28 Tex. Admin. Code § 3.3304 - Policy Definitions and Terms
No insurance policy, subscriber contract, certificate, or evidence of coverage may be advertised, solicited, or issued for delivery in this state as a Medicare supplement policy unless the policy, subscriber contract, certificate, or evidence of coverage contains definitions or terms that conform to the requirements of this section.
(1) "Accident" or "Accidental Injury" or
"Accidental Means" must be defined to employ "result" language and may 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 may not
be more restrictive than the following: "Injury or injuries for which benefits
are provided means accidental bodily injury sustained by the insured person
that is the direct result of an accident, independent of disease or bodily
infirmity or any other cause, and occurs while insurance or health coverage is
in force."
(B) The definition may
provide that injuries do not include injuries for which benefits are provided
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" may not be defined as more restrictive than as that defined in the
Medicare program.
(3) "Convalescent
Nursing Home," "Extended Care Facility," or "Skilled Nursing Facility" may not
be defined more restrictively than as defined in the Medicare
program.
(4) "Health Care Expenses"
are, for purposes of §
3.3307 of this title (relating to
Loss Ratio Standards and Refund or Credit of Premiums), those expenses of
health maintenance organizations associated with the delivery of health care
services and 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" must be defined in the policy,
certificate, or evidence of coverage. 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 89th 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."
(7) "Medicare-Approved Amounts" refer to the
level of service or amount of health care reimbursement recognized and approved
for a particular medical or health care service or procedure by
Medicare.
(8) "Medicare-Eligible
Expenses" are health care expenses of the kinds covered by Medicare Parts A and
B, to the extent recognized as reasonable and medically necessary by
Medicare.
(9) "Nurses" may be
defined so that the description of nurse is restricted to a type of nurse, such
as registered graduate professional nurse (RN), a licensed practical nurse
(LPN), or a licensed vocational nurse (LVN). If the words "nurse," "trained
nurse," or "registered nurse" are used without specific instruction, then the
use of the terms requires the issuer to recognize the services of any
individual who qualifies under such terminology in accordance with the
applicable statutes or administrative rules of the Texas Board of
Nursing.
(10) "Physician" may not
be defined more restrictively than as defined in the Medicare program. An
issuer must recognize and accept, to the extent of its obligation under the
contract, all providers of medical care and treatment, when such services are
within the scope of the provider's licensed authority and are provided under
applicable laws.
(11) "Sickness"
may not be defined to be more restrictive than the following: "Sickness means
illness or disease of a covered person that first manifests itself after the
effective date of insurance or health coverage and while the insurance or
health coverage is in force." The definition may not be construed to limit §
3.3306(b)(1) of
this title (relating to Minimum Benefit Standards). 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
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