Section 687B.215 - Definitions and terms used in policy or certificate1. Each policy to supplement Medicare or certificate advertised, solicited or issued for delivery in this State must contain definitions or terms conforming to the requirements of this section.2. "Accident," "accidental injury" or "accidental means" must be defined to employ "result" language and may not include words that establish an accidental means test or use words such as "external," "violent," "visible wounds" or similar words of description or characterization. The definition:(a) May not define the terms more restrictively than as the direct result of an accident, independent of disease or bodily infirmity or any other cause, that occurs while insurance coverage is in force.(b) Unless prohibited by law, may provide that the terms do not include any injury for benefits which are provided or available under any workers' compensation, employer's liability or similar law, or motor vehicle no-fault plan.3. "Benefit period" or "Medicare benefit period" may not be defined more restrictively than as defined by Medicare.4. "Convalescent nursing home," "extended care facility" or "skilled nursing facility" may not be defined more restrictively than as defined by Medicare.5. "Health care expenses" means the expenses of a health maintenance organization associated with the delivery of services for health care that are analogous to the incurred losses of an issuer.6. "Hospital" may 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 must not be more restrictive than as defined by Medicare.7. "Medicare" must be defined in the policy and certificate. The term may be defined as "The Health Insurance for the Aged Act, Title XVIII of the Social Security Amendments of 1965 as then constituted or later amended," or "Title I, Part I 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 thereof," or words of similar import.8. "Medicare eligible expenses" means expenses for health care of the kinds covered by Medicare Parts A and B, to the extent recognized as reasonable and medically necessary by Medicare.9. "Physician" may not be defined more restrictively than as defined by Medicare.10. Except as otherwise provided in this subsection, "sickness" must not be defined more restrictively than the following: "Sickness" means an illness or disease of an insured person that first manifests itself after the effective date of insurance and while the insurance is in force.
The definition may be modified to exclude sicknesses or diseases for which benefits are provided under any workers' compensation, occupational disease, employer's liability or similar law.
Nev. Admin. Code § 687B.215
Added to NAC by Comm'r of Insurance, 2-21-89, eff. 3-15-89; A 7-16-92, eff. 7-30-92; 8-2-94; A by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit