Title 3 . Commerce, Community, and Economic Development

Chapter 28 . Miscellaneous

Section 510. Definitions

3 AAC 28.510. Definitions

For purposes of 3 AAC 28.410 - 3 AAC 28.510,

(1) "applicant" means,

(A) for an individual medicare supplement policy, the person who seeks to contract for insurance benefits; and

(B) for a group medicare supplement policy, the person who seeks to be the certificate holder;

(2) "bankruptcy" means when a medicare+choice 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 this state;

(3) "certificate" means a certificate delivered or issued for delivery in this state under a group medicare supplement policy;

(4) "certificate form" means the form on which the certificate is delivered or issued for delivery by the issuer;

(5) "claim reserves" include only those unpaid liabilities for claims that have already been incurred;

(6) "continuous period of creditable coverage" means the period during which an individual was covered by creditable coverage, if the individual had no breaks in coverage greater than 63 days during the period of the coverage;

(7) "creditable coverage" has the meaning given in AS 21.54.500 ;

(8) "director" means the director of insurance;

(9) "employee welfare benefit plan" means a plan, fund, or program of employee benefits as defined in 29 U.S.C. 1002 (Employee Retirement Income Security Act);

(10) "incurred claims" means paid claims plus the increase in claim reserves; "incurred claims" do not include policy (additional) reserves;

(11) "insolvency" means when an issuer who is licensed to transact the business of insurance in this state has had a final 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" means an insurance company, fraternal benefit society, health care service plan, health maintenance organization, or other entity delivering or issuing for delivery in this state a medicare supplement policy or certificate;

(13) "medicare" means Title I, Part I of Public Law 89-97, as enacted by the 89th Congress of the United States of America (popularly known as the Health Insurance for the Aged Act);

(14) "medicare advantage plan" means a plan of coverage for health benefits under medicare Part C as defined in 42 U.S.C. 1395w-28; "medicare advantage plan" includes a

(A) coordinated care plan that provides health care services including health maintenance organization plans, with or without a point-of-service option, plans offered by provider-sponsored organizations, and preferred provider organization plans;

(B) medical savings account plan coupled with a contribution into a medicare advantage medical savings account; and

(C) medicare advantage private fee-for-service plan;

(15) "medicare supplement policy" means a group or individual policy of insurance or a subscriber contract, which is advertised, marketed, or designed primarily as a supplement to reimbursement under medicare for the hospital, medical, or surgical expenses of a person eligible for medicare; "medicare supplement policy" does not include

(A) a policy or contract 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 any combination of these, for employees or former employees, or any combination of these, of the labor organizations;

(B) a policy or contract of any professional, trade, or occupational association for its members, former or retired members, or any combination of these, if the association

(i) is comprised of individuals all of whom are actively engaged in the same profession, trade, or occupation;

(ii) has been maintained in good faith for purposes other than obtaining insurance; and

(iii) has been in existence for at least two years before the date of the initial offering of this policy, contract, or plan to its members;

(C) a policy issued by a contract under 42 U.S.C. 1395mm (sec. 1876 of the Social Security Act) or an issued policy under a demonstration project specified in 42 U.S.C. 1395ss(g)(1); or

(D) medicare advantage plans established under medicare Part C, outpatient prescription drug plans established under medicare Part D, or any health care prepayment plan that provides benefits under an agreement under 42 U.S.C. 1395 l (a)(1)(A);

(16) "policy form" means the form on which a policy is delivered or issued for delivery by an issuer;

(17) "secretary" means the secretary of the United States Department of Health and Human Services.

History: Eff. 3/26/82, Register 81; am 8/8/90, Register 115; am 7/1/92, Register 122; am 7/12/96, Register 139; am 4/21/99, Register 150; am 9/4/2005, Register 175

Authority: AS 21.06.090

AS 21.42.130

AS 21.89.060