Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 35 - Accident and Health Insurance › Rule 191-35.23 - Definitions

Current through Register Vol. 47, No. 3, July 24, 2024
"Affiliation period"
means a period of time
				  that must expire before health insurance coverage provided by an HMO becomes
				  effective, and during which the HMO is not required to provide benefits.
"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.
"Bonafide association"
means, with respect
				  to group health insurance coverage offered in Iowa, an association that meets
				  the following conditions:
1. Has been actively in existence for at least five
				  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.
"Carrier"
means an entity subject to the
				  insurance laws and regulations of this state, or subject to the jurisdiction of
				  the commissioner, that contracts or offers to contract to provide, deliver,
				  arrange for, pay for, or reimburse any of the costs of health care services,
				  including an insurance company offering sickness and accident plans, a health
				  maintenance organization, a nonprofit health service corporation, or any other
				  entity providing a plan of health insurance, health benefits or health
				  services.
"COBRA"
means Title X of the Consolidated
				  Omnibus Budget Reconciliation Act of 1985, as amended.
"Commissioner"
means the commissioner of
				  insurance.
"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.
"Creditable coverage"
means health benefits
				  or coverage provided to an individual under any of the following:
1. A group health plan.
2. Health insurance coverage.
3. Part A or Part B Medicare pursuant to Title XVIII of the
				  federal Social Security Act.
4. Medicaid pursuant to Title XIX of the federal Social
				  Security Act, other than coverage consisting solely of benefits under Section
				  1928 of that Act.
5. 10 U.S.C. ch.55.
6. A health or medical care program provided through the
				  Indian Health Service or a tribal organization.
7. A state health benefits risk pool.
8. A health plan offered under 5 U.S.C. ch. 89.
9. A public health plan as defined under federal
				  regulations.
10. A health benefit plan under Section 5(e) of the Peace
				  Corps Act,
				  22 U.S.C.
				  2504(e).
11. A short-term limited-duration policy.
"Director"
means the director of public
				  health appointed pursuant to Iowa Code section
				  1352..
"Division "
means the division of
				  insurance.
"Eligible employee"
means an individual who
				  is eligible to enroll in group health insurance coverage offered to a group
				  health plan maintained by an employer, in accordance with the terms of the
				  group health plan.
"Employee"
means any individual employed by
				  an employer.
"Enrollment date"
means the first day of
				  coverage or, if there is a waiting period, the first day of the waiting
				  period.
"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:
1. Coverage ceases due to the failure of the employer or
				  other responsible entity to remit premiums on a timely basis, or
2. 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.
"Group health plan"
means an employee
				  welfare benefit plan as defined in Section 3(1) of the federal Employee
				  Retirement Income Security Act of 1974, to the extent that the plan provides
				  medical care including items and services paid for as medical care to employees
				  or their dependents as defined under the terms of the plan directly or through
				  insurance, reimbursement, or otherwise.
1. For purposes of this rule, "medical care" means amounts
				  paid for any of the following:
* The diagnosis, cure, mitigation, treatment, or prevention
				  of disease, or amounts paid for the purpose of affecting a structure or
				  function of the body.
* Transportation primarily for and essential to medical care
				  referred to in this definition.
* Insurance covering medical care referred to in this
				  definition.
2. For purposes of this division, a plan, fund, or program
				  established or maintained by a partnership which, but for this paragraph, would
				  not be an employee welfare benefit plan, shall be treated as an employee
				  welfare benefit plan which is a group health plan to the extent that the plan,
				  fund, or program provides medical care, including items and services paid for
				  as medical care, for present or former partners in the partnership or to the
				  dependents of such partners, as defined under the terms of the plan, fund, or
				  program, either directly or through insurance, reimbursement, or
				  otherwise.
3. With respect to a group health plan, the term "employer"
				  includes a partnership with respect to a partner.
4. With respect to a group health plan the term "participant"
				  includes the following:
* With respect to a group health plan maintained by a
				  partnership, an individual who is a partner in the partnership.
* With respect to a group health plan maintained by a
				  self-employed individual, under which one or more of the self-employed
				  individual's employees are participants, the self-employed individual, if that
				  individual is, or may become, eligible to receive benefits under the plan or
				  the individual's dependents may be eligible to receive benefits under the
				  plan.
