Chapter
469
2006 -- H 7145 SUBSTITUTE A
Enacted 07/07/06
A N A C T
RELATING TO INSURANCE
-- THE RHODE ISLAND HEALTH CARE AFFORDABILITY ACT OF 2006 PART III -- COVERAGE
OF DEPENDENT CHILDREN
Introduced By: Representatives E Coderre, Kennedy, and Naughton
Date Introduced: February
08, 2006
It is
enacted by the General Assembly as follows:
SECTION
1. Section 27-18.6-2 of the General Laws in Chapter 27-18.6 entitled
"Large
Groups
Health Insurance Coverage" is hereby amended to read as follows:
27-18.6-2.
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) "Affiliation period" means a period which, under the terms of the
health insurance
coverage
offered by a health maintenance organization, must expire before the health
insurance
coverage
becomes effective. The health maintenance organization is not required to
provide
health
care services or benefits during the period and no premium shall be charged to
the
participant
or beneficiary for any coverage during the period;
(2) "Beneficiary" has the meaning given that term under section 3(8)
of the Employee
Retirement
Security Act of 1974, 29 U.S.C. section 1002(8);
(3) "Bona fide association" means, with respect to health insurance
coverage 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-relating
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;
(4) "COBRA continuation provision" means any of the following:
(i) Section 4980(B) of the Internal Revenue Code of 1986, 26 U.S.C. section
4980B,
other
than the subsection (f)(1) of that section insofar as it relates to pediatric
vaccines;
(ii) Part 6 of subtitle B of title 1 of the Employee Retirement Income Security
Act of
1974, 29
U.S.C. section 1161 et seq., other than section 609 of that act, 29 U.S.C.
section 1169;
or
(iii) Title XXII of the United States Public Health Service Act, 42 U.S.C.
section 300bb-
1 et
seq.;
(5) "Creditable coverage" has the same meaning as defined in the
United States Public
Health
Service Act, section 2701(c), 42 U.S.C. section 300gg(c), as added by P.L.
104-191;
(6) "Church plan" has the meaning given that term under section 3(33)
of the Employee
Retirement
Income Security Act of 1974, 29 U.S.C. section 1002(33);
(7) "Dependent" means a spouse or unmarried child under the age of
nineteen (19) years;
an
unmarried child who is a full-time student under the age of twenty-five (25)
years and who is
financially
dependent upon the parent; and an unmarried child of any age who is medically
certified
as disabled and dependent upon the parent;
(8) (7) "Director" means the director of the department
of business regulation;
(9) (8) "Employee" has the meaning given that term
under section 3(6) of the Employee
Retirement
Income Security Act of 1974, 29 U.S.C. section 1002(6);
(10) (9) "Employer" has the meaning given that term
under section 3(5) of the Employee
Retirement
Income Security Act of 1974, 29 U.S.C. section 1002(5), except that the term
includes
only
employers of two (2) or more employees;
(11) (10) "Enrollment date" means, with respect to an
individual covered under a group
health
plan or health insurance coverage, the date of enrollment of the individual in
the plan or
coverage
or, if earlier, the first day of the waiting period for the enrollment;
(12) (11) "Governmental plan" has the meaning given
that term under section 3(32) of
the
Employee Retirement Income Security Act of 1974, 29 U.S.C. section 1002(32),
and includes
any
governmental plan established or maintained for its employees by the government
of the
United
States, the government of any state or political subdivision of the state, or
by any agency
or
instrumentality of government;
(13) (12) "Group health insurance coverage" means, in
connection with a group health
plan,
health insurance coverage offered in connection with that plan;
(14) (13) "Group health plan" means an employee welfare
benefits plan as defined in
section
3(1) of the Employee Retirement Income Security Act of 1974, 29 U.S.C. section
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;
(15) (14) "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, health benefits, or
health
services;
(16) (15)(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. Health insurance coverage does
include short-
term and
catastrophic health insurance policies, and a policy that pays on a
cost-incurred basis,
except
as otherwise specifically exempted in this definition;
(ii) "Health insurance coverage" does not include one or more, or any
combination of,
the
following "excepted benefits":
(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; and
(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;
(iii) "Health insurance coverage" does not include the following
"limited, excepted
benefits"
if they are provided under a separate policy, certificate of insurance, or are
not an
integral
part of the plan:
(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 those; and
(C) Any other similar, limited benefits that are specified in federal
regulations issued
pursuant
to P.L. 104-191;
