Md. Code Regs. 31.10.06.02

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

Section 31.10.06.02 - Definitions

A. In this chapter, the following terms have the meanings indicated.

B. Terms Defined.

(1) "Adverse decision" has the meaning stated in Insurance Article, § 15-10 A-01, Annotated Code of Maryland.

(2) "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 certificate holder.

(3) "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.

(4) "Certificate" means any certificate delivered or issued for delivery in this State under a group Medicare supplement policy.

(5) "Certificate form" means the form on which the certificate is delivered or issued for delivery by the issuer.

(6) "Complaint" means any dissatisfaction expressed by an individual concerning a Medicare Select issuer or its network providers.

(7) "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 63 days.

(8) "Coverage decision" has the meaning stated in Insurance Article, § 15-10 D-01, Annotated Code of Maryland.

(9) Creditable coverage.

(a) "Creditable coverage" means, with respect to an individual, coverage of the individual provided under any of the following:

(i) A group health plan;

(ii) Health insurance coverage;

(iii) Part A or Part B of Title XVIII of the Social Security Act (Medicare);

(iv) Title XIX of the Social Security Act (Medicaid), other than coverage consisting solely of benefits under § 1928;

(v) Chapter 55 of Title 10 United States Code (CHAMPUS);

(vi) A medical care program of the Indian Health Service or of a tribal organization;

(vii) A State health benefits risk pool;

(viii) A health plan offered under Chapter 89 of Title 5 United States Code (Federal Employees Health Benefits Program);

(ix) A public health plan as defined in federal regulation; and

(x) A health benefit plan under § 5(e) of the Peace Corps Act (22 U.S.C. § 2504(e)).

(b) "Creditable coverage" does not include one or more, or any combination of, the following:

(i) Coverage only for accident or disability income insurance, or any combination of them;

(ii) Coverage issued as a supplement to liability insurance;

(iii) Liability insurance, including general liability insurance and automobile liability insurance;

(iv) Workers' compensation or similar insurance;

(v) Automobile medical payment insurance;

(vi) Credit-only insurance;

(vii) Coverage for on-site medical clinics; and

(viii) Other similar insurance coverage, specified in federal regulations, under which benefits for medical care are secondary or incidental to other insurance benefits.

(c) "Creditable coverage" does not include coverage for the following benefits if they are provided under a separate policy, certificate, or contract of insurance, or are otherwise not an integral part of a plan of coverage described in §B(9)(a) of this regulation:

(i) Limited scope dental or vision benefits;

(ii) Benefits for long-term care, nursing home care, home health care, community-based care, or any combination of these coverages; and

(iii) Other similar, limited benefits as are specified in federal regulations.

(d) "Creditable coverage" does not include coverage for the following benefits if offered as independent, noncoordinated benefits:

(i) Coverage only for a specified disease or illness; and

(ii) Hospital indemnity or other fixed indemnity insurance.

(e) "Creditable coverage" does not include the following coverage if it is offered as a separate policy, certificate, or contract of insurance:

(i) Medicare supplemental health insurance as defined under § 1882(g)(1) of the Social Security Act;

(ii) Coverage supplemental to the coverage provided under Chapter 55 of Title 10, United States Code; and

(iii) Similar supplemental coverage provided to coverage under a group health plan.

(10) "Employee welfare benefit plan" means a plan, fund, or program of employee benefits as defined in 29 U.S.C. § 1002 (Employee Retirement Income Security Act).

(11) "Grievance" means dissatisfaction expressed in writing by an individual insured under a Medicare Select policy or certificate with the administration, claims practices, or provision of services concerning a Medicare Select issuer or its network providers.

(12) "Insolvency" means when an issuer, licensed to transact the business of insurance in this State, has had a final order of liquidation entered against it with a finding of insolvency by a court of competent jurisdiction in the issuer's state of domicile.

(13) "Issuer" means insurance companies, fraternal benefit societies, nonprofit health service plans, health maintenance organizations, and any other entity delivering or issuing for delivery in this State Medicare supplement policies or certificates.

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

(15) Medicare Advantage Plan.

(a) "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).

(b) "Medicare Advantage plan" includes:

(i) Coordinated care plans that 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) 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.

(16) "Medicare Select certificate" means a Medicare supplement certificate that contains restricted network provisions.

(17) "Medicare Select issuer" means an issuer offering, or seeking to offer, a Medicare Select policy or certificate.

(18) "Medicare Select policy" means a Medicare supplement policy that contains restricted network provisions.

(19) Medicare Supplement Policy.

(a) "Medicare supplement policy" means a group or individual policy of health insurance, or a certificate of a fraternal benefit society, or a subscriber contract of a nonprofit health service plan or of a health maintenance organization, other than a policy issued pursuant to a contract under the federal Social Security Act, § 1876, or an issued policy under a demonstration project specified in 42 U.S.C. § 1395s s(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.

(b) "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.

(20) "Network provider" means a provider, or group of providers, of health care which has entered into a written agreement with the issuer to provide benefits insured under a Medicare Select policy.

(21) "Newly eligible for Medicare" means the individual:

(a) Attained age 65; or

(b) Became entitled to benefits under part A pursuant to § 226(b) or 226A of the Social Security Act, or is deemed to be eligible for benefits under § 226(a) of the Social Security Act.

(22) 1990 standardized Medicare Supplement Benefit Plan.

(a) "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 14, 1992, and with an effective date for coverage before June 1, 2010.

(b) "1990 standardized Medicare supplement benefit plan", "1990 standardized benefit plan", or "1990 plan" includes Medicare supplement insurance policies and certificates described in §B(21)(a) of this regulation that are renewed on or after June 1, 2010, which are not replaced by the issuer at the request of the insured.

(23) "Policy form" means the form on which the policy or certificate is delivered or issued for delivery by the issuer.

(24) "Restricted network provision" means any provision which conditions the payment of benefits, in whole or in part, on the use of network providers.

(25) "Secretary" means the Secretary of the United States Department of Health and Human Services.

(26) "Service area" means the geographic area approved by the Secretary of the Department of Health and Mental Hygiene within which an issuer is authorized to offer a Medicare Select policy.

(27) "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.

Md. Code Regs. 31.10.06.02

Regulations .02 adopted as an emergency provision effective July 14, 1992 (19:16 Md. R. 1466); adopted permanently effective August 3, 1992 (19:15 Md. R. 1389)
Regulation .02 amended as an emergency provision effective January 1, 1999 (26:1 Md. R. 18); amended permanently effective March 22, 1999 (26:6 Md. R. 489)
Regulation .02 amended as an emergency provision effective July 25, 2000 (27:16 Md. R. 1520); amended permanently effective November 13, 2000 (27:22 Md. R. 2061)
Regulation .02 amended as an emergency provision effective October 1, 2001 (28:23 Md. R. 2053); emergency status expired March 29, 2002; amended permanently effective April 1, 2002 (29:6 Md. R. 570)
Regulation .02B amended effective September 21, 2009 (36:19 Md. R. 1439); amended effective 46:1 Md. R. 13, eff. 1/14/2019