Current through Register Vol. XLI, No. 38, September 20, 2024
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.
