New Jersey Administrative Code
Title 11 - INSURANCE
Chapter 4 - ACTUARIAL SERVICES
Subchapter 23 - MINIMUM STANDARDS FOR MEDICARE SUPPLEMENT COVERAGE
Section 11:4-23.3 - Definitions
The following words and terms, when used in this subchapter, shall have the following meanings unless the context clearly indicates otherwise.
"Aggregate loss ratio" means the ratio of the accumulated value of past benefits (from the original effective date of the form to the date as of which the ratio is determined) and the present value of future benefits to the accumulated value of past premiums (from the original effective date of the form to the date as of which the ratio is determined) and the present value of future premiums. Benefits shall not be increased nor premiums reduced by actual or anticipated dividends, and interest shall be included in the accumulated and present values on the same basis as in the present values of the anticipated loss ratio.
"Anticipated loss ratio" means the ratio of the present value of the expected benefits, not including dividends, to the present value of the expected premiums, not reduced by dividends, over the entire period for which rates are computed to provide coverage. For purposes of this ratio, the present values must incorporate realistic rates of interest which are determined before Federal taxes but after investment expenses. Benefits and premiums shall be discounted from the year of payment, with reasonable assumptions as to time of payment within the year.
"Applicant" means:
1. In the case of a group policy, the proposed certificate holder;
2. In the case of an individual policy, the person who seeks to contract for coverage.
"Bankruptcy" means when a Medicare Advantage organization that is not a carrier has filed, or has had filed against it, a petition for declaration of bankruptcy pursuant to the United States Bankruptcy Code, 11 U.S.C. §§ 101 et seq. and has ceased doing business in the State.
"Carrier" means any person who contracts to provide health services, reimburse the cost of health services in whole or in part, or provide an indemnity in the event that health services are used, in return for a prepaid or postpaid premium or other consideration, including insurance companies, fraternal benefit societies, hospital, medical and health service corporations, health maintenance organizations and such other similar entities.
"Certificate" means any certificate or other document which sets forth or summarizes the essential features of the coverage issued under a group policy, which certificate or other document has been delivered or issued for delivery in this State.
"Certificate form" means the form on which a certificate is delivered or issued for delivery by a carrier.
"Continuous period of creditable coverage" means 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 63 days.
"Coverage" means:
1. Any arrangement whereby a carrier agrees to indemnify or reimburse an individual or group member for some portion or part of the health related costs incurred by that individual or member, subject to the terms of the written agreement and law; and
2. Any arrangement whereby a carrier agrees to provide direct or indirect health care services to the individual or group member, subject to the terms of the written agreement and law.
"Creditable coverage" means, with respect to an individual, coverage of the individual provided under any of the following:
1. A group health plan;
2. Health insurance coverage;
3. Part A or Part B of Title XVIII of the Social Security Act (Medicare);
4. Title XIX of the Social Security Act (Medicaid), other than coverage consisting solely of benefits under section 1928;
5. Chapter 55 of Title 10 United States Code (CHAMPUS);
6. A medical care program of the Indian Health Service or of a tribal organization;
7. A State health benefits risk pool;
8. A health plan offered under chapter 89 of Title 5 United States Code (Federal Employees Health Benefits Program);
9. A public health benefit plan as defined in Federal regulations; and
10. A health benefit plan under Section 5(e) of the Peace Corps Act ( 22 U.S.C. § 2504(e) ).
"Creditable coverage" shall not include one or more, or any combination of the following:
1. Coverage only for accident or disability income insurance, or any combination thereof;
2. Coverage issued as a supplement to liability insurance;
3. Liability insurance, including general liability insurance and automobile liability insurance;
4. Workers' compensation or similar insurance;
5. Automobile medical payment insurance;
6. Credit-only insurance;
7. Coverage for on-site medical clinics; and
8. Other similar insurance coverage, specified in Federal regulations, under which benefits for medical care are secondary or incidental to other insurance benefits.
