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5 | 5 | | 2025 -- H 5418 |
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6 | 6 | | ======== |
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7 | 7 | | LC001085 |
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8 | 8 | | ======== |
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9 | 9 | | S T A T E O F R H O D E I S L A N D |
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10 | 10 | | IN GENERAL ASSEMBLY |
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11 | 11 | | JANUARY SESSION, A.D. 2025 |
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12 | 12 | | ____________ |
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13 | 13 | | |
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14 | 14 | | A N A C T |
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15 | 15 | | RELATING TO INSURANCE -- SMALL EMPLOYER HEALTH INSURANCE |
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16 | 16 | | AVAILABILITY ACT |
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17 | 17 | | Introduced By: Representatives Nardone, Santucci, Paplauskas, Quattrocchi, Hull, |
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18 | 18 | | Cortvriend, and Place |
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19 | 19 | | Date Introduced: February 12, 2025 |
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20 | 20 | | Referred To: House Corporations |
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21 | 21 | | |
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22 | 22 | | |
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23 | 23 | | It is enacted by the General Assembly as follows: |
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24 | 24 | | SECTION 1. Section 27-50-3 of the General Laws in Chapter 27-50 entitled "Small 1 |
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25 | 25 | | Employer Health Insurance Availability Act" is hereby amended to read as follows: 2 |
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26 | 26 | | 27-50-3. Definitions. 3 |
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27 | 27 | | (a) “Actuarial certification” means a written statement signed by a member of the American 4 |
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28 | 28 | | Academy of Actuaries or other individual acceptable to the director that a small employer carrier 5 |
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29 | 29 | | is in compliance with the provisions of § 27-50-5, based upon the person’s examination and 6 |
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30 | 30 | | including a review of the appropriate records and the actuarial assumptions and methods used by 7 |
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31 | 31 | | the small employer carrier in establishing premium rates for applicable health benefit plans. 8 |
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32 | 32 | | (b) “Adjusted community rating” means a method used to develop a carrier’s premium that 9 |
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33 | 33 | | spreads financial risk across the carrier’s entire small group population in accordance with the 10 |
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34 | 34 | | requirements in § 27-50-5. 11 |
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35 | 35 | | (c) “Affiliate” or “affiliated” means any entity or person who directly or indirectly through 12 |
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36 | 36 | | one or more intermediaries controls or is controlled by, or is under common control with, a specified 13 |
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37 | 37 | | entity or person. 14 |
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38 | 38 | | (d) “Affiliation period” means a period of time that must expire before health insurance 15 |
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39 | 39 | | coverage provided by a carrier becomes effective, and during which the carrier is not required to 16 |
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40 | 40 | | provide benefits. 17 |
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41 | 41 | | (e) “Bona fide association” means, with respect to health benefit plans offered in this state, 18 |
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42 | 42 | | |
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43 | 43 | | |
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44 | 44 | | LC001085 - Page 2 of 11 |
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45 | 45 | | an association that: 1 |
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46 | 46 | | (1) Has been actively in existence for at least five (5) years; 2 |
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47 | 47 | | (2) Has been formed and maintained in good faith for purposes other than obtaining 3 |
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48 | 48 | | insurance; 4 |
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49 | 49 | | (3) Does not condition membership in the association on any health status-related factor 5 |
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50 | 50 | | relating to an individual (including an employee of an employer or a dependent of an employee); 6 |
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51 | 51 | | (4) Makes health insurance coverage offered through the association available to all 7 |
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52 | 52 | | members regardless of any health status-related factor relating to those members (or individuals 8 |
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53 | 53 | | eligible for coverage through a member); 9 |
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54 | 54 | | (5) Does not make health insurance coverage offered through the association available 10 |
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55 | 55 | | other than in connection with a member of the association; 11 |
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56 | 56 | | (6) Is composed of persons having a common interest or calling; 12 |
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57 | 57 | | (7) Has a constitution and bylaws; and 13 |
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58 | 58 | | (8) Meets any additional requirements that the director may prescribe by regulation. 14 |
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59 | 59 | | (f) “Carrier” or “small employer carrier” means all entities licensed, or required to be 15 |
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60 | 60 | | licensed, in this state that offer health benefit plans covering eligible employees of one or more 16 |
