Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 170 - RULES GOVERNING MINIMUM STANDARDS FOR MEDICARE SUPPLEMENT POLICIES › Section 14VAC5-170-30 - Definitions

Current through Register Vol. 40, No. 24, July 15, 2024
The following words and terms when used in this chapter shall
				  have the following meanings unless the context clearly indicates
				  otherwise:
"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 30, 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
				  that 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 with an effective date for coverage on or
				  after June 1, 2010.
"Applicant" means:
1.  In the case of an individual Medicare supplement policy,
				  the person who seeks to contract for insurance benefits; and
2.  In the case of a group Medicare supplement policy, the
				  proposed certificateholder.
"Attained age rating" means a premium structure under which
				  premiums are based on the covered individual's age at the time of application
				  of the policy or certificate, and for which premiums increase based on the
				  covered individual's increase in age during the life of the policy or
				  certificate.
"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 this
				  Commonwealth.
"Certificate" means any certificate delivered or issued for
				  delivery in this Commonwealth under a group Medicare supplement policy.
"Certificate form" means the form on which the certificate is
				  delivered or issued for delivery by the issuer.
"Community rating" means a premium structure under which
				  premium rates are the same for all covered individuals of all ages in a given
				  area.
"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 did not have a break in coverage greater
				  than 63 days.
"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
				  of 1935 (Medicare) ( 42 USC
				  §
										1395 et seq.);
4.  Title XIX of the Social Security Act of 1935 (Medicaid) (
				  42 USC §
										1396 et seq.), other than coverage consisting
				  solely of benefits under § 1928;
5.  Chapter 55 of Title 10 of the United States Code (TRICARE)
				  ( 10 USC§§ 1071-1107 );
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 the Federal Employees Health
				  Benefits Act of 1959 ( 5 USC §§ 8901-8914 );
9.  A public health plan as defined in federal regulation;
				  and
10.  A health benefit plan under § 5(e) of the Peace
				  Corps Act of 1961 ( 22 USC
				  §
										2504(e) ).
"Creditable coverage" shall 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 expense insurance;
6.  Credit-only insurance;
7.  Coverage for on-site 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.
"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:
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.
"Creditable coverage" shall 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.
"Creditable coverage" shall 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
				  § 1882(g)(1) of the Social Security Act of 1935 (
				  42 USC §
										1395ss );
2.  Coverage supplemental to the coverage provided under
				  Chapter 55 of Title 10 of the United States Code ( 10 USC §§
				  1071-1107 ); and
3.  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 the Employee Retirement Income Security Act
				  of 1974 ( 29 USC §
										1002 ).
"Insolvency" means when an issuer, duly licensed to transact
				  an insurance business in this Commonwealth in accordance with the provisions of
				  Chapter 10, 41, 42 or 43, respectively, of Title 38.2 of the Code of Virginia,
				  is determined to be insolvent and placed under a final order of liquidation by
				  a court of competent jurisdiction.
"Issue age rating" means a premium structure based upon the
				  covered individual's age at the time of purchase of the policy or certificate.
				  Under an issue age rating structure, premiums do not increase due to the
				  covered individual's increase in age during the life of the policy or
				  certificate.
"Issuer" includes insurance companies, fraternal benefit
				  societies, corporations licensed pursuant to Chapter 42 of Title 38.2 of the
				  Code of Virginia to offer health services plans, health maintenance
				  organizations, and any other entity delivering or issuing for delivery in this
				  Commonwealth Medicare supplement policies or certificates.
"Medicare" means the "Health Insurance for the Aged Act,"
				  Title XVIII of the Social Security Act (
				  42 USC §
										1395 et seq.), as then constituted or later
				  amended.
"Medicare Advantage plan" means a plan of coverage for health
				  benefits under Medicare Part C as defined in § 1859 (
				  42 USC §
										1395w-28(b)(1) of the Social
				  Security Act, and includes:
1.  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;
2.  Medical savings account plans coupled with a contribution
				  into a Medicare Advantage medical savings account; and
3.  Medicare Advantage private fee-for-service plans.
"Medicare supplement policy" means a group or individual
				  policy of accident and sickness insurance or a subscriber contract of health
				  service plans or health maintenance organizations, other than a policy issued
				  pursuant to a contract under § 1876 of the federal Social Security Act of
				  1935 ( 42 USC §
										1395 et seq.) or an issued policy under a
				  demonstration project specified in
				  42 USC §
										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
				  that provides benefits pursuant to an agreement under § 1833(a)(1)(A) of
				  the Social Security Act.
"Policy form" means the form on which the policy is delivered
				  or issued for delivery by the issuer.
"Prestandardized Medicare supplement benefit plan,"
				  "prestandardized benefit plan" or "prestandardized plan" means a group or
				  individual policy of Medicare supplement insurance issued prior to July 30,
				  1992.
"Secretary" means the Secretary of the U.S. Department of
				  Health and Human Services.
Statutory Authority: §§
											12.1-13 and
					 38.2-223 of the Code of
					 Virginia.