Alabama Administrative Code › Title 482 - ALABAMA DEPARTMENT OF INSURANCE › Chapter 482-1-116 - ALABAMA SMALL EMPLOYER ALLOCATION PROGRAM › Section 482-1-116-.04 - Definitions

Current through Register Vol. 42, No. 9, June 28, 2024
The following definitions shall apply for purposes of this
				Regulation:
(1) Actuarial
			 certification. A written statement signed by a member of the American Academy
			 of Actuaries or other individual acceptable to the commissioner that a small
			 employer carrier is in compliance with the provisions of Section 5 of this
			 Regulation, based upon the person's examination and including a review of the
			 appropriate records and the actuarial assumptions and methods used by the small
			 employer carrier in establishing premium rates for applicable health benefit
			 plans.
(2) "Adjusted community
			 rate" or "Adjusted community rating." A method used to develop a carrier's
			 premium which spreads financial risk across the carrier's entire small group
			 population in accordance with the requirements in Section 5 of this
			 Regulation.
(3) "Affiliate" or
			 "affiliated." Any entity or person who directly or indirectly through one or
			 more intermediaries, controls or is controlled by, or is under common control
			 with, a specified entity or person.
(4) "Carrier" or "small employer carrier."
			 All entities licensed, or required to be licensed, by the Department of
			 Insurance that offer health plans covering eligible employees of one or more
			 small employers pursuant to this Regulation. For the purposes of this
			 Regulation, carrier includes an insurance company licensed pursuant to Section
			 27-3-1,
et
seq
.; a health care
			 service plan licensed pursuant to Section
			 10-4-100,
et
seq
.; a fraternal benefit
			 society licensed pursuant to Section
			 27-34-1,
et
seq
.; a health maintenance
			 organization licensed pursuant to Section
			 27-21A-1,
et
seq
.; and any other entity
			 providing a plan of health insurance or health benefits whether or not subject
			 to state insurance regulation. For the purposes of this Regulation, carrier
			 does not include health benefit plans covering eligible employees of small
			 employers when these plans are sold exclusively through the vehicle of
			 associations.
(5) Commissioner. The
			 Alabama Commissioner of Insurance.
(6) Dependent. A spouse, an unmarried child
			 under the age of nineteen (19) years, an unmarried child who is a full-time
			 student under the age of twenty-three (23) years and who is financially
			 dependent upon the enrollee, and an unmarried child of any age who is medically
			 certified as disabled and dependent upon the enrollee.
(7) Eligible employee. An employee who works
			 on a full-time basis with a normal work week of thirty (30) or more hours,
			 except that at the employer's sole discretion, the term shall also include an
			 employee who works on a full-time basis with a normal work week of anywhere
			 between at least seventeen and one-half (17.5) and thirty (30) hours, so long
			 as this eligibility criterion is applied uniformly among all of the employer's
			 employees. The term includes a sole proprietor, a partner of a partnership, and
			 may include an independent contractor, if the sole proprietor, partner or
			 independent contractor is included as an employee under a health benefit plan
			 of a small employer, but does not include an employee who works on a temporary
			 or substitute basis or who works less than seventeen and one-half (17.5) hours
			 per week. Persons covered under a health benefit plan pursuant to the
			 Consolidated Omnibus Budget Reconciliation Act of 1986 shall not be considered
			 "eligible employees" for purposes of minimum participation requirements
			 pursuant to Subdivision (4) of Subsection (c) of Section 7 of this
			 Regulation.
(8) Established
			 geographic service area. A geographic area, as approved by the commissioner and
			 based on the carrier's certificate of authority to transact insurance in this
			 state, within which the carrier is authorized to provide coverage.
(9) Family composition. Enrollee; enrollee,
			 spouse and children; enrollee and spouse; or enrollee and children.
(10) Geographic area. An area approved by the
			 commissioner and used for adjusting the rates for a health benefit
			 plan.
(11) Health benefit plan.
a. Any hospital or medical policy or
			 certificate, major medical expense insurance, subscriber contract or contract
			 of insurance provided by a prepaid hospital or medical service plan, or health
			 maintenance organization subscriber contract. Health benefit plan does not
			 include accident-only, credit, dental, vision, Medicare supplement, long-term
			 care, disability income insurance, coverage issued as a supplement to liability
			 insurance, worker's compensation or similar insurance, or automobile medical
			 payment insurance. Health benefit plan does include short-term and catastrophic
			 health insurance policies, and a policy that pays on a cost-incurred basis,
			 except as otherwise specifically exempted in this definition.
b. "Health benefit plan" shall not include
			 policies or certificates of specified disease, hospital confinement indemnity
			 or limited benefit health insurance, provided that the carrier offering such
			 policies or certificates complies with the following:
1. The carrier files on or before March 1 of
			 each year a certification with the commissioner that contains the statement and
			 information described in Subparagraph 2.
2. The certification required in Subparagraph
			 1. shall contain both of the following:
(i) A
			 statement from the carrier certifying that policies or certificates described
			 in this paragraph are being offered and marketed as supplemental health
			 insurance and not as a substitute for hospital or medical expense insurance or
			 major medical expense insurance.
(ii) A summary description of each policy or
			 certificate described in this paragraph, including the average annual premium
			 rates (or range of premium rates in cases where premiums vary by age or other
			 factors) charged for such policies and certificates in this state.
3. In the case of a policy or
			 certificate that is described in this paragraph and that is offered for the
			 first time in this state on or after the effective date of the Regulation, the
			 carrier files with the commissioner the information and statement required in
			 Subparagraph 2. at least thirty (30) days prior to the date such a policy or
			 certificate is issued or delivered in this state.