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 71.03 - Definitions

Current through Register 1525, July 5, 2024
Actuarial Opinion
. A signed written
				statement by a member of the American Academy of Actuaries based upon the
				person's examination, including a review of the appropriate records and of the
				actuarial assumptions and methods utilized by the Issuer in establishing
				premium rates for Policies for Medicare Supplement Insurance.
Advertisement
. Advertisement shall
				include, but is not limited to:
(a) Printed and published material, audio-visual material and
				descriptive literature of an Issuer used in direct mail, newspapers, websites,
				magazines, radio scripts, television scripts, billboards and similar
				displays;
(b) Descriptive literature and sales aids of all kinds issued
				by an Issuer, producer or other entity for presentation to members of the
				insurance-buying public including, but not limited to, circulars, leaflets,
				booklets, depictions, illustrations, electronic messaging, and form letters;
				and
(c) Prepared sales talks, presentations and material for use by
				producers (and solicitors).
Alternate Innovative Benefit Rider
.
				Any rider issued, renewed, or delivered by an Issuer which provides alternate
				innovative benefits consistent with
				211 CMR 71.09(5)
				 and may only be offered as optional
				additional coverage with a Medicare Supplement Core Insurance Policy, or a
				Medicare Supplement 1 Insurance Policy, or a Medicare Supplement 1A Insurance
				Policy, or a Medicare Select Insurance Policy described in
				211 CMR 71.21.
				Consistent with
				42
				U.S.C. §
									1395ss(p)(4)(B), an
Alternate Innovative Benefit Rider
is to be Guaranteed
				Renewable.
Applicant
. In the case of an
				individual Medicare Supplement Insurance Policy, the person who seeks to
				contract for insurance benefits, and in the case of a group Medicare Supplement
				Insurance Policy, the proposed certificateholder.
Bankruptcy
. 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
				Massachusetts.
BBA. The federal Balanced Budget Act of 1997 (P.L. 105-33).
Benefit Level
. The health benefits
				supplemental to Medicare provided by, and the benefit payment structure of, a
				Medicare Supplement Insurance Policy or Alternate Innovative Benefit
				Rider.
Biologically-based Mental Disorders
.
				Those disorders that are described in M.G.L. c. 175, § 47B(a), (b) and
				(c), M.G.L. c. 176A, § 8A(a), (b), and (c), and M.G.L. c. 176B, §
				4A(a), (b) and (c).
Certificate
. Any Certificate issued,
				renewed, delivered or issued for delivery in Massachusetts under a group
				Medicare Supplement Insurance Policy.
Certificate Form
. The form on which
				the Certificate is issued, renewed, delivered or issued for delivery by the
				Issuer.
Class. The underwriting and rating classifications originally
				used at the time the Policy was issued.
Cold Lead Advertising
. Making use
				directly or indirectly of any method of marketing which fails to disclose in a
				conspicuous manner that a purpose of the method of marketing is solicitation of
				insurance and that contact will be made by an insurance producer or
				Issuer.
Commissioner
. The Commissioner of
				Insurance or his or her designee.
Community Rating
. A rating methodology
				in which the premium for all persons covered by a particular Medicare
				Supplement Insurance Policy or Alternate Innovative Benefit Rider is the same,
				based on the experience of all persons covered by the plan, without regard to
				age, sex, health status, occupation, or genetic information.
Compensation
. Includes pecuniary or
				non-pecuniary remuneration of any kind relating to the sale or renewal of the
				Medicare Supplement Insurance Policy including, but not limited to,
				commissions, bonuses, gifts, prizes, awards and finders' fees.
Creditable Coverage
.
(a) Means, with respect to an individual, coverage provided
				under any of the following:
1. A group health plan;
2. Health insurance coverage;
3. Part A or Part B of Title XVIII of the Social Security Act
				(Medicare);
4. Title XIX of the Social Security Act (Medicaid), other than
				coverage consisting solely of benefits under the federal Social Security Act
				§ 1928;
5. 10 U.S.C. c. 55 (CHAMPUS);
6. A medical care program of the Indian Health Service or of a
				tribal organization;
7. A State health benefits risk pool;
8. A health plan offered under 5 U.S.C. c. 89 (Federal
				Employees Health Benefits Program);
9. A public health plan as defined in federal regulation;
				and
10. A health benefit plan under 22 U.S.C. c. 2504(e), §
				5(e) (Peace Corps Act).
