Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 37 - Medicare Supplement Insurance › Rule 191-37.3 - Definitions

Current through Register Vol. 47, No. 3, July 24, 2024
For purposes of this chapter, in addition to the definitions
				  in Iowa Code section
				  514D2., the following
				  definitions shall apply, unless otherwise specified:
"1990 standardized Medicare supplement benefit
				  plan"
or
"1990 plan "
means a group or individual
				  Medicare supplement policy issued on or after January 1, 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 June 1,
				  2010, which are not replaced by the issuer at the request of the
				  insured.
"2010 standardized Medicare supplement benefit
				  plan"
or
"2010 plan "
means a group or individual
				  Medicare supplement policy issued with an effective date for coverage on or
				  after June 1, 2010.
"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 covered individual, unless stated otherwise.
"Basic core benefits"
are benefits defined
				  in subrule 37.7(2) for 1990 plans, subrule 37.8(2) for 2010 plans, and subrule
				  37.9(1) for Medicare supplement policies or certificates delivered or issued
				  for delivery to individuals newly eligible for Medicare on or after January 1,
				  2020.
"Certificate"
means any certificate of
				  coverage delivered or issued for delivery in this state to a covered individual
				  under a group Medicare supplement policy.
"Certificate form"
means the form (as
				  defined in Iowa Code section
				  514D2(2).) on which
				  the certificate is delivered or issued for delivery by the issuer.
"Certificate holder"
means the named
				  individual to whom the certificate of coverage under a group policy is issued,
				  or a spouse, if applicable.
"CMS"
means the Centers for Medicare and
				  Medicaid Services of the U.S. Department of Health and Human Services.
"Commissioner"
means the Iowa insurance
				  commissioner, and includes the insurance division as delegated.
"Covered individual"
means an individual who
				  may receive benefits under an individual or group Medicare supplement policy
				  because the individual is one of the following: the named insured under an
				  individual Medicare supplement policy; the named certificate holder under a
				  group Medicare supplement policy; or an individual such as a spouse covered by
				  way of the named certificate holder's group Medicare supplement policy. For
				  purposes of rule 191-3720. (514D), "covered
				  individual" means an individual who may receive benefits under an individual or
				  group Medicare Select policy because the individual is one of the following:
				  the named insured under an individual Medicare Select policy; the named
				  certificate holder under a group Medicare Select policy; or an individual such
				  as a spouse covered by way of the named certificate holder's group Medicare
				  Select policy.
"Creditable coverage."
1. "Creditable coverage" means, with respect to an
				  individual, health coverage of the individual provided under any of the
				  following:
* A group health plan;
* Health insurance coverage;
* Part A or Part B of Title XVIII of the Social Security Act
				  (Medicare);
* Title XIX of the Social Security Act (Medicaid), other than
				  coverage consisting solely of benefits under Section 1928;
* Chapter 55 of Title 10, United States Code
				  (CHAMPUS);
* A medical care program of the Indian Health Service or of a
				  tribal organization;
* A state health benefits risk pool;
* A health plan offered under Chapter 89 of Title 5, United
				  States Code (Federal Employees Health Benefits Program);
* A public health plan as defined in federal regulation;
				  and
* A health benefit plan under Section 5 (e) of the Peace
				  Corps Act ( 22 United States Code 2504(e)).
2. "Creditable coverage" shall not include one or more of, or
				  any combination of, the following:
* Coverage only for accident or disability income insurance,
				  or any combination thereof;
* Coverage issued as a supplement to liability
				  insurance;
* Liability insurance, including general liability insurance
				  and automobile liability insurance;
* Workers' compensation or similar insurance;
* Automobile medical payment insurance;
* Credit-only insurance;
* Coverage for on-site medical clinics; and
* Other similar insurance coverage, specified in federal
				  regulations, under which benefits for medical care are secondary or incidental
				  to other insurance benefits.
