280-20-55 R.I. Code R. § 15.6

Current through June 20, 2024

Section 280-RICR-20-55-15.6 - Definitions

A. "Applicable entity" means any of the following, as defined in R.I. Gen. Laws § 44-30-102:

1. An employer or other sponsor of an employment-based health plan that offers employment-based minimum essential coverage to any resident of Rhode Island.

2. The Rhode Island Medicaid single State agency providing Medicaid or Children's Health Insurance (CHIP) coverage.

3. Carriers licensed or otherwise authorized by the Rhode Island Office of the Health Insurance Commissioner to offer health coverage.

B. "Applicable individual" has the same meaning as set forth in 26 U.S.C. § 5000A(d), as in effect on December 15, 2017:

1. In general. The term "applicable individual" means, with respect to any month, an individual other than an individual described in §§ 15.6(B)(2), (3), or (4).

2. Religious exemptions

a. Religious conscience exemption. Such term shall not include any individual for any month if such individual has in effect an exemption under §1311(d)(4)(H) of the Patient Protection and Affordable Care Act (42 U.S.C. § 18031(d)(4)(H)) which certifies that such individual is:

(1) A member of a recognized religious sect or division thereof which is described in 26 U.S.C. § 1402(g)(1); and

(2) An adherent of established tenets or teachings of such sect or division as described in such section.

b. Health care sharing ministry

(1) In general. Such term shall not include any individual for any month if such individual is a member of a health care sharing ministry for the month.

(2) Health care sharing ministry. The term "health care sharing ministry" means an organization:

(AA) Which is described in 26 U.S.C. § 501(c)(3) and is exempt from taxation under 26 U.S.C. § 501(a),

(BB) Members of which share a common set of ethical or religious beliefs and share medical expenses among members in accordance with those beliefs and without regard to the State in which a member resides or is employed,

(CC) Members of which retain membership even after they develop a medical condition,

(DD) Which (or a predecessor of which) has been in existence at all times since December 31, 1999, and medical expenses of its members have been shared continuously and without interruption since at least December 31, 1999, and

(EE) Which conducts an annual audit which is performed by an independent certified public accounting firm in accordance with generally accepted accounting principles and which is made available to the public upon request.

3. Individuals not lawfully present. Such term shall not include an individual for any month if, for the month, the individual is not a citizen or national of the United States or an alien lawfully present in the United States.

4. Incarcerated individuals. Such term shall not include an individual for any month if, for the month, the individual is incarcerated, other than incarceration pending the disposition of charges.

C. "Child" means any individual under the age of eighteen (18).

D. "Dependent" means any individual who is or may become eligible for minimum essential coverage under the terms of a health insurance plan because of a relationship to a qualified individual or enrollee.

E. "Division of Taxation" means the Rhode Island Department of Revenue, Division of Taxation, a Rhode Island State agency authorized and empowered to make Rules and Regulations pursuant to R.I. Gen. Laws § 44-1-4.

F. "Exchange" means the Rhode Island health benefit exchange, known as Health Source RI, as defined in R.I. Gen. Laws § 42-157-1.

G. "Minimum essential coverage" has the same meaning as set forth in 26 U.S.C § 5000A(f), as in effect on December 15, 2017:

1. In general. The term "minimum essential coverage" means any of the following:

a. Government sponsored programs. Coverage under:

(1) The Medicare program under the Social Security Act, 42 U.S.C. § 1395(c)et seq.,

(2) The Medicaid program under the Social Security Act, 42 U.S.C. § 1396et seq.,

(3) The CHIP program under the Social Security Act, 42 U.S.C. § 1397(aa)et seq.,

(4) Medical coverage under 10 U.S.C. § 1071et seq., including coverage under the TRICARE program;

(5) A health care program under 38 U.S.C. §§ 1701et seq. or 1801 et seq., as determined by the Secretary of Veterans Affairs, in coordination with the Secretary of Health and Human Services and the Secretary of the Treasury,

(6) A health plan under 22 U.S.C. § 2504(e) (relating to Peace Corps volunteers); or

(7) The Nonappropriated Fund Health Benefits Program of the Department of Defense, established under the National Defense Authorization Act for Fiscal Year 1995, 10 U.S.C. § 1587 (1995) note.

b. Employer-sponsored plan. Coverage under an eligible employer-sponsored plan.

c. Plans in the individual market. Coverage under a health plan offered in the individual market within a State.

d. Grandfathered health plan. Coverage under a grandfathered health plan.

e. Other coverage. Such other health benefits coverage, such as a State health benefits risk pool, as the Federal Secretary of Health and Human Services, in coordination with the Secretary of the Treasury, recognizes for purposes of this subsection.

2. Eligible employer-sponsored plan. The term "eligible employer-sponsored plan" means, with respect to any employee, a group health plan or group health insurance coverage offered by an employer to the employee which is:

a. A governmental plan (within the meaning of the Public Health Service Act, 42 U.S.C. § 300gg-91(d)(8)), or

b. Any other plan or coverage offered in the small or large group market within a State.

c. Such term shall include a grandfathered health plan described in § 15.6(G)(1)(d) of this Part offered in a group market.

3. Excepted benefits not treated as minimum essential coverage. The term "minimum essential coverage" shall not include health insurance coverage which consists of coverage of excepted benefits:

a. Described in the Public Health Service Act, 42 U.S.C. §§ 300gg-91(c)(1); or

b. Described in the Public Health Service Act, 42 U.S.C. §§ 300gg-91(c)(2), (3) or (4) if the benefits are provided under a separate policy, certificate, or contract of insurance.

4. Individuals residing outside United States or residents of territories. Any applicable individual shall be treated as having minimum essential coverage for any month:

a. If such month occurs during any period described in 26 U.S.C. §§ 911(d)(1) ((A)) or ((B)) which is applicable to the individual, or

b. If such individual is a bona fide resident of any possession of the United States (as determined under 26 U.S.C. § 937(a)) for such month.

5. Insurance-related terms. Any term used in this section which is also used in Title I of the Patient Protection and Affordable Care Act (Pub. Law 111-148) shall have the same meaning as when used in such Title.

H. "Part-year resident" means an individual who is a Rhode Island resident as defined in R.I. Gen. Laws § 44-30-5 for less than one (1) full calendar year.

I. "Protected health information" means any personally identifiable health information as defined in Pub. Law 104-191.

J. "Protected taxpayer information" means any State or Federal tax information that is protected by Rhode Island and/or Federal tax law including, but not limited to, tax returns, tax return information, and/or any other documentation and/or information on file with the Division of Taxation.

K. "Resident" means an individual who is domiciled in the State of Rhode Island as defined in R.I. Gen. Laws § 44-30-5.

L. "R.I. Gen. Laws" means the General Laws of Rhode Island, as amended.

M. "Shared responsibility payment penalty," as defined in R.I. Gen. Laws § 44-30-101(a)(3), is a tax assessed when a taxpayer fails to maintain minimum essential coverage for each month beginning after December 31, 2019.

N. "Taxpayer" means any resident as defined in R.I. Gen. Laws §§ 44-30-5 and 44-30-101(a)(4).

280 R.I. Code R. § 280-RICR-20-55-15.6

Adopted effective 12/28/2020