Md. Code Regs. 31.10.05.04

Current through Register Vol. 51, No. 24, December 2, 2024

Section 31.10.05.04 - Definitions

A. Whenever used in this chapter or in a Medicare supplement policy subject to these regulations, or in any advertisement soliciting a Medicare supplement policy, the following terms shall have the meanings indicated.

B. Terms Defined.

(1) "Applicant" means, in the case of:

(a) An individual Medicare supplement policy or subscriber contract, the person who seeks to contract for insurance benefits; and

(b) A group Medicare supplement policy or subscriber contract, the proposed certificate holder.

(2) "Certificate" means any certificate issued under a group Medicare supplement policy or contract which has been delivered or issued for delivery in this State, including any individual certificate issued by a nonprofit health service plan or by a health maintenance organization.

(3) "Direct response solicitation" means solicitation of individuals or groups through the mail or by mass media advertising, including both print and broadcast advertising.

(4) "Health care expenses" means expenses of health maintenance organizations associated with the delivery of health care services which are analogous to incurred losses of insurers. These expenses do not include:

(a) Home office and overhead costs;

(b) Advertising costs;

(c) Commissions and other acquisition costs;

(d) Taxes;

(e) Capital costs;

(f) Administrative costs; or

(g) Claims processing costs.

(5) "Health insurance" means insurance coverage as defined in Insurance Article, § 1-101(q), Annotated Code of Maryland.

(6) "Individual policy" means:

(a) Individually issued policies and certificates; and

(b) Certificates issued under group policies as a result of the direct response solicitation.

(7) "Low-dose mammography" means X-ray examination of the breast using dedicated equipment including an X-ray tube, filter, compression device, screens, films, and cassettes specifically for mammography with average radiation exposure to deliver less than 1 rad mid-breast, two views per breast.

(8) "Medicaid" means the Maryland Medical Assistance Program or any similar program provided by the State in which the insured person resides.

(9) "Medicare" means the Health Insurance for the Aged Act, Title XVIII of the Social Security Amendments of 1965 as then constituted or later amended.

(10) "Medicare eligible expenses" means health care expenses of the kinds covered by Medicare to the extent these services are considered reasonable under Medicare rules and regulations.

(11) Medicare Supplement Policy.

(a) "Medicare supplement policy" means an individual or group policy, subscriber contract, or certificate of health insurance primarily designed, advertised, marketed, or otherwise purported to be a supplement to reimbursements under Medicare for the hospital, medical, surgical, nursing, or related expenses of persons eligible for Medicare by reason of age.

(b) "Medicare supplement policy" does not include benefits offered by a health maintenance organization or other direct service organization in connection with a contract with the United States Health Care Financing Administration.

(12) "Medigap policy" means a Medicare supplement policy.

(13) "Policy and subscriber contracts", whenever they appear in these regulations, include "certificate" unless the context indicates otherwise.

Md. Code Regs. 31.10.05.04

Regulations .04, Appendixes A_C adopted as an emergency provision effective July 1, 1982 (9:13 Md. R. 1340); adopted permanently effective October 1, 1982 (9:17 Md. R. 1707)
Regulations .04 and Appendices A_C repealed, and new Regulations .04 and Appendices A_C adopted as an emergency provision effective July 25, 1989 (16:16 Md. R. 1738); emergency status extended at 16:26 Md. R. 2782 and 17:5 Md. R. 633; emergency status expired July 20, 1990
Regulations .04 and Appendices A_C repealed, and new Regulations .04 adopted effective July 23, 1990 (17:14 Md. R. 1757)