TITLE 27
Insurance
CHAPTER 27-18.5
Individual Health Insurance Coverage
SECTION 27-18.5-2
§ 27-18.5-2 Definitions.
The following words and phrases as used in this chapter have the following
meanings unless a different meaning is required by the context:
(1) "Bona fide association" means, with respect to health
insurance coverage offered in this state, an association which:
(i) Has been actively in existence for at least five (5)
years;
(ii) Has been formed and maintained in good faith for
purposes other than obtaining insurance;
(iii) 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 an employee);
(iv) 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);
(v) Does not make health insurance coverage offered through
the association available other than in connection with a member of the
association;
(vi) Is composed of persons having a common interest or
calling;
(vii) Has a constitution and bylaws; and
(viii) Meets any additional requirements that the director
may prescribe by regulation;
(2) "COBRA continuation provision" means any of the following:
(i) Section 4980(B) of the Internal Revenue Code of 1986, 26
U.S.C. § 4980B, other than subsection (f)(1) of that section insofar as it
relates to pediatric vaccines;
(ii) Part 6 of subtitle B of Title I of the Employee
Retirement Income Security Act of 1974, 29 U.S.C. § 1161 et seq., other
than Section 609 of that act, 29 U.S.C. § 1169; or
(iii) Title XXII of the United States Public Health Service
Act, 42 U.S.C. § 300bb-1 et seq.;
(3) "Creditable coverage" has the same meaning as defined in
the United States Public Health Service Act, Section 2701(c), 42 U.S.C. §
300gg(c), as added by P.L. 104-191;
(4) "Director" means the director of the department of
business regulation;
(5) "Eligible individual" means an individual:
(i) For whom, as of the date on which the individual seeks
coverage under this chapter, the aggregate of the periods of creditable
coverage is eighteen (18) or more months and whose most recent prior creditable
coverage was under a group health plan, a governmental plan established or
maintained for its employees by the government of the United States or by any
of its agencies or instrumentalities, or church plan (as defined by the
Employee Retirement Income Security Act of 1974, 29 U.S.C. § 1001 et seq.);
(ii) Who is not eligible for coverage under a group health
plan, part A or part B of title XVIII of the Social Security Act, 42 U.S.C.
§ 1395c et seq. or 42 U.S.C. § 1395j et seq., or any state plan under
title XIX of the Social Security Act, 42 U.S.C. § 1396 et seq. (or any
successor program), and does not have other health insurance coverage;
(iii) With respect to whom the most recent coverage within
the coverage period was not terminated based on a factor described in §
27-18.5-4(b)(relating to nonpayment of premiums or fraud);
(iv) If the individual had been offered the option of
continuation coverage under a COBRA continuation provision, or under chapter
19.1 of this title or under a similar state program of this state or any other
state, who elected the coverage; and
(v) Who, if the individual elected COBRA continuation
coverage, has exhausted the continuation coverage under the provision or
program;
(6) "Group health plan" means an employee welfare benefit
plan as defined in section 3(1) of the Employee Retirement Income Security Act
of 1974, 29 U.S.C. § 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;
(7) "Health insurance carrier" or "carrier" means any entity
subject to the insurance laws and regulations of this state, or subject to the
jurisdiction of the director, that contracts or offers to contract to provide,
deliver, arrange for, pay for, or reimburse any of the costs of health care
services, including, without limitation, an insurance company offering accident
and sickness insurance, a health maintenance organization, a nonprofit
hospital, medical or dental service corporation, or any other entity providing
a plan of health insurance or health benefits by which health care services are
paid or financed for an eligible individual or his or her dependents by such
entity on the basis of a periodic premium, paid directly or through an
association, trust, or other intermediary, and issued, renewed, or delivered
within or without Rhode Island to cover a natural person who is a resident of
this state, including a certificate issued to a natural person which evidences
coverage under a policy or contract issued to a trust or association;
(8)(i) "Health insurance coverage" means a policy, contract,
certificate, or agreement offered by a health insurance carrier to provide,
deliver, arrange for, pay for or reimburse any of the costs of health care
services.
(ii) "Health insurance coverage" does not include one or
more, or any combination of, the following:
(A) Coverage only for accident, or disability income
insurance, or any combination of those;
(B) Coverage issued as a supplement to liability insurance;
(C) Liability insurance, including general liability
insurance and automobile liability insurance;
(D) Workers' compensation or similar insurance;
(E) Automobile medical payment insurance;
(F) Credit-only insurance;
(G) Coverage for on-site medical clinics;
(H) Other similar insurance coverage, specified in federal
regulations issued pursuant to P.L. 104-191, under which benefits for medical
care are secondary or incidental to other insurance benefits; and
(I) Short term limited duration insurance;
(iii) "Health insurance coverage" does not include the
following benefits if they are provided under a separate policy, certificate,
or contract of insurance or are not an integral part of the coverage:
(A) Limited scope dental or vision benefits;
(B) Benefits for long-term care, nursing home care, home
health care, community-based care, or any combination of these;
(C) Any other similar, limited benefits that are specified in
federal regulation issued pursuant to P.L. 104-191;
(iv) "Health insurance coverage" does not include the
following benefits if the benefits are provided under a separate policy,
certificate, or contract of insurance, there is no coordination between the
provision of the benefits and any exclusion of benefits under any group health
plan maintained by the same plan sponsor, and the benefits are paid with
respect to an event without regard to whether benefits are provided with
respect to the event under any group health plan maintained by the same plan
sponsor:
(A) Coverage only for a specified disease or illness; or
(B) Hospital indemnity or other fixed indemnity insurance; and
(v) "Health insurance coverage" does not include the
following if it is offered as a separate policy, certificate, or contract of
insurance:
(A) Medicare supplemental health insurance as defined under
section 1882(g)(1) of the Social Security Act, 42 U.S.C. § 1395ss(g)(1);
(B) Coverage supplemental to the coverage provided under 10
U.S.C. § 1071 et seq.; and
(C) Similar supplemental coverage provided to coverage under
a group health plan;
(9) "Health status-related factor" means any of the following
factors:
(i) Health status;
(ii) Medical condition, including both physical and mental
illnesses;
(iii) Claims experience;
(iv) Receipt of health care;
(v) Medical history;
(vi) Genetic information;
(vii) Evidence of insurability, including conditions arising
out of acts of domestic violence; and
(viii) Disability;
(10) "Individual market" means the market for health
insurance coverage offered to individuals other than in connection with a group
health plan;
(11) "Network plan" means health insurance coverage offered
by a health insurance carrier 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;
(12) "Preexisting condition" means, with respect to health
insurance coverage, a condition (whether physical or mental), regardless of the
cause of the condition, that was present before the date of enrollment for the
coverage, for which medical advice, diagnosis, care, or treatment was
recommended or received within the six (6) month period ending on the
enrollment date. Genetic information shall not be treated as a preexisting
condition in the absence of a diagnosis of the condition related to that
information; and
(13) "High-risk individuals" means those individuals who do
not pass medical underwriting standards, due to high health care needs or risks;
(14) "Wellness health benefit plan" means that health benefit
plan offered in the individual market pursuant to § 27-18.5-8; and
(15) "Commissioner" means the health insurance commissioner.
History of Section.
(P.L. 2000, ch. 200, § 4; P.L. 2000, ch. 229, § 4; P.L. 2001, ch.
241, § 1; P.L. 2001, ch. 331, § 1; P.L. 2006, ch. 273, § 3; P.L.
2006, ch. 297, § 3; P.L. 2007, ch. 164, § 2.)