23-86-303. Definitions.

23-86-303. Definitions. As used in this subchapter: (1) “Affiliation period” means a period that, under the terms of the coverage offered by the health maintenance organization, must expire before the coverage becomes effective; (2) “Bona fide association” means, with respect to health insurance coverage offered in Arkansas, an association that: (A) Has been actively in existence for at least five (5) years; (B) Has been formed and maintained in good faith for purposes other than obtaining insurance; (C) Does not condition membership in the association on any health status-related factor relating to an individual, including an employee of an employer or a dependent of an employee; (D) Makes health insurance coverage offered through the association available to all members regardless of any health status-related factor relating to the members or individuals eligible for coverage through a member; (E) Does not make health insurance coverage offered through the association available other than in connection with a member of the association; and (F) Meets the additional requirements that may be imposed under Arkansas law; (3) “Church plan” has the meaning given the term under section 3(33) of the Employee Retirement Income Security Act of 1974 (ERISA); (4) “COBRA continuation provision” means any of the following: (A) Part 6 of Subtitle B of Title 1 of the Employee Retirement Income Security Act of 1974, other than section 609 of the act; (B) Section 4980B of the Internal Revenue Code of 1986, other than subsection (f)(1) of the section insofar as it relates to pediatric vaccines; (C) Title XXII of the Public Health Service Act; (5) “Commissioner” means the Insurance Commissioner; (6) “Creditable coverage” means, with respect to an individual, coverage of the individual under any of the following: (A) A group health plan; (B) Health insurance coverage; (C) Part A or Part B of Title XVIII of the Social Security Act; (D) Title XIX of the Social Security Act, other than coverage consisting solely of benefits under section 1928; (E) United States Code Title 10, Chapter 55; (F) A medical care program of the United States Indian Health Service or of a tribal organization; (G) A state health benefits risk pool; (H) A health plan offered under United States Code Title 5, Chapter 89; (I) A public health plan as defined in regulations; (J) A health benefit plan under section 5(e) of the Peace Corps Act, 22 U.S.C. § 2504(e). The term does not include coverage consisting solely of coverage of excepted benefits as defined in § 23-86-310; (7) “Department” means the State Insurance Department unless the context requires otherwise; (8) “Eligible individual” means, with respect to a health insurance issuer that offers health insurance coverage to a small employer in connection with a group health plan in the small-group market, such an individual in relation to the employer as shall be determined: (A) In accordance with the terms of the group health plan; (B) As provided by the issuer under rules of the issuer that are uniformly applicable in Arkansas to small employers in the small-group market; and (C) In accordance with all applicable Arkansas law governing the issuer and the small-group market; (9)(A) “Employee” has the meaning given the term under section 3(6) of the Employee Retirement Income Security Act of 1974. (B) To the extent not in conflict with the Employee Retirement Income Security Act of 1974, the term “employee” also means a person who is employed by an employer for thirty (30) or more hours a week and includes an employee who is employed by a client of a professional employer organization for thirty (30) or more hours a week under a professional employer organization arrangement as governed under the Arkansas Professional Employer Organization Recognition and Licensing Act, § 23-92-401 et seq.; (10) “Employer” has the meaning given the term under section 3(5) of the Employee Retirement Income Security Act of 1974, except that the term shall include only employers of two (2) or more employees; (11) “Employer contribution rule” means a requirement relating to the minimum level or amount of employer contribution toward the premium for enrollment of participants and beneficiaries; (12) “Enrollment date” means, with respect to an individual covered under a group health plan or health insurance coverage, the date of coverage of the individual in the group health plan or, if earlier, the first day of the waiting period for the coverage; (13) “Federal governmental plan” means a governmental plan established or maintained for its employees by the United States Government or by any agency or instrumentality of the government; (14) “Governmental plan” has the meaning given the term under section 3(32) of the Employee Retirement Income Security Act of 1974 and any federal governmental plan; (15) “Group health insurance coverage” means, in connection with a group health plan, health insurance coverage offered in connection with the group health plan; (16) “Group health plan” means an employee welfare benefit plan to the extent that the plan provides medical care as defined in this section and including items and services paid for as medical care, to employees or their dependents as defined under the terms of the plan directly or through insurance, reimbursement, or otherwise; (17) “Group participation rule” means a requirement relating to the minimum number of participants or beneficiaries that must be enrolled in relation to a specified percentage or number of