R590-259-3. Definitions

  In addition to the definitions in Sections 31A-1-301 and 31A-30-103, the following definitions shall apply for the purposes of this rule.

  (1) "Grandfathered plan coverage" means coverage provided by a health insurer in which an individual was enrolled on March 23, 2010 for as long as it maintains that status in accordance with federal regulations.

  (2) "Group health insurance coverage" means, in connection with a group health plan, health insurance coverage offered in connection with such plan.

  (3) "Group health plan" means an employee welfare benefit plan as defined in section 3(1) of the Employee Retirement Income Security Act of 1974, ERISA, to the extent that the plan provides medical care, as defined in R590-259-3(9), and including items and services paid for as medical care to employees, including both current and former employees, or their dependents as defined under the terms of the plan directly or through insurance, reimbursement, or otherwise.

  (4)(a) "Health benefit plan" means a policy, contract, certificate or agreement offered by an insurer to provide, deliver, arrange for, pay for or reimburse any of the costs of health care services.

  (b) "Health benefit plan" includes short-term and catastrophic health insurance policies, and a policy that pays on a cost-incurred basis, except as otherwise specifically exempted in this definition.

  (c) "Health benefit plan" does not include:

  (i) coverage only for accident, or disability income insurance, or any combination thereof;

  (ii) coverage issued as a supplement to liability insurance;

  (iii) liability insurance, including general liability insurance and automobile liability insurance;

  (iv) workers' compensation or similar insurance;

  (v) automobile medical payment insurance;

  (vi) credit-only insurance;

  (vii) coverage for on-site medical clinics; and

  (viii) other similar insurance coverage, specified in federal regulations issued pursuant to Pub. L. No. 104-191, under which benefits for medical care are secondary or incidental to other insurance benefits.

  (d) "Health benefit plan" does not include the following benefits if they are provided under a separate policy, certificate or contract of insurance or are otherwise not an integral part of the plan:

  (i) limited scope dental or vision benefits;

  (ii) benefits for long-term care, nursing home care, home health care, community-based care, or any combination thereof; or

  (iii) other similar, limited benefits specified in federal regulations issued pursuant to Pub. L. No. 104-191.

  (e) "Health benefit plan" does not include the following benefits if the benefits are provided under a separate policy, certificate or contract of insurance, there is no coordination between the provision of the benefits and any exclusion of benefits under any group health plan maintained by the same plan sponsor, and the benefits are paid with respect to an event without regard to whether benefits are provided with respect to such an event under any group health plan maintained by the same plan sponsor:

  (i) coverage only for a specified disease or illness; or

  (ii) hospital indemnity or other fixed indemnity insurance.

  (f) "Health benefit plan" does not include the following if offered as a separate policy, certificate or contract of insurance:

  (i) Medicare supplemental health insurance as defined under section 1882(g)(1) of the Social Security Act;

  (ii) coverage supplemental to the coverage provided under chapter 55 of title 10, United States Code, TRICARE; or

  (iii) similar supplemental coverage added to coverage under a group health plan.

  (5) "Health insurer" means an insurer that offers a health benefit plan.

  (6)(a) "Individual health insurance coverage" means health insurance coverage offered to individuals in the individual market, which includes a health benefit plan provided to individuals through a trust arrangement, association or other discretionary group that is not an employer plan, but does not include short-term limited duration insurance.

  (b) For purposes of this subsection, a health insurer offering health insurance coverage in connection with a group health plan shall not be deemed to be a health insurer offering individual health insurance coverage solely because the insurer offers a conversion policy.

  (7) "Individual market" means the market for health insurance coverage offered to individuals other than in connection with a group health plan.

  (8) "Medical care" means amounts paid for:

  (a) the diagnosis, care, mitigation, treatment or prevention of disease, or amounts paid for the purpose of affecting any structure or function of the body;

  (b) transportation primarily for and essential to medical care referred to in R590-259-3(8)(a); and

  (c) insurance covering medical care referred to in R590-259-3(8)(a) and (b).

  (9) "Participant" adopts the meaning given under section 3(7) of ERISA.

  (10) "Subscriber" means, in the case of individual health insurance contract, the person in whose name the contract is issued.