, title I, § 104(c), Dec. 8, 2003, 117 Stat. 2165, provided that:

“(1)In general.—Nothing in this Act [see Tables for classification] shall be construed to require an issuer of a medicare supplemental policy under section 1882 of the Social Security Act (42 U.S.C. 1395rr) [42 U.S.C. 1395ss] to participate as a PDP sponsor under part D of title XVIII of such Act [42 U.S.C. 1395w–101 et seq.], as added by section 101, as a condition for issuing such policy.

“(2)Prohibition on state requirement.—A State may not require an issuer of a medicare supplemental policy under section 1882 of the Social Security Act (42 U.S.C. 1395rr) [42 U.S.C. 1395ss] to participate as a PDP sponsor under such part D as a condition for issuing such policy.”

Implementation of NAIC Recommendations

Puspan. L. 110–275, title I, § 104(a), July 15, 2008, 122 Stat. 2501, provided that:

“(1)In general.—The Secretary of Health and Human Services (in this section [enacting section 1395ss–1 of this title and amending this section] referred to as the ‘Secretary’) shall provide for implementation of the changes in the NAIC model law and regulations approved by the National Association of Insurance Commissioners in its Model #651 (‘Model Regulation to Implement the NAIC Medicare Supplement Insurance Minimum Standards Model Act’) on March 11, 2007, as modified to reflect the changes made under this Act [see Short Title of 2008 Amendment note set out under section 1305 of this title] and the Genetic Information Nondiscrimination Act of 2008 (Public Law 110–233) [see Short Title note set out under section 2000ff of this title].

“(2)Implementation dates.—

“(A)In general.—The modifications to Model #651 required under paragraph (1) shall be completed by the National Association of Insurance Commissioners not later than October 31, 2008. Except as provided in subparagraph (B), each State shall have 1 year from the date the National Association of Insurance Commissioners adopts the revised NAIC model law and regulations (as changed by Model #651, as so modified) to conform the regulatory program established by the State to such revised NAIC model law and regulations.

“(B)Extension of effective date for state law amendment.—In the case of a State which the Secretary determines requires State legislation in order to conform the regulatory program established by the State to such revised NAIC model law and regulations, the State shall not be regarded as failing to comply with the requirements of this section solely on the basis of its failure to meet such requirements before the first day of the first calendar quarter beginning after the close of the first regular session of the State legislature that begins after the date of the enactment of this Act [July 15, 2008]. For purposes of the previous sentence, in the case of a State that has a 2-year legislative session, each year of the session is considered to be a separate regular session of the State legislature.

“(C)Transition dates.—No carrier may issue a new or revised medicare supplemental policy or certificate under section 1882 of the Social Security Act (42 U.S.C. 1395ss) that meets the requirements of such revised NAIC model law and regulations for coverage effective prior to June 1, 2010. A carrier may continue to offer or issue a medicare supplemental policy under such section that meets the requirements of the NAIC model law and regulations and State law (as in effect prior to the adoption of such revised NAIC model law and regulations) prior to June 1, 2010. Nothing shall preclude carriers from marketing new or revised medicare supplemental policies or certificates that meet the requirements of such revised NAIC model law and regulations on or after the date on which the State conforms the regulatory program established by the State to such revised NAIC model law and regulations.”

Study of Medigap Policies

Puspan. L. 106–113, div. B, § 1000(a)(6) [title V, § 553(a)], Nov. 29, 1999, 113 Stat. 1536, 1501A–393, provided that:

“(1)In general.—The Comptroller General of the United States (in this section referred to as the ‘Comptroller General’) shall conduct a study of the issues described in paragraph (2) regarding medicare supplemental policies described in section 1882(g)(1) of the Social Security Act (42 U.S.C. 1395ss(g)(1)).

“(2)Issues to be studied.—The issues described in this paragraph are the following:

“(A) The level of coverage provided by each type of medicare supplemental policy.

“(B) The current enrollment levels in each type of medicare supplemental policy.

“(C) The availability of each type of medicare supplemental policy to medicare beneficiaries over age 65½.

“(D) The number and type of medicare supplemental policies offered in each State.

“(E) The average out-of-pocket costs (including premiums) per beneficiary under each type of medicare supplemental policy.

“(2)[(3)]Report.—Not later than July 31, 2001, the Comptroller General shall submit a report to Congress on the results of the study conducted under this subsection, together with any recommendations for legislation that the Comptroller General determines to be appropriate as a result of such study.”

Conforming Benefits to Changes in Terminology for Hospital Outpatient Department Cost Sharing

Puspan. L. 105–33, title IV, § 4031(f), Aug. 5, 1997, 111 Stat. 359, provided that: “For purposes of apply [sic] section 1882 of the Social Security Act (42 U.S.C. 1395ss) and regulations referred to in subsection (e) [set out as a note above], copayment amounts provided under section 1833(t)(5) of such Act [42 U.S.C. 1395l(t)(5)] with respect to hospital outpatient department services shall be treated under medicare supplemental policies in the same manner as coinsurance with respect to such services.”