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61 | 61 | | small employers pursuant to this chapter. For the purposes of this chapter, carrier includes an 17 |
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62 | 62 | | insurance company, a nonprofit hospital or medical service corporation, a fraternal benefit society, 18 |
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63 | 63 | | a health maintenance organization as defined in chapter 41 of this title or as defined in chapter 62 19 |
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64 | 64 | | of title 42, or any other entity subject to state insurance regulation that provides medical care as 20 |
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65 | 65 | | defined in subsection (y) that is paid or financed for a small employer by such entity on the basis 21 |
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66 | 66 | | of a periodic premium, paid directly or through an association, trust, or other intermediary, and 22 |
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67 | 67 | | issued, renewed, or delivered within or without Rhode Island to a small employer pursuant to the 23 |
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68 | 68 | | laws of this or any other jurisdiction, including a certificate issued to an eligible employee that 24 |
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69 | 69 | | evidences coverage under a policy or contract issued to a trust or association. 25 |
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70 | 70 | | (g) “Church plan” has the meaning given this term under section 3(33) of the Employee 26 |
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71 | 71 | | Retirement Income Security Act of 1974, 29 U.S.C. § 1002(33). 27 |
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72 | 72 | | (h) “Control” is defined in the same manner as in chapter 35 of this title. 28 |
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73 | 73 | | (i)(1) “Creditable coverage” means, with respect to an individual, health benefits or 29 |
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74 | 74 | | coverage provided under any of the following: 30 |
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75 | 75 | | (i) A group health plan; 31 |
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76 | 76 | | (ii) A health benefit plan; 32 |
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77 | 77 | | (iii) Part A or part B of Title XVIII of the Social Security Act, 42 U.S.C. § 1395c et seq., 33 |
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78 | 78 | | or 42 U.S.C. § 1395j et seq. (Medicare); 34 |
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79 | 79 | | |
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80 | 80 | | |
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81 | 81 | | LC001085 - Page 3 of 11 |
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82 | 82 | | (iv) Title XIX of the Social Security Act, 42 U.S.C. § 1396 et seq. (Medicaid), other than 1 |
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83 | 83 | | coverage consisting solely of benefits under 42 U.S.C. § 1396s (the program for distribution of 2 |
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84 | 84 | | pediatric vaccines); 3 |
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85 | 85 | | (v) 10 U.S.C. § 1071 et seq. (medical and dental care for members and certain former 4 |
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86 | 86 | | members of the uniformed services, and for their dependents) (Civilian Health and Medical 5 |
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87 | 87 | | Program of the Uniformed Services) (CHAMPUS). For purposes of 10 U.S.C. § 1071 et seq., 6 |
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88 | 88 | | “uniformed services” means the armed forces and the commissioned corps of the National Oceanic 7 |
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89 | 89 | | and Atmospheric Administration and of the Public Health Service; 8 |
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90 | 90 | | (vi) A medical care program of the Indian Health Service or of a tribal organization; 9 |
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91 | 91 | | (vii) A state health benefits risk pool; 10 |
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92 | 92 | | (viii) A health plan offered under 5 U.S.C. § 8901 et seq. (Federal Employees Health 11 |
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93 | 93 | | Benefits Program (FEHBP)); 12 |
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94 | 94 | | (ix) A public health plan which for purposes of this chapter, means a plan established or 13 |
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95 | 95 | | maintained by a state, county, or other political subdivision of a state that provides health insurance 14 |
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96 | 96 | | coverage to individuals enrolled in the plan; or 15 |
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97 | 97 | | (x) A health benefit plan under section 5(e) of the Peace Corps Act (22 U.S.C. § 2504(e)). 16 |
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98 | 98 | | (2) A period of creditable coverage shall not be counted, with respect to enrollment of an 17 |
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99 | 99 | | individual under a group health plan, if, after the period and before the enrollment date, the 18 |
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100 | 100 | | individual experiences a significant break in coverage. 19 |
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101 | 101 | | (j) “Dependent” means a spouse, child under the age twenty-six (26) years, and an 20 |
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102 | 102 | | unmarried child of any age who is financially dependent upon the parent and is medically 21 |
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103 | 103 | | determined to have a physical or mental impairment that can be expected to result in death or that 22 |
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104 | 104 | | has lasted or can be expected to last for a continuous period of not less than twelve (12) months. 23 |
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105 | 105 | | (k) “Director” means the director of the department of business regulation. 24 |
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106 | 106 | | (l) [Deleted by P.L. 2006, ch. 258, § 2, and P.L. 2006, ch. 296, § 2.] 25 |
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107 | 107 | | (m) “Eligible employee” means an employee who works on a full-time basis with a normal 26 |
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108 | 108 | | work week of thirty (30) or more hours, except that at the employer’s sole discretion, the term shall 27 |
