New York Codes, Rules and Regulations › Title 11 - INSURANCE › Chapter III - Policy and Certificate Provisions › Subchapter A - Life, Accident and Health Insurance › Part 58 - Minimum Standards For Form, Content And Sale Of Medicare Supplement And Medicare Select Insurance, Including Standards Of Full And Fair Disclosure › Section 58.1 - Rules relating to content of forms for medicare supplement insurance

Current through Register Vol. 46, No. 28, July 10, 2024
The following shall be applicable to Medicare supplement
					 insurance as defined in section
					 52.11 
					 of this Title and shall be in addition to other requirements of this Part. Such
					 rules shall apply to all Medicare supplement and Medicare select policies and
					 certificates.
(a) Definitions.
(1) Subject to any provision dealing with
				  preexisting conditions, incontestability or extension of benefits, the 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. 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.'' The definition may provide that injuries shall not
				  include injuries for which benefits are provided under any State or Federal
				  workers' compensation, employers' liability or occupational disease law, or
				  benefits to the extent provided for any loss, or portion thereof, for which
				  mandatory automobile no-fault benefits are recovered or recoverable.
(2) Applicant means:
(i) in the case of an individual Medicare
				  supplement policy, the person who seeks to contract for insurance benefits;
				  and
(ii) in the case of a group
				  Medicare supplement policy, the proposed certificateholder.
(3) Benefit period or Medicare
				  benefit period shall not be defined more restrictively than as defined in the
				  Medicare program.
(4) Certificate
				  means any certificate delivered or issued for delivery in this State regardless
				  of the situs of delivery of the group Medicare supplement policy.
(5) Certificate form means the form on which
				  the certificate is delivered or issued for delivery by the issuer.
(6) The terms convalescent nursing home,
				  extended care facility, or skilled nursing facility shall not be defined more
				  restrictively than as defined in the Medicare program.
(7)
(i) The
				  term creditable coverage means, with respect to an individual, coverage of the
				  individual provided under any of the following:
(a) a group health plan;
(b) health insurance coverage;
(c) part A or part B of title XVIII of the
				  Social Security Act (Medicare);
(d)
				  title XIX of the Social Security Act (Medicaid), other than coverage consisting
				  solely of benefits under section 1928;
(e) chapter 55 of title 10, United States
				  Code (CHAMPUS and TRICARE health care programs for the uniformed military
				  services);
(f) a medical care
				  program of the Indian Health Service or of a tribal organization;
(g) a State health benefits risk
				  pool;
(h) a health plan offered
				  under chapter 89 of title 5, United States Code (Federal Employees Health
				  Benefits Program);
(i) a public
				  health plan;
(j) a health benefit
				  plan under section 5(e) of the Peace Corps Act (22 U.S.C. section
				  2504 [e]); and
(k) Medicare supplement insurance, Medicare
				  select coverage or Medicare Advantage plan.
(ii) Except as specified in subparagraph (i)
				  of this paragraph, creditable coverage shall not include any coverage in
				  relation to its provision of "excepted benefits'' as defined in section 2791(c)
				  of the Federal Public Health Service Act (42
				  U.S.C. section 300gg-91 [c]) and meeting the
				  requirements for exception as set forth in section 2721(c) or (d) of the
				  Federal Public Health Service Act (42 U.S.C. section
				  300gg-21 [c] and [d] or section 2763[a] or
				  [b] of the Federal Public Health Service Act,
				  42 U.S.C. section
				  300gg-63 [a] and [b]). However, this
				  exemption shall not be applicable to any coverage providing hospital or
				  surgical indemnity benefits with specific dollar amounts that exceed the
				  amounts required to meet the definitions of basic hospital and basic medical
				  insurance in sections
				  52.5 and
				  52.6  of
				  this Title.
(iii) For purposes of
				  subparagraph (b)(3)(ii) of this section, credit for the time that a person was
				  previously covered under part A or part B of title XVIII of the Social Security
				  Act (Medicare) shall be required only if the applicant submits an application
				  for Medicare supplement insurance prior to or during the six-month period
				  beginning with the first day of the first month in which an individual is both
				  65 years of age or older and is enrolled for benefits under Medicare part
				  B.
(8) The term health
				  care expenses shall mean expenses of health maintenance organizations
				  associated with the delivery of health care services, which expenses are
				  analogous to incurred losses of insurers. Expenses shall not include:
(i) home office and overhead costs;
(ii) advertising costs;
(iii) commissions and other acquisition
				  costs;
(iv) taxes;
(v) capital costs;
(vi) administrative costs; and
(vii) claims processing costs.
(9) The term 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 not more restrictively than as defined in the Medicare
				  program.
(10) The term issuer
				  includes insurance companies, fraternal benefit societies, not-for-profit
				  health service, hospital service or medical expense indemnity corporations,
				  health maintenance organizations, and any other entity delivering or issuing
				  for delivery in this State Medicare supplement insurance policies or
				  certificates.
(11) The term
				  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,'' or words of similar import.
(12) 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:
(i) 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 organization
				  plans;
(ii) medical savings account
				  plans coupled with a contribution into a Medicare advantage plan medical
				  savings account; and
(iii) Medicare
				  advantage private fee-for-service plans.
(13) The term 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.
(14) The term physician shall not be defined
				  more restrictively than as defined in the Medicare program.
(15) Policy form means the form on which the
				  policy is delivered or issued for delivery by the issuer.
(16) Secretary means the Secretary of the
				  United States Department of Health and Human Services.
(17) Subject to any provision dealing with
				  preexisting conditions, incontestability or extension of benefits, the term
				  sickness shall not be defined to be more restrictive than the following:
				  illness or disease of an insured person. The definition may be further modified
				  to exclude sicknesses or diseases for which benefits are provided under any
				  State or Federal workers' compensation, employers' liability or occupational
				  disease law.