§ 27-18.6-2 - Definitions.
SECTION 27-18.6-2
§ 27-18.6-2 Definitions. – The following words and phrases as used in this chapter have the followingmeanings unless a different meaning is required by the context:
(1) "Affiliation period" means a period which, under theterms of the health insurance coverage offered by a health maintenanceorganization, must expire before the health insurance coverage becomeseffective. The health maintenance organization is not required to providehealth care services or benefits during the period and no premium shall becharged to the participant or beneficiary for any coverage during the period;
(2) "Beneficiary" has the meaning given that term undersection 3(8) of the Employee Retirement Security Act of 1974, 29 U.S.C. §1002(8);
(3) "Bona fide association" means, with respect to healthinsurance coverage in this state, an association which:
(i) Has been actively in existence for at least five (5)years;
(ii) Has been formed and maintained in good faith forpurposes other than obtaining insurance;
(iii) Does not condition membership in the association on anyhealth status-relating factor relating to an individual (including an employeeof an employer or a dependent of an employee);
(iv) Makes health insurance coverage offered through theassociation available to all members regardless of any health status-relatedfactor relating to the members (or individuals eligible for coverage through amember);
(v) Does not make health insurance coverage offered throughthe association available other than in connection with a member of theassociation;
(vi) Is composed of persons having a common interest orcalling;
(vii) Has a constitution and bylaws; and
(viii) Meets any additional requirements that the directormay prescribe by regulation;
(4) "COBRA continuation provision" means any of the following:
(i) Section 4980(B) of the Internal Revenue Code of 1986, 26U.S.C. § 4980B, other than the subsection (f)(1) of that section insofaras it relates to pediatric vaccines;
(ii) Part 6 of subtitle B of title 1 of the EmployeeRetirement Income Security Act of 1974, 29 U.S.C. § 1161 et seq., otherthan section 609 of that act, 29 U.S.C. § 1169; or
(iii) Title XXII of the United States Public Health ServiceAct, 42 U.S.C. § 300bb-1 et seq.;
(5) "Creditable coverage" has the same meaning as defined inthe United States Public Health Service Act, section 2701(c), 42 U.S.C. §300gg(c), as added by P.L. 104-191;
(6) "Church plan" has the meaning given that term undersection 3(33) of the Employee Retirement Income Security Act of 1974, 29 U.S.C.§ 1002(33);
(7) "Director" means the director of the department ofbusiness regulation;
(8) "Employee" has the meaning given that term under section3(6) of the Employee Retirement Income Security Act of 1974, 29 U.S.C. §1002(6);
(9) "Employer" has the meaning given that term under section3(5) of the Employee Retirement Income Security Act of 1974, 29 U.S.C. §1002(5), except that the term includes only employers of two (2) or moreemployees;
(10) "Enrollment date" means, with respect to an individualcovered under a group health plan or health insurance coverage, the date ofenrollment of the individual in the plan or coverage or, if earlier, the firstday of the waiting period for the enrollment;
(11) "Governmental plan" has the meaning given that termunder section 3(32) of the Employee Retirement Income Security Act of 1974, 29U.S.C. § 1002(32), and includes any governmental plan established ormaintained for its employees by the government of the United States, thegovernment of any state or political subdivision of the state, or by any agencyor instrumentality of government;
(12) "Group health insurance coverage" means, in connectionwith a group health plan, health insurance coverage offered in connection withthat plan;
(13) "Group health plan" means an employee welfare benefitsplan as defined in section 3(1) of the Employee Retirement Income Security Actof 1974, 29 U.S.C. § 1002(1), to the extent that the plan provides medicalcare and including items and services paid for as medical care to employees ortheir dependents as defined under the terms of the plan directly or throughinsurance, reimbursement or otherwise;
(14) "Health insurance carrier" or "carrier" means any entitysubject to the insurance laws and regulations of this state, or subject to thejurisdiction of the director, that contracts or offers to contract to provide,deliver, arrange for, pay for, or reimburse any of the costs of health careservices, including, without limitation, an insurance company offering accidentand sickness insurance, a health maintenance organization, a nonprofithospital, medical or dental service corporation, or any other entity providinga plan of health insurance, health benefits, or health services;
(15) "Health insurance coverage" means a policy, contract,certificate, or agreement offered by a health insurance carrier to provide,deliver, arrange for, pay for, or reimburse any of the costs of health careservices. Health insurance coverage does include short-term and catastrophichealth insurance policies, and a policy that pays on a cost-incurred basis,except as otherwise specifically exempted in this definition;
(ii) "Health insurance coverage" does not include one ormore, or any combination of, the following "excepted benefits":
(A) Coverage only for accident, or disability incomeinsurance, or any combination of those;
(B) Coverage issued as a supplement to liability insurance;
(C) Liability insurance, including general liabilityinsurance and automobile liability insurance;
(D) Workers' compensation or similar insurance;
(E) Automobile medical payment insurance;
