Md. Code Regs. 31.10.05.05

Current through Register Vol. 51, No. 22, November 1, 2024

Section 31.10.05.05 - Policy Definitions and Terms

A. An insurance policy, subscriber contract, or certificate may not be advertised, marketed, solicited, or issued for delivery in this State as a Medicare supplement policy unless it contains definitions or terms which conform to the requirements of this regulation, or definitions which are more favorable to the insured person or certificate holder.

B. Terms To Be Defined in the Policy.

(1) Accident.

(a) "Accident", "accidental injury", or "accidental means" shall be defined to employ "result" language and may not include words which establish an accidental means test or use words such as "external, violent, and accidental means", "visible contusion or wound", or words of similar import, description, or characterization.

(b) 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 which is the direct result of an accident, independent of disease or bodily infirmity or any other cause, and occurs while insurance coverage is in force."

(c) The definition may additionally provide that injuries do not include injuries for which benefits are provided or available to the insured under any workers' compensation, occupational disease, employer's liability, or similar law, or to the extent permitted by law, to benefits provided or available under any motor vehicle no-fault plan.

(2) "Benefit period" or "Medicare benefit period" may not be defined in a manner more restrictive than as defined in the Medicare program.

(3) "Convalescent nursing home", "extended care facility", or "skilled nursing facility" shall be defined in relation to its status, facilities, and available services. The following apply:

(a) The definition may not be more restrictive than one requiring that the home or facility:

(i) Be operated pursuant to law;

(ii) Be approved for payment of Medicare benefits or be qualified to receive that approval;

(iii) Be primarily engaged in providing, in addition to room and board accommodations, skilled nursing care under the supervision of a duly licensed physician;

(iv) Provide continuous 24-hour-a-day nursing service by or under the supervision of a registered graduate professional nurse (R.N.); and

(v) Maintain a daily medical record of each patient.

(b) The definition of the home or facility may provide that the term does not include:

(i) A home, facility, or part of a home or facility used primarily for rest;

(ii) A home or facility for the aged or for the care of drug addicts or alcoholics; or

(iii) A home or facility primarily used for the care and treatment of mental diseases or disorders, or for custodial or educational care.

(4) "Hospital" shall be defined in relation to its status, facilities, and available services, or to reflect its accreditation by the Joint Commission on Accreditation of Hospitals. The definition of the term "hospital":

(a) May not be more restrictive than one requiring that the hospital:

(i) Be an institution operated pursuant to law,

(ii) Be primarily and continuously engaged in providing or operating, either on its premises or in facilities available to the hospital on a prearranged basis and under the supervision of a staff of duly licensed physicians, medical, diagnostic, and major surgical facilities for the medical care and treatment of sick or injured persons on an inpatient basis, for which a charge is made, and

(iii) Provide 24-hour nursing service by or under the supervision of registered graduate professional nurses (R.N.'s);

(b) May provide that the term does not include:

(i) Convalescent homes, convalescent rest or nursing facilities,

(ii) Facilities primarily affording custodial, educational, or rehabilitative care,

(iii) Facilities for the aged, drug addicts or alcoholics, military, veterans' or soldiers' home, or any hospital contracted for or operated by any national government or national governmental agency for the treatment of members or ex-members of the armed forces, except for services rendered on an emergency basis when legal liability exists for charges made to the individual for these services.

(5) "Medicare" shall be defined in the policy substantially either as:

(a) "The Health Insurance for the Aged Act, Title XVIII of the Social Security Amendments of 1965 as then constituted or later amended"; or

(b) "Title I, Part 1 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 of that Act."

(6) "Medicare eligible expenses" shall be defined in the policy as health care expenses of the kind covered by Medicare, to the extent recognized as reasonable by Medicare. The insurer may modify the definition to provide that payments under the policy will be conditioned on less restrictive payment conditions, including determinations of medical necessity, than the conditions applicable to medical claims.

(7) "Mental or nervous disorders" may be defined in a manner which includes neurosis, psychoneurosis, psychopathy, psychosis, and mental and emotional disease or disorder of any kind.

(8) "Nurse" may be defined to include a registered graduate professional nurse (R.N.), a licensed practical nurse (L.P.N.), a licensed nurse anesthetist, or a licensed vocational nurse (L.V.N.). The use of the words "nurse" or "trained nurse" without further qualification will require the insurer to recognize the services of any individual qualified under applicable statutes or regulations provided the nurse is acting within the lawful scope of practice of the nurse's license.

(9) "Physician" shall be defined to include a licensed physician or any duly licensed provider of medical care and treatment when the services to be performed are within the lawful scope of practice of the provider.

(10) "Sickness" shall be defined so as to be not more restrictive than a sickness or disease of an insured person which first manifests itself after the effective date of the insurance and while the insurance is in force. The insurer may modify the definition to exclude sickness or disease for which benefits are provided under any workers' compensation, occupational disease, employer's liability, or similar law.

Md. Code Regs. 31.10.05.05

Regulations .05, Appendixes A_C adopted as an emergency provision effective July 1, 1982 (9:13 Md. R. 1340); adopted permanently effective October 1, 1982 (9:17 Md. R. 1707)
Regulations .05 and Appendices A_C repealed, and new Regulations .05 and Appendices A_C adopted as an emergency provision effective July 25, 1989 (16:16 Md. R. 1738); emergency status extended at 16:26 Md. R. 2782 and 17:5 Md. R. 633; emergency status expired July 20, 1990
Regulations .05 and Appendices A_C repealed, and new Regulations .05 adopted effective July 23, 1990 (17:14 Md. R. 1757)