W. Va. Code R. § 114-17-3

Current through Register Vol. XLI, No. 50, December 13, 2024

Section 114-17-3 - Policy Definitions and Terms

No Medicare Supplement or Limited Benefit Medicare Supplement policy or contract delivered or issued for delivery in this State to any person eligible for Medicare by reason of age shall contain definitions or terms respecting the matters set forth herein unless such definitions or terms conform to the requirements of this section.

3.1. "Medicare" shall be defined in the policy, and may be substantially defined as "The Health Insurance for the Aged Act, Title XVIII of the Social Security Amendments of 1965 as Then Constituted or Later Amended," or words of similar import.

3.2. "Medicare Benefit Period or Benefit Period" shall not be defined as more restrictive than defined in the Medicare Program.

3.3. "Medicare Eligible Expenses" shall mean health care expenses of the kinds covered by Medicare, to the extent recognized as reasonable by Medicare. Payment of benefits by insurers for Medicare eligible expenses may be conditioned upon the same or less restrictive payment conditions, including determinations of medical necessity, as are applicable to Medicare claims.

3.4. "Preexisting Condition" shall not be defined more restrictively than a condition for which medical advice was given or treatment was recommended by or received from a physician within a six (6) month period preceding the effective date of coverage.

W. Va. Code R. § 114-17-3