31 Pa. Code § 89.772

Current through Register Vol. 54, No. 45, November 9, 2024

Section 89.772 - Definitions

The following words and terms, when used in this subchapter, have the following meanings, unless the context clearly indicates otherwise:

1990 Standardized Medicare supplement benefit plan-

(i) A group or individual policy of Medicare supplement insurance issued on or after July 30, 1992, and prior to June 1, 2010.

(ii) The term includes Medicare supplement insurance policies and certificates renewed on or after July 30, 1992, which are not replaced by the issuer at the request of the insured.

2010 Standardized Medicare supplement benefit plan-A group or individual policy of Medicare supplement insurance issued on or after June 1, 2010.

2020 Standardized Medicare supplement benefit plan-A group or individual policy or certificate of Medicare supplement insurance issued on or after January 1, 2020.

Applicant-

(i) In the case of an individual Medicare supplement policy, the person who seeks to contract for insurance benefits.

(ii) In the case of a group Medicare supplement policy, the proposed certificateholder.

Bankruptcy-The condition under which a Medicare Advantage organization plan that is not an issuer has filed, or has had filed against it, a petition or other action seeking a declaration of bankruptcy under the provisions of the United States Bankruptcy Code (11 U.S.C.) and has ceased doing business in this Commonwealth.

Certificate-A certificate delivered or issued for delivery in this Commonwealth under a group Medicare supplement policy.

Certificate form-The form on which the certificate is delivered or issued for delivery by the issuer.

Commissioner-The Insurance Commissioner of the Commonwealth.

Continuous period of creditable coverage-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.

Creditable coverage-The definition contained in the Health Insurance Portability and Accountability Act of 1996 (Pub. L. No. 104-191, 110 Stat. 1936), as adopted by the Commonwealth under the Pennsylvania Health Care Insurance Portability Act (40 P. S. §§ 1302.1-1302.7), is incorporated herein by reference.

Employee welfare benefit plan-A plan, fund or program of employee benefits as defined in section 3 of the Employee Retirement Income Security Act or ERISA (29 U.S.C.A. § 1002).

HHS Secretary-The Secretary of the United States Department of Health and Human Services.

Insolvency-The condition under which an issuer, licensed to transact business in this Commonwealth by the Commissioner, has had a final order of liquidation entered against it, or a finding of insolvency by a court of competent jurisdiction in the issuer's state of domicile.

Issuer-The term includes insurance companies, fraternal benefit societies and nonprofit corporations subject to 40 Pa.C.S. Chapters 61 and 63 (relating to hospital plan corporations; and professional health services plan corporations) and other entities delivering or issuing for delivery Medicare supplement policies or certificates in this Commonwealth.

Medicare-The program established by the Health Insurance for the Aged Act, Title XVIII of the Social Security Amendments of 1965 (42 U.S.C.A. §§ 1395-1395b-4) as then constituted or later amended.

Medicare Advantage plan-A plan of coverage for health benefits under Medicare Part C as defined in section 1859(b)(1) of the Social Security Act (42 U.S.C.A. § 1395w-28(b)(1)) and includes:

(i) Coordinated care plans which 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) Medicare medical savings account plans coupled with a contribution into a Medicare Advantage plan medical savings account.

(iii) Medicare Advantage private fee-for-service plans.

Medicare supplement policy-

(i) A group or individual policy of insurance or a subscriber contract other than a policy issued under a contract under section 1876 of the Social Security Act (42 U.S.C.A. § 1395mm) or a policy issued under a demonstration project specified in section 1882(g)(1), of the Social Security Act (42 U.S.C.A. § 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.

(ii) The term 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 under an agreement under section 1833(a)(1)(A) of the Social Security Act (42 U.S.C.A. § 1395l(a)(1)(A)).

Policy form-The form on which the policy is delivered or issued for delivery by the issuer.

Prestandardized Medicare supplement benefit plan-A group or individual policy of Medicare supplement insurance issued prior to July 30, 1992.

Producer-An insurance producer as defined by the Article VI-A of The Insurance Department Act of 1921 (40 P. S. §§ 310.1-310.99a), known as the Producer Licensing Modernization Act.

31 Pa. Code § 89.772

The provisions of this §89.772 adopted July 24, 1992, effective 7/25/1992, 22 Pa.B. 3841; amended September 2, 1994, effective 11/2/1994, 24 Pa.B. 4467; amended May 10, 1996, effective 5/11/1996, 26 Pa.B. 2196; amended January 8, 1999, effective 1/9/1999, 29 Pa.B. 172; amended December 29, 2000, effective 12/30/2000, 30 Pa.B. 6886; amended May 6, 2005, effective 5/7/2005, 35 Pa.B. 2729; amended April 24, 2009, effective 4/25/2009, 39 Pa.B. 2086; amended September 7, 2018, effective 9/8/2018, 48 Pa.B. 5601.

The provisions of this §89.772 amended under the Omnibus Budget Reconciliation Act (OBRA 90) of November 15, 1990, P. L. 101-508; sections 206, 506, 1501 and 1502 of The Administrative Code of 1929 (71 P.S. §§ 66, 186, 411 and 412); and sections 354 and 616 of The Insurance Company Law of 1921 (40 P.S. §§ 477b and 751); under the Medicare Improvements for Patients and Providers Act of 2008 (Pub. L. No. 100-275, 122 Stat. 2494); the Genetic Information Nondiscrimination Act of 2008 (Pub. L. No. 110-233, 122 Stat. 881); and sections 5 and 9 of the Medicare Supplement Insurance Act (40 P.S. §§ 3105 and 3109); and section 314 of the Accident and Health Filing Reform Act (40 P.S. § 3801.314).

This section cited in 31 Pa. Code § 89.791 (relating to prohibition against use of genetic information and requests for genetic testing).