(iv) "Health insurance coverage" does not include the following
"noncoordinated,
excepted
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; and
(B) Hospital indemnity or other fixed indemnity insurance;
(v) "Health insurance coverage" does not include the following
"supplemental, excepted
benefits"
if 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. section 1395ss(g)(1);
(B) Coverage supplemental to the coverage provided under 10 U.S.C. section 1071
et
seq.;
and
(C) Similar supplemental coverage provided to coverage under a group health
plan;
(17) (16) "Health maintenance organization"
("HMO") means a health maintenance
organization
licensed under chapter 41 of this title;
(18) (17) "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 contributions arising out of acts of
domestic
violence;
and
(viii) Disability;
(19) (18) "Large employer" means, in connection with a
group health plan with respect
to a
calendar year and a plan year, an employer who employed an average of at least
fifty-one
(51)
employees on business days during the preceding calendar year and who employs
at least
two (2)
employees on the first day of the plan year. In the case of an employer which
was not in
existence
throughout the preceding calendar year, the determination of whether the
employer is a
large
employer shall be based on the average number of employees that is reasonably
expected
the
employer will employ on business days in the current calendar year;
(20) (19) "Large 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 large
employer;
(21) (20) "Late enrollee" means, with respect to
coverage under a group health plan, a
participant
or beneficiary who enrolls under the plan other than during:
(i) The first period in which the individual is eligible to enroll under the
plan; or
(ii) A special enrollment period;
(22) (21) "Medical care" means amounts paid for:
(i) The diagnosis, cure, mitigation, treatment, or prevention of disease, or
amounts paid
for the
purpose of affecting any structure or function of the body;
(ii) Amounts paid for transportation primarily for and essential to medical
care referred
to in
paragraph (i) of this subdivision; and
(iii) Amounts paid for insurance covering medical care referred to in
paragraphs (i) and
(ii) of
this subdivision;
(23) (22) "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;
(24) (23) "Participant" has the meaning given such term
under section 3(7) of the
Employee
Retirement Income Security Act of 1974, 29 U.S.C. section 1002(7);
(25) (24) "Placed for adoption" means, in connection
with any placement for adoption of
a child
with any person, the assumption and retention by that person of a legal
obligation for total
or
partial support of the child in anticipation of adoption of the child. The
child's placement with
the
person terminates upon the termination of the legal obligation;
(26) (25) "Plan sponsor" has the meaning given that
term under section 3(16)(B) of the
Employee
Retirement Income Security Act of 1974, 29 U.S.C. section 1002(16)(B).
"Plan
sponsor"
also includes any bona fide association, as defined in this section;
(27) (26) "Preexisting condition exclusion" means, with
respect to health insurance
coverage,
a limitation or exclusion of benefits relating to a condition based on the fact
that the
condition
was present before the date of enrollment for the coverage, whether or not any
medical
advice,
diagnosis, care or treatment was recommended or received before the date; and
(28) (27) "Waiting period" means, with respect to a
group health plan and an individual
who is a
potential participant or beneficiary in the plan, the period that must pass
with respect to
the
individual before the individual is eligible to be covered for benefits under
the terms of the
plan.
SECTION
2. Section 27-18-59 of the General Laws in Chapter 27-18 entitled
"Accident
and
Sickness Insurance Policies" is hereby amended to read as follows:
27-18-59.
Termination of children's benefits. -- (a) Every individual or group
health
insurance
contract, plan, or policy delivered, issued for delivery, or renewed in this
state and
every
group health insurance contract, plan, or policy delivered, issued for delivery
or renewed in
this
state which provides medical coverage
for dependent children that includes coverage for
physician
services in a physician's office, and every policy which provides major medical
or
similar
comprehensive type coverage, except for supplemental policies which only
provide
coverage
for specified diseases and other supplemental policies, shall provide
coverage of an
unmarried
child under the age of nineteen (19) years, an unmarried child who is a student
under
the
age of twenty-five (25) years and who is financially dependent upon the parent
and an
unmarried
child of any age who is financially dependent upon the parent and medically
determined
to have a physical or mental impairment which can be expected to result in
death or
which
has lasted or can be expected to last for a continuous period of not less than
twelve (12)
months.
