26:2J-31. Definitions

1. As used in this act:

"Applicant" means any individual who seeks enrollment with a health maintenance organization for the purpose of obtaining medicare supplement health care services.

"Commissioner" means the Commissioner of Insurance.

"Department" means the Department of Insurance.

"Enrollee" means an individual who is enrolled with a health maintenance organization.

"Evidence of coverage" means any booklet, certificate, agreement or contract issued to an enrollee setting out the services and other benefits to which he is entitled.

"Health care services" means those services, including, but not limited to, inpatient hospital and physician care, and outpatient medical services, as set forth in the evidence of coverage.

"Health maintenance organization" means any person which, directly or through contracts with providers, furnishes health care services on a prepaid basis to enrollees in a designated geographic area in this State pursuant to the provisions of P.L.1973, c.337 (C.26:2J-1 et seq.).

"Medicare" means the program established by the "Health Insurance for the Aged Act," Title XVIII of the "Social Security Act," Pub.L. 89-97, as then constituted or later amended (42 U.S.C. s.1395 et seq.).

"Medicare supplement contract" means a group or individual contract or plan which is advertised, marketed or designed primarily as providing, or is otherwise held out to provide, medicare supplement health care services and under which an individual is enrolled, other than a contract issued pursuant to a contract under 42 U.S.C. s.1395l or 42 U.S.C. s.1395mm or a contract issued under a demonstration project authorized pursuant to the "Health Insurance for the Aged Act," 42 U.S.C. s.1395 et seq. The term does not include health care services provided pursuant to a contract or plan issued to one or more employers or labor organizations, or to the trustees of a fund established by one or more employers or labor organizations, or combination thereof, for employees or former employees of the employers, or a combination thereof, or for members or former members, or a combination thereof, of the labor organizations.

"Medicare supplement evidence of coverage" means an evidence of coverage delivered to an enrollee who has medicare supplement health care services coverage under a medicare supplement contract.

"Medicare supplement health care services" means health care services which supplement medicare, provided under a medicare supplement contract as set forth in a medicare supplement evidence of coverage.

"Provider" means any physician, hospital or other person which is licensed or otherwise authorized in this State to furnish health care services.

L.1992,c.164,s.1.