Ga. Comp. R. & Regs. R. 120-2-8-.04 - Definitions
(1) "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 certificateholder.
(2) "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.
(3)
"Certificate" means any certificate delivered or issued for delivery in this
state under a group Medicare supplement policy.
(4) "Certificate form" means the form on
which the certificate is delivered or issued for delivery by the
issuer.
(5) "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 sixty-three (63) days.
(6)
(a)
"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 (Medicare);
4.
Title XIX of the Social Security Act (Medicaid), other than coverage consisting
solely of benefits under section 1928;
5. Chapter 55 of Title 10 United States Code
(CHAMPUS);
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 chapter 89 of Title 5 United States Code (Federal Employees Health
Benefits Program);
9. A public
health plan as defined in federal regulation; and
10. A health benefit plan under Section 5(e)
of the Peace Corps Act (22
United States Code
2504(e)).
(b) "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 payment 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.
(c)
"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.
(d) "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.
(e) "Creditable coverage" shall not include
the following if it is offered as a separate policy, certificate or contract of
insurance:
1. Medicare supplemental health
insurance as defined under section 1882(g)(1) of the Social Security
Act;
2. Coverage supplemental to
the coverage provided under chapter 55 of Title 10, United States Code;
and
3. Similar supplemental
coverage provided to coverage under a group health plan.
(7) "Employee welfare benefit
plan" means a plan, fund or program of employee benefits as defined in
29 U.S.C. Section
1002 (Employee Retirement Income Security
Act).
(8) "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.
(9) "Issuer" includes
insurance companies, fraternal benefit societies, health care service plans,
health maintenance organizations, and any other entity delivering or issuing
for delivery in this state Medicare supplement policies or
certificates.
(10) "Medicare" means
the "Health Insurance for the Aged Act," Title XVIII of the Social Security
Amendments of 1965, as then constituted or later amended.
(11) "Medicare Advantage plan" means a plan
of coverage for health benefits under Medicare Part C as defined in
42 U.S.C.
1395 w - 28(b)(1), and includes:
(a) 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;
(b) Medical savings account
plans coupled with a contribution into a Medicare Advantage medical savings
account; and
(c) Medicare Advantage
private fee-for-service plans.
(12) "Medicare supplement policy" means a
group or individual policy of accident and sickness insurance or a subscriber
contract of hospital and medical service associations or health maintenance
organizations, other than a policy issued pursuant to a contract under Section
1876 of the federal Social Security Act (42 U.S.C. Section
1395
et seq.) or an issued
policy under a demonstration project specified in
42 U.S.C. §
1395 ss(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 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.
(13) "Policy
form" means the form on which the policy is delivered or issued for delivery by
the issuer.
(14) "Pre-Standardized
Medicare supplement benefit plan," "Pre-Standardized benefit plan" or
"Pre-Standardized plan" means a group or individual policy of Medicare
supplement insurance issued prior to December 1, 1990.
(15) "Secretary" means the Secretary of the
United States Department of Health and Human Services.
(16) "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 December
1, 1990 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 which are not replaced by the issuer at the request of the
insured.
(17) "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.
Notes
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No prior version found.