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

1. (1) Applicant--

   1. (A) In the case of an individual Medicare supplement policy, the person who seeks to contract for insurance or other health benefits.
   2. (B) In the case of a group Medicare supplement policy, the proposed certificate holder.
2. (2) Bankruptcy--The situation that occurs 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. (3) Certificate--Any certificate issued under a group Medicare supplement policy, which certificate has been delivered or issued for delivery in this state regardless of the place where the policy was delivered or issued for delivery.
4. (4) 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.
5. (5) Creditable coverage--Any coverage of an individual as defined in (§21.1101 of this title (relating to Definitions).
6. (6) Employee welfare benefit plan--A plan, fund or program of employee benefits as defined in 29 U.S.C. Section 1002 (Employee Retirement Income Security Act).
7. (7) Health Maintenance Organization (HMO)--An entity as defined in 42 U.S.C. 300e(a).
8. (8) Insolvency--The situation which 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.
9. (9) 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.
10. (10) Medicare--The Health Insurance for the Aged Act, Title XVIII of the Social Security Act Amendments of 1965 as Then Constituted or Later Amended.
11. (11) Medicare+Choice organization--An entity as defined in 42 U.S.C. (1395w-28(a)(1).

12. (12) Medicare+Choice 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:

    1. (A) coordinated care plans which provide health services, including but not limited to health maintenance organization plans (with or without a point-of-service option), plans offered by provider-sponsored organizations, and preferred provider organization plans;
    2. (B) medical savings account plans coupled with a contribution into a Medicare+Choice medical savings account; and
    3. (C) Medicare+Choice private fee-for-service plans.
13. (13) Medicare+Choice private fee-for-service plan--An entity as defined in 42 U.S.C. (1395w-28(b)(2).
14. (14) Medicare Select policy or Medicare Select certificate -- A Medicare supplement policy or certificate, respectively, that contains restricted network provisions.

15. (15) Medicare supplement policy--A group or individual policy of accident and sickness insurance or a subscriber contract of a hospital service corporation subject to the Insurance Code, Chapter 20, or, to the extent required by federal law, an evidence of coverage issued by a health maintenance organization subject to the Texas Health Maintenance Organization Act, which policy, subscriber contract, or such 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:

    1. (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;
    2. (B) a policy or health care benefit plan including a policy or contract of group insurance or group contract of a hospital service corporation subject to the Insurance Code, Chapter 20, or group evidence of coverage issued by a health maintenance organization subject to the Texas Health Maintenance Organization Act, when such policy or plan is not marketed or held to be a Medicare supplement policy or benefit plan; or
    3. (C) an individual or group evidence of coverage issued pursuant to a contract under the Federal Social Security Act, §1876 (42 United States Code §§1395, et seq) by a health maintenance organization subject to the Texas Health Maintenance Organization Act (Texas Insurance Code, Chapter 20A).
16. (16) Point-of-service--A benefit option as defined in 42 C.F.R. (422.2.
17. (17) Provider-Sponsored organization--An entity as defined in 42 U.S.C. (1395w-25(d)(1).
18. (18) Qualified actuary--An actuary who is a member of either the Society of Actuaries or the American Academy of Actuaries.
19. (19) 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.