Utah Admin. Code R590-146-4 - Definitions

Terms used in this rule are defined in Sections 31A-1-301 and 31A-22-620. Additional terms are defined as follows:

(1) "1990 standardized plan" or "1990 plan" means group or individual Medicare supplement insurance issued on or after July 30, 1992, with an effective date of coverage before June 1, 2010, and includes Medicare supplement insurance renewed on or after that date that is not replaced by the issuer at the request of the insured.

(2) "2020 standardized plan" or "2020 plan" means group or individual Medicare supplement insurance issued with an effective date of coverage on or after June 1, 2010.

(3) "Activities of daily living" means:

(a) bathing;

(b) dressing;

(c) personal hygiene;

(d) transferring;

(e) eating;

(f) ambulating;

(g) assistance with drugs that are normally self-administered;

(h) changing bandages or other dressings; or

(i) similar activities.

(4)

(a) "At-home recovery benefit" means coverage for services to provide short-term, at-home assistance with activities of daily living for those recovering from an illness, injury, or surgery, if:

(i) the insured's attending physician certifies that the specific type and frequency of at-home recovery services are necessary because of a condition for which a home care plan of treatment was approved by Medicare; and

(ii) benefits are limited to:

(A) no more than the number and type of at-home recovery visits certified as necessary by the insured's attending physician;

(B) the total number of at-home recovery visits do not exceed the number of Medicare-approved home health care visits under a Medicare-approved home care plan of treatment;

(C) the actual charges for each visit up to a maximum reimbursement of $40 per visit;

(D) $1,600 per calendar year;

(E) seven visits in any one week;

(F) care furnished on a visiting basis in the insured's home;

(G) services provided by a care provider;

(H) at-home recovery visits not otherwise excluded; and

(I) at-home recovery visits received during the period the insured is receiving Medicare-approved home care services or no more than eight weeks after the service date of the last Medicare-approved home health care visit.

(b) "At-home recovery benefit" does not include:

(i) home care visits paid for by Medicare or other government programs; or

(ii) care provided by family members, unpaid volunteers, or providers who are not care providers.

(5) "At-home recovery visit" means the period of a visit required to provide at-home recovery care, without limit on the duration of the visit, except each consecutive four hours in a 24-hour period of services provided by a care provider is one visit.

(6) "Bankruptcy" means when a Medicare Advantage organization that is not an issuer files, or has had filed against it, a petition for declaration of bankruptcy and has stopped doing business in this state.

(7) "Basic core benefits" means:

(a) coverage of Medicare Part A eligible expenses for hospitalization, to the extent not covered by Medicare, from the 61st day through the 90th day in any Medicare benefit period;

(b) coverage of Medicare Part A eligible expenses incurred for hospitalization, to the extent not covered by Medicare, for each Medicare lifetime inpatient reserve day used;

(c) upon exhaustion of the Medicare Part A hospital inpatient coverage, including the lifetime reserve days, coverage of 100% of the Medicare Part A eligible expenses for hospitalization paid at the applicable prospective payment system rate or other appropriate Medicare standard of payment, subject to a lifetime maximum benefit of an additional 365 days, which the provider shall accept the issuer's payment as payment in full and may not bill the insured for any balance;

(d) coverage under Medicare Part A and B for the reasonable cost of the first three pints of blood, or equivalent quantities of packed red blood cells, as defined under federal regulations, unless replaced in accordance with federal regulations; and

(e) coverage for the coinsurance amount, or in the case of hospital outpatient department services paid under a prospective payment system, the copayment amount, of Medicare eligible expenses under Medicaid Part B regardless of hospital confinement, subject to the Medicare Part B deductible.

(8)

(a) "Basic outpatient prescription drug benefit" means coverage for 50% of outpatient prescription drug charges, after a $250 calendar year deductible, to a maximum of $1,250 in benefits received by the insured per calendar year, to the extent not covered by Medicare.

(b) The outpatient prescription drug benefit may be included for sale or issuance in a policy until January 1, 2006.

(9) "Certificate" means a group Medicare supplement insurance certificate.

(10) "Cold lead advertising" means using, directly or indirectly, any method of marketing that fails to disclose in a conspicuous manner that the method of marketing is a solicitation of insurance and that contact will be made by a producer or an issuer.