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109 | 109 | | also include an employee who works on a full-time basis with a normal work week of anywhere 28 |
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110 | 110 | | between at least seventeen and one-half (17.5) and thirty (30) hours, so long as this eligibility 29 |
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111 | 111 | | criterion is applied uniformly among all of the employer’s employees and without regard to any 30 |
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112 | 112 | | health status-related factor. The term includes a self-employed individual, a sole proprietor, a 31 |
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113 | 113 | | partner of a partnership, and may include an independent contractor, if the self-employed 32 |
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114 | 114 | | individual, sole proprietor, partner, or independent contractor is included as an employee under a 33 |
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115 | 115 | | health benefit plan of a small employer, but does not include an employee who works on a 34 |
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116 | 116 | | |
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117 | 117 | | |
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118 | 118 | | LC001085 - Page 4 of 11 |
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119 | 119 | | temporary or substitute basis or who works less than seventeen and one-half (17.5) hours per week. 1 |
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120 | 120 | | Any retiree under contract with any independently incorporated fire district is also included in the 2 |
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121 | 121 | | definition of eligible employee, as well as any former employee of an employer who retired before 3 |
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122 | 122 | | normal retirement age, as defined by 42 U.S.C. § 18002(a)(2)(C), while the employer participates 4 |
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123 | 123 | | in the early retiree reinsurance program defined by that chapter. Persons covered under a health 5 |
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124 | 124 | | benefit plan pursuant to the Consolidated Omnibus Budget Reconciliation Act of 1986 shall not be 6 |
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125 | 125 | | considered “eligible employees” for purposes of minimum participation requirements pursuant to 7 |
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126 | 126 | | § 27-50-7(d)(9). 8 |
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127 | 127 | | (n) “Enrollment date” means the first day of coverage or, if there is a waiting period, the 9 |
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128 | 128 | | first day of the waiting period, whichever is earlier. 10 |
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129 | 129 | | (o) “Established geographic service area” means a geographic area, as approved by the 11 |
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130 | 130 | | director and based on the carrier’s certificate of authority to transact insurance in this state, within 12 |
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131 | 131 | | which the carrier is authorized to provide coverage. 13 |
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132 | 132 | | (p) “Family composition” means the: 14 |
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133 | 133 | | (1) Enrollee; 15 |
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134 | 134 | | (2) Enrollee, spouse, and children; 16 |
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135 | 135 | | (3) Enrollee and spouse; or 17 |
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136 | 136 | | (4) Enrollee and children. 18 |
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137 | 137 | | (q) “Genetic information” means information about genes, gene products, and inherited 19 |
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138 | 138 | | characteristics that may derive from the individual or a family member. This includes information 20 |
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139 | 139 | | regarding carrier status and information derived from laboratory tests that identify mutations in 21 |
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140 | 140 | | specific genes or chromosomes, physical medical examinations, family histories, and direct 22 |
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141 | 141 | | analysis of genes or chromosomes. 23 |
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142 | 142 | | (r) “Governmental plan” has the meaning given the term under section 3(32) of the 24 |
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143 | 143 | | Employee Retirement Income Security Act of 1974, 29 U.S.C. § 1002(32), and any federal 25 |
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144 | 144 | | governmental plan. 26 |
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145 | 145 | | (s)(1) “Group health plan” means an employee welfare benefit plan as defined in section 27 |
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146 | 146 | | 3(1) of the Employee Retirement Income Security Act of 1974, 29 U.S.C. § 1002(1), to the extent 28 |
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147 | 147 | | that the plan provides medical care, as defined in subsection (y) of this section, and including items 29 |
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148 | 148 | | and services paid for as medical care to employees or their dependents as defined under the terms 30 |
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149 | 149 | | of the plan directly or through insurance, reimbursement, or otherwise. 31 |
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150 | 150 | | (2) For purposes of this chapter: 32 |
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151 | 151 | | (i) Any plan, fund, or program that would not be, but for Public Health Service Act Section 33 |
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152 | 152 | | 2721(e), 42 U.S.C. § 300gg(e), as added by Pub. L. No. 104-191, an employee welfare benefit plan 34 |
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153 | 153 | | |
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154 | 154 | | |
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155 | 155 | | LC001085 - Page 5 of 11 |
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156 | 156 | | and that is established or maintained by a partnership, to the extent that the plan, fund, or program 1 |
