Title 3 . Commerce, Community, and Economic Development

Chapter 28 . Miscellaneous

Section 430. Policy definitions and terms

3 AAC 28.430. Policy definitions and terms

(a) A medicare supplement policy or certificate using the following terms or their equivalent must contain terms and definitions as follows:

(1) "accident," "accidental injury," or "accidental means" must use "result" language and may not include words that establish an accidental-means test or use words characterizing the accident or injury as "external, violent, or visible wounds" or similar words of description or characterization; the definition may not be more restrictive than "injury or injuries for which benefits are provided means accidental bodily injury sustained by the insured person that is the direct result of an accident, independent of disease, bodily infirmity, or other cause, and occurs while insurance coverage in in force"; the definition may provide that injuries must not include injuries for which benefits are provided or available under a workers' compensation, employer's liability, or similar law or a motor vehicle no-fault plan, unless prohibited by law;

(2) "benefit period" or "medicare benefit period" may not be more restrictively defined than in the medicare program;

(3) "convalescent nursing home," "extended care facility," or "skilled nursing facility" may not be more restrictively defined than in the medicare program;

(4) repealed 7/1/92;

(5) "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;

(6) repealed 7/1/92;

(7) "medicare" means Title I, Part I of Public Law 89-97, as enacted by the Eighty-Ninth Congress of the United States of America, including subsequent amendments, (popularly known as the Health Insurance for the Aged Act) and each policy or certificate must include this or a substantively equivalent definition;

(8) "injury or injuries for which benefits are provided" means accidental bodily injury sustained by the insured person that is the direct result of an accident, independent of disease or bodily infirmity or any other cause, and occurs while the insurance coverage is in force; however, injuries for which benefits are provided under any workers compensation, employer's liability or similar law may be excluded;

(9) "medicare eligible expenses" must include expenses of the kind covered by medicare Parts A and B, to the extent recognized as reasonable and medically necessary by medicare;

(10) repealed 7/1/92;

(11) repealed 7/1/92;

(12) if the terms "qualified physician" or "licensed physician" are used, the insurer must accept, to the extent of its obligation under the policy, all services provided that are within the scope of the provider's licensed authority, and the terms must not be defined more restrictively than as defined in the medicare program;

(13) "sickness" must be defined to include any disease or illness of a covered person which first manifests itself after the effective date of coverage and while the coverage is in force, but may exclude disease or illness for which benefits are provided under any workers compensation, occupational disease, employer's liability, or similar law;

(14) "health care expenses" must mean, for purposes of 3 AAC 28.468, expenses of a health maintenance organization associated with the delivery of health care services that are analogous to incurred losses of insurers.

(b) Repealed 7/1/92.

History: Eff. 3/26/82, Register 81; am 8/8/90, Register 115; am 7/1/92, Register 122; am 6/4/93, Register 126; am 9/4/2005, Register 175

Authority: AS 21.06.090

AS 21.42.130

AS 21.89.060