SECTION 3.3303. Definitions

The following words and terms, when used in this subchapter, have the following meanings, unless the context clearly indicates otherwise.

(1) 1990 Standardized Medicare supplement benefit plan, 1990 Standardized benefit plan, or 1990 plan--A group or individual policy of Medicare supplement insurance issued or issued for delivery on or after March 1, 1992, and with an effective date for coverage before June 1, 2010.

(2) 2010 Standardized Medicare supplement benefit plans, 2010 Standardized benefit plan, or 2010 plan--A group or individual policy of Medicare supplement insurance with an effective date for coverage on or after June 1, 2010.

(3) 2020 newly eligible individual--An individual who is newly eligible for Medicare on or after January 1, 2020:

(A) by reason of attaining age 65 on or after January 1, 2020; or

(B) by reason of entitlement to benefits under Part A under section 42 U.S.C. §426(b) or 42 U.S.C. §426-1, or who is deemed to be eligible for benefits under section 42 U.S.C. §426(a) on or after January 1, 2020. An individual who becomes Medicare eligible or turns 65 before January 1, 2020, is not a 2020 newly eligible individual.

(4) Applicant--

(A) In the case of an individual Medicare supplement policy, the person who seeks to contract for insurance or other health benefits.

(B) In the case of a group Medicare supplement policy, the proposed certificate holder.

(5) Bankruptcy--The situation that occurs when 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 Texas.

(6) Certificate--Any certificate issued under a group Medicare supplement policy, for which a certificate has been delivered or issued for delivery in this state regardless of the place where the policy was delivered or issued for delivery.

(7) 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 63 days.

(8) Creditable coverage--Any coverage of an individual as defined in §21.1101 of this title (relating to Definitions).

(9) Employee welfare benefit plan--A plan, fund, or program of employee benefits as defined in 29 U.S.C. §1002 (Employee Retirement Income Security Act).

(10) Health Maintenance Organization (HMO)--An entity as defined in 42 U.S.C. §300e(a).

(11) Insolvency--The situation that occurs when an issuer has had an order of liquidation entered against it with a finding of insolvency by a court of competent jurisdiction in the issuer's state of domicile.

(12) Issuer--An insurance company, fraternal benefit society, health care service plan, health maintenance organization, or any other entity delivering or issuing for delivery in this state Medicare supplement policies or certificates.

(13) Medicaid--Grants to States for Medical Assistance Programs, Title XIX of the Social Security Act Amendments of 1965 as then constituted or later amended.

(14) Medicare--The Health Insurance for the Aged Act, Title XVIII of the Social Security Act Amendments of 1965 as then constituted or later amended.

(15) Medicare Advantage organization--An entity as defined in 42 U.S.C. §1395w-28(a)(1).

(16) 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 that provide health services, including but not limited to HMO plans (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.

(17) Medicare Advantage private fee-for-service plan--An entity as defined in 42 U.S.C. §1395w-28(b)(2).

(18) MMA--The Medicare Prescription Drug, Improvement, and Modernization Act of 2003.

(19) Medicare Select policy or Medicare Select certificate--A Medicare supplement policy or certificate, respectively, that contains restricted network provisions.

(20) Medicare supplement policy--A group or individual policy of accident and sickness insurance or a subscriber contract of a group hospital service corporation subject to Insurance Code Chapter 842 (concerning Group Hospital Service Corporations), or, to the extent required by federal law, an evidence of coverage issued by an HMO subject to Insurance Code Chapter 843 (concerning Health Maintenance Organizations), for which a policy, subscriber contract, or evidence of coverage 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. The term does not include:

(A) a policy, contract, subscriber contract, or evidence of coverage of one or more employers or labor organizations, or of the trustees of a fund established by one or more employers or labor organizations, or combination thereof, for employees or former employees, or combination thereof, or for members or former members, or combination thereof, of the labor organizations;

(B) a policy or health care benefit plan including a policy or contract of group insurance or group contract of a group hospital service corporation subject to Insurance Code Chapter 842, or group evidence of coverage issued by an HMO subject to Insurance Code Chapter 843, when such policy or plan is not marketed or held to be a Medicare supplement policy or benefit plan; or

(C) an individual or group evidence of coverage issued under a contract in accordance with the Federal Social Security Act, §1876 (42 U.S.C. §§1395, et seq.) by an HMO subject to Insurance Code Chapter 843;

(D) a Medicare Advantage plan established under Medicare Part C;

(E) an Outpatient Prescription Drug plan established under Medicare Part D; or

(F) a Health Care Prepayment Plan (HCPP) that provides benefits under an agreement under §1833(a)(1)(A) of the Federal Social Security Act (42 U.S.C. §§1395, et seq.)

(21) Point of service--A benefit option as defined in 42 C.F.R. §422.2.

(22) Pre-Standardized Medicare supplement benefit plan, Pre-Standardized benefit plan or Pre-Standardized plan--A group or individual policy of Medicare supplement insurance issued or issued for delivery before March 1, 1992.

(23) Provider-sponsored organization--An entity as defined in 42 U.S.C. §1395w-25(d)(1).

(24) Qualified actuary--An actuary who is a member of either the Society of Actuaries or the American Academy of Actuaries.

(25) Secretary--The Secretary of the United States Department of Health and Human Services.

Source Note: The provisions of this §3.3303 adopted to be effective June 1, 1982, 7 TexReg 1303; amended to be effective February 14, 1990, 15 TexReg 540; amended to be effective April 15, 1992, 17 TexReg 2238; amended to be effective January 1, 1997, 21 TexReg 10753; amended to be effective April 14, 1999, 24 TexReg 3353; amended to be effective May 10, 2005, 30 TexReg 2669; amended to be effective July 6, 2009, 34 TexReg 4532; amended to be effective June 13, 2018, 43 TexReg 3787