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157 | 157 | | provides medical care, including items and services paid for as medical care, to present or former 2 |
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158 | 158 | | partners in the partnership, or to their dependents, as defined under the terms of the plan, fund, or 3 |
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159 | 159 | | program, directly or through insurance, reimbursement or otherwise, shall be treated, subject to 4 |
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160 | 160 | | subsection (s)(2)(ii) of this section, as an employee welfare benefit plan that is a group health plan; 5 |
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161 | 161 | | (ii) In the case of a group health plan, the term “employer” also includes the partnership in 6 |
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162 | 162 | | relation to any partner; and 7 |
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163 | 163 | | (iii) In the case of a group health plan, the term “participant” also includes an individual 8 |
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164 | 164 | | who is, or may become, eligible to receive a benefit under the plan, or the individual’s beneficiary 9 |
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165 | 165 | | who is, or may become, eligible to receive a benefit under the plan, if: 10 |
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166 | 166 | | (A) In connection with a group health plan maintained by a partnership, the individual is a 11 |
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167 | 167 | | partner in relation to the partnership; or 12 |
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168 | 168 | | (B) In connection with a group health plan maintained by a self-employed individual, under 13 |
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169 | 169 | | which one or more employees are participants, the individual is the self-employed individual. 14 |
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170 | 170 | | (t)(1) “Health benefit plan” means any hospital or medical policy or certificate, major 15 |
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171 | 171 | | medical expense insurance, hospital or medical service corporation subscriber contract, or health 16 |
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172 | 172 | | maintenance organization subscriber contract. Health benefit plan includes short-term and 17 |
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173 | 173 | | catastrophic health insurance policies, and a policy that pays on a cost-incurred basis, except as 18 |
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174 | 174 | | otherwise specifically exempted in this definition. 19 |
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175 | 175 | | (2) “Health benefit plan” does not include one or more, or any combination of, the 20 |
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176 | 176 | | following: 21 |
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177 | 177 | | (i) Coverage only for accident or disability income insurance, or any combination of those; 22 |
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178 | 178 | | (ii) Coverage issued as a supplement to liability insurance; 23 |
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179 | 179 | | (iii) Liability insurance, including general liability insurance and automobile liability 24 |
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180 | 180 | | insurance; 25 |
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181 | 181 | | (iv) Workers’ compensation or similar insurance; 26 |
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182 | 182 | | (v) Automobile medical payment insurance; 27 |
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183 | 183 | | (vi) Credit-only insurance; 28 |
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184 | 184 | | (vii) Coverage for on-site medical clinics; and 29 |
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185 | 185 | | (viii) Other similar insurance coverage, specified in federal regulations issued pursuant to 30 |
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186 | 186 | | Pub. L. No. 104-191, under which benefits for medical care are secondary or incidental to other 31 |
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187 | 187 | | insurance benefits. 32 |
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188 | 188 | | (3) “Health benefit plan” does not include the following benefits if they are provided under 33 |
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189 | 189 | | a separate policy, certificate, or contract of insurance or are otherwise not an integral part of the 34 |
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190 | 190 | | |
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191 | 191 | | |
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192 | 192 | | LC001085 - Page 6 of 11 |
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193 | 193 | | plan: 1 |
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194 | 194 | | (i) Limited scope dental or vision benefits; 2 |
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195 | 195 | | (ii) Benefits for long-term care, nursing home care, home health care, community-based 3 |
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196 | 196 | | care, or any combination of those; or 4 |
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197 | 197 | | (iii) Other similar, limited benefits specified in federal regulations issued pursuant to Pub. 5 |
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198 | 198 | | L. No. 104-191. 6 |
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199 | 199 | | (4) “Health benefit plan” does not include the following benefits if the benefits are provided 7 |
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200 | 200 | | under a separate policy, certificate, or contract of insurance, there is no coordination between the 8 |
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201 | 201 | | provision of the benefits and any exclusion of benefits under any group health plan maintained by 9 |
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202 | 202 | | the same plan sponsor, and the benefits are paid with respect to an event without regard to whether 10 |
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203 | 203 | | benefits are provided with respect to such an event under any group health plan maintained by the 11 |
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204 | 204 | | same plan sponsor: 12 |
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205 | 205 | | (i) Coverage only for a specified disease or illness; or 13 |
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206 | 206 | | (ii) Hospital indemnity or other fixed indemnity insurance. 14 |
