01.
Applicant. (3-31-22)
a. In the case of an individual Medicare
supplement policy, the person who seeks to contract for insurance benefits; and
(3-31-22)
b. In the case of a group
Medicare supplement policy, the proposed certificate holder.
(3-31-22)
02.
Bankruptcy. 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. (3-31-22)
03.
Continuous Period of Creditable
Coverage. 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 (63) days. (3-31-22)
04.
Creditable Coverage.
(3-31-22)
a. With respect to an individual,
coverage of the individual provided under any of the following: (3-31-22)
i. A group health plan; (3-31-22)
ii. Health insurance coverage;
(3-31-22)
iii. Part A or Part B of
Title XVIII of the Social Security Act (Medicare); (3-31-22)
iv. Title XIX of the Social Security Act
(Medicaid), other than coverage consisting solely of benefits under Section
1928; (3-31-22)
v. Title 10, Chapter 55, United States Code
(CHAMPUS); (3-31-22)
vi. A medical
care program of the Indian Health Service or of a tribal organization;
(3-31-22)
vii. A state health
benefits risk pool; (3-31-22)
viii.
A health plan offered under Title 5, Chapter 89, United States Code (Federal
Employees Health Benefits Program); (3-31-22)
ix. A public health plan as defined in
federal regulation; and (3-31-22)
x. A health benefit plan under Section
5(e) of the Peace
Corps Act ( 22 United States
Code 2504(e) ).
(3-31-22)
b. Creditable
coverage does not include one (1) or more, or any combination of, the
following: (3-31-22)
i. Coverage only for
accident or disability income insurance, or any combination thereof;
(3-31-22)
ii. Coverage issued as a
supplement to liability insurance; (3-31-22)
iii. Liability insurance, including general
liability insurance and automobile liability insurance; (3-31-22)
iv. Workers ' compensation or similar
insurance; (3-31-22)
v. Automobile
medical payment insurance; (3-31-22)
vi. Credit-only insurance;
(3-31-22)
vii. Coverage for on-site
medical clinics; and (3-31-22)
viii. Other similar insurance coverage,
specified in federal regulations, under which benefits for medical care are
secondary or incidental to other insurance benefits.
(3-31-22)
c. Creditable
coverage does not include the following benefits if they are provided under a
separate policy, certificate or contract of insurance or are not an integral
part of the plan: (3-31-22)
i. Limited scope
dental or vision benefits; (3-31-22)
ii. Benefits for long-term care, nursing home
care, home health care, community-based care, or any combination thereof; and
(3-31-22)
iii. Such other similar,
limited benefits as are specified in federal regulations.
(3-31-22)
d. Creditable
coverage does not include the following benefits if offered as independent,
noncoordinated benefits: (3-31-22)
i. Coverage
only for a specified disease or illness; and (3-31-22)
ii. Hospital indemnity or other fixed
indemnity insurance. (3-31-22)
e. Creditable coverage does not include the
following if it is offered as a separate policy, certificate, or contract of
insurance: (3-31-22)
i. Medicare supplemental
health insurance as defined under Section
1882(g)(1) of
the Social Security Act; (3-31-22)
ii. Coverage supplemental to the coverage
provided under Title 10, Chapter 55, United States Code; and
(3-31-22)
iii. Similar supplemental
coverage provided to coverage under a group health plan.
(3-31-22)
f. The Health
Insurance Portability and Accountability Act of 1996 (HIPAA) specifically
addressed separate, noncoordinated benefits in the group market at PHSA Section
2721(d)(2) and
the individual market at Section
2791(c)(3). HIPAA
also references excepted benefits at PHSA Sections
2701(c)(1),
2721(d),
2763(b) and
2791(c). In
addition, credible coverage has been addressed in an interim final rule (62
Fed. Reg. At 16960-16962 (April 8, 1997)) issued by the Secretary of Health and
Human Services, pursuant to HIPAA, and may be addressed in subsequent
regulations. (3-31-22)
05.
Employee Welfare Benefit
Plan. A plan, fund, or program of employee benefits as defined in
29 U.S.C. Section
1002 (Employee Retirement Income Security
Act). (3-31-22)
06.
Insolvency. When an issuer, licensed to transact the business of
insurance in this state, has had a final order of liquidation entered against
it with a finding of insolvency by a court of competent jurisdiction in the
issuer's state of domicile. (3-31-22)
07.
Medicare Advantage Plan. A
plan of coverage for health benefits under Medicare Part C as defined in
42 U.S.C.
1395w -
28
(b)(1), and includes: (3-31-22)
a. Coordinated care plans which provide
health care services, including but not limited to managed care organization
(with or without a point-of-service option), plans offered by
provider-sponsored organizations, and preferred provider organization plans;
(3-31-22)
b. Medical savings
account plans coupled with a contribution into a Medicare Advantage medical
savings account; and (3-31-22)
c.
Medicare Advantage private fee-for-service plans. (3-31-22)
08.
Medicare Supplement Policy.
As defined in Section
41-4402 and in addition, "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 (HCPP) that provides benefits
pursuant to an agreement under Section
1833(a)(1)(A) of
the Social Security Act; provided, however, that under Section
104(c) of the
Medicare Improvements for Patients and Providers Act of 2008 (MIPPA), policies
that are advertised, marketed or designed primarily to cover out-of-pocket
costs under Medicare Advantage Plans (established under Medicare Part C) need
to comply with the Medicare supplement requirements of Section
1882(o) of the
Social Security Act. (3-31-22)
09.
Pre-Standardized Benefit Plan. A group or individual policy of
Medicare supplement insurance issued prior to July 1, 1992. (3-31-22)
10.
1990 Standardized Benefit
Plan. A group or individual policy of Medicare supplement insurance
issued on or after July 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. (3-31-22)
11.
2010 Standardized Benefit
Plan. A group or individual policy of Medicare supplement insurance with
an effective date for coverage issued on or after June 1, 2010.
(3-31-22)
12.
Secretary. The Secretary of the United States Department of Health
and Human Services. (3-31-22)
