23-79-503. Definitions.

23-79-503. Definitions. As used in this subchapter: (1) “Agent” means any person who is licensed to sell health insurance in this state; (2) “Board” means the Board of Directors of the Arkansas Comprehensive Health Insurance Pool; (3) “Church plan” has the same meaning given that term in the Health Insurance Portability and Accountability Act of 1996; (4) “Commissioner” means the Insurance Commissioner; (5) “Continuation coverage” means continuation of coverage under a group health plan or other health insurance coverage for former employees or dependents of former employees that would otherwise have terminated under the terms of that coverage pursuant to any continuation provisions under federal or state law, including the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), as amended, § 23-86-114 of the Arkansas Insurance Code, or any other similar requirement in another state; (6) “Covered person” means a person who is and continues to remain eligible for pool coverage and is covered under one (1) of the plans offered by the pool; (7)(A) “Creditable coverage” means, with respect to a federally eligible individual or a qualified trade adjustment assistance eligible person, coverage of the individual under any of the following: (i) A group health plan; (ii) Health insurance coverage, including group health insurance coverage; (iii) Medicare; (iv) Medical assistance; (v) 10 U.S.C. § 1071 et seq.; (vi) A medical care program of the Indian Health Service or of a tribal organization; (vii) A state health benefits risk pool; (viii) A health plan offered under 5 U.S.C. § 8901 et seq.; (ix) A public health plan, as defined in regulations consistent with section 104 of the Health Insurance Portability and Accountability Act of 1996 that may be promulgated by the Secretary of the United States Department of Health and Human Services; and (x) A health benefit plan under section 5(e) of the Peace Corps Act, 22 U.S.C. § 2504(e). (B) “Creditable coverage” does not include: (i) Coverage consisting solely of coverage of excepted benefits as defined in section 2791(C) of Title XXVII of the Public Health Service Act, 42 U.S.C. § 300gg-91; or (ii)(a) Any period of coverage under subdivisions (7)(A)(i)-(x) of this section that occurred before a break of more than sixty-three (63) days during all of which the individual was not covered under subdivisions (7)(A)(i)-(x) of this section. (b) Any period that an individual is in a waiting period for any coverage under a group health plan or for group health insurance coverage or is in an affiliation period under the terms of health insurance coverage offered by a health maintenance organization shall not be taken into account in determining if there has been a break of more than sixty-three (63) days in any creditable coverage; (8) “Department” means the State Insurance Department; (9) “Excess or stop-loss coverage” means an arrangement whereby an insurer insures against the risk that any one (1) claim will exceed a specific dollar amount or that the entire loss of a self-insurance plan will exceed a specific amount; (10) “Federally eligible individual” means an individual resident of Arkansas: (A) For whom: (i) As of the date on which the individual seeks pool coverage under § 23-79-509, the aggregate of the periods of creditable coverage is eighteen (18) or more months; and (ii) The most recent prior creditable coverage was under group health insurance coverage offered by an insurer, a group health plan, a governmental plan, a church plan, or health insurance coverage offered in connection with any such plans; (B) Who is not eligible for coverage under: (i) A group health plan; (ii) Part A or Part B of Medicare; or (iii) Medical assistance and does not have other health insurance coverage; (C) With respect to whom the most recent coverage within the coverage period described in subdivision (10)(A)(i) of this section was not terminated based upon a factor related to nonpayment of premiums or fraud; (D) If the individual has been offered the option of continuation coverage under a Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) continuation provision or under a similar state program, who elected such coverage; and (E) Who, if the individual elected the continuation coverage, has exhausted the continuation coverage under such a provision or program; (11) “Governmental plan” has the same meaning given that term in the federal Health Insurance Portability and Accountability Act of 1996; (12) “Group health plan” has the same meaning given that term in the federal Health Insurance Portability and Accountability Act of 1996; (13)(A) “Health insurance” means any hospital and medical expense-incurred policy, certificate, or contract provided by an insurer, hospital or medical service corporation, health maintenance organization, or any other healthcare plan or arrangement that pays for or furnishes medical or healthcare services whether by insurance or otherwise and includes any excess or stop-loss coverage. (B) “Health