West Virginia Code of State Rules
Agency 114 - Insurance Commission
Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER
Series 114-24 - Medicare Supplement Insurance
Section 114-24-2 - Definitions

Universal Citation: 114 WV Code of State Rules 114-24-2

Current through Register Vol. XLI, No. 38, September 20, 2024

2.1. "Applicant" means:

2.1.a. In the case of an individual Medicare supplement policy, the person who seeks to contract for insurance benefits, and

2.1.b. In the case of a group Medicare supplement policy, the proposed certificate holder.

2.2. "Bankruptcy" means when 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.

2.3. "Certificate" means any certificate delivered or issued for delivery in this state under a group Medicare supplement policy.

2.4. "Certificate Form" means the form on which the certificate is delivered or issued for delivery by the issuer.

2.5. "Creditable coverage" means:

2.5.a. With respect to an individual, coverage of the individual provided under any of the following:
2.5.a.1. A group health plan;

2.5.a.2. Health insurance coverage;

2.5.a.3. Part A or Part B of Title XVIII of the Social Security Act (Medicare);

2.5.a.4. Title XIX of the Social Security Act (Medicaid), other than coverage consisting solely of benefits under section 1928;

2.5.a.5. Chapter 55 of Title 10 United States Code (CHAMPUS);

2.5.a.6. A medical care program of the Indian Health Service or of a tribal organization;

2.5.a.7. A State health benefits risk pool;

2.5.a.8. A health plan offered under chapter 89 of Title 5 United States Code (Federal Employees Health Benefits Program);

2.5.a.9. A public health plan as defined in federal regulation; and

2.5.a.10. A health benefit plan under Section 5(e) of the Peace Corps Act ( 22 United States Code 2504(e)) .

2.5.b. "Creditable coverage" shall not include one or more, or any combination of, the following:
2.5.b.1. Coverage only for accident or disability income insurance, or any combination thereof;

2.5.b.2. Coverage issued as a supplement to liability insurance;

2.5.b.3. Liability insurance, including general liability insurance and automobile liability insurance;

2.5.b.4. Workers' compensation or similar insurance;

2.5.b.5. Automobile medical payment insurance;

2.5.b.6. Credit-only insurance;

2.5.b.7. Coverage for on-site medical clinics; and

2.5.b.8. Other similar insurance coverage, specified in federal regulations, under which benefits for medical care are secondary or incidental to other insurance benefits.

2.5.c. "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:
2.5.c.1. Limited scope dental or vision benefits;

2.5.c.2. Benefits for long-term care, nursing home care, home health care, community-based care, or any combination thereof; and

2.5.c.3. Other similar, limited benefits as are specified in federal regulations.

2.5.d. "Creditable coverage" shall not include the following benefits if offered as independent, non-coordinated benefits:
2.5.d.1. Coverage only for a specified disease or illness; and

2.5.d.2. Hospital indemnity or other fixed indemnity insurance.

2.5.e. "Creditable coverage" shall not include the following if it is offered as a separate policy, certificate or contract of insurance:
2.5.e.1. Medicare supplemental health insurance as defined under section 1882(g)(1) of the Social Security Act;

2.5.e.2. Coverage supplemental to the coverage provided under Chapter 55 of Title 10, United States Code; and

2.5.e.3. Similar supplemental coverage provided to coverage under a group health plan.

2.6. "Commissioner" means the Insurance Commissioner of the State of West Virginia.

2.7. "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 sixty-three (63) days.

2.8. "Employee welfare benefit plan" means a plan, fund or program of employee benefits as defined in 29 U.S.C. Section 1002 (Employee Retirement Income Security Act).

2.9. "Insolvency" means 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.

2.10. "Issuer" means an insurance company, fraternal benefit society, health care service plan, health maintenance organization, or any other entity delivering or issuing for delivery in this state Medicare supplement policies or certificates.

2.11. "Medicare" means the "Health Insurance for the Aged Act," Title XVIII of the Social Security Amendments of 1965, as then constituted or later amended.

2.12. "Medicare Advantage plan" means a plan of coverage for health benefits under Medicare Part C as defined in 42 U.S.C. 1395w-28(b)(1), and includes:

2.12.a. 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;

2.12.b. Medical savings account plans coupled with a contribution into a Medicare Advantage plan medical savings account; and

2.12.c. Medicare Advantage private fee-for-service plans.

2.13. "Medicare Supplement Policy" means a group or individual policy of accident and sickness insurance or a subscriber contract of hospital and medical service associations or corporations or health maintenance organizations, other than a policy issued pursuant to a contract under Section 1876 of the federal Social Security Act ( 42 U.S.C. Section 1395 et seq.) or an issued policy under a demonstration project specified in 42 U.S.C. § 1395ss(g)(1), which is advertised, marketed or designed primarily as a supplement to reimbursements under Medicare for the hospital, medical or surgical expenses of persons eligible for Medicare. "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.

2.14. "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 August 5, 1991.

2.15. "Policy Form" means the form on which the policy is delivered or issued for delivery by the issuer.

2.16. "Secretary" means the Secretary of the United States Department of Health and Human Services.

2.17. "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 August 5, 1991 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.

2.18. "2010 Standardized Medicare supplement benefit plan," "2010 Standardized benefit plan" or "2010 plan" means a group or individual policy of Medicare supplement insurance with an effective date for coverage on or after June 1, 2010.

Disclaimer: These regulations may not be the most recent version. West Virginia 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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