Such contract, plan or policy shall also
include a provision that policyholders shall
receive
no less than thirty (30) days notice from the accident and sickness insurer
that a child
covered
as a dependent by the policy holder is about to lose his or her coverage as a
result of
reaching
the maximum age for a dependent child, and that the child will only continue to
be
covered
upon documentation being provided of current college full or
part-time enrollment in a
post-secondary
educational institution or that the
child may purchase a conversion policy if he or
she is
not a college an eligible student. Nothing in this section
prohibits an accident and sickness
insurer
from requiring a policyholder to annually provide proof of a child's current college
full or
part-time enrollment in a post-secondary educational
institution in order to maintain the child's
coverage.
Provided, nothing in this section requires coverage inconsistent with the
membership
criteria
in effect under the policyholder's health benefits coverage.
(b) This section does not apply to insurance coverage providing benefits for:
(1) hospital
confinement
indemnity; (2) disability income; (3) accident only; (4) long term care; (5)
Medicare
supplement;
(6) limited benefit health; (7) specified diseased indemnity; or (8) other
limited
benefit
policies.
SECTION
3. Section 27-19-50 of the General Laws in Chapter 27-19 entitled
"Nonprofit
Hospital
Service Corporations" is hereby amended to read as follows:
27-19-50.
Termination of children's benefits. -- (a) Every individual or group
health
insurance
contract, plan, or policy delivered, issued for delivery, or renewed in this
state and
every
group health insurance contract, plan, or policy delivered, issued for delivery
or renewed in
this
state which provides medical coverage
for dependent children that includes coverage for
physician
services in a physician's office, and every policy which provides major medical
or
similar
comprehensive type coverage, except for supplemental policies which only
provide
coverage
for specified diseases and other supplemental policies, shall provide
coverage of an
unmarried
child under the age of nineteen (19) years, an unmarried child who is a student
under
the
age of twenty-five (25) years and who is financially dependent upon the parent
and an
unmarried
child of any age who is financially dependent upon the parent and medically
determined
to have a physical or mental impairment which can be expected to result in
death or
which
has lasted or can be expected to last for a continuous period of not less than
twelve (12)
months.
Such contract, plan or policy shall also
include a provision that policyholders shall
receive
no less than thirty (30) days notice from the nonprofit hospital service
corporation that a
child
covered as a dependent by the policyholder is about to lose his or her coverage
as a result of
reaching
the maximum age for a dependent child and that the child will only continue to
be
covered
upon documentation being provided of current college full or
part-time enrollment in a
post-secondary
educational institution, or that the
child may purchase a conversion policy if he or
she is
not a college an eligible student.
(b) Nothing in this section prohibits a nonprofit hospital service corporation
from
requiring
a policyholder to annually provide proof of a child's current college full
or part-time
enrollment
in a post-secondary educational institution in order to maintain the
child's coverage.
Provided,
nothing in this section requires coverage inconsistent with the membership
criteria in
effect
under the policyholder's health benefits coverage.
SECTION
4. Section 27-20-45 of the General Laws in Chapter 27-20 entitled
"Nonprofit
Medical
Service Corporations" is hereby amended to read as follows:
27-20-45.
Termination of children's benefits. -- (a) Every individual or group
health
insurance
contract, plan, or policy delivered, issued for delivery, or renewed in this
state and
every
group health insurance contract, plan, or policy delivered, issued for delivery
or renewed in
this
state which provides medical coverage
for dependent children that includes coverage for
physician
services in a physician's office, and every policy which provides major medical
or
similar
comprehensive type coverage, except for supplemental policies which only
provide
coverage
for specified diseases and other supplemental policies, shall provide
coverage of an
unmarried
child under the age of nineteen (19) years, an unmarried child who is a student
under
the
age of twenty-five (25) years and who is financially dependent upon the parent
and an
unmarried
child of any age who is financially dependent upon the parent and medically
determined
to have a physical or mental impairment which can be expected to result in
death or
which
has lasted or can be expected to last for a continuous period of not less than
twelve (12)
months.
