Virginia Administrative Code › Title 1 - ADMINISTRATION › Agency 55 - DEPARTMENT OF HUMAN RESOURCE MANAGEMENT › Chapter 20 - COMMONWEALTH OF VIRGINIA HEALTH BENEFITS PROGRAM › Part I - General › Section 1VAC55-20-20 - Definitions

Current through Register Vol. 40, No. 24, July 15, 2024
The following words and terms when used in this chapter
					 shall have the following meanings unless the context clearly indicates
					 otherwise:
"Accident or health plan" means a plan described in the
					 Internal Revenue Code § 105.
"Administrative services arrangement" means an arrangement
					 whereby a third party administrator agrees to administer all or part of the
					 health benefits program.
"Adoption agreement" means an agreement executed between a
					 local employer and the department specifying the terms and conditions of the
					 local employer's participation in the health benefits program.
"Alternative health benefits plans" means optional medical
					 benefits plans, inclusive of but not limited to HMOs and PPOs, which are
					 offered pursuant to the health benefits program in addition to the basic
					 statewide plan(s).
"Basic statewide plan(s)" means the statewide
					 hospitalization, medical and major medical plan offered at a uniform rate to
					 all state employees pursuant to § 2.2-2818 of the Code of Virginia.
"Benefits administrator" means the person or office
					 designated in the application and adoption agreement to be responsible for the
					 day-to-day administration of the health benefits program at the local level.
					 The benefits administrator is an employee of the agency or local employer that
					 employs the benefits administrator. The benefits administrator is not an agent
					 of the health insurance plan or the Department of Human Resource
					 Management.
"Coordinated service" means a health care service or supply
					 covered under both the program and another health plan. The coordinated service
					 will be provided under the program only to the extent it is not excluded or
					 limited under the program.
"Coordination of benefits" means the establishment of a
					 priority between two or more underwriters which provide health benefits
					 protection covering the same claims incident.
"Department" means the Department of Human Resource
					 Management.
"Dependent" means any person who is determined to be an
					 eligible family member of an employee pursuant to subsection E of
					 1VAC55-20-320.
"Director" means the Director of the Department of Human
					 Resource Management.
"Dual membership" means the coverage in the health benefits
					 program of the employee and either the spouse or one dependent. This definition
					 does not include coverage of retirees or employees or their spouses who are
					 otherwise covered by Medicare.
"Effective date of coverage" means the date on which a
					 participant is enrolled for benefits under a plan or plans elected under the
					 health benefits program.
"Employee" means a person employed by an employer
					 participating in the health benefits program or, where demanded by the context
					 of this chapter, a retired employee of such an employer. The term "employee"
					 shall include state employees and employees of local employers.
"Employee health insurance fund" or "health insurance
					 funds" means accounts established by the state treasury and maintained by the
					 department within which contributions to the plan shall be deposited.
"Employer" means the entity with whom a person maintains a
					 common law employee-employer relationship. The term "employer" is inclusive of
					 each state agency and of a local employer.
"Employer application" or "application" means the form, to
					 be provided by the department, to be used by the local employer for applying to
					 participate in the health benefits program.
"Enrollment action" means providing the information, which
					 would otherwise be contained on an enrollment form, through an alternative
					 means such as through the world wide web or through an interactive voice
					 response system, for the purpose of securing or changing membership or coverage
					 in the employee health benefits program. Submitting a properly completed
					 enrollment form and taking an enrollment action through an employee
					 self-service system are used interchangeably to indicate equivalent
					 actions.
"Enrollment form" means the form, to be provided by the
					 department, to be used by participants to enroll in a plan or to indicate a
					 change in coverage.
"Experience adjustment" means the adjustment determined by
					 the department, consistent with its actuarial practices, to premiums for the
					 year in which a local employer withdraws from the plan.
"Family membership" means the coverage in the health
					 benefits program of the employee and two or more eligible dependents.
"Health Maintenance Organization" or "HMO" means an entity
					 created under federal law, "The Health Maintenance Organization Act of 1973"
					 (Title XIII of the Public Health Service Act), as amended, or one defined under
					 state law.
"Health benefits program" or "program" means, individually
					 or collectively, the plan or plans the department may establish pursuant to §§
					 2.2-1204 and 2.2-2818 of the Code of Virginia.
"Health plan" means:
1. A plan or program offering benefits for,
				  or as a result of, any type of health care service when it is:
a. Group or blanket insurance (including
				  school insurance programs);
b. Blue
				  Cross, Blue Shield, group practice (including HMOs and PPOs), individual
				  practice (including IPAs), or any other prepayment arrangement (including this
				  program) when;
(1) An employer contributes any
				  portion of the premium; or
(2) An
				  employer contracts for the group coverage on behalf of employees; or
(3) It is any labor-management trustee plan,
				  union welfare plan, employer organization plan, or employee benefit
				  organization plan.