Or. Admin. Code § 836-052-0119 - Definitions
As used in OAR 836-052-0103 to 836-052-0194:
(1) "Applicant" means:
(a) In the case of an individual Medicare
supplement policy, the person who seeks to contract for insurance
benefits;
(b) In the case of a
group Medicare supplement policy, the proposed certificate holder.
(2) "Bankruptcy" occurs 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 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
break in coverage greater than 63 days.
(6)
(a)
"Creditable coverage" means, with respect to an individual, coverage of the
individual provided under any of the following:
(A) A group health plan;
(B) Health insurance coverage;
(C) Part A or Part B of Title XVIII of the
Social Security Act (Medicare);
(D)
Title XIX of the Social Security Act (Medicaid), other than coverage consisting
solely of benefits under section 1928;
(E) Chapter 55 of Title 10 United States Code
(CHAMPUS);
(F) A medical care
program of the Indian Health Service or of a tribal organization;
(G) A state health benefits risk
pool;
(H) A health plan offered
under chapter 89 of Title 5 United States Code (Federal Employees Health
Benefits Program);
(I) A public
health plan as defined in federal regulation; and
(J) A health benefit plan under Section 5(e)
of the Peace Corps Act (22 United States Code
2504(e)).
(b) "Creditable coverage" does not include
one or more, or any combination of the following:
(A) Coverage only for accident or disability
income insurance, or any combination thereof;
(B) Coverage issued as a supplement to
liability insurance;
(C) Liability
insurance, including general liability insurance and automobile liability
insurance;
(D) Workers'
compensation or similar insurance;
(E) Automobile medical payment
insurance;
(F) Credit-only
insurance;
(G) Coverage for on-site
medical clinics; and
(H) Other
similar insurance coverage, specified in federal regulations, under which
benefits for medical care are secondary or incidental to other medical
benefits.
(c) "Creditable
coverage" does not include the following benefits if they are provided under a
separate policy, certificate or contact of insurance or are otherwise not an
integral part of the plan:
(A) Limited scope
dental or vision benefits;
(B)
Benefits for long-term care, nursing home care, home health care, community
based care, or any combination thereof; and
(C) Such other similar, limited benefits as
are specified in federal regulations.
(d) "Creditable coverage" does not include
the following benefits if offered as independent noncoordinated benefits:
(A) Coverage only for a specified disease or
illness; and
(B) 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:
(A) Medicare supplemental health
insurance as defined under section 1882(g)(1) of the Social Security
Act;
(B) Coverage supplemental to
the coverage provided under chapter 55 of title 10, United States Code;
and
(C) 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)
"Insurance Policy" includes a subscriber contract or a prepayment contract of a
health care service contractor and a policy or contract of a fraternal benefit
society.
(10) "Issuer" includes
insurers, fraternal benefit societies, health care service plans, health
maintenance organizations as that term is defined in ORS
750.005, health care service
contractors as that term is defined in 750.005, 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.
1395w-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.
(13) "Medicare Supplement Policy" means a
group or individual insurance policy or a subscriber contract, 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)
that 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
sec. 1833(a)(1)(A) of the Social Security Act.
(14) "Newly eligible" means those individuals
who become eligible for Medicare due to age, disability or end-stage renal
disease on or after January 1, 2020.
(15) "Policy Form" means the form on which
the policy is delivered or issued for delivery by the issuer.
(16) "Pre-Standardized Medicare supplement
benefit plan," means a group or individual policy of Medicare supplement
insurance issued prior to July 1, 1992.
(17) "Secretary" means the Secretary of the
United States Department of Health and Human Services.
(18) "1990 Standardized Medicare supplement
benefit plan," means a group or individual policy of Medicare supplement
insurance issued on or after July 1, 1992 and with an effective date of
coverage prior to June 1, 2010 and includes Medicare supplement insurance
policies and certificates renewed on or after that date that are not replaced
by the issuer at the request of the insured.
(19) "2010 Standardized Medicare supplement
benefit plan," means a group or individual policy of Medicare supplement
insurance issued with an effective date of coverage on or after June 1,
2010.
Notes
Publications: Publications referenced are available from the agency.
Statutory/Other Authority: 743.682 & ORS 731.244
Statutes/Other Implemented: ORS 743.010 & 743.683
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