23-64-602. Definitions.

23-64-602. Definitions. As used in this subchapter: (1) “Applicant” means a person who has applied to become licensed under this subchapter as a navigator, guide, certified application counselor, or certified licensed producer; (2) “Certified application counselor” means a person who is licensed under this subchapter to assist in enrolling consumers in a variety of marketplace-designated organizations settings, including without limitation a healthcare facility, but is not compensated by federal marketplace funds; (3) “Certified licensed producer” means a person who is: (A) Licensed as an insurance producer as defined in § 23-64-502; (B) Certified under this subchapter to: (i) Educate consumers about health insurance marketplaces, Medicaid, tax credits, and other cost-sharing reductions; and (ii) Assist consumers with enrollment in a health insurance marketplace; (C) Eligible to receive commissions from health insurers; and (D) Not compensated under the federal act, federal regulations, or any guidance issued under the federal act or federal regulations; (4) “Consumer” means an individual, family, or small business located in this state; (5) “Enrollment” means enrolling in a qualified health plan offered through a health insurance marketplace; (6) “Federal act” means the federal healthcare laws established by Pub. L. No. 111-148, as amended by Pub. L. No. 111-152, and any amendments to or regulations or guidance issued under those statutes existing on the effective date of this act; (7) “Guide” means a person who is licensed under this subchapter to provide in-person assistance and services as stated in 45 C.F.R. § 155.210; (8)(A) “Health benefit plan” means a policy, contract, certificate, or agreement offered or issued by a health insurer to provide, deliver, arrange for, pay for, or reimburse any of the costs of healthcare services. (B) “Health benefit plan” does not include: (i) Coverage only for accident or disability income insurance, or both; (ii) Coverage issued as a supplement to liability insurance; (iii) Liability insurance, including without limitation 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; or (viii) Other similar insurance coverage, specified in federal regulations issued under the Health Insurance Portability and Accountability Act of 1996, Pub. L. No. 104-191, and existing on the effective date of this act, under which benefits for healthcare services are secondary or incidental to other insurance benefits. (C) “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 a combination of these; or (iii) Other similar limited benefits specified in federal regulations issued under the Health Insurance Portability and Accountability Act of 1996, Pub. L. No. 104-191, and existing on the effective date of this act. (D) “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. (E) “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, Pub. L. No. 74-271, as existing on the effective date of this act; (ii) Coverage supplemental to the coverage provided to military personnel and their dependents under Chapter 55 of Title 10 of the United States Code and the Civilian Health and Medical Program of the Uniformed Services, 32 C.F.R. Part 199; or (iii) Similar supplemental coverage provided to coverage under a group health plan; (9) “Health insurance” means insurance that is primarily for the diagnosis, cure, mitigation, treatment, or prevention of disease or amounts paid for the purpose of affecting any structure of the body, including transportation that is essential to obtaining health insurance, but excluding: (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) Coverage only for limited scope vision benefits; (I) Benefits for long-term care, nursing home care, home health care, community-based care, or any combination thereof; (J) Coverage for specified disease or critical illness; (K) Hospital indemnity or other fixed indemnity insurance; (L) Medicare supplement policies; (M) Medicare, Medicaid, or the Federal Employee Health Benefit Program, 5 U.S.C. §§ 8901 — 8914, as it existed on January 1, 2013; (N) Coverage only for medical and surgical outpatient benefits; (O) Excess or stop-loss insurance; and (P) Other similar insurance coverage: (i) Under which benefits for health insurance are secondary or incidental to other insurance benefits; or (ii) Specified in federal regulations issued under the Health Insurance Portability and Accountability Act of 1996, Pub. L. No. 104-191, and existing on the effective date of this act, under which benefits for healthcare services are secondary or incidental to other insurance benefits; (10) “Health insurance marketplace” means the vehicle created to help consumers in this state shop for and select health insurance coverage in a way that permits comparison of available qualified health plans based on price, benefits, services, and quality, regardless of its governance structure; (11) “Health insurer” means an entity that provides health insurance or a health benefit plan in this state, including without limitation an insurance company, medical services plan, hospital plan, hospital medical service corporation, health maintenance organization, fraternal benefits society, or any other entity providing a plan of health insurance or health benefits in this state, and is subject to state insurance regulation; (12) “License” means a document issued by the Insurance Commissioner authorizing a person to act as a navigator, guide, certified application counselor, or certified licensed producer; (13) “Licensee” means a navigator, guide, certified application counselor, or certified licensed producer who is licensed under this subchapter; (14) “Navigator” means a person authorized under the federal act to assist consumers to shop for and select health insurance offered through a health insurance marketplace, including providing information to a consumer on a health benefit plan or coverage offered through a health insurance marketplace, or facilitates enrollment in a health insurance marketplace; (15) “Non-navigator assistance personnel” means a person authorized under the federal act to assist consumers to enroll and understand the health insurance offered through a health insurance marketplace; (16) “Person” means an individual, company, firm, organization, association, corporation, government entity, nongovernmental entity, or any other type of legal entity; and (17) “Qualified health plan” means a health benefit plan that has in effect a certification that the plan meets the criteria for certification described in section 1311(c) of the federal act.