Alaska Administrative Code › Title 3 - Commerce, Community, and Economic Development › Part 2 - Division of Insurance › Chapter 28 - Life, Health, Variable, and Related Insurance › Article 5 - Health Insurance Marketed as Medicare Supplements › 3 AAC 28.430 - Policy definitions and terms

Current through May 31, 2024
(a) A medicare
				  supplement policy or certificate using the following terms or their equivalent
				  must contain terms and definitions as follows:
(1) "accident," "accidental injury," or
				  "accidental means" must use "result" language and may not include words that
				  establish an accidental-means test or use words characterizing the accident or
				  injury as "external, violent, or visible wounds" or similar words of
				  description or characterization; the definition may not be more restrictive
				  than "injury or injuries for which benefits are provided means accidental
				  bodily injury sustained by the insured person that is the direct result of an
				  accident, independent of disease, bodily infirmity, or other cause, and occurs
				  while insurance coverage is in force"; the definition may provide that injuries
				  must not include injuries for which benefits are provided or available under a
				  workers' compensation, employer's liability, or similar law or a motor vehicle
				  no-fault plan, unless prohibited by law;
(2) "benefit period" or "medicare benefit
				  period" may not be more restrictively defined than in the medicare
				  program;
(3) "convalescent nursing
				  home," "extended care facility," or "skilled nursing facility" may not be more
				  restrictively defined than in the medicare program;
(4) repealed 7/1/92;
(5) "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 not more
				  restrictively than as defined in the medicare program;
(6) repealed 7/1/92;
(7) "medicare" means Title I, Part I of
				  Public Law 89-97, as enacted by the Eighty-Ninth Congress of the United States
				  of America, including subsequent amendments, (popularly known as the Health
				  Insurance for the Aged Act) and each policy or certificate must include this or
				  a substantively equivalent definition;
(8) "injury or injuries for which benefits
				  are provided" means accidental bodily injury sustained by the insured person
				  that is the direct result of an accident, independent of disease or bodily
				  infirmity or any other cause, and occurs while the insurance coverage is in
				  force; however, injuries for which benefits are provided under any workers
				  compensation, employer's liability or similar law may be excluded;
(9) "medicare eligible expenses" must include
				  expenses of the kind covered by medicare Parts A and B, to the extent
				  recognized as reasonable and medically necessary by medicare;
(10) repealed 7/1/92;
(11) repealed 7/1/92;
(12) if the terms "qualified physician" or
				  "licensed physician" are used, the insurer must accept, to the extent of its
				  obligation under the policy, all services provided that are within the scope of
				  the provider's licensed authority, and the terms must not be defined more
				  restrictively than as defined in the medicare program;
(13) "sickness" must be defined to include
				  any disease or illness of a covered person which first manifests itself after
				  the effective date of coverage and while the coverage is in force, but may
				  exclude disease or illness for which benefits are provided under any workers
				  compensation, occupational disease, employer's liability, or similar
				  law;
(14) "health care expenses"
				  must mean, for purposes of
				  3 AAC 28.468, expenses of a health maintenance
				  organization associated with the delivery of health care services that are
				  analogous to incurred losses of insurers.