Source: https://www.law.cornell.edu/cfr/text/45/144.103
Timestamp: 2017-10-19 13:11:17
Document Index: 612889151

Matched Legal Cases: ['art 144', 'arts 146', 'arts 146', 'art 146', 'art 148', 'art 146', 'art 148', '§ 146', '§ 146', '§ 147', '§ 146', '§ 147', '§ 148', 'art 147', '§ 146', '§ 147', 'art 144', 'art 600']

45 CFR 144.103 - Definitions. | US Law | LII / Legal Information Institute
CFR › Title 45 › Chapter A › Subchapter B › Part 144 › Subpart A › Section 144.103
45 CFR 144.103 - Definitions.
For purposes of parts 146 (group market), 147 (group and individual market), 148 (individual market), and 150 (enforcement) of this subchapter, the following definitions apply unless otherwise provided:
Applicable State authority means, with respect to a health insurance issuer in a State, the State insurance commissioner or official or officials designated by the State to enforce the requirements of 45 CFR parts 146 and 148 for the State involved with respect to the issuer.
Beneficiary has the meaning given the term under section 3(8) of the Employee Retirement Income Security Act of 1974 (ERISA), which states, “a person designated by a participant, or by the terms of an employee benefit plan, who is or may become entitled to a benefit” under the plan.
Bona fide association means, with respect to health insurance coverage offered in a State, an association that meets the following conditions:
(1) Has been actively in existence for at least 5 years.
(2) Has been formed and maintained in good faith for purposes other than obtaining insurance.
(3) Does not condition membership in the association on any health status-related factor relating to an individual (including an employee of an employer or a dependent of any employee).
(4) Makes health insurance coverage offered through the association available to all members regardless of any health status-related factor relating to the members (or individuals eligible for coverage through a member).
(5) Does not make health insurance coverage offered through the association available other than in connection with a member of the association.
(6) Meets any additional requirements that may be imposed under State law.
Church plan means a Church plan within the meaning of section 3(33) of ERISA.
(3)COBRA continuation provision means sections 601-608 of the Employee Retirement Income Security Act, section 4980B of the Internal Revenue Code of 1986 (other than paragraph (f)(1) of such section 4980B insofar as it relates to pediatric vaccines), or Title XXII of the PHS Act.
(4)Continuation coverage means coverage under a COBRA continuation provision or a similar State program. Coverage provided by a plan that is subject to a COBRA continuation provision or similar State program, but that does not satisfy all the requirements of that provision or program, will be deemed to be continuation coverage if it allows an individual to elect to continue coverage for a period of at least 18 months. Continuation coverage does not include coverage under a conversion policy required to be offered to an individual upon exhaustion of continuation coverage, nor does it include continuation coverage under the Federal Employees Health Benefits Program.
(5)Exhaustion of COBRA continuation coverage means that an individual's COBRA continuation coverage ceases for any reason other than either failure of the individual to pay premiums on a timely basis, or for cause (such as making a fraudulent claim or an intentional misrepresentation of a material fact in connection with the plan). An individual is considered to have exhausted COBRA continuation coverage if such coverage ceases -
(i) Due to the failure of the employer or other responsible entity to remit premiums on a timely basis;
(6)Exhaustion of continuation coverage means that an individual's continuation coverage ceases for any reason other than either failure of the individual to pay premiums on a timely basis, or for cause (such as making a fraudulent claim or an intentional misrepresentation of a material fact in connection with the plan). An individual is considered to have exhausted continuation coverage if -
(i) Coverage ceases due to the failure of the employer or other responsible entity to remit premiums on a timely basis;
(ii) When the individual no longer resides, lives or works in a service area of an HMO or similar program (whether or not within the choice of the individual) and there is no other continuation coverage available to the individual; or
(iii) When the individual incurs a claim that would meet or exceed a lifetime limit on all benefits and there is no other continuation coverage available to the individual.