Transition Provisions

Puspan. L. 110–233, title I, § 104(d), May 21, 2008, 122 Stat. 903, provided that:

“(1)In general.—If the Secretary of Health and Human Services identifies a State as requiring a change to its statutes or regulations to conform its regulatory program to the changes made by this section [amending this section], the State regulatory program shall not be considered to be out of compliance with the requirements of section 1882 of the Social Security Act [42 U.S.C. 1395ss] due solely to failure to make such change until the date specified in paragraph (4).

“(2) NAIC standards.—If, not later than October 31, 2008, the National Association of Insurance Commissioners (in this subsection referred to as the ‘NAIC’) modifies its NAIC Model Regulation relating to section 1882 of the Social Security Act [42 U.S.C. 1395ss] (referred to in such section as the 1991 NAIC Model Regulation, as subsequently modified) to conform to the amendments made by this section [amending this section], such revised regulation incorporating the modifications shall be considered to be the applicable NAIC model regulation (including the revised NAIC model regulation and the 1991 NAIC Model Regulation) for the purposes of such section.

“(3)Secretary standards.—If the NAIC does not make the modifications described in paragraph (2) within the period specified in such paragraph, the Secretary of Health and Human Services shall, not later than July 1, 2009, make the modifications described in such paragraph and such revised regulation incorporating the modifications shall be considered to be the appropriate regulation for the purposes of such section.

“(4)Date specified.—

“(A)In general.—Subject to subparagraph (B), the date specified in this paragraph for a State is the earlier of—

“(i) the date the State changes its statutes or regulations to conform its regulatory program to the changes made by this section, or

“(ii)July 1, 2009.

“(B)Additional legislative action required.—In the case of a State which the Secretary identifies as—

“(i) requiring State legislation (other than legislation appropriating funds) to conform its regulatory program to the changes made in this section, but

“(ii) having a legislature which is not scheduled to meet in 2009 in a legislative session in which such legislation may be considered, the date specified in this paragraph is the first day of the first calendar quarter beginning after the close of the first legislative session of the State legislature that begins on or after July 1, 2009. For purposes of the previous sentence, in the case of a State that has a 2-year legislative session, each year of such session shall be deemed to be a separate regular session of the State legislature.”

Puspan. L. 105–33, title IV, § 4031(e), Aug. 5, 1997, 111 Stat. 358, provided that:

“(2) NAIC standards.—If, within 9 months after the date of the enactment of this Act [Aug. 5, 1997], the National Association of Insurance Commissioners (in this subsection referred to as the ‘NAIC’) modifies its NAIC Model Regulation relating to section 1882 of the Social Security Act [42 U.S.C. 1395ss] (referred to in such section as the 1991 NAIC Model Regulation, as modified pursuant to section 171(m)(2) of the Social Security Act Amendments of 1994 (Public Law 103–432) [set out as a note below] and as modified pursuant to section 1882(d)(3)(A)(vi)(IV) of the Social Security Act [42 U.S.C. 1395ss(d)(3)(A)(vi)(IV)], as added by section 271(a) of the Health Insurance Portability and Accountability Act of 1996 (Public Law 104–191) to conform to the amendments made by this section [amending this section], such revised regulation incorporating the modifications shall be considered to be the applicable NAIC model regulation (including the revised NAIC model regulation and the 1991 NAIC Model Regulation) for the purposes of such section.

“(3)Secretary standards.—If the NAIC does not make the modifications described in paragraph (2) within the period specified in such paragraph, the Secretary of Health and Human Services shall make the modifications described in such paragraph and such revised regulation incorporating the modifications shall be considered to be the appropriate Regulation for the purposes of such section.

“(4)Date specified.—

“(A)In general.—Subject to subparagraph (B), the date specified in this paragraph for a State is the earlier of—

“(i) the date the State changes its statutes or regulations to conform its regulatory program to the changes made by this section, or

“(ii) 1 year after the date the NAIC or the Secretary first makes the modifications under paragraph (2) or (3), respectively.

“(B)Additional legislative action required.—In the case of a State which the Secretary identifies as—

“(i) requiring State legislation (other than legislation appropriating funds) to conform its regulatory program to the changes made in this section, but

“(ii) having a legislature which is not scheduled to meet in 1999 in a legislative session in which such legislation may be considered,

the date specified in this paragraph is the first day of the first calendar quarter beginning after the close of the first legislative session of the State legislature that begins on or after July 1, 1999. For purposes of the previous sentence, in the case of a State that has a 2-year legislative session, each year of such session shall be deemed to be a separate regular session of the State legislature.”

