31A-30-103 (Superseded 01/01/11) - Definitions.
31A-30-103 (Superseded 01/01/11). Definitions.
As used in this chapter:
(1) "Actuarial certification" means a written statement by a member of the AmericanAcademy of Actuaries or other individual approved by the commissioner that a covered carrier isin compliance with Section 31A-30-106, based upon the examination of the covered carrier,including review of the appropriate records and of the actuarial assumptions and methods used bythe covered carrier in establishing premium rates for applicable health benefit plans.
(2) "Affiliate" or "affiliated" means any entity or person who directly or indirectlythrough one or more intermediaries, controls or is controlled by, or is under common controlwith, a specified entity or person.
(3) "Base premium rate" means, for each class of business as to a rating period, thelowest premium rate charged or that could have been charged under a rating system for that classof business by the covered carrier to covered insureds with similar case characteristics for healthbenefit plans with the same or similar coverage.
(4) "Basic coverage" means the coverage provided in the Basic Health Care Plan underSection 31A-22-613.5.
(5) "Carrier" means any person or entity that provides health insurance in this stateincluding:
(a) an insurance company;
(b) a prepaid hospital or medical care plan;
(c) a health maintenance organization;
(d) a multiple employer welfare arrangement; and
(e) any other person or entity providing a health insurance plan under this title.
(6) (a) Except as provided in Subsection (6)(b), "case characteristics" meansdemographic or other objective characteristics of a covered insured that are considered by thecarrier in determining premium rates for the covered insured.
(b) "Case characteristics" do not include:
(i) duration of coverage since the policy was issued;
(ii) claim experience; and
(iii) health status.
(7) "Class of business" means all or a separate grouping of covered insureds establishedunder Section 31A-30-105.
(8) "Conversion policy" means a policy providing coverage under the conversionprovisions required in Chapter 22, Part 7, Group Accident and Health Insurance.
(9) "Covered carrier" means any individual carrier or small employer carrier subject tothis chapter.
(10) "Covered individual" means any individual who is covered under a health benefitplan subject to this chapter.
(11) "Covered insureds" means small employers and individuals who are issued a healthbenefit plan that is subject to this chapter.
(12) "Dependent" means an individual to the extent that the individual is defined to be adependent by:
(a) the health benefit plan covering the covered individual; and
(b) Chapter 22, Part 6, Accident and Health Insurance.
(13) "Established geographic service area" means a geographical area approved by the
commissioner within which the carrier is authorized to provide coverage.
(14) "Index rate" means, for each class of business as to a rating period for coveredinsureds with similar case characteristics, the arithmetic average of the applicable base premiumrate and the corresponding highest premium rate.
(15) "Individual carrier" means a carrier that provides coverage on an individual basisthrough a health benefit plan regardless of whether:
(a) coverage is offered through:
(i) an association;
(ii) a trust;
(iii) a discretionary group; or
(iv) other similar groups; or
(b) the policy or contract is situated out-of-state.
(16) "Individual conversion policy" means a conversion policy issued to:
(a) an individual; or
(b) an individual with a family.
(17) "Individual coverage count" means the number of natural persons covered under acarrier's health benefit products that are individual policies.
(18) "Individual enrollment cap" means the percentage set by the commissioner inaccordance with Section 31A-30-110.
(19) "New business premium rate" means, for each class of business as to a rating period,the lowest premium rate charged or offered, or that could have been charged or offered, by thecarrier to covered insureds with similar case characteristics for newly issued health benefit planswith the same or similar coverage.
(20) "Plan year" means the year that is designated as the plan year in the plan documentof a group health plan, except that if the plan document does not designate a plan year or if thereis not a plan document, the plan year is:
(a) the deductible or limit year used under the plan;
(b) if the plan does not impose a deductible or limit on a yearly basis, the policy year;
(c) if the plan does not impose a deductible or limit on a yearly basis and either the planis not insured or the insurance policy is not renewed on an annual basis, the employer's taxableyear; or
(d) in any case not described in Subsections (20)(a) through (c), the calendar year.
(21) "Preexisting condition" is as defined in Section 31A-1-301.
(22) "Premium" means all monies paid by covered insureds and covered individuals as acondition of receiving coverage from a covered carrier, including any fees or other contributionsassociated with the health benefit plan.
(23) (a) "Rating period" means the calendar period for which premium rates establishedby a covered carrier are assumed to be in effect, as determined by the carrier.
(b) A covered carrier may not have:
(i) more than one rating period in any calendar month; and
(ii) no more than 12 rating periods in any calendar year.
(24) "Resident" means an individual who has resided in this state for at least 12consecutive months immediately preceding the date of application.
(25) "Short-term limited duration insurance" means a health benefit product that:
(a) is not renewable; and
(b) has an expiration date specified in the contract that is less than 364 days after the datethe plan became effective.
(26) "Small employer carrier" means a carrier that provides health benefit plans coveringeligible employees of one or more small employers in this state, regardless of whether:
(a) coverage is offered through:
(i) an association;
(ii) a trust;
(iii) a discretionary group; or
(iv) other similar grouping; or
(b) the policy or contract is situated out-of-state.
(27) "Uninsurable" means an individual who:
(a) is eligible for the Comprehensive Health Insurance Pool coverage under theunderwriting criteria established in Subsection 31A-29-111(5); or
(b) (i) is issued a certificate for coverage under Subsection 31A-30-108(3); and
(ii) has a condition of health that does not meet consistently applied underwriting criteriaas established by the commissioner in accordance with Subsections 31A-30-106(1)(i) and (j) forwhich coverage the applicant is applying.
(28) "Uninsurable percentage" for a given calendar year equals UC/CI where, forpurposes of this formula:
(a) "CI" means the carrier's individual coverage count as of December 31 of thepreceding year; and
(b) "UC" means the number of uninsurable individuals who were issued an individualpolicy on or after July 1, 1997.
Amended by Chapter 12, 2009 General Session