211 CMR, § 71.03
Actuarial Opinion. A signed written statement by a member of the American Academy of Actuaries based upon the person's examination, including a review of the appropriate records and of the actuarial assumptions and methods utilized by the Issuer in establishing premium rates for Policies for Medicare Supplement Insurance.
Advertisement. Advertisement shall include, but is not limited to:
(a) Printed and published material, audio-visual material and descriptive literature of an Issuer used in direct mail, newspapers, websites, magazines, radio scripts, television scripts, billboards and similar displays;
(b) Descriptive literature and sales aids of all kinds issued by an Issuer, producer or other entity for presentation to members of the insurance-buying public including, but not limited to, circulars, leaflets, booklets, depictions, illustrations, electronic messaging, and form letters; and
(c) Prepared sales talks, presentations and material for use by producers (and solicitors).
Alternate Innovative Benefit Rider. Any rider issued, renewed, or delivered by an Issuer which provides alternate innovative benefits consistent with 211 CMR 71.09(5) and may only be offered as optional additional coverage with a Medicare Supplement Core Insurance Policy, or a Medicare Supplement 1 Insurance Policy, or a Medicare Supplement 1A Insurance Policy, or a Medicare Select Insurance Policy described in 211 CMR 71.21. Consistent with 42 U.S.C. § 1395ss(p)(4)(B), an Alternate Innovative Benefit Rider is to be Guaranteed Renewable.
Applicant. In the case of an individual Medicare Supplement Insurance Policy, the person who seeks to contract for insurance benefits, and in the case of a group Medicare Supplement Insurance Policy, the proposed certificateholder.
Bankruptcy. 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 Massachusetts.
BBA. The federal Balanced Budget Act of 1997 (P.L. 105-33).
Benefit Level. The health benefits supplemental to Medicare provided by, and the benefit payment structure of, a Medicare Supplement Insurance Policy or Alternate Innovative Benefit Rider.
Biologically-based Mental Disorders. Those disorders that are described in M.G.L. c. 175, § 47B(a), (b) and (c), M.G.L. c. 176A, § 8A(a), (b), and (c), and M.G.L. c. 176B, § 4A(a), (b) and (c).
Certificate. Any Certificate issued, renewed, delivered or issued for delivery in Massachusetts under a group Medicare Supplement Insurance Policy.
Certificate Form. The form on which the Certificate is issued, renewed, delivered or issued for delivery by the Issuer.
Class. The underwriting and rating classifications originally used at the time the Policy was issued.
Cold Lead Advertising. Making use directly or indirectly of any method of marketing which fails to disclose in a conspicuous manner that a purpose of the method of marketing is solicitation of insurance and that contact will be made by an insurance producer or Issuer.
Commissioner. The Commissioner of Insurance or his or her designee.
Community Rating. A rating methodology in which the premium for all persons covered by a particular Medicare Supplement Insurance Policy or Alternate Innovative Benefit Rider is the same, based on the experience of all persons covered by the plan, without regard to age, sex, health status, occupation, or genetic information.
Compensation. Includes pecuniary or non-pecuniary remuneration of any kind relating to the sale or renewal of the Medicare Supplement Insurance Policy including, but not limited to, commissions, bonuses, gifts, prizes, awards and finders' fees.
Creditable Coverage.
(a) Means, with respect to an individual, coverage provided under any of the following:
1. A group health plan;
2. Health insurance coverage;
3. Part A or Part B of Title XVIII of the Social Security Act (Medicare);
4. Title XIX of the Social Security Act (Medicaid), other than coverage consisting solely of benefits under the federal Social Security Act § 1928;
5. 10 U.S.C. c. 55 (CHAMPUS);
6. A medical care program of the Indian Health Service or of a tribal organization;
7. A State health benefits risk pool;
8. A health plan offered under 5 U.S.C. c. 89 (Federal Employees Health Benefits Program);
9. A public health plan as defined in federal regulation; and
10. A health benefit plan under 22 U.S.C. c. 2504(e), § 5(e) (Peace Corps Act).
(b) Shall not include one or more, or any combination, of the following:
1. Coverage only for accident or disability income insurance, or any combination thereof;
2. Coverage issued as a supplement to liability insurance;
3. Liability insurance, including general liability insurance and automobile liability insurance;
4. Workers' compensation or similar insurance;
5. Automobile medical payment insurance;
6. Credit-only insurance;
7. Coverage for on-site medical clinics; and
8. Other similar insurance coverage, specified in federal regulations, under which benefits for medical care are secondary or incidental to other insurance benefits.
(c) Shall not include the following benefits if they are provided under a separate policy, certificate or contract of insurance or are otherwise not an integral part of the plan:
1. Limited scope dental or vision benefits;
2. Benefits for long-term care, nursing home care, home health care, community-based care, or any combination thereof; and
3. Such other similar, limited benefits as are specified in federal regulations.
(d) Shall not include the following benefits if offered as independent, non-coordinated benefits:
1. Coverage only for a specified disease or illness; and
2. Hospital indemnity or other fixed indemnity insurance.
(e) Shall not include the following if it is offered as a separate policy, certificate or contract of insurance:
1. Medicare supplemental health insurance as defined under the Social Security Act § 1882(g)(1);
2. Coverage supplemental to the coverage provided under 10 U.S.C. c. 55; and
3. Similar supplemental coverage provided to coverage under a group health plan.
Division. The Division of Insurance.
