Hawaii Administrative Rules › Title 16 - DEPARTMENT OF COMMERCE AND CONSUMER AFFAIRS › Chapter 12 - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS › Section 16-12-3 - Definitions

Current through June, 2024
Unless the context indicates otherwise, as used in this
				chapter:
"Applicant" means:
(1) In the case of an individual Medicare supplement policy,
				the person who seeks to contract for insurance benefits; and
(2) In the case of a group Medicare supplement policy, the
				proposed certificate holder.
"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.
"Certificate" means any certificate delivered or issued for
				delivery in this State under a group Medicare supplement policy.
"Certificate form" means the form on which the certificate is
				delivered or issued for delivery by the issuer.
"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 days. "Creditable coverage":
(1) Means, with respect to an individual, coverage of the
				individual provided under any of the following:
(A) A group health plan;
(B) Health insurance coverage;
(C) Part A or Part B of Title XVIII of the Social Security Act
				(Medicare);
(D) Title XIX of the Social Security Act (Medicaid), other than
				coverage consisting solely of benefits under Section 1928;
(E) Chapter 55 of Title 10 United States Code (CHAMPUS);
(F) A medical care program of the Indian Health Service or of a
				tribal organization;
(G) A state health benefits risk pool;
(H) A health plan offered under Chapter 89 of Title 5 United
				States Code (Federal Employees Health Benefits Program;
(I) A public health plan as defined in federal regulation;
				and
(J) A health benefit plan under Section 5(e) of the Peace Corps
				Act (
				22 United States Code Section
				2504(e) ).
(2) Shall not include one or more, or any combination of, the
				following:
(A) Coverage only for accident or disability income insurance,
				or any combination thereof;
(B) Coverage issued as a supplement to liability
				insurance;
(C) Liability insurance, including general liability insurance
				and automobile liability insurance;
(D) Workers' compensation or similar insurance;
(E) Automobile medical payment insurance;
(F) Credit-only insurance;
(G) Coverage for on-site medical clinics; and
(H) Other similar insurance coverage, specified in federal
				regulations, under which benefits for medical care are secondary or incidental
				to other insurance benefits.
(3) 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:
(A) Limited scope dental or vision benefits;
(B) Benefits for long-term care, nursing home care, home health
				care, community-based care, or any combination thereof; and
(C) Those other similar, limited benefits as are specified in
				federal regulations.
(4) Shall not include the following benefits if offered as
				independent, noncoordinated benefits:
(A) Coverage only for a specified disease or illness;
				and
(B) Hospital indemnity or other fixed indemnity
				insurance.
(5) Shall not include the following if it is offered as a
				separate policy, certificate, or contract of insurance:
(A) Medicare supplemental health insurance as defined under
				Section 1882(g)(1) of the Social Security Act;
(B) Coverage supplemental to the coverage provided under
				Chapter 55 of Title 10, United States Code; and
(C) 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
				United States Code Section 1002 (Employee
				Retirement Income Security Act).
"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.
"Issuer" includes insurance companies, fraternal benefit
				societies, health care service plans, health maintenance organizations, and any
				other entity delivering or issuing for delivery in this State Medicare
				supplement policies or certificates.
"Medicare" means the "Health Insurance for the Aged Act," Title
				XVIII of the Social Security Amendments of 1965, as then constituted or later
				amended.
"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:
(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 plan medical savings account; and
(3) Medicare Advantage private fee-for-service plans.
"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 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. Section
				1395 ss(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 that
				provides benefits pursuant to an agreement under section 1833(a)(1)(A) of the
				Social Security Act.
"Policy form" means the form on which the policy is delivered
				or issued for delivery by the issuer.
"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 September 3,
				1992.
"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 September 3, 1992, 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.
"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.
"Secretary" means the Secretary of the United States Department
				of Health and Human Services.