Fla. Admin. Code Ann. R. 69O-156.003 - Definitions

For purposes of this rule:

(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 certificate holder.

(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) "Creditable coverage" means, with respect to an individual, coverage of the individual as defined in Section 627.6561(5), F.S.

(7) "Office" means the Office of Insurance Regulation.

(8) "Employee welfare benefit plan" means a plan, fund or program of employee benefits as defined in 29 U.S.C. Section 1002 (1999) (Employee Retirement Income Security Act) which is hereby incorporated by reference.

(9) "Insolvency" means that all the assets of the insurer, if made immediately available, would not be sufficient to discharge all its liabilities or that the insurer is unable to pay its debts as they become due in the usual course of business. When the context of any provision of the insurance code so indicates, insolvency also includes and is defined as impairment of surplus as defined in Section 631.011(10), F.S., and impairment of capital as defined in Section 631.011(9), F.S.

(10) "Issuer" includes insurance companies, fraternal benefit societies, health maintenance organizations, and any other entity delivering or issuing for delivery in this state Medicare supplement policies or certificates.

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

(12) "Medicare Advantage plan" means a plan of coverage for health benefits under Medicare Part C as defined in 42 U.S.C. Section 1395w-28(b)(1), which is hereby incorporated by reference, and includes:

(a) Coordinated care plans which provide health care services, including but not limited to health maintenance organization plans (with or without a point-of-service option), plans offered by provide-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.

(13) "Medicare Supplement Policy" means a group or individual policy of health insurance or a subscriber contract of 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 as specified in 42 U.S.C. Section 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 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."

(14) "Newly Eligible Medicare Beneficiary" means anyone who attains age 65 on or after January 1, 2020, or who first becomes eligible for Medicare benefits due to age, disability, or end-stage renal disease on or after January 1, 2020.

(15) "Policy" as used herein is as defined in Section 627.672, F.S.

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

(17) "Pre-existing condition" shall not be defined to limit or preclude liability under a policy for a period longer than six (6) months because of a condition for which medical advice was given or treatment was recommended by or received from a physician within six months before the effective date of the coverage.

(18) "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 January 1, 1992.

(19) "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 January 1, 1992, and with an effective date for coverage prior to June 1, 2010.

(20) "2010 Standardized Medicare supplement benefit plan," "2010 Standardized benefit plan" or "2010 plan" means a group or individual policy of Medicare supplement insurance with an effective date for coverage on or after June 1, 2010.

(21) "2020 Standardized Medicare supplement benefit plan," "2020 Standardized benefit plan," or "2020 plan" means

(a) For any eligible person, a group or individual policy of Medicare supplement insurance Plan A, B, D, G, High Deductible G, K, L, M, or N with an effective date for coverage on or after January 1, 2020; or

(b) For individuals eligible for Medicare prior to January 1, 2020, a group or individual policy of Medicare supplement insurance Plan A, B, C, D, F, High Deductible F, G, High Deductible G, K, L, M, or N with an effective date for coverage on or after January 1, 2020.

(22) "Replacement" is any transaction wherein new Medicare supplement insurance is to be purchased and it is known to the agent, broker or insurer at the time of application that, as a part of the transaction, existing accident and health insurance has been or is to be lapsed or the benefits thereof substantially reduced.

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

Notes

Fla. Admin. Code Ann. R. 69O-156.003

Rulemaking Authority 624.308(1), 627.674(2), 627.6741(5) FS. Law Implemented 624.307(1), 627.674, 627.6741 FS.

New 1-1-81, Formerly 4-51.03, Amended 11-7-88, 9-4-89, 12-9-90, Formerly 4-51.003, Amended 1-1-92, 7-14-96, 7-26-99, 3-4-01, Formerly 4-156.003, Amended 9-15-05, 1-4-10, Amended by Florida Register Volume 45, Number 238, December 10, 2019 effective 12/26/2019.

New 1-1-81, Formerly 4-51.03, Amended 11-7-88, 9-4-89, 12-9-90, Formerly 4-51.003, Amended 1-1-92, 7-14-96, 7-26-99, 3-4-01, Formerly 4-156.003, Amended 9-15-05, 1-4-10, 12-26-19.