Such contract, plan or policy shall also
include a provision that policyholders shall
receive
no less than thirty (30) days notice from the nonprofit medical service
corporation that a
child
covered as a dependent by the policyholder is about to lose his or her coverage
as a result of
reaching
the maximum age for a dependent child and that the child will only continue to
be
covered
upon documentation being provided of current college full or
part-time enrollment in a
post-secondary
educational institution, or that the
child may purchase a conversion policy if he or
she is
not a college an eligible student.
(b) Nothing in this section prohibits a nonprofit medical service corporation
from
requiring
a policyholder to annually provide proof of a child's current college full
or part-time
enrollment
in a post-secondary educational institution in order to maintain the
child's coverage.
Provided,
nothing in this section requires coverage inconsistent with the membership
criteria in
effect
under the policyholder's health benefits coverage.
SECTION
5. Section 27-41-61 of the General Laws in Chapter 27-41 entitled "Health
Maintenance
Organizations" is hereby amended to read as follows:
27-41-61.
Termination of children's benefits. -- (a) Every individual or group
health
insurance
contract, plan, or policy delivered, issued for delivery, or renewed in this
state which
provides
medical coverage for dependent children that includes coverage for
physician services in
a
physician's office, and every policy which provides major medical or similar
comprehensive
type
coverage, except for supplemental policies which only provide coverage for
specified
diseases
and other supplemental policies, shall provide coverage of an unmarried
child under the
age
of nineteen (19) years, an unmarried child who is a student under the age of
twenty-five (25)
years
and who is financially dependent upon the parent and an unmarried child of any
age who is
financially
dependent upon the parent and medically determined to have a physical or mental
impairment
which can be expected to result in death or which has lasted or can be expected
to last
for a
continuous period of not less than twelve (12) months. Such contract, plan or
policy shall
also include a provision that policyholders shall receive
no less than thirty (30) days notice from
the
health maintenance organization that a child is about to lose his or her
coverage as a result of
reaching
the maximum age for a dependent child and that the child will only continue to
be
covered
upon documentation being provided of current college full or
part-time enrollment in a
post-secondary
educational institution, or that the
child may purchase a conversion policy if he or
she is
not a college an eligible student.
(b) Nothing in this section prohibits a nonprofit health maintenance
organization from
requiring
a policyholder to annually provide proof of a child's current college full
or part-time
enrollment
in a post-secondary educational institution in order to maintain the
child's coverage.
Provided,
nothing in this section requires coverage inconsistent with the membership
criteria in
effect
under the policyholder's health benefits coverage.
SECTION
6. Section 27-50-3 of the General Laws in Chapter 27-50 entitled "Small
Employer
Health Insurance Availability Act" is hereby amended to read as follows:
27-50-3.
Definitions. -- (a) "Actuarial certification" means a written
statement signed by
a member
of the American Academy of Actuaries or other individual acceptable to the
director
that a
small employer carrier is in compliance with the provisions of section 27-50-5,
based upon
the
person's examination and including a review of the appropriate records and the
actuarial
assumptions
and methods used by the small employer carrier in establishing premium rates
for
applicable
health benefit plans.
(b) "Adjusted community rating" means a method used to develop a
carrier's premium
which
spreads financial risk across the carrier's entire small group population in
accordance with
the
requirements in section 27-50-5.
(c) "Affiliate" or "affiliated" means any entity or person
who directly or indirectly
through
one or more intermediaries controls or is controlled by, or is under common
control with,
a
specified entity or person.
(d) "Affiliation period" means a period of time that must expire
before health insurance
coverage
provided by a carrier becomes effective, and during which the carrier is not
required to
provide
benefits.
(e) "Bona fide association" means, with respect to health benefit
plans offered in this
state,
an association which:
(1) Has been actively in existence for at least five (5) years;
(2) Has been formed and maintained in good faith for purposes other than
obtaining
insurance;
(3) 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);
(4) Makes health insurance coverage offered through the association available
to all
members
regardless of any health status-related factor relating to those members (or
individuals
eligible
for coverage through a member);
(5) Does not make health insurance coverage offered through the association
available
other
than in connection with a member of the association;
(6) Is composed of persons having a common interest or calling;
(7) Has a constitution and bylaws; and
(8) Meets any additional requirements that the director may prescribe by
regulation.