Creditable coverage has the meaning given the term in 45 CFR 146.113(a).
Eligible individual, for purposes of -
(1) The group market provisions in 45 CFR part 146, subpart E, is defined in 45 CFR 146.150(b); and
(2) The individual market provisions in 45 CFR part 148, is defined in 45 CFR 148.103.
Employee has the meaning given the term under section 3(6) of ERISA, which states, “any individual employed by an employer.”
Employer has the meaning given the term under section 3(5) of ERISA, which states, “any person acting directly as an employer, or indirectly in the interest of an employer, in relation to an employee benefit plan; and includes a group or association of employers acting for an employer in such capacity.”
ERISA stands for the Employee Retirement Income Security Act of 1974, as amended ( 29 U.S.C. 1001et seq.).
Excepted benefits, consistent for purposes of the -
(1) Group market provisions in 45 CFR part 146, subpart D, is defined in 45 CFR 146.145(b); and
(2) Individual market provisions in 45 CFR part 148, is defined in 45 CFR 148.220.
Federal governmental plan means a governmental plan established or maintained for its employees by the Government of the United States or by any agency or instrumentality of such Government.
Genetic information has the meaning specified in § 146.122(a) of this subchapter.
Governmental plan means a governmental plan within the meaning of section 3(32) of ERISA.
Group health plan or plan means a group health plan within the meaning of 45 CFR 146.145(a).
Group market means the market for health insurance coverage offered in connection with a group health plan.
Health insurance issuer or issuer means an insurance company, insurance service, or insurance organization (including an HMO) that is required to be licensed to engage in the business of insurance in a State and that is subject to State law that regulates insurance (within the meaning of section 514(b)(2) of ERISA). This term does not include a group health plan.
Health maintenance organization or HMO means -
(1) A Federally qualified health maintenance organization (as defined in section 1301(a) of the PHS Act);
Health status-related factor is any factor identified as a health factor in 45 CFR 146.121(a).
Individual market means the market for health insurance coverage offered to individuals other than in connection with a group health plan, or other than coverage offered pursuant to a contract between the health insurance issuer with the Medicaid, Children's Health Insurance Program, or Basic Health programs.
Large employer means, in connection with a group health plan with respect to a calendar year and a plan year, an employer who employed an average of at least 51 employees on business days during the preceding calendar year and who employs at least 1 employee on the first day of the plan year. A State may elect to define large employer by substituting “101 employees” for “51 employees.” In the case of an employer that was not in existence throughout the preceding calendar year, the determination of whether the employer is a large employer is based on the average number of employees that it is reasonably expected the employer will employ on business days in the current calendar year.
Large group market means the health insurance market under which individuals obtain health insurance coverage (directly or through any arrangement) on behalf of themselves (and their dependents) through a group health plan maintained by a large employer, unless otherwise provided under State law.
Late enrollment means enrollment of an individual under a group health plan other than on the earliest date on which coverage can become effective for the individual under the terms of the plan; or through special enrollment. (For rules relating to special enrollment and limited open enrollment, see §§ 146.117 and 147.104 of this subchapter.) If an individual ceases to be eligible for coverage under a plan, and then subsequently becomes eligible for coverage under the plan, only the individual's most recent period of eligibility is taken into account in determining whether the individual is a late enrollee under the plan with respect to the most recent period of coverage. Similar rules apply if an individual again becomes eligible for coverage following a suspension of coverage that applied generally under the plan.
Medical care means amounts paid for -
Network plan means health insurance coverage of a health insurance issuer under which the financing and delivery of medical care (including items and services paid for as medical care) are provided, in whole or in part, through a defined set of providers under contract with the issuer.
Non-Federal governmental plan means a governmental plan that is not a Federal governmental plan.
Participant has the meaning given the term under section 3(7) of ERISA, which States, “any employee or former employee of an employer, or any member or former member of an employee organization, who is or may become eligible to receive a benefit of any type from an employee benefit plan which covers employees of such employer or members of such organization, or whose beneficiaries may be eligible to receive any such benefit.”