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207 | 207 | | (5) “Health benefit plan” does not include the following if offered as a separate policy, 15 |
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208 | 208 | | certificate, or contract of insurance: 16 |
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209 | 209 | | (i) Medicare supplemental health insurance as defined under section 1882(g)(1) of the 17 |
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210 | 210 | | Social Security Act, 42 U.S.C. § 1395ss(g)(1); 18 |
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211 | 211 | | (ii) Coverage supplemental to the coverage provided under 10 U.S.C. § 1071 et seq.; or 19 |
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212 | 212 | | (iii) Similar supplemental coverage provided to coverage under a group health plan. 20 |
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213 | 213 | | (6) A carrier offering policies or certificates of specified disease, hospital confinement 21 |
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214 | 214 | | indemnity, or limited benefit health insurance shall comply with the following: 22 |
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215 | 215 | | (i) The carrier files on or before March 1 of each year a certification with the director that 23 |
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216 | 216 | | contains the statement and information described in subsection (t)(6)(ii) of this section; 24 |
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217 | 217 | | (ii) The certification required in subsection (t)(6)(i) of this section shall contain the 25 |
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218 | 218 | | following: 26 |
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219 | 219 | | (A) A statement from the carrier certifying that policies or certificates described in this 27 |
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220 | 220 | | subsection (t)(6) are being offered and marketed as supplemental health insurance and not as a 28 |
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221 | 221 | | substitute for hospital or medical expense insurance or major medical expense insurance; and 29 |
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222 | 222 | | (B) A summary description of each policy or certificate described in this subsection (t)(6), 30 |
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223 | 223 | | including the average annual premium rates (or range of premium rates in cases where premiums 31 |
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224 | 224 | | vary by age or other factors) charged for those policies and certificates in this state; and 32 |
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225 | 225 | | (iii) In the case of a policy or certificate that is described in this subsection (t)(6) and that 33 |
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226 | 226 | | is offered for the first time in this state on or after July 13, 2000, the carrier shall file with the 34 |
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227 | 227 | | |
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228 | 228 | | |
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229 | 229 | | LC001085 - Page 7 of 11 |
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230 | 230 | | director the information and statement required in subsection (t)(6)(ii) of this section at least thirty 1 |
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231 | 231 | | (30) days prior to the date the policy or certificate is issued or delivered in this state. 2 |
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232 | 232 | | (u) “Health maintenance organization” or “HMO” means a health maintenance 3 |
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233 | 233 | | organization licensed under chapter 41 of this title. 4 |
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234 | 234 | | (v) “Health status-related factor” means any of the following factors: 5 |
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235 | 235 | | (1) Health status; 6 |
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236 | 236 | | (2) Medical condition, including both physical and mental illnesses; 7 |
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237 | 237 | | (3) Claims experience; 8 |
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238 | 238 | | (4) Receipt of health care; 9 |
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239 | 239 | | (5) Medical history; 10 |
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240 | 240 | | (6) Genetic information; 11 |
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241 | 241 | | (7) Evidence of insurability, including conditions arising out of acts of domestic violence; 12 |
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242 | 242 | | or 13 |
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243 | 243 | | (8) Disability. 14 |
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244 | 244 | | (w)(1) “Late enrollee” means an eligible employee or dependent who requests enrollment 15 |
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245 | 245 | | in a health benefit plan of a small employer following the initial enrollment period during which 16 |
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246 | 246 | | the individual is entitled to enroll under the terms of the health benefit plan, provided that the initial 17 |
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247 | 247 | | enrollment period is a period of at least thirty (30) days. 18 |
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248 | 248 | | (2) “Late enrollee” does not mean an eligible employee or dependent: 19 |
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249 | 249 | | (i) Who meets each of the following provisions: 20 |
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250 | 250 | | (A) The individual was covered under creditable coverage at the time of the initial 21 |
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251 | 251 | | enrollment; 22 |
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252 | 252 | | (B) The individual lost creditable coverage as a result of cessation of employer 23 |
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253 | 253 | | contribution, termination of employment or eligibility, reduction in the number of hours of 24 |
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254 | 254 | | employment, involuntary termination of creditable coverage, or death of a spouse, divorce, or legal 25 |
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255 | 255 | | separation, or the individual and/or dependents are determined to be eligible for RIteCare under 26 |
