28 Tex. Admin. Code § 3.3303 - Definitions
The following words and terms, when used in this subchapter, have the following meanings, unless the context clearly indicates otherwise.
(1) 1990 Standardized
Medicare supplement benefit plan, 1990 Standardized benefit plan, or 1990
plan--A group or individual policy of Medicare supplement insurance issued or
issued for delivery on or after March 1, 1992, and with an effective date for
coverage before June 1, 2010.
(2)
2010 Standardized Medicare supplement benefit plans, 2010 Standardized benefit
plan, or 2010 plan--A group or individual policy of Medicare supplement
insurance with an effective date for coverage on or after June 1,
2010.
(3) 2020 newly eligible
individual--An individual who is newly eligible for Medicare on or after
January 1, 2020:
(A) by reason of attaining
age 65 on or after January 1, 2020; or
(B) by reason of entitlement to benefits
under Part A under section
42 U.S.C. §
426(b) or 42 U.S.C. §426-1,
or who is deemed to be eligible for benefits under section
42 U.S.C. §
426(a) on or after January
1, 2020. An individual who becomes Medicare eligible or turns 65 before January
1, 2020, is not a 2020 newly eligible individual.
(4) Applicant--
(A) In the case of an individual Medicare
supplement policy, the person who seeks to contract for insurance or other
health benefits.
(B) In the case of
a group Medicare supplement policy, the proposed certificate
holder.
(5)
Bankruptcy--The situation that 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 Texas.
(6) Certificate--Any certificate issued under
a group Medicare supplement policy, for which a certificate has been delivered
or issued for delivery in this state regardless of the place where the policy
was delivered or issued for delivery.
(7) Continuous period of creditable
coverage--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 63 days.
(8) Creditable coverage--Any coverage of an
individual as defined in §
21.1101 of this title (relating to
Definitions).
(9) Employee welfare
benefit plan--A plan, fund, or program of employee benefits as defined in
29
U.S.C. §
1002 (Employee Retirement Income
Security Act).
(10) Health
Maintenance Organization (HMO)--An entity as defined in
42 U.S.C. §
300e(a).
(11) Insolvency--The situation that occurs
when an issuer has had an order of liquidation entered against it with a
finding of insolvency by a court of competent jurisdiction in the issuer's
state of domicile.
(12) Issuer--An
insurance company, fraternal benefit society, health care service plan, health
maintenance organization, or any other entity delivering or issuing for
delivery in this state Medicare supplement policies or certificates.
(13) Medicaid--Grants to States for Medical
Assistance Programs, Title XIX of the Social Security Act Amendments of 1965 as
then constituted or later amended.
(14) Medicare--The Health Insurance for the
Aged Act, Title XVIII of the Social Security Act Amendments of 1965 as then
constituted or later amended.
(15)
Medicare Advantage organization--An entity as defined in
42 U.S.C. §
1395w-28(a)(1).
(16) Medicare Advantage plan--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 services, including but not limited to HMO 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.
(17) Medicare Advantage private
fee-for-service plan--An entity as defined in
42 U.S.C. §
1395w-28(b)(2).
(18) MMA--The Medicare Prescription Drug,
Improvement, and Modernization Act of 2003.
(19) Medicare Select policy or Medicare
Select certificate--A Medicare supplement policy or certificate, respectively,
that contains restricted network provisions.
(20) Medicare supplement policy--A group or
individual policy of accident and sickness insurance or a subscriber contract
of a group hospital service corporation subject to Insurance Code Chapter 842
(concerning Group Hospital Service Corporations), or, to the extent required by
federal law, an evidence of coverage issued by an HMO subject to Insurance Code
Chapter 843 (concerning Health Maintenance Organizations), for which a policy,
subscriber contract, or evidence of coverage 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. The
term does not include:
(A) a policy, contract,
subscriber contract, or evidence of coverage of one or more employers or labor
organizations, or of the trustees of a fund established by one or more
employers or labor organizations, or combination thereof, for employees or
former employees, or combination thereof, or for members or former members, or
combination thereof, of the labor organizations;
(B) a policy or health care benefit plan
including a policy or contract of group insurance or group contract of a group
hospital service corporation subject to Insurance Code Chapter 842, or group
evidence of coverage issued by an HMO subject to Insurance Code Chapter 843,
when such policy or plan is not marketed or held to be a Medicare supplement
policy or benefit plan; or
(C) an
individual or group evidence of coverage issued under a contract in accordance
with the Federal Social Security Act, §1876 (42 U.S.C. §§
1395, et seq.) by an HMO subject to Insurance
Code Chapter 843;
(D) a Medicare
Advantage plan established under Medicare Part C;
(E) an Outpatient Prescription Drug plan
established under Medicare Part D; or
(F) a Health Care Prepayment Plan (HCPP) that
provides benefits under an agreement under §1833(a)(1)(A) of the Federal Social
Security Act (42 U.S.C. §§
1395, et seq.)
(21) Point of service --A benefit option as
defined in
42
C.F.R. §
422.2.
(22) Pre-Standardized Medicare supplement
benefit plan, Pre-Standardized benefit plan or Pre-Standardized plan--A group
or individual policy of Medicare supplement insurance issued or issued for
delivery before March 1, 1992.
(23)
Provider-sponsored organization--An entity as defined in
42
U.S.C. §
1395w-25(d)(1).
(24) Qualified actuary--An actuary who is a
member of either the Society of Actuaries or the American Academy of
Actuaries.
(25) Secretary--The
Secretary of the United States Department of Health and Human
Services.
Notes
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