(11) "Continuous period of creditable coverage" means the period during which an individual was covered by creditable coverage, if during the period of coverage the individual had no breaks in coverage greater than 63 days.

(12) "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.

(13)

(a) "Extended outpatient prescription drug benefit" means coverage for 50% of outpatient prescription drug charges, after a $250 calendar year deductible to a maximum of $3,000 in benefits received by the insured per calendar year, to the extent not covered by Medicare.

(b) The outpatient prescription drug benefit may be included for sale or issuance in a policy until January 1, 2006.

(14) "High pressure tactics" means using a method of marketing to induce, or tend to induce, the purchase of insurance through force, fright, threat, whether explicit or implied, or undue pressure to purchase or recommend the purchase of insurance.

(15)

(a) "Home" means any place used by the insured as a place of residence, provided that the place would qualify as a residence for home health care services covered by Medicare.

(b) "Home" does not mean a hospital or skilled nursing facility.

(16) "Insolvency" means when an issuer licensed to transact the business of insurance in this state has 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.

(17)

(a) "Medically necessary emergency care in a foreign country" means:

(i) coverage that, to the extent not covered by Medicare for 80% of the billed charges for Medicare-eligible expenses for medically necessary emergency hospital, physician, and medical care received in a foreign country:

(A) would have been covered by Medicare if provided in the United States; and

(B) began during the first 60 consecutive days of a trip outside the United States; and

(ii) coverage that is subject to a calendar year deductible of $250 and a lifetime maximum benefit of $50,000.

(b) For the purposes of "medically necessary emergency are in a foreign country," "emergency care" means care needed immediately because of an injury or an illness of sudden and unexpected onset.

(18) "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 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 plan medical savings account; and

(c) Medicare Advantage private fee-for-service plans.

(19) "Medicare Part A deductible" means coverage for a Medicare Part A inpatient hospital deductible amount per benefit period.

(20) "Medicare Part B deductible" means coverage for a Medicare Part B deductible amount per calendar year regardless of hospital confinement.

(21) "Medicare Part B excess charges" means coverage for the difference between the actual Medicare Part B charge as billed, not to exceed any charge limitation established by the Medicare program or state law, and the Medicare-approved Part B charge.

(22) "Newly eligible" means an individual who became eligible for Medicare due to age, disability, or end-stage renal disease on or after January 1, 2020.

(23) "Policy" means a Medicare supplement insurance policy.

(24) "Pre-standardized plan" means group or individual Medicare supplement insurance issued before December 12, 1994.

(25)

(a) "Preventive medical care benefit" means coverage for preventive health services not covered by Medicare as follows:

(i) an annual clinical preventive medical history and physical examination that may include tests, services, and patient education to address preventive health care measures; and

(ii) preventive screening tests or preventive services determined to be medically appropriate by the attending physician.

(b) "Preventive medical care benefit":

(i) is limited to reimbursement for actual charges, up to 100% of the Medicare-approved amount for each service, as if Medicare were to cover the service as identified in American Medical Association Current Procedural Terminology codes, to a maximum of $120 annually; and

(ii) may not include payment or a procedure covered by Medicare.

(26) "Secretary" means the Secretary of the United States Department of Health and Human Services.

(27) "Skilled nursing facility care" means coverage for the actual billed charges up to the coinsurance amount from the 21st day through the 100th day in a Medicare benefit period for post-hospital skilled nursing facility care eligible under Medicare Part A.

(28) "Standardized plan" means Medicare supplement:

(a) Plan A;

(b) Plan B;

(c) Plan C;

(d) Plan D;

(e) Plan E;

(f) Plan F;

(g) Plan High Deductible F;

(h) Plan G;

(i) Plan High Deductible G;

(j) Plan H;

(k) Plan I;

(l) Plan J;

(m) Plan High Deductible J;

(n) Plan K;

(o) Plan L;

(p) Plan M; or

(q) Plan N.

(28) "Twisting" means knowingly making any misleading representation or incomplete or fraudulent comparison of any insurance policy or issuer to induce, or tend to induce, any person to lapse, forfeit, surrender, terminate, retain, pledge, assign, borrow on, or convert any insurance policy or to take out an insurance policy with another issuer.

Notes

Utah Admin. Code R590-146-4

Amended by Utah State Bulletin Number 2019-13, effective 6/7/2019 Adopted by Utah State Bulletin Number 2024-16, effective 8/7/2024