Compilation of Rules and Regulations of the State of Georgia › Department 120 - OFFICE OF COMMISSIONER OF INSURANCE, SAFETY FIRE COMMISSIONER AND INDUSTRIAL LOAN COMMISSIONER › Chapter 120-2 - RULES OF COMMISSIONER OF INSURANCE › Subject 120-2-81 - INDIVIDUAL HEALTH INSURANCE ASSIGNMENT SYSTEMS › Rule 120-2-81-.03 - Definitions

Current through Rules and Regulations filed through June 27, 2024
(1) For the purpose
				of this Regulation Chapter, the following definitions shall apply:
(a) "Assignment System" shall mean the
				Georgia Health Insurance Assignment System (GHIAS) and the Georgia Health
				Benefits Assignment System (GHBAS) as established by O.C.G.A. §
										33-29A-1
et
				seq.
and this Regulation Chapter.
(b) "Continuation Coverage" shall mean any
				coverage under the Consolidated Omnibus Budget Reconciliation Act of 1986
				(COBRA).
(c) "Eligible Dependent"
				shall mean a dependent of a qualifying eligible individual, including a spouse,
				covered under the qualifying eligible individual's most recent group health
				plan, or continuation coverage thereof, who meets the requirements of
				subparagraphs (f)(1) through (6) below. Eligible dependents shall include any
				dependents who would otherwise not qualify for coverage because they have less
				than eighteen (18) months previous creditable coverage, provided:
(1) they were born, adopted, or placed for
				adoption during coverage under the most recent group health plan or
				continuation coverage of the qualifying eligible individual; and
(2) were enrolled under such coverage within
				31 days of birth, adoption, or placement for adoption.
(d) "Group Health Plan" shall mean creditable
				coverage under an employer sponsored health benefit arrangement which does not
				provide benefits through a group health insurance policy or contract, or a
				group health insurance policy or contract subject to the laws of another state
				and not required to issue conversion policies pursuant to O.C.G.A. §
										33-24-21.1.
(e) "Individual Health Insurance" or
				"Individual Health Benefits" shall mean any creditable coverage offered by a
				health insurer or managed care organization in the individual market as defined
				in Section 2791(e)(1) of the federal Public Health Service Act, issued or
				actively marketed to an individual in Georgia through a policy or certificate
				of coverage approved by the Commissioner or otherwise permitted by state law or
				the Rules and Regulations of the Office of Commissioner of Insurance, and as
				determined by the Commissioner pursuant to O.C.G.A.
				33-29A-1
et seq.
and Rule 120-2-81-.17,
				but, in any case, not including:
(1) limited
				benefit insurance as defined in O.C.G.A. §
											33-24-21.1(I)  or
				excepted benefits pursuant to
				45 CFR
				148.220; and
(2) certificates issued to individuals
				through a true association as defined in O.C.G.A. §
											33-30-1(b).
(f) "Qualifying Eligible
				Individual" shall mean any Georgia domiciliary who meets all of the following:
(1) As of the date on which the individual
				seeks coverage under this section, the aggregate period of previous creditable
				coverage is 18 months or more;
(2)
				The individual's most recent coverage was under a group health plan, or
				continuation coverage thereof;
(3)
				The individual's insurance under the group health plan has been terminated for
				any reason, including discontinuance of the group health plan in its entirety
				or with respect to a class, except for non-payment of premium contribution
				pertaining to the qualifying eligible individual;
(4) With regard to such an individual's
				coverage under a group health plan or continuation thereof, a qualifying event
				has occurred on or after October 30, 1997;
(5) The individual is not eligible for, or
				has not declined, any of the following:
(a)
				Coverage under a group health insurance policy or contract, or other group
				health plan, including continuation coverage under COBRA or O.C.G.A.
				§§
												33-24-21.1 or
				33-24-21.2;
(b) Medicare;
(c) The state plan under Medicaid or any
				successor program; or
(d) Enhanced
				conversion coverage offered in accordance with O.C.G.A. §
												33-24-21.1 and the Rules and
				Regulations of the Office of Commissioner of Insurance;
(6) The individual is not enrolled in or
				covered under any other creditable health insurance coverage, including
				individual health insurance policies or blanket accident and sickness insurance
				pertaining to student health coverage; and
(7) The individual is one of the following:
(a) A current or former employee, member, or
				enrollee covered under the group health plan or continuation coverage thereof,
				if applicable;
(b) The surviving
				spouse, if any, of a deceased covered employee, member, or enrollee, with or
				without dependents;
(c) The spouse,
				or a former spouse, with or without dependents, of a covered employee, member,
				or enrollee upon a qualifying event of the spouse while the employee, member,
				or enrollee remains insured under the group health plan or continuation
				thereof, by ceasing to be a qualified family member under the group health
				plan, such as a result of a valid decree of divorce; or
(d) An otherwise eligible dependent upon
				reaching limiting age or otherwise losing dependent status under the group
				health plan or continuation thereof, or under coverage issued to another
				qualifying eligible individual in the assignment system.
(g) "Qualifying Event" shall mean
				loss of creditable coverage resulting from either:
(1) Exhaustion of continuation coverage to
				the maximum extent eligible under federal law; or
(2) Termination of coverage under a group
				health plan, in the event such a qualifying eligible individual is not eligible
				for continuation coverage.
(h) "Schedule of Benefits" shall mean the
				outline of benefit levels for a policy or plan, including but not limited to
				the types of benefits covered and associated cost-sharing provisions.