Ala. Admin. Code r. 482-1-116-.04

Current through Register Vol. 43, No. 02, November 27, 2024

Section 482-1-116-.04 - Definitions

The following definitions shall apply for purposes of this Regulation:

(1) Actuarial certification. A written statement signed by a member of the American Academy of Actuaries or other individual acceptable to the commissioner that a small employer carrier is in compliance with the provisions of Section 5 of this Regulation, 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.

(2) "Adjusted community rate" or "Adjusted community rating." 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 5 of this Regulation.

(3) "Affiliate" or "affiliated." 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.

(4) "Carrier" or "small employer carrier." All entities licensed, or required to be licensed, by the Department of Insurance that offer health plans covering eligible employees of one or more small employers pursuant to this Regulation. For the purposes of this Regulation, carrier includes an insurance company licensed pursuant to Section 27-3-1, etseq.; a health care service plan licensed pursuant to Section 10-4-100, etseq.; a fraternal benefit society licensed pursuant to Section 27-34-1, etseq.; a health maintenance organization licensed pursuant to Section 27-21A-1, etseq.; and any other entity providing a plan of health insurance or health benefits whether or not subject to state insurance regulation. For the purposes of this Regulation, carrier does not include health benefit plans covering eligible employees of small employers when these plans are sold exclusively through the vehicle of associations.

(5) Commissioner. The Alabama Commissioner of Insurance.

(6) Dependent. 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-three (23) years and who is financially dependent upon the enrollee, and an unmarried child of any age who is medically certified as disabled and dependent upon the enrollee.

(7) Eligible employee. 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. The term includes a sole proprietor, a partner of a partnership, and may include an independent contractor, if the 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. 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 Subdivision (4) of Subsection (c) of Section 7 of this Regulation.

(8) Established geographic service area. A geographic area, as approved by the commissioner and based on the carrier's certificate of authority to transact insurance in this state, within which the carrier is authorized to provide coverage.

(9) Family composition. Enrollee; enrollee, spouse and children; enrollee and spouse; or enrollee and children.

(10) Geographic area. An area approved by the commissioner and used for adjusting the rates for a health benefit plan.

(11) Health benefit plan.

a. Any hospital or medical policy or certificate, major medical expense insurance, subscriber contract or contract of insurance provided by a prepaid hospital or medical service plan, or health maintenance organization subscriber contract. Health benefit plan does not include accident-only, credit, dental, vision, Medicare supplement, long-term care, disability income insurance, coverage issued as a supplement to liability insurance, worker's compensation or similar insurance, or automobile medical payment insurance. Health benefit plan 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.

b. "Health benefit plan" shall not include policies or certificates of specified disease, hospital confinement indemnity or limited benefit health insurance, provided that the carrier offering such policies or certificates complies with the following:

1. The carrier files on or before March 1 of each year a certification with the commissioner that contains the statement and information described in Subparagraph 2.

2. The certification required in Subparagraph 1. shall contain both of the following:

(i) 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.

(ii) 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 such policies and certificates in this state.

3. 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 the effective date of the Regulation, the carrier files with the commissioner the information and statement required in Subparagraph 2. at least thirty (30) days prior to the date such a policy or certificate is issued or delivered in this state.

(12) Late enrollee. 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. However, an eligible employee or dependent shall not be considered a late enrollee in any of the following instances:

a. The individual meets each of the following:

1. The individual was covered under qualifying previous coverage at the time of the initial enrollment.

2. The individual lost coverage under qualifying previous coverage as a result of cessation of employer contribution, termination of employment or eligibility, involuntary termination of the qualifying previous coverage, or death of a spouse or divorce.

3. The individual requests enrollment within thirty (30) days after termination of the qualifying previous coverage or the change in conditions that gave rise to the termination of coverage.

b. Where provided for in contract or where otherwise provided in state law, the individual enrolls during the specified bona fide open enrollment period.

c. 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.

d. A court has ordered coverage be provided for a spouse or minor or dependent child under a covered employee's health benefit plan and request for enrollment is made within thirty (30) days after issuance of the court order.

e. 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.

(13) Limited benefit health insurance. 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.

(14) Premium. 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.

(15) "Qualifying previous coverage" and "qualifying existing coverage." Benefits or coverage provided under any of the following:

a. Medicare, Medicaid, CHAMPUS, TRICARE, Indian Health Service program or any other similar publicly sponsored program.

b. A group health insurance or health benefit arrangement that provides benefits similar to or exceeding benefits provided under the Alabama Health Insurance Plan established in the Act and implemented in Regulation No. 115.

c. An individual health insurance policy, including coverage issued by a health maintenance organization, prepaid hospital or medical care plan, or for fraternal benefit society, that provides benefits similar to or exceeding the benefits provided under the Alabama Health Insurance Plan established in the Act and implemented in Regulation No. 115.

(16) Rating period. The calendar period for which premium rates established by small employer carrier are assumed to be in effect.

(17) Restricted network provision. 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 to provide health care services to covered individuals.

(18) Small employer. Any person, firm, corporation, partnership, association, political subdivision, or self-employed individual that is actively engaged in business that, on at least fifty percent (50%) of its working days during the preceding calendar quarter, employed no less than two and no more than 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 Regulation 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.

(19) The Act. Alabama Act No. 97-713 (Senate Bill 688, 1997 Regular Legislative Session).

Author: Reyn Norman, Associate Counsel

Ala. Admin. Code r. 482-1-116-.04

New Rule: September 3, 1997; effective September 28, 1997. Amended: October 14, 1999; effective January 1, 2000. Amended: September 12, 2001; effective October 1, 2001. Filed with LRS September 14, 2001. Rule is not subject to the Alabama Administrative Procedure Act.

Statutory Authority:Code of Ala. 1975, § 27-52-21.