(b) Shall not include one or more, or any combination, of the
				following:
1. Coverage only for accident or disability income insurance,
				or any combination thereof;
2. Coverage issued as a supplement to liability
				insurance;
3. Liability insurance, including general liability insurance
				and automobile liability insurance;
4. Workers' compensation or similar insurance;
5. Automobile medical payment insurance;
6. Credit-only insurance;
7. Coverage for on-site medical clinics; and
8. Other similar insurance coverage, specified in federal
				regulations, under which benefits for medical care are secondary or incidental
				to other insurance benefits.
(c) 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:
1. Limited scope dental or vision benefits;
2. Benefits for long-term care, nursing home care, home health
				care, community-based care, or any combination thereof; and
3. Such other similar, limited benefits as are specified in
				federal regulations.
(d) Shall not include the following benefits if offered as
				independent, non-coordinated benefits:
1. Coverage only for a specified disease or illness; and
2. Hospital indemnity or other fixed indemnity
				insurance.
(e) Shall not include the following if it is offered as a
				separate policy, certificate or contract of insurance:
1. Medicare supplemental health insurance as defined under the
				Social Security Act § 1882(g)(1);
2. Coverage supplemental to the coverage provided under 10
				U.S.C. c. 55; and
3. Similar supplemental coverage provided to coverage under a
				group health plan.
Division
. The Division of
				Insurance.
Eligible Person
. Any person who is
				eligible for Medicare Part A and B and is enrolled in Medicare Part B
				regardless of age; provided, however, that Issuers are not required to provide
				coverage to a person who is younger than 65 years old and eligible for Medicare
				coverage due solely to end-stage renal disease; provided, further, that nothing
				in
				211 CMR 71.00 prevents an
				Issuer from providing coverage to a person who is younger than 65 years old and
				is eligible for Medicare coverage due solely to end-stage renal disease; and
				provided, further, that if an Issuer determines that it will provide coverage
				to people who are younger than 65 years old and eligible for Medicare coverage
				due solely to end-stage renal disease, it shall do so in accordance with all of
				the provisions of
				211 CMR 71.00. A Medicare
				Supplement 1 policy shall, on or after January 1, 2020, only be offered to
				Eligible Persons who:
(a) have attained 65 years of age before January 1, 2020;
				or
(b) first became eligible for Medicare due to age, disability
				or end-stage renal disease, before January 1, 2020. Persons who are otherwise
				eligible for Medicare Part A and B and who are enrolled in Medicare Part B, but
				who are not eligible to purchase Medicare Supplement 1 coverage, shall be
				eligible to purchase all other Medicare Supplement coverage that is currently
				offered. For the definition of eligible persons related to the federal Balanced
				Budget Act of 1997 (BBA Eligible Person),
see
211
				CMR 71.10(12)(a). For the
				definition of eligible persons related to the federal Medicare Prescription
				Drug, Improvement, and Modernization Act of 2003 (MMA Eligible Person),
see
211
				CMR 71.10(13)(a).
Employee Welfare Benefit Plan
. A plan,
				fund or program of employee benefits as defined in
				29
				U.S.C. §
									1002 (Employee Retirement
				Income Security Act).
Evidence of Coverage
. Any certificate,
				contract or agreement issued to a Member stating health services and benefits
				to which the Member is entitled as described in M.G.L. c. 176K.
Genetic Information
. Any written,
				recorded, individually identifiable result of a genetic test or explanation of
				such a result.
Genetic Test
. A test of human DNA,
				RNA, mitochondrial DNA, chromosomes or proteins for the purpose of identifying
				the genes, or genetic abnormalities, or the presence or absence of inherited or
				acquired characteristics in genetic material.
Group
. An entity, as described in
				M.G.L. c. 175, § 110, to which a general or blanket Medicare Supplement
				Insurance Policy is issued or an entity to which a Medicare Supplement
				Insurance contract is issued pursuant to M.G.L. c. 176A, § 10 and M.G.L.
				c. 176B, § 4, except Group shall not include one or more employers or
				labor organizations, or of the trustees of a fund established by one or more
				employers or labor organizations, or combination thereof, for employees or
				former employees, or a combination thereof, or for members or former members,
				or a combination thereof, of the labor organizations.
