Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 135 - RULES GOVERNING INDIVIDUAL AND SMALL GROUP MARKET HEALTH BENEFIT PLANS › Section 14VAC5-135-20 - 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:
"Affordable Care Act" or "ACA" means the Patient Protection
				  and Affordable Care Act (P.L. 111-148), as amended by
				  the Health Care and Education Reconciliation Act of 2010 (P.L. 111-152) and
				  any federal regulations issued pursuant thereto.
"Covered benefits" or "benefits" means those health care
				  services to which an enrollee is entitled under the terms of a health benefit
				  plan.
"Dependent" means the spouse, child, or other class of
				  persons of an enrollee or eligible individual, subject to the applicable terms
				  of the policy, contract, or plan.
"Eligible individual" means an employee of a small employer
				  as shall be determined (i) in accordance with the terms of the group health
				  benefit plan; (ii) as provided by the health carrier under rules of the health
				  carrier that are uniformly applicable to employers in the small group market;
				  and (iii) in accordance with all applicable laws of the Commonwealth.
"Enrollee" means a policyholder, subscriber, participant,
				  member, insured, or other individual covered by a health benefit plan.
"Exchange" means either (i) the federal health benefit
				  exchange established pursuant to § 1321 of the Affordable Care Act or (ii)
				  the Virginia Health Benefit Exchange established pursuant to Chapter 65 (§
				  38.2-6500 et seq.) of Title 38.2 of the Code of Virginia, through which
				  qualified health plans and qualified dental plans are made available to
				  qualified individuals.
"Group health plan" means an employee welfare benefit plan as
				  defined in § 3(1) of the Employee Retirement Income Security Act of 1974
				  (ERISA) (29 USC §
										1002(1)) to the extent that
				  the plan provides medical care within the meaning of § 733(a) of ERISA
				  (29 USC §
										1191b(a)) to employees,
				  including both current and former employees, or their dependents as defined
				  under the terms of the plan directly or through insurance, reimbursement, or
				  otherwise.
"Health benefit plan" means a policy, contract, certificate,
				  or agreement offered by a health carrier to provide, deliver, arrange for, pay
				  for, or reimburse any of the costs of health care services, except as otherwise
				  specifically exempted. "Health benefit plan" does not include the "excepted
				  benefits" as defined in § 38.2-3431 of the Code of Virginia.
"Health carrier" means an entity subject to the insurance
				  laws and regulations of the Commonwealth and subject to the jurisdiction of the
				  State Corporation Commission that contracts or offers to contract to provide,
				  deliver, arrange for, pay for, or reimburse any of the costs of health care
				  services, including a health carrier licensed to sell accident and sickness
				  insurance, a health maintenance organization, a health services plan, or any
				  other entity providing a plan of health insurance, health benefits, or health
				  care services.
"Health insurance coverage" means benefits consisting of
				  medical care (provided directly, through insurance or reimbursement, or
				  otherwise) under any hospital or medical service policy or certificate,
				  hospital or medical service plan contract, or health maintenance organization
				  contract offered by a health carrier.
"Health status-related factor" means any of the following
				  factors: health status; medical condition, including physical and mental
				  illnesses; claims experience; receipt of health care services; medical history;
				  genetic information; evidence of insurability, including conditions arising out
				  of acts of domestic violence or extra-hazardous activities; disability; or any
				  other health status-related factor as determined by federal regulation.
"Individual market" means the market for health insurance
				  coverage offered to individuals other than in connection with a group health
				  plan.
"Medical necessity" or "medically necessary" means
				  appropriate and necessary health care services that are rendered for a
				  condition that, according to generally accepted principles of good medical
				  practice, requires the diagnosis or direct care and treatment of an illness,
				  injury, or pregnancy-related condition, and are not provided only as a
				  convenience.
"Premium" means all moneys paid by an employer, eligible
				  individual, or enrollee as a condition of coverage from a health carrier,
				  including fees and other contributions associated with the health benefit
				  plan.
"Small group market" means the health insurance market under
				  which eligible individuals obtain health benefit plans directly or through any
				  arrangement on behalf of themselves and their dependents through a group health
				  plan maintained by a small employer.
Statutory Authority: §§ 12.1-13 and 38.2-223 of
					 the Code of Virginia.