§ 27-18.5-2 - Definitions. - Rhode Island Statutes

SECTION 27-18.5-2

   § 27-18.5-2  Definitions. – The following words and phrases as used in this chapter have the followingmeanings unless a different meaning is required by the context:

   (1) "Bona fide association" means, with respect to healthinsurance coverage offered 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-related 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;

   (2) "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 subsection (f)(1) of that section insofar as itrelates to pediatric vaccines;

   (ii) Part 6 of subtitle B of Title I 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.;

   (3) "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;

   (4) "Director" means the director of the department ofbusiness regulation;

   (5) "Eligible individual" means an individual:

   (i) For whom, as of the date on which the individual seekscoverage under this chapter, the aggregate of the periods of creditablecoverage is eighteen (18) or more months and whose most recent prior creditablecoverage was under a group health plan, a governmental plan established ormaintained for its employees by the government of the United States or by anyof its agencies or instrumentalities, or church plan (as defined by theEmployee Retirement Income Security Act of 1974, 29 U.S.C. § 1001 et seq.);

   (ii) Who is not eligible for coverage under a group healthplan, part A or part B of title XVIII of the Social Security Act, 42 U.S.C.§ 1395c et seq. or 42 U.S.C. § 1395j et seq., or any state plan undertitle XIX of the Social Security Act, 42 U.S.C. § 1396 et seq. (or anysuccessor program), and does not have other health insurance coverage;

   (iii) With respect to whom the most recent coverage withinthe coverage period was not terminated based on a factor described in §27-18.5-4(b)(relating to nonpayment of premiums or fraud);

   (iv) If the individual had been offered the option ofcontinuation coverage under a COBRA continuation provision, or under chapter19.1 of this title or under a similar state program of this state or any otherstate, who elected the coverage; and

   (v) Who, if the individual elected COBRA continuationcoverage, has exhausted the continuation coverage under the provision orprogram;

   (6) "Group health plan" means an employee welfare benefitplan 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;

   (7) "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 or health benefits by which health care services arepaid or financed for an eligible individual or his or her dependents by suchentity on the basis of a periodic premium, paid directly or through anassociation, trust, or other intermediary, and issued, renewed, or deliveredwithin or without Rhode Island to cover a natural person who is a resident ofthis state, including a certificate issued to a natural person which evidencescoverage under a policy or contract issued to a trust or association;

   (8) "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.

   (ii) "Health insurance coverage" does not include one ormore, or any combination of, the following:

   (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;

   (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; and

   (I) Short term limited duration insurance;

   (iii) "Health insurance coverage" does not include thefollowing benefits if they are provided under a separate policy, certificate,or contract of insurance or are not an integral part of the coverage:

   (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 these;

   (C) Any other similar, limited benefits that are specified infederal regulation issued pursuant to P.L. 104-191;

   (iv) "Health insurance coverage" does not include thefollowing benefits if the benefits are provided under a separate policy,certificate, or contract of insurance, there is no coordination between theprovision of the benefits and any exclusion of benefits under any group healthplan maintained by the same plan sponsor, and the benefits are paid withrespect to an event without regard to whether benefits are provided withrespect to the event under any group health plan maintained by the same plansponsor:

   (A) Coverage only for a specified disease or illness; or

   (B) Hospital indemnity or other fixed indemnity insurance; and

   (v) "Health insurance coverage" does not include thefollowing if it is offered as a separate policy, certificate, or contract ofinsurance:

   (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;

   (9) "Health status-related factor" means any of the followingfactors:

   (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 conditions arisingout of acts of domestic violence; and

   (viii) Disability;

   (10) "Individual market" means the market for healthinsurance coverage offered to individuals other than in connection with a grouphealth plan;

   (11) "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;

   (12) "Preexisting condition" means, with respect to healthinsurance coverage, a condition (whether physical or mental), regardless of thecause of the condition, that was present before the date of enrollment for thecoverage, for which medical advice, diagnosis, care, or treatment wasrecommended or received within the six (6) month period ending on theenrollment date. Genetic information shall not be treated as a preexistingcondition in the absence of a diagnosis of the condition related to thatinformation; and

   (13) "High-risk individuals" means those individuals who donot pass medical underwriting standards, due to high health care needs or risks;

   (14) "Wellness health benefit plan" means that health benefitplan offered in the individual market pursuant to § 27-18.5-8; and

   (15) "Commissioner" means the health insurance commissioner.