W. Va. Code R. § 114-55-2

Current through Register Vol. XLI, No. 45, November 8, 2024

Section 114-55-2 - Definitions

2.1. "Affiliation period" means a period of time that must expire before accident and sickness insurance coverage provided by a health maintenance organization becomes effective, and during which the health maintenance organization is not required to provide benefits.

2.2. "COBRA continuation provision" means any of the following:

a. Section 4980B of the Internal Revenue Code of 1986, other than subsection (f)(1) of such section insofar as it relates to pediatric vaccines;

b. Part 6 of Subtitle B of Title I of the Employee Retirement Income Security Act of 1974, other than Section 609 of such act; or

c. Title XXII of the Public Health Service Act.

2.3. "Commissioner" means the West Virginia commissioner of insurance.

2.4. "Creditable coverage" means, with respect to an individual, coverage of the individual under any of the following:

a. A group health plan;

b. Accident and sickness insurance coverage;

c. Part A or part B of Title XVIII of the Social Security Act;

d. Title XIX of the Social Security Act, other than coverage consisting solely of benefits under section 1928;

e. Chapter 55 of Title 10 of the United States Code;

f. A medical care program of the Indian Health Service or of a tribal organization;

g. A state health benefits risk pool;

h. A health plan offered under Chapter 89 of Title 5 of the United States Code;

i. A public health plan (as defined in federal regulations); or

j. A health benefit plan under section 5(e) of the Peace Corps Act ( 22 U.S.C. 2504(e)) .

k. The term "creditable coverage" does not include excepted benefits.

2.5. "Eligible individual" means an individual:

a. For whom, as of the date on which the individual seeks coverage, the aggregate period of creditable coverage is eighteen months or more and whose most recent prior creditable coverage was under a group health plan, governmental plan (as defined in section 3(32) of the Employee Retirement Income Security Act of 1974), church plan (as defined in section 3(33) of the Employee Retirement Income Security Act of 1974), or accident and sickness insurance coverage offered in connection with any such plan;

b. Who is not eligible for coverage under a group health plan, part A or part B of Title XVIII of the Social Security Act, or state plan under Title XIX of such act (or any successor program), and does not have other accident and sickness insurance coverage;

c. With respect to whom the most recent prior creditable coverage was not terminated as a result of fraud, intentional misrepresentation of material fact under the terms of the coverage, or nonpayment of premium;

d. Who did not turn down an offer of continuation of coverage under a COBRA continuation provision or under a similar state program if it was offered; and

e. Who, if the individual elected such continuation coverage, has exhausted that coverage under the COBRA continuation provision or similar state program.

2.6. "Excepted benefits" means benefits under one or more (or any combination) of the following:

a. Coverage only for accident, or disability income insurance, or any combination thereof;

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 under which benefits for medical care are secondary or incidental to other insurance;

i. If provided under a separate policy, certificate or contract of insurance:

1. Limited scope dental or vision benefits;

2. Benefits for long-term care, nursing home care, home health care, community-based care or any combination thereof;

3. Coverage for only a specified disease or illness;

4. Hospital indemnity or other fixed indemnity insurance; and

5. Medicare supplement insurance (as defined under 1882 (g)(1) of the Social Security Act [42 U.S.C. '301 et seq.]), coverage supplemental to the coverage provided under chapter 55 [10 U.S.C. '1071 et seq.] of title 10, United States Code and similar supplemental coverage provided under group accident and sickness insurance.

2.7. "Individual market" means the market for accident and sickness insurance coverage offered to individuals other than in connection with a group health plan.

2.8. "Insurer" means any of the following entities that hold a valid certificate of authority from the commissioner: An insurance company authorized to transact accident and sickness insurance; a fraternal benefit society organized pursuant to W.Va. Code '33-23-1 et seq.; a hospital, medical, dental or health service corporation organized pursuant to W. Va. Code '33-24-1 et seq.; a health care corporation organized pursuant to W. Va. Code '33-25-1 et seq.; or a health maintenance organization pursuant to W. Va. Code '33-25A-1 et seq.

2.9. "Preexisting condition exclusion" means 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 coverage, whether or not any medical advice, diagnosis, care or treatment was recommended or received before such date.

2.10. "Significant break in coverage" means a period of 63 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.

2.11. "Waiting period" means the period that must pass before an employee or dependent is eligible to enroll under the terms of a group health plan.

2.12. "Weighted average" means the average actuarial value of benefits provided by all the accident and sickness insurance coverage issued by one of the following:

a. An insurer in the individual market in the State during the previous calendar year, weighted by enrollment for each policy form, but not including coverage issued to eligible individuals; or

b. All insurers in the individual market in the State if the data are available for the previous calendar year, weighted by enrollment for each policy form.

W. Va. Code R. § 114-55-2