Code of Massachusetts Regulations
211 CMR - DIVISION OF INSURANCE
Title 211 CMR 71.00 - Medicare Supplement Insurance To Facilitate The Implementation Of M.G.L. c. 176k And Section 1882 Of The Federal Social Security Act
Section 71.05 - Standards for Policy Definitions
Current through Register 1531, September 27, 2024
(1) No Policy may be advertised, solicited, issued, renewed, delivered or issued for delivery in Massachusetts as a Medicare Supplement Insurance Policy, unless such Policy contains definitions or terms which conform to the requirements of 211 CMR 71.05.
(2) All definitions used in a Medicare Supplement Insurance Policy shall be compatible with Medicare definitions and practice.
(3) All Medicare Supplement Insurance Policies shall include a definition for the following terms:
Accident, Accidental Injury, or Accidental Means shall be defined to employ "result" language and shall not include words which establish an accidental means test or use words such as "external, violent, visible wounds" or similar words of description or characterization.
Benefit Period or Medicare Benefit Period shall not be defined more restrictively than as defined in the Medicare program.
Convalescent Nursing Home, Extended Care Facility, or Skilled Nursing Facility shall not be defined more restrictively than as defined in the Medicare program. Convalescent Nursing Home, Extended Care Facility, or Skilled Nursing Facility must take into account that there are Policy benefits for these providers' services which are paid for only by the Medicare Supplement Insurance Policy and for which Medicare does not contribute payment.
Hospital may be defined in relation to its status, facilities and available services or to reflect its accreditation by the Joint Commission on Accreditation of Hospitals, but shall not be defined more restrictively than as defined in the Medicare program. The definition must take into account that there are Policy benefits for these providers' services which are paid for only by the Medicare Supplement Insurance Policy and for which Medicare does not contribute payment.
Medicare shall be defined in the Policy and Certificate. Medicare may be substantially defined as "The Health Insurance for the Aged Act", Title XVIII of the Social Security Amendments of 1965 as Then Constituted or Later Amended, or "Title I, Part I of Public Law 89-97, as Enacted by the Eighty-ninth Congress of the United States of America and popularly known as the Health Insurance for the Aged Act, as then constituted and any later amendments or substitutes thereof."
Medicare Eligible Expenses shall mean expenses of the kinds covered by Medicare Parts A and B, to the extent recognized as reasonable and medically necessary by Medicare.
Physician shall not be defined more restrictively than as defined in the Medicare program. The definition must take into account that there are Policy benefits for this provider's services which are paid for only by the Medicare Supplement Insurance Policy and for which Medicare does not contribute payment.
Sickness shall not be defined more restrictively than the following: an illness or disease of an insured person for which expenses are incurred after the effective date of insurance and while the insurance is in force. Sickness 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.
