Idaho Admin. Code r. 18.04.10.010

Current through September 2, 2024

Section 18.04.10.010 - DEFINITIONS

01.Applicant.

a. In the case of an individual Medicare supplement policy, the person who seeks to contract for insurance benefits; and

b. In the case of a group Medicare supplement policy, the proposed certificate holder.

02.Bankruptcy. 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 the state.

03.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 sixty-three (63) days.

04.Creditable Coverage.

a. With respect to an individual, coverage of the individual provided under any of the following:

i. A group health plan;

ii. Health insurance coverage;

iii. Part A or Part B of Title XVIII of the Social Security Act (Medicare);

iv. Title XIX of the Social Security Act (Medicaid), other than coverage consisting solely of benefits under Section 1928;

v. Title 10, Chapter 55, United States Code (CHAMPUS);

vi. A medical care program of the Indian Health Service or of a tribal organization;

vii. A state health benefits risk pool;

viii. A health plan offered under Title 5, Chapter 89, United States Code (Federal Employees Health Benefits Program);

ix. A public health plan as defined in federal regulation; and

x. A health benefit plan under Section 5(e) of the Peace Corps Act (22 United States Code 2504(e)).

b. Creditable coverage does not include one (1) or more, or any combination of, the following:

i. Coverage only for accident or disability income insurance, or any combination thereof;

ii. Coverage issued as a supplement to liability insurance;

iii. Liability insurance, including general liability insurance and automobile liability insurance;

iv. Workers' compensation or similar insurance;

v. Automobile medical payment insurance;

vi. Credit-only insurance;

vii. Coverage for on-site medical clinics; and

viii. Other similar insurance coverage, specified in federal regulations, under which benefits for medical care are secondary or incidental to other insurance benefits.

c. Creditable coverage does not include the following benefits if they are provided under a separate policy, certificate or contract of insurance or are not an integral part of the plan:

i. Limited scope dental or vision benefits;

ii. Benefits for long-term care, nursing home care, home health care, community-based care, or any combination thereof; and

iii. Such other similar, limited benefits as are specified in federal regulations.

d. Creditable coverage does not include the following benefits if offered as independent, non-coordinated benefits:

i. Coverage only for a specified disease or illness; and

ii. Hospital indemnity or other fixed indemnity insurance.

e. Creditable coverage does not include the following if it is offered as a separate policy, certificate, or contract of insurance:

i. Medicare supplemental health insurance as defined under Section 1882(g)(1) of the Social Security Act;

ii. Coverage supplemental to the coverage provided under Title 10, Chapter 55, United States Code; and

iii. Similar supplemental coverage provided to coverage under a group health plan.

f. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) specifically addressed separate, noncoordinated benefits in the group market at PHSA Section 2721(d)(2) and the individual market at Section 2791(c)(3). HIPAA also references excepted benefits at PHSA Sections 2701(c)(1), 2721(d), 2763(b) and 2791(c). In addition, credible coverage has been addressed in an interim final rule (62 Fed. Reg. At 16960-16962 (April 8, 1997)) issued by the Secretary of Health and Human Services, pursuant to HIPAA, and may be addressed in subsequent regulations.

05.Employee Welfare Benefit Plan. A plan, fund, or program of employee benefits as defined in 29 U.S.C. Section 1002 (Employee Retirement Income Security Act).

06.Insolvency. When an issuer, licensed to transact the business of insurance in this state, 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.

07.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 which provide health care services, including but not limited to managed care organization (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.

08.Medicare Supplement Policy. As defined in Section 41-4402 and in addition, "Medicare Supplement 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 Section 1833(a)(1)(A) of the Social Security Act; provided, however, that under Section 104(c) of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA), policies that are advertised, marketed or designed primarily to cover out-of-pocket costs under Medicare Advantage Plans (established under Medicare Part C) need to comply with the Medicare supplement requirements of Section 1882(o) of the Social Security Act.

09.Pre-Standardized Benefit Plan. A group or individual policy of Medicare supplement insurance issued prior to July 1, 1992.

10.1990 Standardized Benefit Plan. A group or individual policy of Medicare supplement insurance issued on or after July 1, 1992 and with an effective date for coverage prior to June 1, 2010 and includes Medicare supplement insurance policies and certificates renewed on or after that date which are not replaced by the issuer at the request of the insured.

11.2010 Standardized Benefit Plan. A group or individual policy of Medicare supplement insurance with an effective date for coverage issued on or after June 1, 2010.

12.Secretary. The Secretary of the United States Department of Health and Human Services.

Idaho Admin. Code r. 18.04.10.010

Effective March 31, 2022