New Jersey Administrative Code
Title 11 - INSURANCE
Chapter 4 - ACTUARIAL SERVICES
Subchapter 23 - MINIMUM STANDARDS FOR MEDICARE SUPPLEMENT COVERAGE
Section 11:4-23.4 - Policy definitions and terms
Universal Citation: NJ Admin Code 11:4-23.4
Current through Register Vol. 56, No. 24, December 18, 2024
(a) No policy or certificate may be advertised, solicited or issued for delivery in this State as a Medicare supplement policy or certificate unless such policy or certificate contains definitions or terms which conform to the requirements of this section.
1. "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.
i. "Injury" shall not be
defined more restrictively than as a bodily injury sustained by the covered
person as a result of an accident, which injury is the direct cause of the
loss, independent of disease, bodily infirmity or any other cause, and which
occurs while coverage is in force.
ii. The definition may provide that injuries
shall not include injuries for which benefits are provided under any workers'
compensation, employer's liability or similar law, mandatory motor vehicle
no-fault plan, unless prohibited by law.
2. "Benefit period" or "Medicare benefit
period" shall not be defined more restrictively than as defined in the Medicare
program.
3. "Convalescent nursing
home," "extended care facility," or "skilled nursing facility" shall not be
defined more restrictively than as defined by the Medicare program.
4. "Health care expenses" means, for purposes
of N.J.A.C. 11:4-23.1 1, expenses of health
maintenance organizations which expenses are associated with the delivery of
health care services and are analogous to incurred losses of insurers. Expenses
shall not include the following costs:
i.
Home office and overhead costs;
ii.
Advertising costs;
iii. Commissions
and other acquisition costs;
iv.
Taxes;
v. Capital costs;
vi. Administrative costs; and
vii. Claims processing costs.
5. "Hospital" may be defined in
relation to its status, facilities, and available services or to reflect
accreditation by the Joint Commission on Accreditation of Hospitals, but not
more restrictively than as defined by the Medicare program.
6. "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 Laws 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.
7. . "Medicare eligible
expense" shall mean expenses of the kinds covered by Medicare 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 by the Medicare
program.
9. "Preexisting condition"
shall not be defined more restrictively than a condition for which medical
advice was given or treatment was recommended by or received from a physician
within six months before the effective date of coverage.
10. "Sickness" shall not be defined more
restrictively than a sickness or disease which causes loss commencing while the
insurance or coverage is in force and which is not excluded under a preexisting
condition limitation. 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.
11. "Totally disabled" shall
not be defined more restrictively than as:
i.
An injury or sickness that continuously confines an individual in a hospital or
skilled nursing facility; or
ii. A
continuous disability resulting from an injury or sickness not requiring
confinement of an individual in a hospital or skilled nursing facility, but
which a physician certifies as preventing that individual from engaging in the
normal activities of a person of like age and sex in good health.
Disclaimer: These regulations may not be the most recent version. New Jersey may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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