W. Va. Code R. § 114-39-2

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

Section 114-39-2 - Definitions

As used in this legislative rule:

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

2.2. "Basic Hospital and Medical Surgical Expense Coverage" means policies designed to provide coverage for hospital and medical surgical expenses only incurred as a result of a covered accident or sickness. Coverage is provided for daily hospital room and board, miscellaneous hospital services, hospital out-patient services, surgical services, anesthesia services, and in-hospital medical services, subject to any limitations, deductibles and copayment requirements set forth in the policy. Coverage is not provided for unlimited hospital or medical surgical expenses.

2.3. "Bona Fide Association" means an association which:

a. Has been organized in good faith for purposes other than that of obtaining or providing insurance;

b. Has a minimum of one hundred members;

c. Has been actively in existence for at least five years;

d. Has a constitution and bylaws providing that:

1. The association holds annual meetings to further purposes of its members;

2. Except in the case of credit unions, the association collects dues or solicits contributions from members; and

3. The members have voting privileges and representation on the governing board and committees that exist under the authority of the association;

e. Does not condition membership in the association on any health status-related factor relating to an individual;

f. Makes accident and sickness insurance offered through the association available to all members regardless of any health status-related factor relating to members or individuals eligible for coverage through a member;

g. Does not make accident and sickness insurance coverage offered through the association available other than in connection with a member of the association; and

h. Meets any additional requirements as may be set forth in chapter thirty-three of the W. Va. Code or by rule.

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

2.5. "Commissioner" means the Insurance Commissioner of the state of West Virginia.

2.6. "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.

2.7. "Enrollment date" means the first day of an individual's coverage under a policy, or if there is a waiting period for coverage, the first day of the waiting period.

2.8. "Excepted benefits" means:

a. Any policy of liability insurance or contract supplemental thereto; coverage only for accident or disability income insurance or any combination thereof; automobile medical payment insurance; credit-only insurance; coverage for on-site medical clinics, workers' compensation insurance; or other similar insurance under which benefits for medical care are secondary or incidental to other insurance benefits; or

b. If offered separately, a policy providing benefits for long-term care, nursing home care, home health care, community-based care or any combination thereof, dental or vision benefits, or other similar, limited benefits; or

c. If offered as independent, noncoordinated benefits under separate policies or certificates, specified disease or illness coverage, hospital indemnity or other fixed indemnity insurance, or coverage, such as medicare supplement insurance, supplemental to a group health plan; or

d. A policy of accident and sickness insurance covering a period of less than one year.

2.9. "Group health plan" means an employee welfare benefit plan, including a church plan or a governmental plan, all as defined in section three of the Employee Retirement Income Security Act of 1974, 29 U.S.C. §1003, to the extent that the plan provides medical care. For purposes of this rule, "group health plan" includes any plan, fund or program which would not (but for this subsection) be a group health plan and which is established or maintained by a partnership, to the extent that such plan, fund or program provides medical care to present or former partners or their dependents (as defined under terms of the plan, fund or program).

2.10. "Health benefit plan" means benefits consisting of medical care provided, directly through insurance or reimbursement, or indirectly, including items and services paid for as medical care, under any hospital or medical expense incurred policy or certificate; hospital; medical or health service corporation contract; health maintenance organization contract; or plan provided by a multiple-employer trust or a multiple-employer welfare arrangement. "Health benefit plan" does not include a policy consisting solely of excepted benefits.

2.11. "Health 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; 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 organized pursuant to W. Va. Code §§ 33-25A-1 et seq.

2.12. 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.

2.13. "Individual" means any private or natural person as distinguished from a partnership, corporation, limited liability company or other legal entity.

2.14. "Insurance producer" means a person required to be licensed under the laws of this state to sell, solicit or negotiate insurance.

2.15. "Limited benefits insurance coverage," for purposes of this rule, is any policy, other than a policy, covering only a specified disease or diseases, which provides benefits that are less than the minimum standards for benefits required under subsections 5.2, 5.3, 5.5 and 5.6 of this rule.

2.16. "Medical care" means amounts paid for, or paid for insurance covering, the diagnosis, cure, mitigation, treatment or prevention of disease, or amounts paid for the purpose of affecting any structure or function of the body, including amounts paid for transportation primarily for and essential to such care.

2.17. "Medical care provider" means an individual licensed or similarly authorized to provide medical care and operating within the scope of services authorized for the individual.

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

2.19. "Medicare supplement policy" means a policy of accident and sickness insurance, a subscriber contract of a hospital, medical, dental or health service corporation or health care corporation, or an enrollee agreement or contract of a health maintenance organization, other than a policy issued pursuant to a contract under section 1876 or 1833 of the federal Social Security Act, 42 U.S.C. section 1395 et seq., or an issued policy under a demonstration project authorized pursuant to amendments to the federal Social Security Act, 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.

2.20. "Mental health benefits" means benefits with respect to mental health services, as defined under the terms of a group health plan or a health benefit plan offered in connection with the group health plan.

2.21. "Policy" means any health benefit plan, policy, plan, contract, agreement, provision, rider or endorsement delivered or issued for delivery in this state by a health insurer subject to this rule.

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

2.23. "Small employer" means any person, firm, corporation, partnership or bona fide association actively engaged in business in the state of West Virginia who during the preceding calendar year, employed an average of no more than fifty but not fewer than two eligible employees and employs at least two employees on the first day of its group health plan year. A new employer, not in existence for all of the preceding calendar year, shall be considered a small employer if it is reasonably expected to employ an average of no more than fifty but not fewer than two eligible employees on business days in the current calendar year. Companies which are affiliated companies or which are eligible to file a combined tax return for state tax purposes shall be considered one employer.

2.24. "Specified accident coverage" is an accident insurance policy which provides coverage for a specifically identified kind of accident (or accidents) for each person insured under the policy for accidental death or accidental death and dismemberment combined, with a benefit amount not less than one thousand dollars ($1,000) for accidental death, one thousand dollars ($1,000) for double dismemberment, and five hundred dollars ($500) for single dismemberment.

W. Va. Code R. § 114-39-2