20-2301

20-2301. Definitions; late enrollee
coverage

A. In this chapter, unless the context otherwise requires:

1. "Accountable health plan" means an entity that offers, issues or otherwise
provides a health benefits plan and is approved by the director as an accountable health
plan pursuant to section 20-2303.

2. "Affiliation period" means a period of two months, or three months for late
enrollees, that under the terms of the health benefits plan offered by a health care
services organization must expire before the health benefits plan becomes effective and
in which the health care services organization is not required to provide health care
services or benefits and cannot charge the participant or beneficiary a premium for any
coverage during the period.

3. "Base premium rate" means, for each rating period, the lowest premium rate that
could have been charged under a rating system by the accountable health plan to small
employers for health benefits plans involving the same or similar coverage, family size
and composition, and geographic area.

4. "Basic health benefit plan" means a plan that is developed by a committee
established by the legislature and that is adopted by the director.

5. "Bona fide association" means, for a health benefits plan issued by an
accountable health plan, an association that meets the requirements of section 20-2324.

6. "COBRA continuation provision" means:

(a) Section 4980B, except subsection (f)(1) as it relates to pediatric vaccines, of
the internal revenue code of 1986.

(b) Title I, subtitle B, part 6, except section 609, of the employee retirement
income security act of 1974 (P.L. 93-406; 88 Stat. 829; 29 United States Code sections
1001 through 1461).

(d) Any similar provision of the law of this state or any other state.

7. "Creditable coverage" means coverage solely for an individual, other than
limited benefits coverage, under any of the following:

(a) An employee welfare benefit plan that provides medical care to employees or the
employees' dependents directly or through insurance or reimbursement or otherwise
pursuant to the employee retirement income security act of 1974.

(b) A church plan as defined in the employee retirement income security act of
1974.

(d) Part A or part B of title XVIII of the social security act.

(e) Title XIX of the social security act, other than coverage consisting solely of
benefits under section 1928.

(f) Title 10, chapter 55 of the United States Code.

(g) A medical care program of the Indian health service or of a tribal
organization.

(h) A health benefits risk pool operated by any state of the United States.

(i) A health plan offered pursuant to title 5, chapter 89 of the United States
Code.

(j) A public health plan as defined by federal law.

(k) A health benefit plan pursuant to section 5(e) of the peace corps act (P.L.
87-293; 75 Stat. 612; 22 United States Code sections 2501 through 2523).

(l) A policy or contract, including short-term limited duration insurance, issued
on an individual basis by an insurer, a health care services organization, a hospital
service corporation, a medical service corporation or a hospital, medical, dental and
optometric service corporation or made available to persons defined as eligible under
section 36-2901, paragraph 6, subdivisions (b), (c), (d) and (e).

(m) A policy or contract issued by a health care insurer or an accountable health
plan to a member of a bona fide association.

8. "Demographic characteristics" means objective factors an insurer considers in
determining premium rates. Demographic characteristics do not include health
status-related factors, industry or duration of coverage since issue.

9. "Different policy forms" means variations between policy forms offered by a
health care insurer, including policy forms that have different cost sharing arrangements
or different riders.

10. "Genetic information" means information about genes, gene products and inherited
characteristics that may derive from the individual or a family member, including
information regarding carrier status and information derived from laboratory tests that
identify mutations in specific genes or chromosomes, physical medical examinations,
family histories and direct analyses of genes or chromosomes.

11. "Health benefits plan" means a hospital and medical service corporation policy
or certificate, a health care services organization contract, a group disability policy,
a certificate of insurance of a group disability policy that is not issued in this state,
a multiple employer welfare arrangement or any other arrangement under which health
services or health benefits are provided to two or more individuals. Health benefits plan
does not include the following:

(a) Accident only, dental only, vision only, disability income only or long-term
care only insurance, fixed or hospital indemnity coverage, limited benefit coverage,
specified disease coverage, credit coverage or Taft-Hartley trusts.

(b) Coverage that is issued as a supplement to liability insurance.

(d) Workers' compensation insurance.

(e) Automobile medical payment insurance.

12. "Health status-related factor" means any factor in relation to the health of the
individual or a dependent of the individual enrolled or to be enrolled in an accountable
health plan, including:

(a) Health status.

(b) Medical condition, including physical and mental illness.

(d) Receipt of health care.

