Definitions for the Market Share Reports
Comprehensive Major Medical Insurance: These policies include but are not limited to policies that provide indemnity, HMO, PPO, POS or expense based coverage including coverage for hospital, medical and surgical expenses. This category excludes limited benefit plans such as Short Term Medical Insurance, hospital only, medical only, hospital confinement indemnity, surgical, outpatient indemnity, specified disease, intensive care, and organ and tissue transplant coverage as well as any other coverage described in the other categories of this exhibit.
Medicare Supplement Insurance: These are policies sold by insurance companies to fill “gaps” in a policyholder’s Medicare coverage.
Long Term Care Insurance: Policies that provide coverage for not less than one year for diagnostic, preventive, therapeutic, rehabilitative, maintenance, or personal care services provided in a setting other than an acute care unit of a hospital including policies that provide benefits for cognitive impairment, or loss of functional capacity. This includes policies providing nursing home care plus home health care and/or community based care.
Third Party Administrators/Administrative Services Only (Group Only): This means an entity or person contracting to provide any combination of services in administering health benefits for a health insurer or other entity such as self-insured employer plans, to include claims processing, underwriting, premium collection, case management, authorizations and customer service.
Medicare Part D (Individual Only): Created under the Medicare Modernization Act of 2003 (MMA), it is a voluntary outpatient prescription drug benefit for Medicare Beneficiaries that began in 2006. Medicare Part D does not need to be Licensed by the state of Vermont as it is Licensed by Centers for Medicare and Medicaid Services (CMS).
Medicare Part C: Are private managed care plans that offer Parts A and B services together. Also known as Medicare Advantage program, which offers the option of enrolling in a managed care plan to receive Medicare benefits (both medical and drug coverage). Types of plans authorized under The Federal Balanced Budget Act of 1997 include preferred provider organizations (PPO’s), provider-sponsored organizations (PSO’s), private fee-for-service (PFFS) plans and high deductible plans linked to Medical Savings Accounts (MSA’s), and as of 2003, Special Needs Plans (SNP’s) for dual eligibles and other vulnerable populations.