Eligible Person. Any person who is eligible for Medicare Part A and B and is enrolled in Medicare Part B regardless of age; provided, however, that Issuers are not required to provide coverage to a person who is younger than 65 years old and eligible for Medicare coverage due solely to end-stage renal disease; provided, further, that nothing in 211 CMR 71.00 prevents an Issuer from providing coverage to a person who is younger than 65 years old and is eligible for Medicare coverage due solely to end-stage renal disease; and provided, further, that if an Issuer determines that it will provide coverage to people who are younger than 65 years old and eligible for Medicare coverage due solely to end-stage renal disease, it shall do so in accordance with all of the provisions of 211 CMR 71.00. A Medicare Supplement 1 policy shall, on or after January 1, 2020, only be offered to Eligible Persons who:
(a) have attained 65 years of age before January 1, 2020; or
(b) first became eligible for Medicare due to age, disability or end-stage renal disease, before January 1, 2020. Persons who are otherwise eligible for Medicare Part A and B and who are enrolled in Medicare Part B, but who are not eligible to purchase Medicare Supplement 1 coverage, shall be eligible to purchase all other Medicare Supplement coverage that is currently offered. For the definition of eligible persons related to the federal Balanced Budget Act of 1997 (BBA Eligible Person), see211 CMR 71.10(12)(a). For the definition of eligible persons related to the federal Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA Eligible Person), see211 CMR 71.10(13)(a).
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).
Evidence of Coverage. Any certificate, contract or agreement issued to a Member stating health services and benefits to which the Member is entitled as described in M.G.L. c. 176K.
Genetic Information. Any written, recorded, individually identifiable result of a genetic test or explanation of such a result.
Genetic Test. A test of human DNA, RNA, mitochondrial DNA, chromosomes or proteins for the purpose of identifying the genes, or genetic abnormalities, or the presence or absence of inherited or acquired characteristics in genetic material.
Group. An entity, as described in M.G.L. c. 175, § 110, to which a general or blanket Medicare Supplement Insurance Policy is issued or an entity to which a Medicare Supplement Insurance contract is issued pursuant to M.G.L. c. 176A, § 10 and M.G.L. c. 176B, § 4, except Group shall not include 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 a combination thereof, or for members or former members, or a combination thereof, of the labor organizations.
Guaranteed Renewable. A Policy provision whereby the Insured has the right, subject to the provisions of 211 CMR 71.07(5), to continue the Medicare Supplement Insurance Policy in force by the timely payment of premiums and the Issuer has no unilateral right to make any change in any provision of the Policy or rider(s), including Alternate Innovative Benefit Rider(s), while the insurance is in force other than changes in premiums, and cannot cancel or decline to renew, except for the nonpayment of premium or material misrepresentation; provided that no Nonprofit Hospital Service Corporation or Medical Service Corporation shall be required to continue the coverage of a Policyholder who becomes a resident of a state other than Massachusetts.
High Pressure Tactics. Employing any method of marketing having the effect of or tending 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.
Individual. A person or family to which a Medicare Supplement Insurance Policy is issued pursuant to M.G.L. c. 175, § 108 or M.G.L. c. 176A, § 6, and M.G.L. c. 176B, § 4.
Initially Eligible for Coverage. The date when an Eligible Person first enrolled for benefits under Medicare Part B, lost employer-sponsored health coverage due to termination of employment or because of employer bankruptcy or because of discontinuance of employer-sponsored health coverage available to similarly situated employees by the employer, moved out of the service area of a Health Maintenance Organization, or became a resident of Massachusetts.
Insolvency. When an Issuer, licensed to transact the business of insurance in Massachusetts, 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.
Insured. A subscriber, Policyholder, member, enrollee or certificateholder under a Medicare Supplement Insurance Policy.
Issue. To offer, sell, issue, deliver, or otherwise make effective, or renew.
Issuer. Any company as defined in M.G.L. c. 175, § 1 and authorized to write accident and health insurance; any hospital service corporation as defined in M.G.L. c. 176A, § 1, any medical service corporation as defined in M.G.L. c. 176B, § 1, any health maintenance organization licensed under M.G.L. c. 176G, or any Fraternal Benefit Society as authorized in M.G.L. c. 176 which offers, sells, delivers or otherwise makes effective, or renews in Massachusetts Medicare Supplement Insurance Policies. For purposes of determining whether an Issuer is offering a non-network Medicare Supplement plan, an Issuer shall include the Issuer, its parent company or companies, its affiliated companies, and/or its subsidiary companies.
