Compilation of Rules and Regulations of the State of Georgia
Department 120 - OFFICE OF COMMISSIONER OF INSURANCE, SAFETY FIRE COMMISSIONER AND INDUSTRIAL LOAN COMMISSIONER
Chapter 120-2 - RULES OF COMMISSIONER OF INSURANCE
Subject 120-2-67 - PORTABILITY AND RENEWABILITY
Rule 120-2-67-.03 - Definitions

(a) "Association" shall mean an organization as defined in O.C.G.A. § 33-30-1(b) and the Rules and Regulations of the Office of Commissioner of Insurance.

(b) "Creditable Coverage" shall mean any hospital, surgical, or medical expense coverage, or any combination of these coverages, as defined in O.C.G.A. § 33-30-15(a)(2), regardless of exclusions or waivers related to such coverage, other than coverage under a disability income policy, a long-term care insurance policy, a medicare supplement policy, a health insurance policy written as part of workers' compensation equivalent coverage or supplemental to a liability policy, a specified disease policy, a credit insurance policy, a dental or vision benefit policy which is not an integral part of creditable coverage, a fixed indemnity policy, or a limited accident policy. Creditable coverage shall include coverage under a short-term, limited duration policy or a blanket accident and sickness policy which includes basic or comprehensive hospital, surgical, or medical expense coverage, or any combination of these coverages, which is (are) not exclusively contingent on accident or injury resulting from particular activities or limited to liability arising from such activities.

(c) "Employer based accident and sickness insurance or health benefit arrangement," as used in O.C.G.A. § 33-30-15(a)(2)(B) and in this Regulation Chapter, shall mean any insured plan or self-funded plan, regardless of whether such plan is, or claims to be, subject to the Employee Retirement Income Security Act of 1974, 29 U.S.C. Section 1001, et seq.

(d) "Group Member" shall mean any individual in a group eligible for coverage under a group health insurance policy or contract.

(e) "Health Insurance" shall mean, for purposes of this Regulation Chapter, any creditable coverage as defined in paragraph (b) issued by an insurer on a group or individual basis, other than a blanket accident and sickness policy or a short-term, limited duration policy which limits coverage to a maximum of twelve month. Such blanket or short-term policies which constitute creditable coverage shall be considered health insurance in this Regulation Chapter only for the purposes of Rule 120-2-67-.12.

(f) "Health Status Related Factor" shall mean any of the factors described in Rule 120-2-67-.13(a)(1).

(g) ''Insured'' shall mean:

(h) "Late Enrollee" shall mean an employee, group member, or enrollee who enrolls other than:

(i) "Placement for adoption" shall mean the assumption and retention by an employee, member or enrollee covered or eligible for coverage under a group health insurance policy or contract of a legal obligation for total or partial support of a child in anticipation of adoption of such child. The child's placement with such employee, member or enrollee terminates upon the termination of such legal obligation.

(j) "Policyholder" shall mean, with respect to group health insurance coverage, the entity to which a group health insurance policy or contract is issued in accordance with O.C.G.A.§ 33-30-1, including, but not limited to, an employer, an association, or employer members issued certificates of coverage through a trust.

(k) "Portability" shall mean that any employee, group member, subscriber, enrollee, or dependent who was enrolled under prior "creditable coverage" and who meets the eligibility requirements under Rule 120-2-67-.04 shall be eligible immediately, subject to applicable waiting or affiliation periods, for the same coverage provided other employees, group members, subscribers, enrollees, or dependents under a new group insurance health benefit plan without limitations for preexisting conditions, subject to the requirements of O.C.G.A. § 33-30-15 and this Regulation Chapter.

(l) "Preexisting Condition" shall mean any physical or mental condition, sickness, impairment, or ailment, regardless of cause, for which medical advice, diagnosis, care, or treatment was received within the six month period ending on the effective date of coverage under a group health plan, the date of enrollment under a group health insurance plan, or the first date of a waiting period for a group health insurance plan, whichever is earliest. In no case shall any of the following be considered a preexisting condition:

(m) "Small Employer" shall mean any employer that employed an average of at least two but not more than 50 employees on business days during the preceding calendar year and that employs at least two employees on the first day of the rating period. All employers treated as a single employer under subsection (b), (c), (m), or (o) of Section 414 of the Internal Revenue Code of 1986 shall be treated as one employer. In the case of an employer which was not in existence throughout the preceding calendar year, the determination of whether or not an employer is a small employer shall be based on the average number of employees that it is reasonably expected that the employer will employ on business days in the current calendar year.

(n) "Waiting Period" shall mean any period of time which must pass before a newly eligible employee, group member, or enrollee is first covered by a group health insurance policy or contract, provided an employee or group member elects coverage when first eligible under the terms of the group health insurance plan. With regard to coverage under an individual health insurance policy or contract, the waiting period shall mean the period of time beginning with the date a substantially completed application for coverage is received by an insurer, and ending with the effective date of coverage; however, such a waiting period exists only if the application results in the actual purchase of an individual health insurance policy or contract. A waiting period shall not constitute a gap in coverage for the purposes of determining any previous creditable coverage.