Guaranteed Renewable
. A Policy
				provision whereby the Insured has the right, subject to the provisions of
				211 CMR
				71.07(5), to continue the
				Medicare Supplement Insurance Policy in force by the timely payment of premiums
				and the Issuer has no unilateral right to make any change in any provision of
				the Policy or rider(s), including Alternate Innovative Benefit Rider(s), while
				the insurance is in force other than changes in premiums, and cannot cancel or
				decline to renew, except for the nonpayment of premium or material
				misrepresentation; provided that no Nonprofit Hospital Service Corporation or
				Medical Service Corporation shall be required to continue the coverage of a
				Policyholder who becomes a resident of a state other than Massachusetts.
High Pressure Tactics
. Employing any
				method of marketing having the effect of or tending to induce the purchase of
				insurance through force, fright, threat, whether explicit or implied, or undue
				pressure to purchase or recommend the purchase of insurance.
Individual
. A person or family to
				which a Medicare Supplement Insurance Policy is issued pursuant to M.G.L. c.
				175, § 108 or M.G.L. c. 176A, § 6, and M.G.L. c. 176B, §
				4.
Initially Eligible for Coverage
. The
				date when an Eligible Person first enrolled for benefits under Medicare Part B,
				lost employer-sponsored health coverage due to termination of employment or
				because of employer bankruptcy or because of discontinuance of
				employer-sponsored health coverage available to similarly situated employees by
				the employer, moved out of the service area of a Health Maintenance
				Organization, or became a resident of Massachusetts.
Insolvency
. When an Issuer, licensed
				to transact the business of insurance in Massachusetts, 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.
Insured
. A subscriber, Policyholder,
				member, enrollee or certificateholder under a Medicare Supplement Insurance
				Policy.
Issue
. To offer, sell, issue, deliver,
				or otherwise make effective, or renew.
Issuer
. Any company as defined in
				M.G.L. c. 175, § 1 and authorized to write accident and health insurance;
				any hospital service corporation as defined in M.G.L. c. 176A, § 1, any
				medical service corporation as defined in M.G.L. c. 176B, § 1, any health
				maintenance organization licensed under M.G.L. c. 176G, or any Fraternal
				Benefit Society as authorized in M.G.L. c. 176 which offers, sells, delivers or
				otherwise makes effective, or renews in Massachusetts Medicare Supplement
				Insurance Policies. For purposes of determining whether an Issuer is offering a
				non-network Medicare Supplement plan, an Issuer shall include the Issuer, its
				parent company or companies, its affiliated companies, and/or its subsidiary
				companies.
Late Enrollee
. An Eligible Person who
				has submitted an application for a Medicare Supplement Insurance Policy after
				the six-month period beginning with the first month in which the Eligible
				Person first enrolled for benefits under Medicare Part B, or lost
				employer-sponsored coverage due to termination of employment or because of
				employer bankruptcy or because of discontinuance of employer-sponsored health
				coverage by the employer, or became a resident of Massachusetts; provided,
				however, that an Eligible Person shall not be considered a Late Enrollee if the
				person was covered under a Reasonably Actuarially Equivalent previous health
				plan and the previous coverage was continuous for the lesser of three years or
				the period since first eligibility and to a date not more than 30 days prior to
				the effective date of the new coverage.
Medicare
. "Health Insurance for the
				Aged Act", Title XVIII of the Social Security Amendments of 1965, as then
				constituted or later amended.
Medicare Advantage Plan
. A plan of
				coverage for health benefits under Medicare Part C as defined in
				42 U.S.C.
				1395w-28(b)(1), and
				includes:
(a) Coordinated care plans that 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 plans;
(b) Medical savings account plans coupled with a contribution
				into a Medicare Advantage medical savings account; and
(c) Medicare Advantage private fee-for-service plans.
Medicare Eligible Expense
. Expenses of
				the kinds covered by Medicare Parts A and B, to the extent recognized as
				reasonable and medically necessary by Medicare.
Medicare Supplement Insurance Policy
.
