W. Va. Code R. § 114-12-2

Current through Register Vol. XLI, No. 50, December 13, 2024

Section 114-12-2 - Definitions

As used in this legislative rule:

2.1. "Applicant" means a person who seeks to contract for insurance coverage.

2.2. "Certificate" means any certificate delivered or issued for delivery in this State under a policy subject to this rule.

2.3. "Commissioner" means the Insurance Commissioner of the State of West Virginia.

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 [42 U.S.C. '301 et seq.];

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

e. Chapter 55 [10 U.S.C. '1071 et seq.] 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 [5 U.S.C. '8901 et seq.] 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)) .

2.5. "Direct response insurance product" means a policy, the sale of which is effected through direct contact between an insurer and an individual insured, without employing the intermediary services of an agent, broker or solicitor.

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. "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.

2.8. A "home health care agency" is:

a. An agency approved under Title XVIII of the Social Security Act (42 U.S.C. '1395 et seq.) (Medicare); or

b. An agency certified to provide home health care in this State.

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

2.10. "Insurer" means any of the following entities that holds a valid certificate of authority from the commissioner: An insurance company authorized to transact accident and sickness insurance; 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 organized pursuant to W. Va. Code ''33-25A-1 et seq.

2.11. "Medicare" means the "Health Insurance for the Aged Act," Title XVIII of the Social Security Amendments of 1965, as then constituted or later amended.

2.12. "Medicare supplement policy" means a policy of accident and sickness insurance or a subscriber contract of a hospital, medical, dental or health service corporation, other than a policy issued pursuant to a contract under Section 1876 of the federal Social Security Act ( 42 U.S.C. Sections 1395 et seq.) or an issued policy under a demonstration project specified in 42 U.S.C. '1395ss(g)(1), which is advertised, marketed or designed primarily as a supplement to reimbursements under Medicare for the hospital, medical or surgical expenses of persons eligible for Medicare.

2.13. "Policy" means any policy, plan, contract, agreement, provision, rider or endorsement delivered or issued for delivery in this State by an insurer subject to this rule.

2.14. "Premium" means the consideration for insurance, by whatever name called.

2.15. "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.

W. Va. Code R. § 114-12-2