eligible individuals or employees of an employer; (18) “Health insurance coverage” means benefits consisting of medical care, provided directly, through insurance or reimbursement or otherwise and including items and services paid for as medical care, under any hospital or medical service policy or certificate, hospital or medical service plan contract, or health maintenance organization contract offered by a health insurance issuer; (19) “Health insurance issuer” means an insurance company, insurance service, or insurance organization including a health maintenance organization as defined in this section that is licensed to engage in the business of insurance in a state and that is subject to Arkansas law that regulates insurance. The term does not include a group health plan; (20) “Health maintenance organization” means: (A) A federally qualified health maintenance organization as defined in section 1301(a) of the Public Health Service Act, 42 U.S.C. § 300e(a); (B) An organization recognized under state law as a health maintenance organization; or (C) A similar organization regulated under state law for solvency in the same manner and to the same extent as a health maintenance organization; (21) “Health status-related factor” means any of the factors described in § 23-86-306(a)(1); (22) “Individual market” means the market for health insurance coverage offered to individuals other than in connection with a group health plan; (23) “Large employer” means, in connection with a group health plan with respect to a calendar year and a plan year, an employer who employed an average of at least fifty-one (51) employees on business days during the preceding calendar year and who employs at least two (2) employees on the first day of the plan year; (24) “Large-group market” means the health insurance market under which individuals obtain health insurance coverage directly or through any arrangement on behalf of themselves and their dependents through a group health plan maintained by a large employer; (25) “Late enrollee” means, with respect to coverage under a group health plan, a participant or beneficiary who enrolls under the group health plan other than during: (A) The first period in which the individual is eligible to enroll under the group health plan; or (B) A special enrollment period under § 23-86-304(f); (26) “Medical care” means amounts paid for or services provided for: (A) The diagnosis, cure, mitigation, treatment, or prevention of disease, or amounts paid for the purpose of affecting any structure or function of the body; (B) Amounts paid for transportation primarily for and essential to medical care referred to in subdivision (26)(A) of this section; and (C) Amounts paid for insurance covering medical care referred to in subdivisions (26)(A) and (B) of this section; (27) “Network plan” means health insurance coverage offered by a health insurance issuer under which the financing and delivery of medical care, including items and services paid for as medical care are provided, in whole or in part, through a defined set of providers under contract with the issuer; (28) “Nonfederal governmental plan” means a governmental plan that is not a federal governmental plan; (29) “Participant” has the meaning given the term under section 3(7) of the Employee Retirement Income Security Act of 1974; (30) “Placement”, or being “placed”, for adoption, in connection with any placement for adoption of a child with any person, means the assumption and retention by the person of a legal obligation for total or partial support of the child in anticipation of adoption of the child. The child's placement with the person terminates upon the termination of the legal obligation; (31) “Plan sponsor” has the meaning given the term under section 3(16)(B) of the Employee Retirement Income Security Act of 1974; (32) “Preexisting condition exclusion” means, with respect to coverage, 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 the coverage, whether or not any medical advice, diagnosis, care, or treatment was recommended or received before that date; (33) “Rules” means rules promulgated by the Insurance Commissioner unless the context requires otherwise; (34) “Small employer” means, in connection with a group health plan with respect to a calendar year and a plan year, an employer who employed an average of at least two (2) but not more than fifty (50) employees on business days during the preceding calendar year and who employs at least two (2) employees on the first day of the plan year; (35) “Small-group market” means the health insurance market under which individuals obtain health insurance coverage directly or through any arrangement on behalf of themselves and their dependents through a group health plan maintained by a small employer; (36) “State” means each of the several states, the District of Columbia, Puerto Rico, the Virgin Islands, Guam, American Samoa, and the Northern Mariana Islands; (37)(A) “State law” includes all laws, decisions, rules, regulations, or other state action having the effect of law, of any state. (B) A law of the United States applicable only to the District of Columbia shall be treated as a state law rather than a law of the United States; and (38) “Waiting period” means, with respect to a group health plan and an individual who is a potential participant or beneficiary in the group health plan, the period that must pass with respect to the individual before the individual is eligible to be covered for benefits under the terms of the group health plan.