Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 89 - APPROVAL OF LIFE, ACCIDENT AND HEALTH INSURANCE › Subchapter K - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS › Section 89.772 - Definitions

Current through Register Vol. 54, No. 28, July 13, 2024
The following words and terms, when used in this
					 subchapter, have the following meanings, unless the context clearly indicates
					 otherwise:
1990 Standardized Medicare supplement benefit
					 plan
-
(i) A group or
				  individual policy of Medicare supplement insurance issued on or after July 30,
				  1992, and prior to June 1, 2010.
(ii) The term includes Medicare supplement
				  insurance policies and certificates renewed on or after July 30, 1992, which
				  are not replaced by the issuer at the request of the insured.
2010 Standardized Medicare supplement benefit
					 plan
-A group or individual policy of Medicare supplement insurance
					 issued on or after June 1, 2010.
2020 Standardized Medicare supplement benefit
					 plan
-A group or individual policy or certificate of Medicare
					 supplement insurance issued on or after January 1, 2020.
Applicant
-
(i) In the case of an individual Medicare
				  supplement policy, the person who seeks to contract for insurance
				  benefits.
(ii) In the case of a
				  group Medicare supplement policy, the proposed certificateholder.
Bankruptcy
-The condition under which a
					 Medicare Advantage organization plan that is not an issuer has filed, or has
					 had filed against it, a petition or other action seeking a declaration of
					 bankruptcy under the provisions of the United States Bankruptcy Code (11
					 U.S.C.) and has ceased doing business in this Commonwealth.
Certificate
-A certificate delivered or
					 issued for delivery in this Commonwealth 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 Insurance Commissioner of
					 the Commonwealth.
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
-The definition
					 contained in the Health Insurance Portability and Accountability Act of 1996
					 (Pub. L. No.
					 104-191, 110 Stat. 1936), as adopted by the
					 Commonwealth under the Pennsylvania Health Care Insurance Portability Act
					 (40
					 P. S. §§
											1302.1-1302.7), is
					 incorporated herein by reference.
Employee welfare benefit plan
-A plan,
					 fund or program of employee benefits as defined in section 3 of the Employee
					 Retirement Income Security Act or ERISA (29 U.S.C.A. §
											1002).
HHS Secretary
-The Secretary of the United
					 States Department of Health and Human Services.
Insolvency
-The condition under which an
					 issuer, licensed to transact business in this Commonwealth by the Commissioner,
					 has had a final order of liquidation entered against it, or a finding of
					 insolvency by a court of competent jurisdiction in the issuer's state of
					 domicile.
Issuer
-The term includes insurance
					 companies, fraternal benefit societies and nonprofit corporations subject to 40
					 Pa.C.S. Chapters 61 and 63 (relating to hospital plan corporations; and
					 professional health services plan corporations) and other entities delivering
					 or issuing for delivery Medicare supplement policies or certificates in this
					 Commonwealth.
Medicare
-The program established by the
					 Health Insurance for the Aged Act, Title XVIII of the Social Security
					 Amendments of 1965 (42
					 U.S.C.A. §§
											1395-1395b-4) 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(b)(1) of
					 the Social Security Act (42
					 U.S.C.A. §
											1395w-28(b)(1)) and
					 includes:
(i) 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.
(ii) Medicare medical
				  savings account plans coupled with a contribution into a Medicare Advantage
				  plan medical savings account.
(iii)
				  Medicare Advantage private fee-for-service plans.
Medicare supplement policy
-
(i) A group or individual policy of insurance
				  or a subscriber contract other than a policy issued under a contract under
				  section 1876 of the Social Security Act (42 U.S.C.A. §
											1395mm) or a policy issued under a
				  demonstration project specified in section 1882(g)(1), of the Social Security
				  Act (42 U.S.C.A. §
											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.
(ii) The
				  term 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 under an agreement
				  under section 1833(a)(1)(A) of the Social Security Act (42 U.S.C.A. §
											1395l(a)(1)(A)).
Policy form
-The form on which the policy
					 is delivered or issued for delivery by the issuer.
Prestandardized Medicare supplement benefit
					 plan
-A group or individual policy of Medicare supplement insurance
					 issued prior to July 30, 1992.
Producer
-An insurance producer as defined
					 by the Article VI-A of The Insurance Department Act of 1921 (40 P. S.
					 §§
											310.1-310.99a), known as the
					 Producer Licensing Modernization Act.
The provisions of this §
												89.772 amended under the Omnibus
						Budget Reconciliation Act (OBRA 90) of November 15, 1990,
						P. L.
						101-508; sections 206, 506, 1501 and 1502 of The
						Administrative Code of 1929 (71 P.S. §§
													66,
						186,
						411 and
						412); and sections 354 and
						616 of The Insurance Company Law of 1921 (40 P.S. §§
													477b and
						751); under the Medicare
						Improvements for Patients and Providers Act of 2008 (Pub. L. No. 100-275, 122
						Stat. 2494); the Genetic Information Nondiscrimination Act of 2008
						(Pub. L. No.
						110-233, 122 Stat. 881); and sections 5 and 9 of
						the Medicare Supplement Insurance Act (40 P.S. §§
													3105 and
						3109); and section 314 of the
						Accident and Health Filing Reform Act (40 P.S. §
													3801.314).
This section cited in 31 Pa. Code §
												89.791 (relating to prohibition
						against use of genetic information and requests for genetic
						testing).