3. "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:
* Limited scope dental or vision benefits;
* Benefits for long-term care, nursing home care, home health
				  care, community-based care, or any combination thereof; and
* Such other similar limited benefits as are specified in
				  federal regulations.
4. "Creditable coverage" shall not include the following
				  benefits if offered as independent, noncoordinated benefits:
* Coverage only for a specified disease or illness;
				  and
* Hospital indemnity or other fixed indemnity
				  insurance.
5. "Creditable coverage" shall not include the following if
				  it is offered as a separate policy, certificate or contract of
				  insurance:
* Medicare supplemental health insurance as defined under
				  Section 1882(g)(1) of the Social Security Act;
* Coverage supplemental to the coverage provided under
				  Chapter 55 of Title 10, United States Code; and
* Similar supplemental coverage provided to the coverage
				  under a group health plan.
"File"
or
"filing,"
when
				  used in reference to filing information with the commissioner or with the
				  insurance division, means submitting information as set forth in these rules
				  through the System for Electronic Rate and Form Filing (SERFF),
www.serff.com
, or as otherwise directed by the
				  insurance division through its website,iid.iowa.gov.
"Group member"
means the individual who is a
				  member of the group entity to which the group policy is issued.
"Group policyholder"
means the group entity
				  to which a group Medicare supplement policy is issued.
"Insolvency"
means that 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.
"Insurance division"
means the Iowa
				  insurance division.
"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 medical savings account; and
3. Medicare Advantage private fee-for-service plans.
"Medicare Select policy" "Medicare Select
				  certificate," "Medicare Select issuer,"
and
"Medicare Select
				  network provider"
are defined in subrule 37.20(2).
"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 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, outpatient prescription drug plans established under Medicare
				  Part D, or any health care prepayment plan (HCPP) that provides benefits
				  pursuant to an agreement under Section 1833(a)(1)(A) of the Social Security
				  Act.
"MMA"
means the Medicare Prescription Drug,
				  Improvement, and Modernization Act of 2003,
				  Pub. L. No.
				  108-173, 117 Stat. 2066.
"PACE program"
means a program of
				  all-inclusive care for the elderly, operated by an approved PACE organization
				  (an entity that is approved as a PACE program by the Iowa department of human
				  services and that has in effect a PACE program agreement between the entity,
				  CMS, and the Iowa department of human services to operate a PACE program) that
				  provides comprehensive health care services to enrollees in Iowa, pursuant to
				  Section 1894 of the Social Security Act (
				  42
				  U.S.C. 1395ee e) and Iowa Administrative Code
				  rules 441-8821. (249A) through
				  441-8828. (249A).
"Person"
means any individual, corporation,
				  association, or partnership.
"Policy form"
means the form (as defined by
				  Iowa Code section
				  514D2(2).) on which
				  the policy (as defined by Iowa Code section
				  514D2(4).) is
				  delivered or issued for delivery by the issuer.
"Policyholder"
means the individual person
				  to whom or group entity to which an individual or group Medicare supplement
				  policy is issued.
"PPS"
means prospective payment
				  system.
"Prestandardized Medicare supplement benefit
				  plan"
or
"prestandardized plan"
means a group or
				  individual Medicare supplement policy issued prior to January 1, 1992.
"Producer"
means a person licensed in this
				  state pursuant to Iowa Code chapter 522B and Iowa Administrative Code
				  191-Chapter 10 to sell, solicit, negotiate, effect, procure, deliver, renew,
				  continue or bind policies of insurance for persons residing or located, or for
				  policies to be performed, in this state.
"Secretary"
means the Secretary of the U.S.
				  Department of Health and Human Services.
"SMSBP"
or
"standardized Medicare
				  supplement benefit plan"
means a 1990 plan, a 2010 plan, or a plan
				  described in subrule 37.9(1) for Medicare supplement policies or certificates
				  delivered or issued for delivery to individuals newly eligible for Medicare on
				  or after January 1, 2020.