Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 5 - Regulation 33-Medicare Supplement Insurance Minimum Standards › Section XIII-503 - Definitions

Current through Register Vol. 50, No. 6, June 20, 2024
A. For purpose of this regulation:
Applicant
-
a. in the case of an individual Medicare supplement policy,
				  the person who seeks to contract for insurance benefits; and
b. in the case of a group Medicare supplement 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 the
				  state.
Certificate
-any certificate delivered or
				  issued for delivery in this state under a group Medicare supplement
				  policy.
Certificate Form
-the form on which the
				  certificate is delivered or issued for delivery by the issuer.
Commissioner
-the Commissioner of Insurance
				  of the state of Louisiana.
Continuous Period of Creditable Coverage
-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 63 days.
Creditable Coverage
-
a. with respect to an individual, coverage of the individual
				  provided under any of the following:
i. a group health plan;
ii. health insurance coverage;
iii. Part A or Part B of Title XVIII of the Social Security
				  Act (Medicare);
iv. Title XIX of the Social Security Act (Medicaid), other
				  than coverage consisting solely of benefits under Section 1928;
v. Chapter 55 of Title 10 United States Code
				  (CHAMPUS);
vi. a medical care program of the Indian Health Service or of
				  tribal organization;
vii. a state health benefits risk pool;
viii. a health plan offered under Chapter 89 of Title 5
				  United States Code (Federal Employees Health Benefits Program);
ix. a public health plan as defined in federal regulation;
				  and
x. a health benefit plan under Section 5(e) of the Peace
				  Corps Act [
				  22 United States Code
				  2504(e)] ;
b. creditable coverage shall not include one or more, or any
				  combination, of the following:
i. coverage only for accident or disability income insurance,
				  or any combination thereof;
ii. coverage issued as a supplement to liability
				  insurance;
iii. liability insurance, including general liability
				  insurance and automobile liability insurance;
iv. workers compensation or similar insurance;
v. automobile medical payment insurance;
vi. credit-only insurance;
vii. coverage for on-site medical clinics; and
viii. other similar insurance coverage, specified in federal
				  regulations, under which benefits for medical care are secondary or incidental
				  to other insurance benefits;
c. 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:
i. limited scope dental or vision benefits;
ii. benefits for long-term care, nursing home care, home
				  health care, community-based care, or any combination thereof; and
iii. such other similar, limited benefits as are specified in
				  federal regulations;
d. creditable coverage shall not include the following
				  benefits if offered as independent, noncoordinated benefits:
i. coverage only for a specified disease or illness;
				  and
ii. hospital indemnity or other fixed indemnity
				  insurance;
e. creditable coverage shall not include the following if it
				  is offered as a separate policy, certificate or contract of insurance:
i. Medicare supplemental health insurance as defined under
				  Section 1882(g)(1) of the Social Security Act;
ii. coverage supplemental to the coverage provided under
				  Chapter 55 of Title 10, United States Code; and
iii. similar supplemental coverage provided to coverage under
				  a group health plan.
a. any capital and surplus required by law for its
				  organization; and
b. the total par or stated value of its authorized and issued
				  capital stock;
c. for purposes of this Subsection, liabilities shall include
				  but not be limited to reserves required by statute, by general regulations of
				  the Department of Insurance or by specific requirements imposed by the
				  commissioner upon a subject company at the time of admission or subsequent
				  thereto.
Issuer
-insurance companies, fraternal
				  benefit societies, health care service plans, health maintenance organizations,
				  and any other entity authorized to deliver or issue for delivery in this state
				  Medicare supplement policies or certificates. For purposes of §591. A 10.a. of
				  this regulation, the term shall also include third party administrators, or any
				  other person acting for or on behalf of such issuer.
Medicare
-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
-a plan of coverage
				  for health benefits under Medicare Part C as defined in Section 1859 found in
				  Title
				  42
				  U.S.C. 1395w - 28(b)(1), and includes:
a. 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;
b. medical savings account plans coupled with a contribution
				  into a Medicare advantage plan medical savings account; and
c. Medicare advantage private fee-for-service plans.
Medicare Supplement Policy
-a group or
				  individual policy of health 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. §
										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 (HCPP) that provides benefits pursuant to an agreement under
				  §1833(a)(1)(A) of the Social Security Act.
Policy Form
-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
-a group or
				  individual policy of Medicare supplement insurance issued prior to July 20,
				  1992.
1990 Standardized Medicare Supplement Benefit Plan,
				  1990 Standardized Benefit Plan or 1990 Plan
-a group or individual
				  policy of Medicare supplement insurance issued on or after July 20, 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
-a group or individual
				  policy of Medicare supplement insurance issued with an effective date for
				  coverage on or after June 1, 2010.
Qualified Actuary
-an actuary who is a member
				  of either the Society of Actuaries or the American Academy of Actuaries.
Secretary
-the Secretary of the United States
				  Department of Health and Human Services.
AUTHORITY NOTE:
				  Promulgated in accordance with
				  R.S.
				  22:1111 (re-designated from LSA-R.S. 22:224 pursuant
				  to Acts 2008, No. 415, effective January 1, 2009) and
				  42 U.S.C.
				  1395 et seq.