insurance” does not include long-term care, disability income, short-term, accident, dental-only, vision-only, fixed indemnity, limited-benefit or credit insurance, coverage issued as a supplement to liability insurance, insurance arising out of workers' compensation or similar law, automobile medical-payment insurance, or insurance under which benefits are payable with or without regard to fault and that is statutorily required to be contained in any liability insurance policy or equivalent self-insurance; (14) “Health maintenance organization” shall have the same meaning as defined in § 23-76-102; (15) “Hospital” shall have the same meaning as defined in § 20-9-201; (16) “Individual health insurance coverage” means health insurance coverage offered to individuals in the individual market but does not include short-term, limited-duration insurance; (17)(A) “Insurer” means any entity that provides health insurance, including excess or stop-loss health insurance, in the State of Arkansas. (B) For the purposes of this subchapter, “insurer” includes an insurance company, medical services plans, hospital plans, hospital medical service corporations, health maintenance organizations, fraternal benefits society, or any other entity providing a plan of health insurance or health benefits subject to state insurance regulation; (18) “Medical assistance” means the state medical assistance program provided under Title XIX of the Social Security Act or under any similar program of healthcare benefits in a state other than Arkansas; (19)(A)(i) “Medically necessary” means that a service, drug, supply, or article is necessary and appropriate for the diagnosis or treatment of an illness or injury in accord with generally accepted standards of medical practice at the time the service, drug, or supply is provided. (ii) When specifically applied to a confinement, “medically necessary” further means that the diagnosis or treatment of the covered person's medical symptoms or condition cannot be safely provided to that person as an outpatient. (B) A service, drug, supply, or article shall not be medically necessary if it: (i) Is investigational, experimental, or for research purposes; (ii) Is provided solely for the convenience of the patient, the patient's family, physician, hospital, or any other provider; (iii) Exceeds in scope, duration, or intensity that level of care that is needed to provide safe, adequate, and appropriate diagnosis or treatment; (iv) Could have been omitted without adversely affecting the covered person's condition or the quality of medical care; or (v) Involves the use of a medical device, drug, or substance not formally approved by the United States Food and Drug Administration; (20) “Medicare” means coverage under Part A and Part B of Title XVIII of the Social Security Act, 42 U.S.C. § 1395 et seq.; (21) “Physician” means a person licensed to practice medicine as duly licensed by the State of Arkansas; (22) “Plan” means the comprehensive health insurance plan as adopted by the board or by rule; (23) “Plan administrator” means the insurer designated under § 23-79-508 to carry out the provisions of the plan of operation; (24) “Plan of operation” means the plan of operation of the pool, including articles, bylaws, and operating rules adopted by the board pursuant to this subchapter; (25) “Provider” means any hospital, skilled nursing facility, hospice, home health agency, physician, pharmacist, or any other person or entity licensed in Arkansas to furnish medical care, articles, and supplies; (26) “Qualified high-risk pool” has the same meaning given that term in the Health Insurance Portability and Accountability Act of 1996; (27) “Qualified trade adjustment assistance eligible person” means a person who is a trade adjustment assistance eligible person as defined by this section and for whom, on the date an application for the individual is received by the pool under § 23-79-509, has an aggregate of at least three (3) months of creditable coverage without a break in coverage of sixty-three (63) days or more; (28) “Resident eligible person” means a person who: (A) Has been legally domiciled in the State of Arkansas for a period of at least: (i) Ninety (90) days and continues to be domiciled in Arkansas; or (ii) Thirty (30) days, continues to be domiciled in Arkansas, and was covered under a qualified high-risk pool in another state up until sixty-three (63) days or less prior to the date that the pool receives his or her application for coverage; and (B) Is not eligible for coverage under: (i) A group health plan; (ii) Part A or Part B of Medicare; or (iii) Medical assistance as defined in this section and does not have other health insurance coverage as defined in this section; and (29) “Trade adjustment assistance eligible person” means a person who is legally domiciled in the State of Arkansas on the date of application to the pool and is eligible for the tax credit for health insurance coverage premiums under section 35 of the Internal Revenue Code of 1986.