Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 13 - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS › Section 365:10-5-123 - Definitions

Current through Vol. 41, No. 20, July 1, 2024
The following words or terms, when used in this Part,
					 shall have the following meaning, unless the context clearly indicates
					 otherwise:
"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 certificateholder.
"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.
"Certificate"
means any certificate delivered
					 or issued for delivery in this state under a group Medicare supplement
					 policy.
"Certificate Form"
means the form on which the
					 certificate is delivered or issued for delivery by the issuer.
"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 (63) days.
"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);
(F) A medical care program of the Indian Health Service or
					 of a tribal organization;
(G) A state health benefits risk pool;
(H) A state health benefits program;
(I) A health plan offered under Chapter 89 of Title 5
					 United States Code (Federal Employees Health Benefits Program);
(J) A public health plan as defined in federal regulation;
					 and
(K) A health benefit plan under section
					 5 of the
					 Peace Corps Act (
					 22 United States Code
					 2504(e) ).
"Creditable coverage"
shall not include one or
					 more, or any combination of the following:
(A) Coverage only for accident or disability income
					 insurance, or any combination thereof;
(B) Coverage issued as a supplement to liability
					 insurance;
(C) Liability insurance, including general liability
					 insurance and automobile liability insurance;
(D) Workers' compensation or similar insurance;
(E) Automobile medical payment insurance;
(F) Credit-only insurance;
(G) Coverage for on-site medical clinics; and
(H) Other similar insurance coverage, specified in federal
					 regulations, under which benefits for medical care are secondary or incidental
					 to other insurance benefits;
"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:
(A) Limited scope dental or vision benefits;
(B) Benefits for long-term care, nursing home care, home
					 health care, community-based care, or any combination thereof; and
(C) Such other similar, limited benefits as are specified
					 in federal regulations.
"Creditable coverage"
shall not include the
					 following benefits if offered as independent, noncoordinated benefits:
(A) Coverage only for a specified disease or illness;
					 and
(B) Hospital indemnity or other fixed indemnity
					 insurance.
"Creditable coverage"
shall not include the
					 following if it is offered as a separate policy, certificate or contract of
					 insurance:
(A) Medicare supplemental health insurance as defined under
					 Section 1822(g)(1) of the Social Security Act;
(B) Coverage supplemental to the coverage provided under
					 Chapter 55 of the Title 10, United States Code; and
(C) Similar supplemental coverage provided to coverage
					 under a group health plan.
"Employee welfare benefit plan"
means a plan,
					 fund or program of employee benefits as defined in
					 29
					 U.S.C. Section 1002 (Employee Retirement
					 Income Security Act).
"Insolvency"
means an issuer is placed under
					 an order of liquidation by a court of competent jurisdiction with a finding of
					 insolvency.
"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:
(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) Medicare 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 Supplement Policy"
means a group or
					 individual policy of accident and health insurance or a subscriber contract of
					 a non-profit hospital service and medical indemnity corporation or health
					 maintenance organization, 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 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.
"Pre-Standardized Medicare supplement benefit plan,"
					 "Pre-Standardized benefit plan"
or
"Pre-Standardized plan"
means a group or individual policy of Medicare supplement insurance issued
					 prior to July 1, 1992.
"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
					 July 1, 1992 and 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"
means a
					 group or individual policy of Medicare supplement insurance issued on or after
					 June 1, 2010.
"Policy Form"
means the form on which the
					 policy is delivered or issued for delivery by the issuer.
"Secretary"
means the Secretary of the United
					 States Department of Health and Human Services.
Added at 9 Ok Reg
					 2499, eff 6-26-92; Amended at 14 Ok Reg 2292, eff 7-1-97; Amended at 15 Ok Reg
					 3569, eff 5-29-98 (emergency); Amended at 16 Ok Reg 1088, eff 4-26-99; Amended
					 at 22 Ok Reg 1954, eff 7-14-05; Amended at 26 Ok Reg 1551, eff
					 7-1-09