				A type of health insurance issued by a carrier, other than a policy issued
				pursuant to a contract under the Social Security Act § 1876 or § 1833
				(42 U.S.C. §
									1395
et seq
.), or a policy
				issued under a demonstration project authorized pursuant to amendments to the
				federal Social Security Act, 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. Unless otherwise
				set forth within
				211 CMR 71.00, Core Medicare
				Supplement Policies, Medicare Supplement 1 Policies, Medicare Supplement 1A
				Policies, and Medicare Supplement 2 Policies are all subject to Medicare
				Supplement Insurance Policy requirements.
Mental Disorder
. A condition as
				described in the 5th edition of the
Diagnostic and Statistical Manual
of the American Psychiatric
				Association.
MMA
. The federal Medicare Prescription
				Drug, Improvement, and Modernization Act of 2003 (Pub. L.
				108-173).
Off-label Use
. A drug that has not
				been specifically approved by the United States Food and Drug Administration
				for the treatment of cancer or HIV/AIDS, but is a drug approved for other
				indications by the Food and Drug Administration.
Other Mental Health Disorders
. All
				other mental disorders described in the 5th edition
				of the
Diagnostic and Statistical Manual
that are not
				biologically-based.
Outpatient Prescription Drug
. A
				prescription drug that is administered on an outpatient basis.
Participate in the Market
. To offer,
				sell, issue, deliver, or otherwise make effective, or renew, a Medicare
				Supplement Insurance Policy, Alternate Innovative Benefit Rider in
				Massachusetts, and to have not discontinued the availability of all of its
				Policy forms or Certificate forms.
Policy
. Any Policy, Certificate,
				contract, agreement, statement of coverage, rider or endorsement issued by an
				Issuer as defined in
				211 CMR 71.00 which provides
				Medicare Supplement Insurance as defined in 211 CMR 71.03:
Policy
other than a policy issued pursuant to a
				contract under the Social Security Act § 1876 (42 U.S.C. §
									1395
et seq
.) or an issued
				policy under a demonstration project specified in
				42
				U.S.C. §
									1395ss(g)(1),
				which provides Medicare Supplement Insurance as defined herein.
Policy
, unless stated otherwise within
				211 CMR 71.00, includes any
				Alternate Innovative Benefits Riders.
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
				the Social Security Act § 1833(a)(1)(A).
Policy Form
. The form on which the
				Medicare Supplement Insurance Policy is delivered or issued for delivery by the
				Issuer.
Policyholder
. Any person holding a
				Policy as defined in 211 CMR 71.03.
Pre-existing Conditions Limitation or
				Exclusion
. A provision in a Medicare Supplement Insurance Policy
				which limits or excludes coverage for charges or expenses incurred following
				the Insured's coverage effective date as to 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.
Producer
. Any insurance producer,
				advisor or other person engaged in activities described in M.G.L. c. 175,
				§§ 162 through 177D.
Rate Anniversary Date
. The calendar
				date in any year at least one year later than the date on which an Issuer's
				most recent Medicare Supplement rate increase became effective.
Reasonably Actuarially Equivalent
. The
				Benefit Level of one of two Medicare Supplement Insurance Policies or Evidences
				of Coverage Issued Pursuant to a Medicare Part C Contract with Medicare or
				other health benefit plan being compared is no more than ten percentage points
				greater in value than the Benefit Level for the other Medicare Supplement
				Insurance Policy, Alternate Innovative Benefit Rider or Evidence of Coverage
				Issued Pursuant to a Medicare Part C Contract with Medicare or health benefit
				plan, assuming that the benefits are offered to identical populations.
Secretary
. The Secretary of the United
				States Department of Health and Human Services.
Twisting
. Knowingly making any
				misleading representation or incomplete or fraudulent comparison of any
				insurance policies or carriers for the purpose of inducing, or tending to
				induce, any person to lapse, forfeit, surrender, terminate, retain, pledge,
				assign, borrow on, or convert any insurance policy or to take out a policy of
				insurance with another carrier.
Upgrade Coverage
. The Medicare
				Supplement Insurance Policy or Alternate Innovative Benefit Rider under which
				the Eligible Person is covered at the time of application for new coverage has
				a lower Benefit Level than the new coverage, and the two coverages are not
				Reasonably Actuarially Equivalent.
Waiting Period
. A period immediately
				subsequent to the effective date of an Insured's coverage during which the
				insurance coverage does not pay for some or all hospital or medical
				expenses.