(e) Medical history.

(f) Genetic information.

(g) Evidence of insurability, including conditions arising out of acts of domestic
violence as defined in section 20-448.

(h) The existence of a physical or mental disability.

13. "Higher level of coverage" means a health benefits plan offered by an
accountable health plan for which the actuarial value of the benefits under the coverage
is at least fifteen per cent more than the actuarial value of the health benefits plan
offered by the accountable health plan as a lower level of coverage in this state but not
more than one hundred twenty per cent of a policy form weighted average.

14. "Index rate" means, as to a rating period, the arithmetic average of the
applicable base premium rate and the highest premium rate that could have been charged
under a rating system by the accountable health plan to small employers for a health
benefits plan involving the same or similar coverage, family size and composition, and
geographic area.

15. "Late enrollee" means an employee or dependent who requests enrollment in a
health benefits plan after the initial enrollment period that is provided under the terms
of the health benefits plan if the initial enrollment period is at least thirty-one days.
An employee or dependent shall not be considered a late enrollee if:

(a) The person:

(i) At the time of the initial enrollment period was covered under a public or
private health insurance policy or any other health benefits plan.

(ii) Lost coverage under a public or private health insurance policy or any other
health benefits plan due to the employee's termination of employment or eligibility, the
reduction in the number of hours of employment, the termination of the other plan's
coverage, the death of the spouse, legal separation or divorce or the termination of
employer contributions toward the coverage.

(iii) Requests enrollment within thirty-one days after the termination of
creditable coverage that is provided under a public or private health insurance or other
health benefits plan.

(iv) Requests enrollment within thirty-one days after the date of marriage.

(b) The person is employed by an employer that offers multiple health benefits
plans and the person elects a different plan during an open enrollment period.

(c) A court orders that coverage be provided for a spouse or minor child under a
covered employee's health benefits plan and the person requests enrollment within
thirty-one days after the court order is issued.

(d) The person becomes a dependent of a covered person through marriage, birth,
adoption or placement for adoption and requests enrollment no later than thirty-one days
after becoming a dependent.

16. "Lower level of coverage" means a health benefits plan offered by an accountable
health plan for which the actuarial value of the benefits under the health benefits plan
is at least eighty-five per cent but not more than one hundred per cent of the policy
form weighted average.

17. "Network plan" means a health benefits plan provided by an accountable health
plan under which the financing and delivery of health benefits are provided, in whole or
in part, through a defined set of providers under contract with the accountable health
plan in accordance with the determination made by the director pursuant to section
20-1053 regarding the geographic or service area in which an accountable health plan may
operate.

18. "Policy form weighted average" means the average actuarial value of the benefits
provided by all health benefits plans issued by either the accountable health plan or, if
the data are available, by all accountable health plans in the group market in this state
during the previous calendar year, weighted by the enrollment for all coverage forms.

19. "Preexisting condition" means a condition, regardless of the cause of the
condition, for which medical advice, diagnosis, care or treatment was recommended or
received within not more than six months before the date of the enrollment of the
individual under a health benefits plan issued by an accountable health plan. A genetic
condition is not a preexisting condition in the absence of a diagnosis of the condition
related to the genetic information and shall not result in a preexisting condition
limitation or preexisting condition exclusion.

20. "Preexisting condition limitation" or "preexisting condition exclusion" means a
limitation or exclusion of benefits for a preexisting condition under a health benefits
plan offered by an accountable health plan.

21. "Small employer" means an employer who employs at least two but not more than
fifty eligible employees on a typical business day during any one calendar year. As used
in this paragraph, "employee" shall include the employees of the employer and the
individual proprietor or self-employed person if the employer is an individual proprietor
or self-employed person.

22. "Taft-Hartley trust" means a jointly-managed trust, as allowed by 29 United
States Code sections 141 through 187, that contains a plan of benefits for employees and
that is negotiated in a collective bargaining agreement governing the wages, hours and
working conditions of the employees, as allowed by 29 United States Code section 157.

23. "Waiting period" means the period that must pass before a potential participant
or beneficiary in a health benefits plan offered by an accountable health plan is
eligible to be covered for benefits as determined by the individual's employer.

B. Coverage for a late enrollee begins on the date the person becomes a dependent
if a request for enrollment is received within thirty-one days after the person becomes a
dependent.