Puspan. L. 104–191, title II, § 271(c), Aug. 21, 1996, 110 Stat. 2036, provided that:

“(1)No penalties.—Subject to paragraph (3), no criminal or civil money penalty may be imposed under section 1882(d)(3)(A) of the Social Security Act [42 U.S.C. 1395ss(d)(3)(A)] for any act or omission that occurred during the transition period (as defined in paragraph (4)) and that relates to any health insurance policy that is described in clause (iv) or (v) of such section (as amended by subsection (a)).

“(2)Limitation on legal action.—Subject to paragraph (3), no legal action shall be brought or continued in any Federal or State court insofar as such action—

“(A) includes a cause of action which arose, or which is based on or evidenced by any act or omission which occurred, during the transition period; and

“(B) relates to the application of section 1882(d)(3)(A) of the Social Security Act to any act or omission with respect to the sale, issuance, or renewal of any health insurance policy that is described in clause (iv) or (v) of such section (as amended by subsection (a)).

“(3)Disclosure condition.—In the case of a policy described in clause (iv) of section 1882(d)(3)(A) of the Social Security Act that is sold or issued on or after the effective date of statements under section 171(d)(3)(C) of the Social Security Act Amendments of 1994 [Puspan. L. 103–432, set out below] and before the end of the 30-day period beginning on the date of the enactment of this Act [Aug. 21, 1996], paragraphs (1) and (2) shall only apply if disclosure was made in accordance with section 1882(d)(3)(C)(ii) of the Social Security Act (as in effect before the date of the enactment of this Act).

“(4)Transition period.—In this subsection, the term ‘transition period’ means the period beginning on November 5, 1991, and ending on the date of the enactment of this Act.”

Applicability of Disclosure Requirement

Puspan. L. 103–432, title I, § 171(d)(3)(C), Oct. 31, 1994, 108 Stat. 4448, provided that: “The requirement of a disclosure under section 1882(d)(3)(C)(ii) of the Social Security Act [42 U.S.C. 1395ss(d)(3)(C)(ii)] shall not apply to an application made for a policy or plan before 60 days after the date the Secretary of Health and Human Services publishes or promulgates all the statements under section 1882(d)(3)(D) of such Act.”

State Regulatory Programs

Puspan. L. 103–432, title I, § 171(m), Oct. 31, 1994, 108 Stat. 4451, provided that:

“(1)In general.—If the Secretary of Health and Human Services identifies a State as requiring a change to its statutes or regulations to conform its regulatory program to the changes made by this section [amending this section and sections 1320c–3, 1395span–2, and 1395span–4 of this title, repealing section 1395zz of this title, and enacting and amending provisions set out as notes under this section], the State regulatory program shall not be considered to be out of compliance with the requirements of section 1882 of the Social Security Act [42 U.S.C. 1395ss] due solely to failure to make such change until the date specified in paragraph (4).

“(2) NAIC standards.—If, within 6 months after the date of the enactment of this Act [Oct. 31, 1994], the National Association of Insurance Commissioners (in this subsection referred to as the ‘NAIC’) modifies its 1991 NAIC Model Regulation (adopted in July 1991) to conform to the amendments made by this section and to delete from section 15C the exception which begins with ‘unless’, such revised regulation incorporating the modifications shall be considered to be the 1991 Regulation for the purposes of section 1882 of the Social Security Act.

“(3)Secretary standards.—If the NAIC does not make the modifications described in paragraph (2) within the period specified in such paragraph, the Secretary of Health and Human Services shall make the modifications described in such paragraph and such revised regulation incorporating the modifications shall be considered to be the 1991 Regulation for the purposes of section 1882 of the Social Security Act.

“(4)Date specified.—

“(A)In general.—Subject to subparagraph (B), the date specified in this paragraph for a State is the earlier of—

“(i) the date the State changes its statutes or regulations to conform its regulatory program to the changes made by this section, or

“(ii) 1 year after the date the NAIC or the Secretary first makes the modifications under paragraph (2) or (3), respectively.

“(B)Additional legislative action required.—In the case of a State which the Secretary identifies as—

“(i) requiring State legislation (other than legislation appropriating funds) to conform its regulatory program to the changes made in this section, but

“(ii) having a legislature which is not scheduled to meet in 1996 in a legislative session in which such legislation may be considered,

the date specified in this paragraph is the first day of the first calendar quarter beginning after the close of the first legislative session of the State legislature that begins on or after January 1, 1996. For purposes of the previous sentence, in the case of a State that has a 2-year legislative session, each year of such session shall be deemed to be a separate regular session of the State legislature.”

Evaluation of 1990 Amendments

Puspan. L. 101–508, title IV, § 4358(d), Nov. 5, 1990, 104 Stat. 1388–137, provided that: “The Secretary of Health and Human Services shall conduct an evaluation of the amendments made by this section [amending this section and section 1320c–3 of this title] and shall report to Congress on such evaluation by not later than January 1, 1995.”