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256 | 256 | | chapter 5.1 of title 40 [repealed] or chapter 12.3 of title 42 or for RIteShare under chapter 8.4 of 27 |
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257 | 257 | | title 40; and 28 |
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258 | 258 | | (C) The individual requests enrollment within thirty (30) days after termination of the 29 |
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259 | 259 | | creditable coverage or the change in conditions that gave rise to the termination of coverage; 30 |
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260 | 260 | | (ii) If, where provided for in contract or where otherwise provided in state law, the 31 |
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261 | 261 | | individual enrolls during the specified bona fide open enrollment period; 32 |
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262 | 262 | | (iii) If the individual is employed by an employer which offers multiple health benefit plans 33 |
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263 | 263 | | and the individual elects a different plan during an open enrollment period; 34 |
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264 | 264 | | |
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265 | 265 | | |
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266 | 266 | | LC001085 - Page 8 of 11 |
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267 | 267 | | (iv) If a court has ordered coverage be provided for a spouse or minor or dependent child 1 |
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268 | 268 | | under a covered employee’s health benefit plan and a request for enrollment is made within thirty 2 |
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269 | 269 | | (30) days after issuance of the court order; 3 |
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270 | 270 | | (v) If the individual changes status from not being an eligible employee to becoming an 4 |
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271 | 271 | | eligible employee and requests enrollment within thirty (30) days after the change in status; 5 |
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272 | 272 | | (vi) If the individual had coverage under a COBRA continuation provision and the 6 |
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273 | 273 | | coverage under that provision has been exhausted; or 7 |
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274 | 274 | | (vii) Who meets the requirements for special enrollment pursuant to § 27-50-7 or § 27-50-8 |
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275 | 275 | | 8. 9 |
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276 | 276 | | (x) “Limited benefit health insurance” means that form of coverage that pays stated 10 |
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277 | 277 | | predetermined amounts for specific services or treatments or pays a stated predetermined amount 11 |
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278 | 278 | | per day or confinement for one or more named conditions, named diseases, or accidental injury. 12 |
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279 | 279 | | (y) “Medical care” means amounts paid for: 13 |
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280 | 280 | | (1) The diagnosis, care, mitigation, treatment, or prevention of disease, or amounts paid for 14 |
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281 | 281 | | the purpose of affecting any structure or function of the body; 15 |
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282 | 282 | | (2) Transportation primarily for and essential to medical care referred to in subsection 16 |
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283 | 283 | | (y)(1) of this section; and 17 |
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284 | 284 | | (3) Insurance covering medical care referred to in subsections (y)(1) and (y)(2) of this 18 |
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285 | 285 | | section. 19 |
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286 | 286 | | (z) “Network plan” means a health benefit plan issued by a carrier under which the 20 |
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287 | 287 | | financing and delivery of medical care, including items and services paid for as medical care, are 21 |
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288 | 288 | | provided, in whole or in part, through a defined set of providers under contract with the carrier. 22 |
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289 | 289 | | (aa) “Person” means an individual, a corporation, a partnership, an association, a joint 23 |
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290 | 290 | | venture, a joint stock company, a trust, an unincorporated organization, any similar entity, or any 24 |
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291 | 291 | | combination of the foregoing. 25 |
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292 | 292 | | (bb) “Plan sponsor” has the meaning given this term under section 3(16)(B) of the 26 |
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293 | 293 | | Employee Retirement Income Security Act of 1974, 29 U.S.C. § 1002(16)(B). 27 |
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294 | 294 | | (cc)(1) “Preexisting condition” means a condition, regardless of the cause of the condition, 28 |
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295 | 295 | | for which medical advice, diagnosis, care, or treatment was recommended or received during the 29 |
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296 | 296 | | six (6) months immediately preceding the enrollment date of the coverage. 30 |
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297 | 297 | | (2) “Preexisting condition” does not mean a condition for which medical advice, diagnosis, 31 |
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298 | 298 | | care, or treatment was recommended or received for the first time while the covered person held 32 |
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299 | 299 | | creditable coverage and that was a covered benefit under the health benefit plan, provided that the 33 |
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300 | 300 | | prior creditable coverage was continuous to a date not more than ninety (90) days prior to the 34 |
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301 | 301 | | |
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302 | 302 | | |
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303 | 303 | | LC001085 - Page 9 of 11 |
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304 | 304 | | enrollment date of the new coverage. 1 |
