Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 71.00 - Medicare Supplement Insurance To Facilitate The Implementation Of M.G.L. c. 176k And Section 1882 Of The Federal Social Security Act › Section 71.05 - Standards for Policy Definitions

Current through Register 1525, July 5, 2024
(1) No Policy
			 may be advertised, solicited, issued, renewed, delivered or issued for delivery
			 in Massachusetts as a Medicare Supplement Insurance Policy, unless such Policy
			 contains definitions or terms which conform to the requirements of 211 CMR
			 71.05.
(2) All definitions used in
			 a Medicare Supplement Insurance Policy shall be compatible with Medicare
			 definitions and practice.
(3) All
			 Medicare Supplement Insurance Policies shall include a definition for the
			 following terms:
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.
(a) The definition shall not be more
			 restrictive than the following: "Injury or injuries for which benefits are
			 provided means accidental bodily injury sustained by the insured person which
			 is the direct result of an accident, independent of disease or bodily infirmity
			 or any other cause, and occurs while insurance coverage is in force."
(b) The definition may provide that injuries
			 shall not include injuries for which benefits are provided or available under
			 any workers' compensation, employer's liability or similar law, motor vehicle
			 no-fault plan, or other motor vehicle insurance related plan, unless prohibited
			 by law.
Benefit Period
or
Medicare
				Benefit Period
shall not be defined more restrictively than as
				defined in the Medicare program.
Convalescent Nursing Home
,
Extended Care Facility
, or
Skilled Nursing
				Facility
shall not be defined more restrictively than as defined
				in the Medicare program.
Convalescent Nursing Home
,
Extended Care Facility
, or
Skilled Nursing
				Facility
must take into account that there are Policy benefits for
				these providers' services which are paid for only by the Medicare Supplement
				Insurance Policy and for which Medicare does not contribute payment.
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 shall not be defined
				more restrictively than as defined in the Medicare program. The definition must
				take into account that there are Policy benefits for these providers' services
				which are paid for only by the Medicare Supplement Insurance Policy and for
				which Medicare does not contribute payment.
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 Law 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."
Medicare Eligible Expenses
shall mean
				expenses of the kinds covered by Medicare Parts A and B, to the extent
				recognized as reasonable and medically necessary by Medicare.
Physician
shall not be defined more
				restrictively than as defined in the Medicare program. The definition must take
				into account that there are Policy benefits for this provider's services which
				are paid for only by the Medicare Supplement Insurance Policy and for which
				Medicare does not contribute payment.
Sickness
shall not be defined more
				restrictively than the following: an illness or disease of an insured person
				for which expenses are incurred after the effective date of insurance and while
				the insurance is in force.
Sickness
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.