Late Enrollee. An Eligible Person who has submitted an application for a Medicare Supplement Insurance Policy after the six-month period beginning with the first month in which the Eligible Person first enrolled for benefits under Medicare Part B, or lost employer-sponsored coverage due to termination of employment or because of employer bankruptcy or because of discontinuance of employer-sponsored health coverage by the employer, or became a resident of Massachusetts; provided, however, that an Eligible Person shall not be considered a Late Enrollee if the person was covered under a Reasonably Actuarially Equivalent previous health plan and the previous coverage was continuous for the lesser of three years or the period since first eligibility and to a date not more than 30 days prior to the effective date of the new coverage.
Medicare. "Health Insurance for the Aged Act", Title XVIII of the Social Security Amendments of 1965, as then constituted or later amended.
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 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 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.
Medicare Eligible Expense. Expenses of the kinds covered by Medicare Parts A and B, to the extent recognized as reasonable and medically necessary by Medicare.
Medicare Supplement Insurance Policy. A type of health insurance issued by a carrier, other than a policy issued pursuant to a contract under the Social Security Act § 1876 or § 1833 (42 U.S.C. § 1395et seq.), or a policy issued under a demonstration project authorized pursuant to amendments to the federal Social Security Act, which 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. Unless otherwise set forth within 211 CMR 71.00, Core Medicare Supplement Policies, Medicare Supplement 1 Policies, Medicare Supplement 1A Policies, and Medicare Supplement 2 Policies are all subject to Medicare Supplement Insurance Policy requirements.
Mental Disorder. A condition as described in the 5th edition of the Diagnostic and Statistical Manual of the American Psychiatric Association.
MMA. The federal Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (Pub. L. 108-173).
Off-label Use. A drug that has not been specifically approved by the United States Food and Drug Administration for the treatment of cancer or HIV/AIDS, but is a drug approved for other indications by the Food and Drug Administration.
Other Mental Health Disorders. All other mental disorders described in the 5th edition of the Diagnostic and Statistical Manual that are not biologically-based.
Outpatient Prescription Drug. A prescription drug that is administered on an outpatient basis.
Participate in the Market. To offer, sell, issue, deliver, or otherwise make effective, or renew, a Medicare Supplement Insurance Policy, Alternate Innovative Benefit Rider in Massachusetts, and to have not discontinued the availability of all of its Policy forms or Certificate forms.
Policy. Any Policy, Certificate, contract, agreement, statement of coverage, rider or endorsement issued by an Issuer as defined in 211 CMR 71.00 which provides Medicare Supplement Insurance as defined in 211 CMR 71.03: Policy other than a policy issued pursuant to a contract under the Social Security Act § 1876 (42 U.S.C. § 1395et seq.) or an issued policy under a demonstration project specified in 42 U.S.C. § 1395ss(g)(1), which provides Medicare Supplement Insurance as defined herein. Policy, unless stated otherwise within 211 CMR 71.00, includes any Alternate Innovative Benefits Riders. 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 the Social Security Act § 1833(a)(1)(A).
Policy Form. The form on which the Medicare Supplement Insurance Policy is delivered or issued for delivery by the Issuer.
Policyholder. Any person holding a Policy as defined in 211 CMR 71.03.
Pre-existing Conditions Limitation or Exclusion. A provision in a Medicare Supplement Insurance Policy which limits or excludes coverage for charges or expenses incurred following the Insured's coverage effective date as to a condition for which medical advice was given or treatment was recommended by or received from a physician within six months before the effective date of coverage.
Producer. Any insurance producer, advisor or other person engaged in activities described in M.G.L. c. 175, §§ 162 through 177D.
Rate Anniversary Date. The calendar date in any year at least one year later than the date on which an Issuer's most recent Medicare Supplement rate increase became effective.
Reasonably Actuarially Equivalent. The Benefit Level of one of two Medicare Supplement Insurance Policies or Evidences of Coverage Issued Pursuant to a Medicare Part C Contract with Medicare or other health benefit plan being compared is no more than ten percentage points greater in value than the Benefit Level for the other Medicare Supplement Insurance Policy, Alternate Innovative Benefit Rider or Evidence of Coverage Issued Pursuant to a Medicare Part C Contract with Medicare or health benefit plan, assuming that the benefits are offered to identical populations.
Secretary. The Secretary of the United States Department of Health and Human Services.
Twisting. Knowingly making any misleading representation or incomplete or fraudulent comparison of any insurance policies or carriers for the purpose of inducing, or tending to induce, any person to lapse, forfeit, surrender, terminate, retain, pledge, assign, borrow on, or convert any insurance policy or to take out a policy of insurance with another carrier.
Upgrade Coverage. The Medicare Supplement Insurance Policy or Alternate Innovative Benefit Rider under which the Eligible Person is covered at the time of application for new coverage has a lower Benefit Level than the new coverage, and the two coverages are not Reasonably Actuarially Equivalent.
Waiting Period. A period immediately subsequent to the effective date of an Insured's coverage during which the insurance coverage does not pay for some or all hospital or medical expenses.
211 CMR, § 71.03