"Creditable coverage" shall not include the following benefits if they are provided under a separate policy, certificate or contract of insurance or are otherwise not an integral part of the plan:
1. Limited scope dental or vision benefits;
2. Benefits for long-term care, nursing home care, home health care, community-based care, or any combination thereof; and
3. Such other similar, limited benefits as are specified in Federal regulations.
"Creditable coverage" shall not include the following benefits if offered as independent, noncoordinated benefits:
1. Hospital indemnity or other fixed indemnity insurance.
"Creditable coverage" shall not include the following if it is offered as a separate policy, certificate or contract of insurance:
1. Medicare supplement health insurance as defined under section 1882(g)(1) of the Social Security Act;
2. Coverage supplemental to the coverage provided under chapter 55 of Title 10 United States Code; and
3. Similar supplemental coverage provided to coverage under a group health plan.
"Employee welfare benefit plan" means a plan, fund or program of employee benefits as defined in 29 U.S.C. § 1002 (Employee Retirement Income Security Act).
"Insolvency" or "insolvent" means:
1. That a carrier:
i. Is unable to pay its obligations when they are due; or
ii. Its admitted assets do not exceed its liabilities plus the greater of:
(1) Any capital and surplus required by law for its organization; or
(2) The total par or stated value of its authorized and issued capital stock.
2. For purposes of the definition of "insolvency" or "insolvent," "liabilities" shall include, but not be limited to, reserves required by law or by regulations of the New Jersey Department of Banking and Insurance (Department) or specific requirements imposed by the Commissioner of the Department upon a carrier at the time of admission or subsequent thereto.
"Insured" means any applicant provided coverage by a carrier.
"Medicare Advantage plan" means a plan of coverage for health benefits under Medicare Part C as defined in Section 1859 of Title IV, Subtitle A, Chapter 1 of P.L. 105-33 ( 42 U.S.C. § 1395w-28 ), and includes:
1. Coordinated care plans which provide health care services, including, but not limited to, health maintenance organization plans (with or without a point-of-service option), plans offered by provider-sponsored organizations and preferred provider organization plans;
2. Medical savings account plans coupled with a contribution into a Medicare Advantage medical savings account; and
3. Medicare Advantage private fee-for-service plans.
"Medicare supplement policy" means a group or individual policy which is advertised, marketed or designed primarily as, or is otherwise held out to be a supplement to reimbursements under Medicare, other than a policy issued pursuant to a contract under Section 1876 of the Federal Social Security Act ( 42 U.S.C. §§ 1395 et seq.), or a contract or policy issued under a demonstration project specified in 42 U.S.C. § 1395ss(g)(1). This term does not include a policy or certificate of one or more employers or labor organizations, or of the trustees of a fund established by one or more employers or labor organizations, or combination thereof, for employees or former employees, or a combination thereof, or for members or former members, or combination thereof, of the labor organization. "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 § 1833(a)(1)(A) of the Social Security Act.
"Months exposed" means, for a given calendar period, the sum of the number of months an insured was covered for all insureds during that period.
"1990 Standardized Medicare supplement benefit plan," "1990 Standardized benefit plan," or "1990 plan" means a group or individual policy of Medicare supplement insurance issued on or after January 4, 1993 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 carrier at the request of the insured.
"Policy" shall mean any policy, contract, certificate or other document which sets forth or summarizes the essential features of the coverage issued to an individual or group by a carrier, for the purpose of providing Medicare supplement coverage, including any such policy issued pursuant to a conversion privilege to an individual 65 years of age or older, except as otherwise provided in this subchapter or Federal law.
"Policy form" means the form on which a policy is delivered or issued for delivery by a carrier.
"Pre-Standardized Medicare supplement benefit plan," "Pre-Standardized benefit plan" or "Pre-Standardized plan" means a group or individual policy of Medicare supplement insurance issued prior to January 4, 1993.
"Secretary" means the Secretary of the United States Department of Health and Human Services.
"2010 Standardized Medicare supplement benefit plan," "2010 Standardized benefit plan" or "2010 plan" means a group or individual policy of Medicare supplement insurance issued with an effective date for coverage on or after June 1, 2010.