(f) "Carrier" or "small employer carrier" means all
entities licensed, or required to be
licensed,
in this state that offer health benefit plans covering eligible employees of
one or more
small
employers pursuant to this chapter. For the purposes of this chapter, carrier
includes an
insurance
company, a nonprofit hospital or medical service corporation, a fraternal
benefit
society,
a health maintenance organization as defined in chapter 41 of this title or as
defined in
chapter
62 of title 42, or any other entity providing a plan of health insurance or
health benefits
subject
to state insurance regulation.
(g) "Church plan" has the meaning given this term under section 3(33)
of the Employee
Retirement
Income Security Act of 1974 [29 U.S.C. section 1002(33)_.
(h) "Control" is defined in the same manner as in chapter 35 of this
title.
(i) (1) "Creditable coverage" means, with respect to an individual,
health benefits or
coverage
provided under any of the following:
(i) A group health plan;
(ii) A health benefit plan;
(iii) Part A or part B of Title XVIII of the Social Security Act, 42 U.S.C.
section 1395c
et seq.,
or 42 U.S.C. section 1395j et seq., (Medicare);
(iv) Title XIX of the Social Security Act, 42 U.S.C. section 1396 et seq.,
(Medicaid),
other
than coverage consisting solely of benefits under 42 U.S.C. section 1396s (the
program for
distribution
of pediatric vaccines);
(v) 10 U.S.C. section 1071 et seq., (medical and dental care for members and
certain
former
members of the uniformed services, and for their dependents)(Civilian Health
and
Medical
Program of the Uniformed Services)(CHAMPUS). For purposes of 10 U.S.C. section
1071 et
seq., "uniformed services" means the armed forces and the
commissioned corps of the
national
oceanic and atmospheric administration and of the public health service;
(vi) A medical care program of the Indian Health Service or of a tribal
organization;
(vii) A state health benefits risk pool;
(viii) A health plan offered under 5 U.S.C. section 8901 et seq., (Federal
Employees
Health
Benefits Program (FEHBP));
(ix) A public health plan, which for purposes of this chapter, means a plan
established or
maintained
by a state, county, or other political subdivision of a state that provides
health
insurance
coverage to individuals enrolled in the plan; or
(x) A health benefit plan under section 5(e) of the Peace Corps Act (22 U.S.C.
section
2504(e)).
(2) A period of creditable coverage shall not be counted, with respect to
enrollment of an
individual
under a group health plan, if, after the period and before the enrollment date,
the
individual
experiences a significant break in coverage.
(j) "Dependent" means a spouse, an unmarried child under the age of
nineteen (19) years,
an
unmarried child who is a full-time student under the age of twenty-five
(25) years and who is
financially
dependent upon the parent, and an
unmarried child of any age who is medically
certified
as disabled and dependent upon the parent is financially dependent upon, the parent and
is
medically determined to have a physical or mental impairment which can be
expected to result
in
death or which has lasted or can be expected to last for a continuous period of
not less than
twelve
(12) months.
(k) "Director" means the director of the department of business
regulation.
(l) "Economy health plan" means a lower cost health benefit plan
developed pursuant to
the
provisions of section 27-50-10.
(m) "Eligible employee" means an employee who works on a full-time
basis with a
normal
work week of thirty (30) or more hours, except that at the employer's sole
discretion, the
term
shall also include an employee who works on a full-time basis with a normal
work week of
anywhere
between at least seventeen and one-half (17.5) and thirty (30) hours, so long
as this
eligibility
criterion is applied uniformly among all of the employer's employees and
without
regard
to any health status-related factor. The term includes a self-employed
individual, a sole
proprietor,
a partner of a partnership, and may include an independent contractor, if the
self-
employed
individual, sole proprietor, partner, or independent contractor is included as
an
employee
under a health benefit plan of a small employer, but does not include an
employee who
works on
a temporary or substitute basis or who works less than seventeen and one-half
(17.5)
hours
per week. Any retiree under contract with any independently incorporated fire
district is
also
included in the definition of eligible employee. Persons covered under a health
benefit plan
pursuant
to the Consolidated Omnibus Budget Reconciliation Act of 1986 shall not be
considered
"eligible
employees" for purposes of minimum participation requirements pursuant to
section 27-
50-7(d)(9).
(n) "Enrollment date" means the first day of coverage or, if there is
a waiting period, the
first
day of the waiting period, whichever is earlier.
