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  • PART I ADMINISTRATION OF THE GOVERNMENT
  • TITLE XXII CORPORATIONS
  • CHAPTER 176K MEDICARE SUPPLEMENT INSURANCE PLANS
  • Section 1 Definitions

Section 1. As used in this chapter the following words shall have the following meanings, unless the context clearly requires otherwise:

“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 carrier in establishing premium rates for policies for medicare supplement insurance or medicare select insurance or policies issued pursuant to a risk or cost contract.

“Carrier”, an insurer licensed or otherwise authorized to transact accident and health insurance under chapter one hundred and seventy-five; a non-profit hospital service corporation organized under chapter one hundred and seventy-six A; a medical service corporation organized under chapter one hundred and seventy-six B; a health maintenance organization organized under chapter one hundred and seventy-six G; and any entity approved by the commissioner under chapter one hundred and seventy-six I to operate an insured health plan that includes a preferred provider arrangement which offer, sell, issue, deliver, or otherwise make effective, or renew in the commonwealth policies for medicare supplement insurance or medicare select insurance or policies issued pursuant to risk or cost contracts.

“Commissioner”, the commissioner of insurance.

“Community rating”, a rating methodology in which the premium for all persons covered by a particular policy for medicare supplement insurance or medicare select insurance or a policy issued pursuant to a risk or cost contract is the same, based on the experience of all persons covered by the plan, without regard to age, sex, health status, or occupation, or any other factor which the commissioner may specify by regulation.

“Eligible person”, any person who resides in the commonwealth for at least six consecutive months of each calendar year and who is eligible for or enrolled in Medicare coverage for both hospital and physician services due to age or disability, and who is not eligible for employer-sponsored health care coverage, other than a person eligible for Medicare coverage due solely to end-stage renal disease.

“Guaranteed renewable”, a policy provision whereby the insured has the right to continue the policy for medicare supplement insurance or medicare select insurance or policy issued pursuant to a risk or cost contract in force by the timely payment of premiums and the carrier has no unilateral right to make any change in any provision of the plan while the plan is in force, unless approved by the commissioner, and cannot cancel or decline to renew, except for the nonpayment of premium, or material misrepresentation.

“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, moved out of the service area of a health maintenance organization or became a resident of the commonwealth.

“Insured”, a subscriber, policyholder, member, enrollee or certificate holder.

“Issue”, to offer, sell, issue, deliver, or otherwise make effective, or renew.

“Late enrollee”, an eligible person who has submitted an application for a policy for medicare supplement insurance or medicare select insurance or a policy issued pursuant to a risk or cost contract after the six month period beginning with the first month in which the individual first enrolled for benefits under Medicare part B, or lost employer-sponsored coverage due to termination of employment or because of employer bankruptcy, or became a resident of the commonwealth; 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 to a date not more than thirty days prior to the effective date of the new coverage.

“Medicare”, Health Insurance for the Aged Act, Title XVIII of the Social Security Act Amendments of 1965, as then constituted or later amended.

“Medicare Part D”, Medicare prescription drug coverage available to Medicare-eligible persons beginning January 1, 2006, as authorized under the federal Medicare Prescription Drug, Improvement, and Modernization Act of 2003.

“Medicare select insurance”, a type of health insurance issued by a carrier 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, and which contains restricted network provisions and is issued under a demonstration project authorized pursuant to amendments to the federal Social Security Act.

“Medicare supplement insurance”, a type of health insurance issued by a carrier, other than a policy issued pursuant to a contract under Section 1876 or Section 1833 of the federal Social Security Act (42 U.S.C. Section 1395 et 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.

“OBRA 90”, the federal Omnibus Budget Reconciliation Act of 1990 (P.L. 101-508) and as this act has been subsequently amended.

“Policy issued pursuant to a risk or cost contract”, a policy issued by a health maintenance organization organized under chapter one hundred and seventy-six G pursuant to a contract under Section 1876 or Section 1833 of the federal Social Security Act (42 U.S.C. Section 1395 et seq.).

“Participate in the market”, to offer, sell, issue, deliver, or otherwise make effective, or renew, a policy for medicare supplement insurance or medicare select insurance or a policy issued pursuant to a risk or cost contract.

“Policy”, any policy, certificate, contract, agreement, statement of coverage, rider or endorsement issued by a carrier for medicare supplement insurance, medicare select insurance, or pursuant to a risk or cost contract.

“Preexisting conditions limitation or exclusion”, a policy provision which limits or excludes coverage for charges or expenses incurred following the insured’s 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.

“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.