(F) Credit-only insurance;
(G) Coverage for on-site medical clinics; and
(H) Other similar insurance coverage, specified in federalregulations issued pursuant to P.L. 104-191, under which benefits for medicalcare are secondary or incidental to other insurance benefits;
(iii) "Health insurance coverage" does not include thefollowing "limited, excepted benefits" if they are provided under a separatepolicy, certificate of insurance, or are not an integral part of the plan:
(A) Limited scope dental or vision benefits;
(B) Benefits for long-term care, nursing home care, homehealth care, community-based care, or any combination of those; and
(C) Any other similar, limited benefits that are specified infederal regulations issued pursuant to P.L. 104-191;
(iv) "Health insurance coverage" does not include thefollowing "noncoordinated, excepted benefits" if the benefits are providedunder a separate policy, certificate, or contract of insurance, there is nocoordination between the provision of the benefits and any exclusion ofbenefits under any group health plan maintained by the same plan sponsor, andthe benefits are paid with respect to an event without regard to whetherbenefits are provided with respect to the event under any group health planmaintained by the same plan sponsor:
(A) Coverage only for a specified disease or illness; and
(B) Hospital indemnity or other fixed indemnity insurance;
(v) "Health insurance coverage" does not include thefollowing "supplemental, excepted benefits" if offered as a separate policy,certificate, or contract of insurance:
(A) Medicare supplemental health insurance as defined undersection 1882(g)(1) of the Social Security Act, 42 U.S.C. § 1395ss(g)(1);
(B) Coverage supplemental to the coverage provided under 10U.S.C. § 1071 et seq.; and
(C) Similar supplemental coverage provided to coverage undera group health plan;
(16) "Health maintenance organization" ("HMO") means a healthmaintenance organization licensed under chapter 41 of this title;
(17) "Health status-related factor" means any of thefollowing factors:
(i) Health status;
(ii) Medical condition, including both physical and mentalillnesses;
(iii) Claims experience;
(iv) Receipt of health care;
(v) Medical history;
(vi) Genetic information;
(vii) Evidence of insurability, including contributionsarising out of acts of domestic violence; and
(viii) Disability;
(18) "Large employer" means, in connection with a grouphealth plan with respect to a calendar year and a plan year, an employer whoemployed an average of at least fifty-one (51) employees on business daysduring the preceding calendar year and who employs at least two (2) employeeson the first day of the plan year. In the case of an employer which was not inexistence throughout the preceding calendar year, the determination of whetherthe employer is a large employer shall be based on the average number ofemployees that is reasonably expected the employer will employ on business daysin the current calendar year;
(19) "Large group market" means the health insurance marketunder which individuals obtain health insurance coverage (directly or throughany arrangement) on behalf of themselves (and their dependents) through a grouphealth plan maintained by a large employer;
(20) "Late enrollee" means, with respect to coverage under agroup health plan, a participant or beneficiary who enrolls under the planother than during:
(i) The first period in which the individual is eligible toenroll under the plan; or
(ii) A special enrollment period;
(21) "Medical care" means amounts paid for:
(i) The diagnosis, cure, mitigation, treatment, or preventionof disease, or amounts paid for the purpose of affecting any structure orfunction of the body;
(ii) Amounts paid for transportation primarily for andessential to medical care referred to in paragraph (i) of this subdivision; and
(iii) Amounts paid for insurance covering medical carereferred to in paragraphs (i) and (ii) of this subdivision;
(22) "Network plan" means health insurance coverage offeredby a health insurance carrier under which the financing and delivery of medicalcare including items and services paid for as medical care are provided, inwhole or in part, through a defined set of providers under contract with thecarrier;
(23) "Participant" has the meaning given such term undersection 3(7) of the Employee Retirement Income Security Act of 1974, 29 U.S.C.§ 1002(7);
(24) "Placed for adoption" means, in connection with anyplacement for adoption of a child with any person, the assumption and retentionby that person of a legal obligation for total or partial support of the childin anticipation of adoption of the child. The child's placement with the personterminates upon the termination of the legal obligation;
(25) "Plan sponsor" has the meaning given that term undersection 3(16)(B) of the Employee Retirement Income Security Act of 1974, 29U.S.C. § 1002(16)(B). "Plan sponsor" also includes any bona fideassociation, as defined in this section;
(26) "Preexisting condition exclusion" means, with respect tohealth insurance coverage, a limitation or exclusion of benefits relating to acondition based on the fact that the condition was present before the date ofenrollment for the coverage, whether or not any medical advice, diagnosis, careor treatment was recommended or received before the date; and
(27) "Waiting period" means, with respect to a group healthplan and an individual who is a potential participant or beneficiary in theplan, the period that must pass with respect to the individual before theindividual is eligible to be covered for benefits under the terms of the plan.