No policy or certificate may be advertised, solicited or
issued for delivery in this state as a Medicare supplement policy or
certificate unless the policy or certificate contains definitions or terms that
conform to the requirements of this Rule.
(1) "Accident," "accidental injury," or
"accidental means" shall be defined to employ "result" language and shall not
include words that establish an accidental means test or use words such as
"external, violent, visible wounds" or similar words of description or
characterization.
(a) 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 person
which is the direct result of an accident, independent of disease or bodily
infirmity or any other cause, and occurs while insurance coverage is in
force."
(b) The definition may
provide that injuries shall not include 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.
(2) "Benefit
period" or "Medicare benefit period" shall not be defined more restrictively
than as defined in the Medicare program.
(3) "Convalescent nursing home," "extended
care facility," or "skilled nursing facility" shall not be defined more
restrictively than as defined in the Medicare program.
(4) "Health care expenses" means, for
purposes of Rule
0780-01-58-.17, expenses of
health maintenance organizations associated with the delivery of health care
services, which expenses are analogous to incurred losses of
insurers.
(5) "Hospital" may be
defined in relation to its status, facilities and available services or to
reflect its accreditation by the Joint Commission on Accreditation of
Hospitals, but not more restrictively than as defined in the Medicare
program.
(6) "Medicare" shall be
defined in the policy and certificate. Medicare may be substantially 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 "Title I, Part I
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 words
of similar import.
(7) "Medicare
eligible expenses" shall mean expenses of the kinds covered by Medicare Parts A
and B, to the extent recognized as reasonable and medically necessary by
Medicare.
(8) "Physician" shall not
be defined more restrictively than as defined in the Medicare
program.
(9) "Sickness" shall not
be defined to be more restrictive than the following: "Sickness means illness
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 be further modified to exclude sicknesses or diseases for which
benefits are provided under any workers' compensation, occupational disease,
employer's liability or similar law.
Notes
Tenn. Comp. R.
& Regs.
0780-01-58-.05
Original
rule filed August 14, 1989; effective September 28, 1989. Repealed and new rule
filed November 26, 1990; effective January 10, 1991. Repealed and new rule
filed September 16, 1992; effective November 1, 1992. Amendment filed August
15, 1996; effective October 29, 1996. Public necessity rule filed September 1,
2005; effective through February 13, 2006. Public necessity rule filed
September 1, 2005; expired on February 13, 2006. On February 14, 2006, reverted
to rule in effect on August 31, 2005. Repeal and new rule filed October 13,
2006; effective December 27, 2006. Public necessity rule filed June 30, 2009;
effective through December 12, 2009. Emergency rule filed December 9, 2009;
effective through June 7, 2010. Amendment filed December 3, 2009; effective
March 3, 2010. Amendment filed December 3, 2009; effective March 3, 2010.
Administrative changes made to the authority of this chapter due to revisions
in the 2016 Tennessee Code Annotated. Amendments filed November 20, 2018;
effective 2/18/2019.
Authority: T.C.A. ยงยง
56-1-701; 56-2-301; 56-6-112;
56-6-124(a); 56-7-1401, et seq.; 56-7-1453; 56-7-1454; 56-7-1455; 56-7-1457;
56-7-1501, et seq.; 56-7-1503; 56-7-1504; 56-7-1505; 56-7-1507; and
56-32-118(a); Omnibus Budget Reconciliation Act of 1990,
Pub. L. No.
101-508, (1990); Genetic Information Non
Discrimination Act, Pub.
L. No. 110-233 (2008); Medicare Improvements for
Patients and Providers Act,
Pub. L. No.
110-275 (2008); and Medicare Access and CHIP
Reauthorization Act, Pub.
L. No. 114-10 (2015).