(o) "Established geographic service area" means a geographic area, as
approved by the
director
and based on the carrier's certificate of authority to transact insurance in
this state, within
which
the carrier is authorized to provide coverage.
(p) "Family composition" means:
(1) Enrollee;
(2) Enrollee, spouse and children;
(3) Enrollee and spouse; or
(4) Enrollee and children.
(q) "Genetic information" means information about genes, gene
products, and inherited
characteristics
that may derive from the individual or a family member. This includes
information
regarding
carrier status and information derived from laboratory tests that identify
mutations in
specific
genes or chromosomes, physical medical examinations, family histories, and
direct
analysis
of genes or chromosomes.
(r) "Governmental plan" has the meaning given the term under section
3(32) of the
Employee
Retirement Income Security Act of 1974, 29 U.S.C. section 1002(32), and any
federal
governmental
plan.
(s) (1) "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. section 1002(1),
to the
extent
that the plan provides medical care, as defined in subsection (y) of this
section, 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.
(2) For purposes of this chapter:
(i) Any plan, fund, or program that would not be, but for PHSA Section 2721(e),
42
U.S.C.
section 300gg(e), as added by P.L. 104-191, an employee welfare benefit plan
and that is
established
or maintained by a partnership, to the extent that the plan, fund or program
provides
medical
care, including items and services paid for as medical care, to present or
former partners
in the
partnership, or to their dependents, as defined under the terms of the plan,
fund or program,
directly
or through insurance, reimbursement or otherwise, shall be treated, subject to
paragraph
(ii) of
this subdivision, as an employee welfare benefit plan that is a group health
plan;
(ii) In the case of a group health plan, the term "employer" also
includes the partnership
in
relation to any partner; and
(iii) In the case of a group health plan, the term "participant" also
includes an individual
who is,
or may become, eligible to receive a benefit under the plan, or the
individual's beneficiary
who is,
or may become, eligible to receive a benefit under the plan, if:
(A) In connection with a group health plan maintained by a partnership, the
individual is
a
partner in relation to the partnership; or
(B) In connection with a group health plan maintained by a self-employed
individual,
under
which one or more employees are participants, the individual is the
self-employed
individual.
(t) (1) "Health benefit plan" means any hospital or medical policy or
certificate, major
medical
expense insurance, hospital or medical service corporation subscriber contract,
or health
maintenance
organization subscriber contract. Health benefit plan includes short-term and
catastrophic
health insurance policies, and a policy that pays on a cost-incurred basis,
except as
otherwise
specifically exempted in this definition.
(2) "Health benefit plan" does not include one or more, or any
combination of, the
following:
(i) Coverage only for accident or disability income insurance, or any
combination of
those;
(ii) Coverage issued as a supplement to liability insurance;
(iii) Liability insurance, including general liability insurance and automobile
liability
insurance;
(iv) Workers' compensation or similar insurance;
(v) Automobile medical payment insurance;
(vi) Credit-only insurance;
(vii) Coverage for on-site medical clinics; and
(viii) Other similar insurance coverage, specified in federal regulations
issued pursuant
to Pub.
L. No. 104-191, under which benefits for medical care are secondary or
incidental to other
insurance
benefits.
(3) "Health benefit plan" does not include the following benefits if
they are provided
under a
separate policy, certificate, or contract of insurance or are otherwise not an
integral part
of the
plan:
(i) Limited scope dental or vision benefits;
(ii) Benefits for long-term care, nursing home care, home health care,
community-based
care, or
any combination of those; or
(iii) Other similar, limited benefits specified in federal regulations issued
pursuant to
Pub. L.
No. 104-191.
(4) "Health benefit plan" 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 such an event under any group
health plan
maintained
by the same plan sponsor:
(i) Coverage only for a specified disease or illness; or
(ii) Hospital indemnity or other fixed indemnity insurance.
(5) "Health benefit plan" does not include the following if offered
as a separate policy,
certificate,
or contract of insurance:
(i) Medicare supplemental health insurance as defined under section 1882(g)(1)
of the
Social
Security Act, 42 U.S.C. section 1395ss(g)(1);
(ii) Coverage supplemental to the coverage provided under 10 U.S.C. section
1071 et
seq.; or
(iii) Similar supplemental coverage provided to coverage under a group health
plan.