PHS Act stands for the Public Health Service Act ( 42 U.S.C. 201et seq.).
Plan means, with respect to a product, the pairing of the health insurance coverage benefits under the product with a particular cost-sharing structure, provider network, and service area. The product comprises all plans offered with those characteristics and the combination of the service areas for all plans offered within a product constitutes the total service area of the product. With respect to a plan that has been modified at the time of coverage renewal consistent with § 147.106 of this subchapter -
Plan sponsor has the meaning given the term under section 3(16)(B) of ERISA, which states, “(i) the employer in the case of an employee benefit plan established or maintained by a single employer, (ii) the employee organization in the case of a plan established or maintained by an employee organization, or (iii) in the case of a plan established or maintained by two or more employers or jointly by one or more employers and one or more employee organizations, the association, committee, joint board of trustees, or other similar group of representatives of the parties who establish or maintain the plan.”
Plan year means the year that is designated as the plan year in the plan document of a group health plan, except that if the plan document does not designate a plan year or if there is no plan document, the plan year is -
Policy year means, with respect to -
(1) A grandfathered health plan offered in the individual health insurance market and student health insurance coverage, the 12-month period that is designated as the policy year in the policy documents of the health insurance coverage. If there is no designation of a policy year in the policy document (or no such policy document is available), then the policy year is the deductible or limit year used under the coverage. If deductibles or other limits are not imposed on a yearly basis, the policy year is the calendar year.
(2) A non-grandfathered health plan offered in the individual health insurance market, or in a market in which the State has merged the individual and small group risk pools, for coverage issued or renewed beginning January 1, 2014, a calendar year for which health insurance coverage provides coverage for health benefits.
Product means a discrete package of health insurance coverage benefits that are offered using a particular product network type (such as health maintenance organization, preferred provider organization, exclusive provider organization, point of service, or indemnity) within a service area. In the case of a product that has been modified, transferred, or replaced, the resulting new product will be considered to be the same as the modified, transferred, or replaced product if the changes to the modified, transferred, or replaced product meet the standards of § 146.152(f), § 147.106(e), or § 148.122(g) of this subchapter (relating to uniform modification of coverage), as applicable.
Public health plan has the meaning given the term in 45 CFR 146.113(a)(1)(ix).
Significant break in coverage has the meaning given the term in 45 CFR 146.113(b)(2)(iii).
Small employer means, in connection with a group health plan with respect to a calendar year and a plan year, an employer who employed an average of at least 1 but not more than 50 employees on business days during the preceding calendar year and who employs at least 1 employee on the first day of the plan year. A State may elect to define small employer by substituting “100 employees” for “50 employees.” In the case of an employer that was not in existence throughout the preceding calendar year, the determination of whether the employer is a small employer is based on the average number of employees that it is reasonably expected the employer will employ on business days in the current calendar year.
Special enrollment means enrollment in a group health plan or group health insurance coverage under the rights described in 45 CFR 146.117.
State means each of the 50 States, the District of Columbia, Puerto Rico, the Virgin Islands, Guam, American Samoa, and the Northern Mariana Islands; except that for purposes of part 147, the term does not include Puerto Rico, the Virgin Islands, Guam, American Samoa, and the Northern Mariana Islands.
State health benefits risk pool has the meaning given the term in 45 CFR § 146.113(a)(1)(vii).
Student health insurance coverage has the meaning given the term in § 147.145.
