Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 71 - Small Group Health Benefit Plans* › Rule 191-71.2 - Definitions

Current through Register Vol. 47, No. 3, July 24, 2024
As used in this chapter:
"Associate member of an employee
				  organization"
means any individual who participates in an employee
				  benefit plan (as defined in
				  29
				  U.S.C. 1002(1)) that is a multiemployer plan
				  (as defined in
				  29
				  U.S.C. 1002(37A)), other than the
				  following:
1. An individual (or the beneficiary of such individual) who
				  is employed by a participating employer within a bargaining unit covered by at
				  least one of the collective bargaining agreements under or pursuant to which
				  the employee benefit plan is established or maintained; or
2. An individual who is a present or former employee (or a
				  beneficiary of such employee) of the sponsoring employee organization, of an
				  employer who is or was a party to at least one of the collective bargaining
				  agreements under or pursuant to which the employee benefit plan is established
				  or maintained, or of the employee benefit plan (or of a related plan).
"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.
"COBRA"
means Title X of the Consolidated
				  Omnibus Budget Reconciliation Act of 1985, as amended.
"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"
includes short-term
				  limited duration insurance.
"Director"
means the director of public
				  health appointed pursuant to Iowa Code section
				  1352..
"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.
"Health insurance coverage"
does not include
				  the following:
1. Flexible spending accounts.
2. Short-term limited duration insurance.
3. Stop loss insurance coverage.
"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
				  5145..
"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 group health plan.
"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.
"New entrant"
means an eligible employee, or
				  the dependent of an eligible employee, who becomes part of an employer group
				  after the initial period for enrollment in health insurance coverage.
"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.
"Risk characteristic"
means the health
				  status, claims experience, duration of coverage, or any similar characteristic
				  related to the health status or experience of a small employer group or of any
				  member of a small employer group.
"Risk load"
means the percentage above the
				  applicable base premium rate that is charged by a small employer carrier to a
				  small employer to reflect the risk characteristics of the small employer
				  group.
"Short-term limited duration insurance"
means health insurance coverage provided under a contract with a carrier that
				  has an expiration date specified in the contract, taking into account any
				  extensions that may be elected by the policyholder without the carrier's
				  consent, that is, within 12 months of the date the contract becomes
				  effective.
"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.
Other terms shall be defined pursuant to Iowa Code chapter
				  513B.