(6) A carrier offering policies or certificates of specified disease, hospital
confinement
indemnity,
or limited benefit health insurance shall comply with the following:
(i) The carrier files on or before March 1 of each year a certification with
the director
that
contains the statement and information described in paragraph (ii) of this
subdivision;
(ii) The certification required in paragraph (i) of this subdivision shall
contain the
following:
(A) A statement from the carrier certifying that policies or certificates
described in this
paragraph
are being offered and marketed as supplemental health insurance and not as a
substitute
for
hospital or medical expense insurance or major medical expense insurance; and
(B) A summary description of each policy or certificate described in this
paragraph,
including
the average annual premium rates (or range of premium rates in cases where
premiums
vary by
age or other factors) charged for those policies and certificates in this
state; and
(iii) In the case of a policy or certificate that is described in this
paragraph and that is
offered
for the first time in this state on or after July 13, 2000, the carrier shall
file with the
director
the information and statement required in paragraph (ii) of this subdivision at
least thirty
(30)
days prior to the date the policy or certificate is issued or delivered in this
state.
(u) "Health maintenance organization" or "HMO" means a
health maintenance
organization
licensed under chapter 41 of this title.
(v) "Health status-related factor" means any of the following
factors:
(1) Health status;
(2) Medical condition, including both physical and mental illnesses;
(3) Claims experience;
(4) Receipt of health care;
(5) Medical history;
(6) Genetic information;
(7) Evidence of insurability, including conditions arising out of acts of
domestic
violence;
or
(8) Disability.
(w) (1) "Late enrollee" means an eligible employee or dependent who
requests
enrollment
in a health benefit plan of a small employer following the initial enrollment
period
during
which the individual is entitled to enroll under the terms of the health
benefit plan,
provided
that the initial enrollment period is a period of at least thirty (30) days.
(2) "Late enrollee" does not mean an eligible employee or dependent:
(i) Who meets each of the following provisions:
(A) The individual was covered under creditable coverage at the time of the
initial
enrollment;
(B) The individual lost creditable coverage as a result of cessation of
employer
contribution,
termination of employment or eligibility, reduction in the number of hours of
employment,
involuntary termination of creditable coverage, or death of a spouse, divorce
or
legal
separation, or the individual and/or dependents are determined to be eligible
for RIteCare
under
chapter 5.1 of title 40 or chapter 12.3 of title 42 or for RIteShare under
chapter 8.4 of title
40; and
(C) The individual requests enrollment within thirty (30) days after
termination of the
creditable
coverage or the change in conditions that gave rise to the termination of
coverage;
(ii) If, where provided for in contract or where otherwise provided in state
law, the
individual
enrolls during the specified bona fide open enrollment period;
(iii) If the individual is employed by an employer which offers multiple health
benefit
plans
and the individual elects a different plan during an open enrollment period;
(iv) If a court has ordered coverage be provided for a spouse or minor or
dependent child
under a
covered employee's health benefit plan and a request for enrollment is made
within thirty
(30)
days after issuance of the court order;
(v) If the individual changes status from not being an eligible employee to
becoming an
eligible
employee and requests enrollment within thirty (30) days after the change in
status;
(vi) If the individual had coverage under a COBRA continuation provision and
the
coverage
under that provision has been exhausted; or
(vii) Who meets the requirements for special enrollment pursuant to section
27-50-7 or
27-50-8.
(x) "Limited benefit health insurance" means that form of coverage
that pays stated
predetermined
amounts for specific services or treatments or pays a stated predetermined
amount
per day
or confinement for one or more named conditions, named diseases or accidental
injury.
(y) "Medical care" means amounts paid for:
(1) The diagnosis, care, mitigation, treatment, or prevention of disease, or
amounts paid
for the
purpose of affecting any structure or function of the body;
(2) Transportation primarily for and essential to medical care referred to in
subdivision
(1); and
(3) Insurance covering medical care referred to in subdivisions (1) and (2) of
this
subsection.
(z) "Network plan" means a health benefit plan issued by a 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.
(aa) "Person" means an individual, a corporation, a partnership, an
association, a joint
venture,
a joint stock company, a trust, an unincorporated organization, any similar
entity, or any
combination
of the foregoing.
