Ins 3.39(3)(i)4.4. “Creditable coverage” shall not include the following benefits if offered as independent, non-coordinated benefits:
Ins 3.39(3)(i)4.a.a. Coverage only for a specified disease or illness; and
Ins 3.39(3)(i)4.b.b. Hospital indemnity or other fixed indemnity insurance.
Ins 3.39(3)(i)5.5. “Creditable coverage” shall not include the following if it is offered as a separate policy, certificate or contract of insurance:
Ins 3.39(3)(i)5.a.a. Medicare supplemental health insurance as defined under section 1882 (g) (1) of the social security act;
Ins 3.39(3)(i)5.b.b. Coverage supplemental to the coverage provided under chapter 55 of title 10, United States Code; and
Ins 3.39(3)(i)5.c.c. Similar supplemental coverage provided to coverage under a group health plan.
Ins 3.39(3)(j)(j) “Employee welfare benefit plan” means a plan, fund or program of employee benefits as defined in 29 USC 1002 (Employee Retirement Income Security Act).
Ins 3.39(3)(jm)(jm) “Grievance” means dissatisfaction with the administration, claims practices or provision of services concerning a Medicare select issuer or its network providers that is expressed in writing by a policyholder or certificateholder under a Medicare select policy or certificate.
Ins 3.39(3)(k)(k) “Health care expense” means, for purposes of sub. (16), expense of health maintenance organizations associated with the delivery of health care services that are analogous to incurred losses of insurers.
Ins 3.39(3)(L)(L) “Health maintenance organization (HMO)” means an insurer as defined in s. 609.01 (2), Stats.
Ins 3.39(3)(m)(m) “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, but not more restrictively than as defined in the Medicare program.
Ins 3.39(3)(n)(n) “Hospital confinement indemnity coverage” means coverage as defined in s. Ins 3.27 (4) (b) 6.
Ins 3.39(3)(o)(o) “Insolvency” is defined in s. 600.03 (24), Stats., and means when an issuer, licensed to transact the business of insurance in this state, has had a final order of liquidation entered against it by a court of competent jurisdiction in the issuer’s state of domicile.
Ins 3.39(3)(p)(p) “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.
Ins 3.39(3)(pm)(pm) “MACRA” means the Medicare Access and CHIP Reauthorization Act of 2015, PL 114-10, signed April 16, 2015.
Ins 3.39(3)(q)(q) “Medicare” shall be defined in the policy or certificate. “Medicare” may be substantially 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 Eighty-Ninth 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.
Ins 3.39(3)(r)(r) “Medicare Advantage plan” means a plan of coverage for health benefits under Medicare Part C as defined in 42 USC 1395w-28 (b) (1), as amended.
Ins 3.39(3)(rm)(rm) “Medicare cost policy” means a Medicare replacement policy that is offered by an issuer that has a contract with CMS to provide coverage when services are provided within the issuer’s geographic service area and through network medical providers selected by the issuer. A “Medicare cost policy” is issued to an individual who is the policyholder.
Ins 3.39(3)(s)(s) “Medicare eligible expenses” means health care expenses that are covered by Medicare Parts A and B, recognized as medically necessary and reasonable by Medicare, and that may or may not be fully reimbursed by Medicare.
Ins 3.39(3)(t)(t) “Medicare eligible person” mean a person who qualifies for Medicare.
Ins 3.39(3)(v)(v) “Medicare replacement policy” or “Medicare replacement insurance policy” means a policy that is described in s. 600.03 (28p) (a) or (c), Stats., as interpreted by sub. (2) (a), and that provides coverage that conforms to subs. (4), (4m), (4t), and (7). “Medicare replacement policy” includes Medicare cost policies.
Ins 3.39(3)(ve)(ve) “Medicare select certificate” means a policy that is issued to a group that provides Medicare supplement coverage to the group’s members when services are obtained through network medical providers selected by the issuer. Individuals that receive coverage through the group Medicare select policy receive a Medicare select certificate that demonstrates participation in the group coverage.
Ins 3.39(3)(vm)(vm) “Medicare select policy” means a policy that is issued to an individual or policyholder that provides Medicare supplement coverage when services are obtained by the policyholder through a network of medical providers selected by the issuer.
Ins 3.39(3)(vs)(vs) “Medicare supplement certificate” means a policy that is issued to a group that provides Medicare supplement coverage to the group’s members. Individuals that receive coverage through the group Medicare supplement policy receive a Medicare supplement certificate that demonstrates participation in the group coverage.
Ins 3.39(3)(w)(w) “Medicare supplement coverage” or “Medicare supplement insurance” means coverage that meets the definition in s. 600.03 (28r), Stats., as interpreted by sub. (2) (a), and that conforms to subs. (4), (4m), (4t), (5), (5m), (5t), (6), (30), (30m), and (30t). “Medicare supplement coverage” is advertised, marketed or designed primarily as a supplement to reimbursements under Medicare for the hospital, medical or surgical expense of persons eligible for Medicare. “Medicare supplement coverage” includes group and individual Medicare supplement and group and individual Medicare select policies and certificates but does not include coverage under Medicare Advantage plans established under Medicare Part C or Outpatient Prescription Drug plans established under Medicare Part D.
Ins 3.39(3)(we)(we) “Medicare supplement policy” means a policy that is issued to an individual or policyholder that provides Medicare supplement coverage.
Ins 3.39(3)(wg)(wg) “MMA” means the Medicare Prescription Drugs, Improvement and Modernization Act of 2003, Public Law 108-173, signed into law on December 8, 2003.
Ins 3.39(3)(wm)(wm) “Network provider,” means a provider of health care, or a group of providers of health care, that have entered into a written agreement with the issuer to provide health care benefits to an insured under a Medicare select policy or Medicare select certificate.