Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 130 - RULES GOVERNING THE FILING OF RATES FOR INDIVIDUAL AND CERTAIN GROUP ACCIDENT AND SICKNESS INSURANCE POLICY FORMS › Section 14VAC5-130-40 - 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:
"Actuarial value" or "AV" means the anticipated covered
				  medical spending for essential health benefits (EHB) coverage paid by a health
				  plan for a standard population, computed in accordance with the plan's
				  cost-sharing, divided by the total anticipated allowed charges for EHB coverage
				  provided to a standard population, and expressed as a percentage.
"Anticipated loss ratio" means the ratio of the present value
				  of the future benefits to the present value of the future premiums of a policy
				  form over the entire period for which rates are computed to provide
				  coverage.
"Grandfathered plan" means coverage provided by a health
				  carrier in which an individual was enrolled on March 23, 2010, for as long as
				  such plan maintains that status in accordance with federal law.
"Group health insurance coverage" means in connection with a
				  group health plan, health insurance coverage offered in connection with such
				  plan.
"Group health plan" means an employee welfare benefit plan
				  (as defined in § 3(1) of the Employee Retirement Income Security Act of
				  1974 (
				  29
				  USC §
										1002(1) ), to the
				  extent that the plan provides medical care and 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.
"Health benefit plan" means any accident and health insurance
				  policy or certificate, health services plan contract, health maintenance
				  organization subscriber contract, plan provided by a multiple employer welfare
				  arrangement, or plan provided by another benefit arrangement. "Health benefit
				  plan" does not mean accident only, credit, or disability insurance; coverage of
				  Medicare services or federal employee health plans, pursuant to contracts with
				  the United States government; Medicare supplement or long-term care insurance;
				  Medicaid coverage; dental only or vision only insurance; specified disease
				  insurance; hospital confinement indemnity coverage; limited benefit health
				  coverage; coverage issued as a supplement to liability insurance; insurance
				  arising out of a workers' compensation or similar law; automobile medical
				  payment insurance; medical expense and loss of income benefits; or insurance
				  under which benefits are payable with or without regard to fault and that is
				  statutorily required to be contained in any liability insurance policy or
				  equivalent self-insurance.
"Health insurance coverage" means benefits consisting of
				  medical care (provided directly, through insurance or reimbursement, or
				  otherwise and including items and services paid for as medical care) under any
				  hospital or medical service policy or certificate, hospital or medical service
				  plan contract, or health maintenance organization contract offered by an
				  insurer.
"Health maintenance organization" means any person who
				  undertakes to provide or arrange for one or more health care plans as defined
				  in §
									38.2-4300 of the Code
				  of Virginia.
"Health system" means an organization that consists of either
				  (i) at least one hospital plus at least one group of physicians or (ii) more
				  than one group of physicians.
"Individual accident and sickness insurance" means insurance
				  against loss resulting from sickness or from bodily injury or death by accident
				  or accidental means or both when sold on an individual rather than group
				  basis.
"Individual health insurance coverage" means health insurance
				  coverage offered to individuals in the individual market, that includes a
				  health benefit plan provided to individuals through a trust arrangement,
				  association, or other discretionary group that is not an employer plan, but
				  does not include coverage defined as "excepted benefits" in §
									38.2-3431
				  of the Code of Virginia or short-term limited duration insurance. Student
				  health insurance coverage shall be considered a type of individual health
				  insurance coverage.
"Individual market" means the market for health insurance
				  coverage offered to individuals other than in connection with a group health
				  plan. Coverage that would be regulated as individual market coverage if it were
				  not sold through an association is individual market coverage.
"Insurer" means a person licensed to issue or that issues any
				  insurance policy in this Commonwealth.
"Medicare supplement policy" means an individual or group
				  accident and sickness insurance policy or certificate, or a health maintenance
				  organization subscription contract or evidence of coverage, designed primarily
				  to supplement Medicare by providing benefits for payment of hospital, medical,
				  or surgical expenses, or is advertised, marketed or otherwise purported to be a
				  supplement to Medicare. For group policies, the term does not include a policy
				  or contract of one or more employers or labor organizations, or of the trustees
				  of a fund established by one or more employers or labor organizations, or a
				  combination of employees and labor organizations, for employees, former
				  employees, or combination of employees and labor organizations or for members
				  or former members, or combination thereof, of the labor organizations.
"Member" means an enrollee, insured, member, subscriber,
				  policyholder, certificate holder, or other individual who is participating in a
				  health benefit plan or covered under accident and sickness insurance.
"Policy" means an insurance policy, form, contract,
				  certificate of insurance, evidence of coverage, subscriber contract or other
				  similar document. A policy shall include any rider or endorsement affecting
				  benefits attached to the base policy.
"Premium" means all moneys paid by an employer, eligible
				  employee, or member as a condition of coverage from an insurer, including fees
				  and other contributions associated with a health benefit plan.
"Qualified actuary" means a member of the American Academy of
				  Actuaries, or other individual qualified as described in the American Academy
				  of Actuaries' U.S. Qualification Standards and the Code of Professional Conduct
				  to render statements of actuarial opinion in the applicable area of
				  practice.
"Rate" or "premium rate" means any rate of premium, policy
				  fee, membership fee, or any other charge made by an insurer for or in
				  connection with a contract or policy of insurance. "Rate" shall not include a
				  membership fee paid to become a member of an organization or association, one
				  of the benefits of which is the purchase of insurance coverage.
"SERFF" means the National Association of Insurance
				  Commissioner's (NAIC) System for Electronic Rate and Form Filing, or its
				  successor.
"Small employer" has the same meaning as in §
									38.2-3431
				  of the Code of Virginia.
"Small group market" means the health insurance market under
				  which individuals obtain health insurance coverage (directly or through any
				  arrangement) on behalf of themselves (and their dependents) through a group
				  health plan maintained by a small employer. Coverage that would be regulated as
				  small group market coverage if it were not sold through an association is small
				  group market coverage.
"Student health insurance coverage" means a type of
				  individual health insurance coverage offered in the individual market that is
				  provided pursuant to a written agreement between an institution of higher
				  education, as defined by the Higher Education Act of 1965 (Public Law No.
				  89-329), and a health carrier and provided to students enrolled in that
				  institution of higher education and their dependents, and that does not make
				  health insurance coverage available other than in connection with enrollment as
				  a student or as a dependent of a student in the institution of higher
				  education, and does not condition eligibility for health insurance coverage on
				  any health status-related factor related to a student or a dependent of the
				  student.
Statutory Authority: §§
											12.1-13
					 and
					 38.2-223
					 of the Code of Virginia.