(bb) "Plan sponsor" has the meaning given this term under section
3(16)(B) of the
Employee
Retirement Income Security Act of 1974, 29 U.S.C. section 1002(16)(B).
(cc) (1) "Preexisting condition" means a condition, regardless of the
cause of the
condition,
for which medical advice, diagnosis, care, or treatment was recommended or
received
during
the six (6) months immediately preceding the enrollment date of the coverage.
(2) "Preexisting condition" does not mean a condition for which
medical advice,
diagnosis,
care, or treatment was recommended or received for the first time while the
covered
person
held creditable coverage and that was a covered benefit under the health
benefit plan,
provided
that the prior creditable coverage was continuous to a date not more than
ninety (90)
days
prior to the enrollment date of the new coverage.
(3) Genetic information shall not be treated as a condition under subdivision
(1) of this
subsection
for which a preexisting condition exclusion may be imposed in the absence of a
diagnosis
of the condition related to the information.
(dd) "Premium" means all moneys paid by a small employer and eligible
employees as a
condition
of receiving coverage from a small employer carrier, including any fees or
other
contributions
associated with the health benefit plan.
(ee) "Producer" means any insurance producer licensed under chapter
2.4 of this title.
(ff) "Rating period" means the calendar period for which premium
rates established by a
small
employer carrier are assumed to be in effect.
(gg) "Restricted network provision" means any provision of a health
benefit plan that
conditions
the payment of benefits, in whole or in part, on the use of health care
providers that
have
entered into a contractual arrangement with the carrier pursuant to provide
health care
services
to covered individuals.
(hh) "Risk adjustment mechanism" means the mechanism established
pursuant to section
27-50-16.
(ii) "Self-employed individual" means an individual or sole
proprietor who derives a
substantial
portion of his or her income from a trade or business through which the
individual or
sole
proprietor has attempted to earn taxable income and for which he or she has
filed the
appropriate
Internal Revenue Service Form 1040, Schedule C or F, for the previous taxable
year.
(jj) "Significant break in coverage" means a period of ninety (90)
consecutive days
during
all of which the individual does not have any creditable coverage, except that
neither a
waiting
period nor an affiliation period is taken into account in determining a
significant break in
coverage.
(kk) "Small employer" means, except for its use in section 27-50-7,
any person, firm,
corporation,
partnership, association, political subdivision, or self-employed individual
that is
actively
engaged in business including, but not limited to, a business or a corporation
organized
under
the Rhode Island Non-Profit Corporation Act, chapter 6 of title 7, or a similar
act of
another
state that, on at least fifty percent (50%) of its working days during the
preceding
calendar
quarter, employed no more than fifty (50) eligible employees, with a normal
work week
of
thirty (30) or more hours, the majority of whom were employed within this
state, and is not
formed
primarily for purposes of buying health insurance and in which a bona fide
employer-
employee
relationship exists. In determining the number of eligible employees, companies
that
are
affiliated companies, or that are eligible to file a combined tax return for
purposes of taxation
by this
state, shall be considered one employer. Subsequent to the issuance of a health
benefit
plan to
a small employer and for the purpose of determining continued eligibility, the
size of a
small
employer shall be determined annually. Except as otherwise specifically
provided,
provisions
of this chapter that apply to a small employer shall continue to apply at least
until the
plan
anniversary following the date the small employer no longer meets the
requirements of this
definition.
The term small employer includes a self-employed individual.
( ll ) "Standard health benefit plan" means a health benefit plan
developed pursuant to
the
provisions of section 27-50-10.
(mm) "Waiting period" means, with respect to a group health plan and
an individual who
is a
potential enrollee in the plan, the period that must pass with respect to the
individual before
the
individual is eligible to be covered for benefits under the terms of the plan.
For purposes of
calculating
periods of creditable coverage pursuant to subsection (j)(2) of this section, a
waiting
period
shall not be considered a gap in coverage.
(nn) "Affordable health benefit plan" means a health benefit plan
that is designed to
promote
health, i.e. disease prevention, wellness, disease management, preventive care,
and/or
similar
health and wellness programs; that is actively marketed by a carrier in
accordance with
this
chapter; and that may be modified or terminated by a carrier in accordance with
section 27-
50-6.
SECTION
7. This act shall take effect on January 1, 2007.
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LC01015/SUB A/2
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