For purposes of this chapter, in addition to the definitions
in Iowa Code section
514D2., the following
definitions shall apply, unless otherwise specified:
"1990 standardized Medicare supplement benefit
plan" or "1990 plan " means a group or individual
Medicare supplement policy issued on or after January 1, 1992, and with an
effective date for coverage prior to June 1, 2010, and includes Medicare
supplement insurance policies and certificates renewed on or after June 1,
2010, which are not replaced by the issuer at the request of the
insured.
"2010 standardized Medicare supplement benefit
plan" or "2010 plan " means a group or individual
Medicare supplement policy issued with an effective date for coverage on or
after June 1, 2010.
"Applicant" means:
1. In the case of an individual Medicare supplement policy,
the person who seeks to contract for insurance benefits; and
2. In the case of a group Medicare supplement policy, the
proposed covered individual, unless stated otherwise.
"Basic core benefits" are benefits defined
in subrule 37.7(2) for 1990 plans, subrule 37.8(2) for 2010 plans, and subrule
37.9(1) for Medicare supplement policies or certificates delivered or issued
for delivery to individuals newly eligible for Medicare on or after January 1,
2020.
"Certificate" means any certificate of
coverage delivered or issued for delivery in this state to a covered individual
under a group Medicare supplement policy.
"Certificate form" means the form (as
defined in Iowa Code section
514D2(2).) on which
the certificate is delivered or issued for delivery by the issuer.
"Certificate holder" means the named
individual to whom the certificate of coverage under a group policy is issued,
or a spouse, if applicable.
"CMS" means the Centers for Medicare and
Medicaid Services of the U.S. Department of Health and Human Services.
"Commissioner" means the Iowa insurance
commissioner, and includes the insurance division as delegated.
"Covered individual" means an individual who
may receive benefits under an individual or group Medicare supplement policy
because the individual is one of the following: the named insured under an
individual Medicare supplement policy; the named certificate holder under a
group Medicare supplement policy; or an individual such as a spouse covered by
way of the named certificate holder's group Medicare supplement policy. For
purposes of rule 191-3720. (514D), "covered
individual" means an individual who may receive benefits under an individual or
group Medicare Select policy because the individual is one of the following:
the named insured under an individual Medicare Select policy; the named
certificate holder under a group Medicare Select policy; or an individual such
as a spouse covered by way of the named certificate holder's group Medicare
Select policy.
"Creditable coverage."
1. "Creditable coverage" means, with respect to an
individual, health coverage of the individual provided under any of the
following:
* A group health plan;
* Health insurance coverage;
* Part A or Part B of Title XVIII of the Social Security Act
(Medicare);
* Title XIX of the Social Security Act (Medicaid), other than
coverage consisting solely of benefits under Section 1928;
* Chapter 55 of Title 10, United States Code
(CHAMPUS);
* A medical care program of the Indian Health Service or of a
tribal organization;
* A state health benefits risk pool;
* A health plan offered under Chapter 89 of Title 5, United
States Code (Federal Employees Health Benefits Program);
* A public health plan as defined in federal regulation;
and
* A health benefit plan under Section 5 (e) of the Peace
Corps Act (22 United States Code 2504(e)).
2. "Creditable coverage" shall not include one or more of, or
any combination of, the following:
* Coverage only for accident or disability income insurance,
or any combination thereof;
* Coverage issued as a supplement to liability
insurance;
* Liability insurance, including general liability insurance
and automobile liability insurance;
* Workers' compensation or similar insurance;
* Automobile medical payment insurance;
* Credit-only insurance;
* Coverage for on-site medical clinics; and
* Other similar insurance coverage, specified in federal
regulations, under which benefits for medical care are secondary or incidental
to other insurance benefits.
3. "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:
* Limited scope dental or vision benefits;
* Benefits for long-term care, nursing home care, home health
care, community-based care, or any combination thereof; and
* Such other similar limited benefits as are specified in
federal regulations.
4. "Creditable coverage" shall not include the following
benefits if offered as independent, noncoordinated benefits:
* Coverage only for a specified disease or illness;
and
* Hospital indemnity or other fixed indemnity
insurance.
5. "Creditable coverage" shall not include the following if
it is offered as a separate policy, certificate or contract of
insurance:
* Medicare supplemental health insurance as defined under
Section 1882(g)(1) of the Social Security Act;
* Coverage supplemental to the coverage provided under
Chapter 55 of Title 10, United States Code; and
* Similar supplemental coverage provided to the coverage
under a group health plan.
"File" or "filing," when
used in reference to filing information with the commissioner or with the
insurance division, means submitting information as set forth in these rules
through the System for Electronic Rate and Form Filing (SERFF),www.serff.com, or as otherwise directed by the
insurance division through its website,iid.iowa.gov.
"Group member" means the individual who is a
member of the group entity to which the group policy is issued.
"Group policyholder" means the group entity
to which a group Medicare supplement policy is issued.
"Insolvency" means that 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.
"Insurance division" means the Iowa
insurance division.
"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.
"Medicare" means the Health Insurance for
the Aged Act, Title XVIII of the Social Security Amendments of 1965, as then
constituted or later amended.
"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)), and includes:
1. 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 provider-sponsored
organizations, and preferred provider organization plans;
2. Medical savings account plans coupled with a contribution
into a Medicare Advantage medical savings account; and
3. Medicare Advantage private fee-for-service plans.
"Medicare Select policy" "Medicare Select
certificate," "Medicare Select issuer," and "Medicare Select
network provider" are defined in subrule 37.20(2).
"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. Section 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. "Medicare supplement policy" does not include Medicare
Advantage plans, outpatient prescription drug plans established under Medicare
Part D, or any health care prepayment plan (HCPP) that provides benefits
pursuant to an agreement under Section 1833(a)(1)(A) of the Social Security
Act.
"MMA" means the Medicare Prescription Drug,
Improvement, and Modernization Act of 2003,
Pub. L. No.
108-173, 117 Stat. 2066.
"PACE program" means a program of
all-inclusive care for the elderly, operated by an approved PACE organization
(an entity that is approved as a PACE program by the Iowa department of human
services and that has in effect a PACE program agreement between the entity,
CMS, and the Iowa department of human services to operate a PACE program) that
provides comprehensive health care services to enrollees in Iowa, pursuant to
Section 1894 of the Social Security Act (42
U.S.C. 1395ee e) and Iowa Administrative Code
rules 441-8821. (249A) through
441-8828. (249A).
"Person" means any individual, corporation,
association, or partnership.
"Policy form" means the form (as defined by
Iowa Code section
514D2(2).) on which
the policy (as defined by Iowa Code section
514D2(4).) is
delivered or issued for delivery by the issuer.
"Policyholder" means the individual person
to whom or group entity to which an individual or group Medicare supplement
policy is issued.
"PPS" means prospective payment
system.
"Prestandardized Medicare supplement benefit
plan" or "prestandardized plan" means a group or
individual Medicare supplement policy issued prior to January 1, 1992.
"Producer" means a person licensed in this
state pursuant to Iowa Code chapter 522B and Iowa Administrative Code
191-Chapter 10 to sell, solicit, negotiate, effect, procure, deliver, renew,
continue or bind policies of insurance for persons residing or located, or for
policies to be performed, in this state.
"Secretary" means the Secretary of the U.S.
Department of Health and Human Services.
"SMSBP" or "standardized Medicare
supplement benefit plan" means a 1990 plan, a 2010 plan, or a plan
described in subrule 37.9(1) for Medicare supplement policies or certificates
delivered or issued for delivery to individuals newly eligible for Medicare on
or after January 1, 2020.
