Advanced Search

§27-18.5-2  Definitions. –


Published: 2015

Subscribe to a Global-Regulation Premium Membership Today!

Key Benefits:

Subscribe Now for only USD$40 per month.
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.)