North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-01.1 - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS › Section 45-06-01.1-02 - Definitions

Current through Supplement No. 393, July, 2024
For purposes of this chapter:
1. "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 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
				  that date which are not replaced by the issuer at the request of the insured.
2. "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.
3. "Applicant" means:
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 certificate holder.
4. "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.
5. "Certificate" means any certificate delivered or issued
				  for delivery in this state under a group medicare supplement policy.
6. "Certificate form" means the form on which the certificate
				  is delivered or issued for delivery by the issuer.
7. "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.
8.
a."Creditable coverage" means, with respect to an individual,
				  coverage of the individual 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 other than coverage
				  consisting solely of benefits under section 1928;
(5) 10 U.S.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. 89 (federal
				  employees health benefits program);
(9) A public health plan as defined in federal regulations;
				  and
(10) A health benefit plan under section 5(e) of the Peace
				  Corps Act ( 22 U.S.C.
				  2504(e) ).
b. "Creditable coverage" does 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 onsite 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. "Creditable coverage" does 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. "Creditable coverage" does not include the following
				  benefits if offered as independent, noncoordinated benefits:
(1) Coverage only for a specified disease or illness; and
(2) Hospital indemnity or other fixed indemnity insurance.
e. "Creditable coverage" does not include the following if it
				  is offered as a separate policy, certificate, or contract of insurance:
(1) Medicare supplement health insurance as defined under
				  section 1882(g)(1) of the Social Security Act;
(2) Coverage supplemental to the coverage provided under 10
				  U.S.C. 55; and
(3) Similar supplemental coverage provided to coverage under
				  a group health plan.
9. "Employee welfare benefit plan" means a plan, fund, or
				  program of employee benefits as defined in
				  29 U.S.C.
				  1002 (Employee Retirement Income Security
				  Act).
10. "Insolvency" means when an issuer, licensed to transact
				  the business of insurance in this state, is unable to pay its obligations when
				  they are due, or when its admitted assets do not exceed its liabilities plus
				  the greater of:
a. Any capital and surplus required by law for its
				  organization; or
b. The total par or stated value of its authorized and issued
				  capital stock.
11. "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.
12. "Medicare" means the Health Insurance for the Aged Act,
				  title XVIII of the Social Security Amendments of 1965, as then constituted or
				  later amended.
13. "Medicare advantage plan" means a plan of coverage for
				  health benefits under medicare part C as defined in
				  42 U.S.C.
				  1395 w - 28(b)(1), and includes:
a. Coordinated care plans which provide health care services,
				  including 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 medical savings account; and
c. Medicare advantage private fee-for-service plans.
14. "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. 1395 et seq.] or an issued policy
				  under the 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 that
				  provides benefits pursuant to an agreement under section 1833(a)(1)(A) of the
				  Social Security Act.
15. "Policy form" means the form on which the policy is
				  delivered or issued for delivery by the issuer.
16. "Prestandardized medicare supplement benefit plan",
				  "prestandardized benefit plan", or "prestandardized plan" means a group or
				  individual policy of medicare supplement insurance issued prior to January 1,
				  1992.
17. "Secretary" means the secretary of the United States
				  department of health and human services.
General Authority: NDCC 26.1-36.1-02(1 )(2), 26.1-36.1-03
Law Implemented: NDCC
					 26.1-36.1