New Hampshire Code of Administrative Rules
Ins - Commissioner, Insurance Department
Chapter Ins 1900 - ACCIDENT AND HEALTH INSURANCE
Part Ins 1902 - MINIMUM STANDARDS FOR MEDICARE SUPPLEMENT POLICIES ISSUED PRIOR TO ADOPTION OF INSURANCE REGULATION 1905
Section Ins 1902.04 - Policy Definitions And Terms
Current through Register No. 12, March 21, 2024
No medicare supplement policy subject to this part shall contain definitions or terms respecting the matters set forth herein unless such definitions or terms conform to the requirements of this section as follows:
(a) "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 so that:
(b) "Benefit period" or "medicare benefit period" shall not be defined as more restrictive than as that defined in the medicare program.
(c) "Convalescent nursing home," "extended care facility," or "skilled nursing facility" shall be defined in relation to its status, facilities, and available services so that:
(d) "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 so that:
(e) "Medicare" shall be 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 Laws of 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," or words of similar import. Medicare consists of Part A and Part B. Part A refers to hospital benefits and Part B refers to Medicaid benefits.
(f) "Issuer" shall be defined as including insurance companies, fraternal benefit societies, nonprofit health service corporations, health maintenance organizations, and any other entity advertising, soliciting, delivering or issuing for delivery in this state medicare supplement policies or certificates.
(g) "Medicare eligible expenses" shall be defined as health care expenses of the kinds covered by medicare, to the extent recognized as reasonable by medicare. Payment of benefits by insurers for medicare eligible expenses may be conditioned upon the same or less restrictive payment conditions, including determinations of medical necessity as are applicable to medicare claims.
(h) "Mental or nervous disorders" shall not be defined more restrictively than a definition including neurosis, psychoneurosis, psychopathy, psychosis, or mental or emotional disease or disorder of any kind.
(i) "Nurses" may be defined so that the description of nurse is restricted to a type of nurse, such as a registered graduate professional nurse, R.N., a licensed practical nurse, L.P.N. or a licensed vocational nurse, L.V.N. If the words "nurse," "trained nurse" or "registered nurse" are used without specific instruction, then the insurer shall recognize the services of any individual who qualified under such terminology in accordance with the applicable statutes or administrative rules of the licensing or registry board of the state.
(j) "Physician" may be defined by including words such as "duly qualified physician" or "duly licensed physician." The use of such terms shall require an insurer to recognize and to accept, to the extent of its obligation under the contract, all providers of medical care and treatment when such services are within the scope of the provider's licensed authority and are provided pursuant to applicable laws.
(k) "Preexisting condition" shall be defined as a condition for which medical advice or treatment was recommended by or received from a physician within the 6 month period preceding the effective date of the coverage of the insured person.
(l) "Sickness" shall not be defined to be more restrictive than the following:
(m) "Health care expenses" shall be defined as expenses of health maintenance organizations associated with the delivery of health care services which are analogous to incurred losses of insurers, but the definition shall not include the following expenses:
#1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5119, eff 4-25-91; ss by #5656, eff 7-1-93; ss by #7017, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
New. #8555, eff 2-1-06