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OAC 365:10

INSURANCE DEPARTMENT

Parts A and B, to the extent recognized as reasonable and medically necessary by Medicare. (8) "Physician" shall not be defined more restrictively than as defined in the Medicare program. (9) "Sickness" shall 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.

[Source: Added at 9 Ok Reg 2499, eff 6-26-92; Amended at 22 Ok Reg 1954, eff 7-14-05]

365:10-5-125. Policy provisions (a) Limitations and exclusions. Except for permitted preexisting condition clauses as described in 365:10-5-126(b)(1) and 365:10-5-127(b)(1), no policy or certificate may be advertised, solicited or issued for delivery in this state as a Medicare supplement policy if such policy or certificate contains limitations or exclusions on coverage that are more restrictive than those of Medicare. (b) Waivers. 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. (c) Duplication of benefits. No Medicare supplement policy or certificate in force in the state shall contain benefits which duplicate benefits provided by Medicare.

  • (d)

    Outpatient prescription drugs.

    • (1)

      Subject to sections 365:10-5-126(b)(4),(5), and (7) and 365:10-5-127 (b) (4) and (5), 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.

    • (2)

      A Medicare Supplement policy with benefits for outpatient prescription drugs shall not be issued after December 31, 2005.

    • (3)

      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:

      • (A)

        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 Part D plan and;

      • (B)

        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.

[Source: Added at 9 Ok Reg 2499, eff 6-26-92; Amended at 22 Ok Reg 1954, eff 7-14-05]

365:10-5-126. Minimum benefit standards for policies or certificates issued for delivery prior to July 1, 1992 (a) Minimum standards. 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

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