02-031 C.M.R. ch. 270, § 5 - Policy definitions and terms

No insurance policy may be advertised, solicited, or issued for delivery in this State as a Medicare supplement policy unless the definitions of terms in that policy conform to the requirements of this section.

(A) "Accident," "Accidental Injury," or "Accidental Means" shall be defined to employ "result" language and shall not include words which establish an accidental means test or use words such as "external, violent, visible wounds" or similar words of description or characterization.

(1) The definition shall not be more restrictive than the following:

Injury or injuries for which benefits are provided means accidental bodily injury sustained by the insured which is the direct result of an accident, independent of disease or bodily infirmity or any other cause, and which occurs while insurance coverage is in force.

(2) The definition may, however, exclude injuries for which benefits are provided or available under any workers' compensation, employer's liability, or similar law, or motor vehicle no-fault plan, unless prohibited by law.

(B) "Benefit Period" or "Medicare Benefit Period" shall not be defined more restrictively than as defined in the Medicare program.

(C) "Skilled Nursing Facility" shall be defined in relation to its license status, facilities, and available services.

(1) The definition shall not be more restrictive than one requiring that a skilled nursing facility or home:

(a) be operated pursuant to law:

(b) be approved for payment of Medicare benefits or be qualified to receive such approval, if so requested;

(c) be primarily engaged in providing, in addition to room and board accommodations, skilled nursing care under the supervision of a duly licensed physician;

(d) provide twenty-four hour nursing service by or under the supervision of a registered graduate professional nurse (R.N.); and

(e) maintain a daily medical record of each patient.

(2) The definition may, however, exclude:

(a) boarding homes and intermediate care facilities providing rest, custodial, or maintenance care;

(b) homes and facilities for the aged, drug addicts, or alcoholics; and

(c) homes and facilities primarily used for the care and treatment of mental diseases or disorders, or for educational care.

(D) "Hospital" may be defined either in relation to its license status, facilities, and available services, or to reflect its accreditation by the Joint Commission of Accreditation of Hospitals.

(1) The definition may not be more restrictive than one requiring current accreditation or one requiring that a hospital:

(a) be an institution operated pursuant to law; and

(b) be primarily and continuously engaged in providing or operating, either on its premises or in facilities available to the hospital on a prearranged basis and under the supervision of a staff of duly licensed physicians, medical, diagnostic, and major surgical facilities for the medical care and treatment of sick or injured persons on an inpatient basis for which a charge is made; and

(c) provide twenty-four hour nursing service by or under the supervision of a registered graduate professional nurse (R.N.).

(2) The definition may, however, exclude:

(a) convalescent, rest, and nursing homes and facilities; or

(b) facilities primarily affording custodial, educational, or rehabilitory care;

(c) homes and facilities for the aged, drug addicts, or alcoholics; and

(d) military and veterans' hospitals, soldiers' homes, and hospitals contracting with or operated by any national government or agency for the treatment of members or ex-members of the armed forces, provided that services rendered on an emergency basis at such facilities may not be excluded if the patient is legally liable to pay for the care received.

(E) "Intermediate Care Facility" shall be defined in relation to its license status, facilities, and available services. The definition shall not be more restrictive than one requiring that the facility:

(1) be operated pursuant to law;

(2) be primarily engaged in providing to residents:

(a) nursing services under the direction of a registered professional nurse or a licensed practical nurse, employed full time (at least 40 hours per week) during the day in the facility and responsible for the total nursing service; and, in addition, sufficient nursing and auxiliary personnel to provide adequate and properly supervised nursing services for its residents during all hours of each day and all days of each week;

(b) care to individuals who, because of their physical and/or mental condition, require living accommodations and care which, as a practical matter, can be made available to them only through institutional facilities; and who do not have such illness, disease, injury, or other conditions as to require the degree of care and treatment that a hospital or skilled nursing facility is designed to provide; and

(c) related services for residents who require medical or nursing care;

(3) have written policies, developed with the advice of, and with the provision for review of such policies at least semiannually by, a group of professional personnel, including the administrator, one or more physicians, one or more registered professional nurses, one or more registered pharmacists, and such other professional personnel as are necessary to govern the services it provides;

(4) have a physician or a registered professional nurse or a medical staff responsible for the execution of such policies;

(5) require that the health care of every resident must be under the supervision of a physician who sees the resident as needed and at least every 60 days, and also provide for having a physician available to furnish necessary medical care in case of emergency;

(6) maintain individual records on each resident;

(7) provide appropriate methods and procedures for dispensing and administering drugs and biologicals; and

(8) have in effect a written transfer agreement with a licensed hospital, under which the hospital will provide needed diagnostic and other services to residents of the facility, and agrees to timely acceptance, as inpatients, of acutely ill residents of the facility who are in need of hospital care.

(F) "Medicare" shall be defined in the policy. Medicare may be 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 as "Title 1, Part 1 of Public Law 89-97, as Enacted by the Eighty-Ninth Congress of the United States of America and popularly known as the Health Insurance for the Aged Act, as then constituted and any later amendments or substitutes thereof," or by words of similar import.

(G) "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, health maintenance organizations, nonprofit hospital or medical service plans, or nonprofit health care plans for Medicare eligible expenses may not be conditioned upon more restrictive payment conditions, including determinations of medical necessity, than are applicable to Medicare claims.

(H) "Mental or Nervous Disorders" shall not be defined more restrictively than a definition including neurosis, psychoneurosis, psychopathy, psychosis, or mental or emotional disease of any kind.

(I) "Nurse" may be defined so that the description of nurse is restricted to a type of nurse, such as registered graduate professional nurse (R.N.) or licensed practical nurse (L.P.N.). If the words "nurse," "trained nurse," or "registered nurse" are used without specific definition, then the use of such terms requires the insurer to recognize the services of any individual qualified under such terminology in accordance with the applicable statutes or administrative rules of the licensing or registry board of the state.

(J) "Physician" shall be defined to include all licensed providers of medical care and treatment who are approved by Medicare for reimbursement.

(K) "Sickness" shall not be defined more restrictively than the following:

Sickness means sickness or disease of an insured person which first manifests itself after the effective date of insurance and while the insurance is in force. The definition may, however, exclude sicknesses or diseases for which benefits are provided or available under any workers' compensation, occupational disease, employer's liability, or similar law.

Notes

02-031 C.M.R. ch. 270, § 5