Iowa Admin. Code r. 191-37.3
For purposes of this chapter, in addition to the definitions in Iowa Code section 514D2., the following definitions shall apply, unless otherwise specified:
"1990 standardized Medicare supplement benefit plan" or "1990 plan " means a group or individual Medicare supplement policy issued on or after January 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 June 1, 2010, which are not replaced by the issuer at the request of the insured.
"2010 standardized Medicare supplement benefit plan" or "2010 plan " means a group or individual Medicare supplement policy issued with an effective date for coverage on or after June 1, 2010.
"Applicant" means:
1. In the case of an individual Medicare supplement policy, the person who seeks to contract for insurance benefits; and
2. In the case of a group Medicare supplement policy, the proposed covered individual, unless stated otherwise.
"Basic core benefits" are benefits defined in subrule 37.7(2) for 1990 plans, subrule 37.8(2) for 2010 plans, and subrule 37.9(1) for Medicare supplement policies or certificates delivered or issued for delivery to individuals newly eligible for Medicare on or after January 1, 2020.
"Certificate" means any certificate of coverage delivered or issued for delivery in this state to a covered individual under a group Medicare supplement policy.
"Certificate form" means the form (as defined in Iowa Code section 514D2(2). ) on which the certificate is delivered or issued for delivery by the issuer.
"Certificate holder" means the named individual to whom the certificate of coverage under a group policy is issued, or a spouse, if applicable.
"CMS" means the Centers for Medicare and Medicaid Services of the U.S. Department of Health and Human Services.
"Commissioner" means the Iowa insurance commissioner, and includes the insurance division as delegated.
"Covered individual" means an individual who may receive benefits under an individual or group Medicare supplement policy because the individual is one of the following: the named insured under an individual Medicare supplement policy; the named certificate holder under a group Medicare supplement policy; or an individual such as a spouse covered by way of the named certificate holder's group Medicare supplement policy. For purposes of rule 191-3720. (514D), "covered individual" means an individual who may receive benefits under an individual or group Medicare Select policy because the individual is one of the following: the named insured under an individual Medicare Select policy; the named certificate holder under a group Medicare Select policy; or an individual such as a spouse covered by way of the named certificate holder's group Medicare Select policy.
"Creditable coverage."
1. "Creditable coverage" means, with respect to an individual, health coverage of the individual provided under any of the following:
* A group health plan;
* Health insurance coverage;
* Part A or Part B of Title XVIII of the Social Security Act (Medicare);
* Title XIX of the Social Security Act (Medicaid), other than coverage consisting solely of benefits under Section 1928;
* Chapter 55 of Title 10, United States Code (CHAMPUS);
* A medical care program of the Indian Health Service or of a tribal organization;
* A state health benefits risk pool;
* A health plan offered under Chapter 89 of Title 5, United States Code (Federal Employees Health Benefits Program);
* A public health plan as defined in federal regulation; and
* A health benefit plan under Section 5 (e) of the Peace Corps Act ( 22 United States Code 2504(e) ).
2. "Creditable coverage" shall not include one or more of, or any combination of, the following:
* Coverage only for accident or disability income insurance, or any combination thereof;
* Coverage issued as a supplement to liability insurance;
* Liability insurance, including general liability insurance and automobile liability insurance;
* Workers' compensation or similar insurance;
* Automobile medical payment insurance;
* Credit-only insurance;
* Coverage for on-site medical clinics; and
* Other similar insurance coverage, specified in federal regulations, under which benefits for medical care are secondary or incidental to other insurance benefits.
3. "Creditable coverage" 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:
* Limited scope dental or vision benefits;
* Benefits for long-term care, nursing home care, home health care, community-based care, or any combination thereof; and
* Such other similar limited benefits as are specified in federal regulations.
4. "Creditable coverage" shall not include the following benefits if offered as independent, noncoordinated benefits:
* Coverage only for a specified disease or illness; and
* Hospital indemnity or other fixed indemnity insurance.
5. "Creditable coverage" shall not include the following if it is offered as a separate policy, certificate or contract of insurance:
* Medicare supplemental health insurance as defined under Section 1882(g)(1) of the Social Security Act;
* Coverage supplemental to the coverage provided under Chapter 55 of Title 10, United States Code; and
* Similar supplemental coverage provided to the coverage under a group health plan.
"File" or "filing," when used in reference to filing information with the commissioner or with the insurance division, means submitting information as set forth in these rules through the System for Electronic Rate and Form Filing (SERFF),www.serff.com , or as otherwise directed by the insurance division through its website,iid.iowa.gov.
"Group member" means the individual who is a member of the group entity to which the group policy is issued.
"Group policyholder" means the group entity to which a group Medicare supplement policy is issued.
"Insolvency" means that 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.
"Insurance division" means the Iowa insurance division.
"Issuer" includes insurance companies, fraternal benefit societies, health care service plans, health maintenance organizations, and any other entity delivering or issuing for delivery in this state Medicare supplement policies or certificates.
"Medicare" means the Health Insurance for the Aged Act, Title XVIII of the Social Security Amendments of 1965, as then constituted or later amended.
"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:
1. Coordinated care plans which 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 organization plans;
2. Medical savings account plans coupled with a contribution into a Medicare Advantage medical savings account; and
3. Medicare Advantage private fee-for-service plans.
"Medicare Select policy" "Medicare Select certificate," "Medicare Select issuer," and "Medicare Select network provider" are defined in subrule 37.20(2).
"Medicare supplement policy" means a group or individual policy of accident and sickness insurance or a subscriber contract of hospital and medical service associations or health maintenance organizations, other than a policy issued pursuant to a contract under Section 1876 of the federal Social Security Act ( 42 U.S.C. Section 1395 et seq.) or an issued policy under a demonstration project specified in 42 U.S.C. Section 1395ss(g)(1), 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. "Medicare supplement policy" does not include Medicare Advantage plans, 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.
"MMA" means the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, Pub. L. No. 108-173, 117 Stat. 2066.
"PACE program" means a program of all-inclusive care for the elderly, operated by an approved PACE organization (an entity that is approved as a PACE program by the Iowa department of human services and that has in effect a PACE program agreement between the entity, CMS, and the Iowa department of human services to operate a PACE program) that provides comprehensive health care services to enrollees in Iowa, pursuant to Section 1894 of the Social Security Act ( 42 U.S.C. 1395ee e) and Iowa Administrative Code rules 441-8821. (249A) through 441-8828. (249A).
"Person" means any individual, corporation, association, or partnership.
"Policy form" means the form (as defined by Iowa Code section 514D2(2). ) on which the policy (as defined by Iowa Code section 514D2(4). ) is delivered or issued for delivery by the issuer.
"Policyholder" means the individual person to whom or group entity to which an individual or group Medicare supplement policy is issued.
"PPS" means prospective payment system.
"Prestandardized Medicare supplement benefit plan" or "prestandardized plan" means a group or individual Medicare supplement policy issued prior to January 1, 1992.
"Producer" means a person licensed in this state pursuant to Iowa Code chapter 522B and Iowa Administrative Code 191-Chapter 10 to sell, solicit, negotiate, effect, procure, deliver, renew, continue or bind policies of insurance for persons residing or located, or for policies to be performed, in this state.
"Secretary" means the Secretary of the U.S. Department of Health and Human Services.
"SMSBP" or "standardized Medicare supplement benefit plan" means a 1990 plan, a 2010 plan, or a plan described in subrule 37.9(1) for Medicare supplement policies or certificates delivered or issued for delivery to individuals newly eligible for Medicare on or after January 1, 2020.
Iowa Admin. Code r. 191-37.3