"Health insurance coverage"
or
"health insurance plan"
means benefits consisting of health
				  care provided directly, through insurance or reimbursement, or otherwise and
				  including items and services paid for as health care under a hospital or health
				  service policy or certificate, hospital or health service plan contract, or
				  health maintenance organization contract offered by a carrier.
1. "Health insurance coverage" does not include any of the
				  following:
* Coverage for accident only, or disability income
				  insurance.
* Coverage issued as a supplement to liability
				  insurance.
* Liability insurance, including general liability insurance
				  and automobile liability insurance.
* Workers' compensation or similar insurance.
* Automobile medical payment insurance.
* Credit-only insurance.
* Coverage for on-site medical clinic care.
* Other similar insurance coverage, specified in federal
				  regulations, under which benefits for medical care are secondary or incidental
				  to other insurance benefits.
* Flexible spending accounts.
2. "Health insurance coverage" does not include benefits
				  provided under a separate policy as follows:
* Limited scope dental or vision benefits.
* Benefits for long-term care, nursing home care, home health
				  care, or community-based care.
* Short-term limited-duration insurance.
* Any other similar, limited benefits as provided by rule of
				  the commissioner.
* Stop loss insurance coverage.
3. "Health insurance coverage" does not include benefits
				  offered as independent noncoordinated benefits as follows:
* Coverage only for a specified disease or illness;
* Hospital indemnity or other fixed indemnity
				  insurance.
4. "Health insurance coverage" does not include Medicare
				  supplemental health insurance as defined under Section 1882(g)(1) of the
				  federal Social Security Act, coverage supplemental to the coverage provided
				  under 10 U.S.C. ch. 55, and similar supplemental coverage provided under
				  insurance coverage.
5. "Group health insurance coverage" means health insurance
				  coverage offered in connection with a group health plan.
"Health maintenance organization"
or
"HMO"
means a federally qualified health maintenance
				  organization as defined in Section 1301(a) of the Public Health Services Act or
				  an organization licensed under Iowa Code section
				  514B5..
"Large employer"
means an employer employing
				  two or more employees and which does not meet the definition of small employer
				  under Iowa Code section
				  513B2(16)..
"Late enrollee"
means an individual, other
				  than one who enrolls during a special enrollment period, who enrolls under a
				  health benefit plan or health insurance coverage in connection with which it is
				  issued, other than during the first period in which the individual is eligible
				  to enroll under terms of the health benefit plan or health insurance
				  coverage.
"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 carrier.
"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:
1. The deductible/limit year used under the plan.
2. If the plan does not impose deductibles or limits on a
				  yearly basis, the plan year is the policy year.
3. If the plan does not impose deductibles or limits on a
				  yearly basis, and either the plan is not insured or the insurance policy is not
				  renewed on an annual basis, the plan year is the employer's taxable
				  year.
"Preexisting condition exclusion"
means,
				  with respect to health insurance coverage, a limitation or exclusion of
				  benefits relating to a condition based on the fact that the condition was
				  present before the date of enrollment for such coverage, whether or not any
				  medical advice, diagnosis, care, or treatment was recommended or received
				  before such date. A preexisting condition exclusion includes any exclusion
				  applicable to an individual as a result of information that is obtained
				  relating to an individual's health status before the individual's first day of
				  coverage, such as a condition identified as a result of a preenrollment
				  questionnaire or physical examination given to the individual, or review of
				  medical records relating to the preenrollment period.
"Short-term limited-duration insurance"
means health coverage provided pursuant to a contract with an issuer that has
				  an expiration date specified in the contract that is less than 12 months after
				  the original effective date of the contract and, taking into account renewals
				  or extensions, has a duration of no longer than 36 months in total.
"Significant break in coverage"
means a
				  period of 63 consecutive days during all of which the individual does not have
				  any creditable coverage, except that neither a waiting period nor an
				  affiliation period is taken into account in determining a significant break in
				  coverage.
"Special enrollment period"
means a period
				  other than the first period in which an eligible employee or a dependent is
				  eligible to enroll under the terms of group health insurance coverage in
				  connection with which it is issued, without regard to other enrollment periods
				  defined under the health insurance coverage.
"Waiting period"
means, with respect to
				  group health insurance coverage and an eligible employee or a dependent who is
				  potentially eligible for coverage under the plan, the period that must pass
				  with respect to the individual before the individual is eligible to be covered
				  for benefits under the terms of the plan.