[ 69 FR 78781, Dec. 30, 2004, as amended at 74 FR 51688, Oct. 7, 2009; 75 FR 27138, May 13, 2010; 75 FR 37235, June 28, 2010; 77 FR 16468, Mar. 21, 2012; 78 FR 65091, Oct. 30, 2013; 79 FR 10313, Feb. 24, 2014; 79 FR 13833, Mar. 11, 2014; 79 FR 14151, Mar. 12, 2014; 79 FR 30335, May 27, 2014; 80 FR 10861, Feb. 27, 2015; 80 FR 72274, Nov. 18, 2015; 81 FR 12333, Mar. 8, 2016; 81 FR 75323, 75326, Oct. 31, 2016; 81 FR 94172, Dec. 22, 2016]
The following are ALL rules, proposed rules, and notices (chronologically) published in the Federal Register relating to 45 CFR Part 144 after this date.
FR Doc. 2014-05299
RIN 0938-AR93
CMS-2380-F
42 CFR Part 600
This final rule establishes the Basic Health Program (BHP), as required by section 1331 of the Affordable Care Act. The BHP provides states the flexibility to establish a health benefits coverage program for low-income individuals who would otherwise be eligible to purchase coverage through the Affordable Insurance Exchange (Exchange, also called Health Insurance Marketplace). The BHP complements and coordinates with enrollment in a QHP through the Exchange, as well as with enrollment in Medicaid and the Children&apos;s Health Insurance Program (CHIP). This final rule also sets forth a framework for BHP eligibility and enrollment, benefits, delivery of health care services, transfer of funds to participating states, and federal oversight. Additionally, this final rule amends another rule issued by the Secretary of the Department of Health and Human Services (Secretary) in order to clarify the applicability of that rule to the BHP.
78 FR 59122 - Basic Health Program: State Administration of Basic Health Programs; Eligibility and Enrollment in Standard Health Plans; Essential Health Benefits in Standard Health Plans; Performance Standards for Basic Health Programs; Premium and Cost Sharing for Basic Health Programs; Federal Funding Process; Trust Fund and Financial Integrity
FR Doc. 2013-23292
To be assured consideration, comments must be received at one of the addresses provided below, no later than 5 p.m. on November 25, 2013.
This proposed rule would establish the Basic Health Program, as required by section 1331 of the Affordable Care Act. The Basic Health Program provides states the flexibility to establish a health benefits coverage program for low-income individuals who would otherwise be eligible to purchase coverage through the state&apos;s Affordable Insurance Exchange (Exchange, also called a Health Insurance Marketplace). The Basic Health Program would complement and coordinate with enrollment in a QHP through the Exchange, as well as with enrollment in Medicaid and the Children&apos;s Health Insurance Program (CHIP). This proposed rule sets forth a framework for Basic Health Program eligibility and enrollment, benefits, delivery of health care services, transfer of funds to participating states, and federal oversight. Additionally, this rule would amend other rules issued by the Secretary of the Department of Health and Human Services (Secretary) in order to clarify the applicability of those rules to the Basic Health Program.
45 CFR 146.117 — Special Enrollment Periods.
45 CFR 147.145 — Student Health Insurance Coverage.
45 CFR 148.220 — Excepted Benefits.
45 CFR 147.116 — Prohibition on Waiting Periods That Exceed 90 Days.
45 CFR 150.103 — Definitions.
45 CFR 158.103 — Definitions.
45 CFR 147.106 — Guaranteed Renewability of Coverage.
45 CFR 146.145 — Special Rules Relating to Group Health Plans.
45 CFR 146.113 — Rules Relating to Creditable Coverage.
45 CFR 155.20 — Definitions.
45 CFR 156.120 — Collection of Data to Define Essential Health Benefits.
45 CFR 146.180 — Treatment of Non-Federal Governmental Plans.
45 CFR 156.20 — Definitions.
45 CFR 153.20 — Definitions.
45 CFR 146.122 — Additional Requirements Prohibiting Discrimination Based on Genetic Information.
45 CFR 146.152 — Guaranteed Renewability of Coverage for Employers in the Group Market.
45 CFR 147.108 — Prohibition of Preexisting Condition Exclusions.
45 CFR 146.125 — Applicability Dates.
45 CFR 146.143 — Preemption; State Flexibility; Construction.