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305 | 305 | | (3) Genetic information shall not be treated as a condition under subsection (cc)(1) of this 2 |
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306 | 306 | | section for which a preexisting condition exclusion may be imposed in the absence of a diagnosis 3 |
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307 | 307 | | of the condition related to the information. 4 |
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308 | 308 | | (dd) “Premium” means all moneys paid by a small employer and eligible employees as a 5 |
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309 | 309 | | condition of receiving coverage from a small employer carrier, including any fees or other 6 |
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310 | 310 | | contributions associated with the health benefit plan. 7 |
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311 | 311 | | (ee) “Producer” means any insurance producer licensed under chapter 2.4 of this title. 8 |
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312 | 312 | | (ff) “Rating period” means the calendar period for which premium rates established by a 9 |
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313 | 313 | | small employer carrier are assumed to be in effect. 10 |
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314 | 314 | | (gg) “Restricted network provision” means any provision of a health benefit plan that 11 |
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315 | 315 | | conditions the payment of benefits, in whole or in part, on the use of healthcare providers that have 12 |
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316 | 316 | | entered into a contractual arrangement with the carrier pursuant to provide healthcare services to 13 |
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317 | 317 | | covered individuals. 14 |
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318 | 318 | | (hh) “Risk adjustment mechanism” means the mechanism established pursuant to § 27-15 |
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319 | 319 | | 50-16. 16 |
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320 | 320 | | (ii) “Self-employed individual” means an individual or sole proprietor who derives a 17 |
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321 | 321 | | substantial portion of his or her income from a trade or business through which the individual or 18 |
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322 | 322 | | sole proprietor has attempted to earn taxable income and for which he or she has filed the 19 |
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323 | 323 | | appropriate Internal Revenue Service Form 1040, Schedule C or F, for the previous taxable year. 20 |
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324 | 324 | | (jj) “Significant break in coverage” means a period of ninety (90) consecutive days during 21 |
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325 | 325 | | all of which the individual does not have any creditable coverage, except that neither a waiting 22 |
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326 | 326 | | period nor an affiliation period is taken into account in determining a significant break in coverage. 23 |
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327 | 327 | | (kk) “Small employer” means, except for its use in § 27-50-7, any person, firm, 24 |
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328 | 328 | | corporation, partnership, association, political subdivision, or self-employed individual who or that 25 |
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329 | 329 | | is actively engaged in business including, but not limited to, a business or a corporation organized 26 |
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330 | 330 | | under the Rhode Island Nonprofit Corporation Act, chapter 6 of title 7, or a similar act of another 27 |
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331 | 331 | | state that, on at least fifty percent (50%) of its working days during the preceding calendar quarter, 28 |
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332 | 332 | | employed no more than fifty (50) one hundred (100) eligible employees, with a normal work week 29 |
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333 | 333 | | of thirty (30) or more hours, the majority of whom were employed within this state, and is not 30 |
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334 | 334 | | formed primarily for purposes of buying health insurance and in which a bona fide employer-31 |
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335 | 335 | | employee relationship exists. In determining the number of eligible employees, companies that are 32 |
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336 | 336 | | affiliated companies, or that are eligible to file a combined tax return for purposes of taxation by 33 |
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337 | 337 | | this state, shall be considered one employer. Subsequent to the issuance of a health benefit plan to 34 |
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338 | 338 | | |
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339 | 339 | | |
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340 | 340 | | LC001085 - Page 10 of 11 |
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341 | 341 | | a small employer and for the purpose of determining continued eligibility, the size of a small 1 |
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342 | 342 | | employer shall be determined annually. Except as otherwise specifically provided, provisions of 2 |
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343 | 343 | | this chapter that apply to a small employer shall continue to apply at least until the plan anniversary 3 |
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344 | 344 | | following the date the small employer no longer meets the requirements of this definition. The term 4 |
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345 | 345 | | small employer includes a self-employed individual. 5 |
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346 | 346 | | (ll) “Waiting period” means, with respect to a group health plan and an individual who is 6 |
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347 | 347 | | a potential enrollee in the plan, the period that must pass with respect to the individual before the 7 |
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348 | 348 | | individual is eligible to be covered for benefits under the terms of the plan. For purposes of 8 |
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349 | 349 | | calculating periods of creditable coverage pursuant to subsection (i)(2) of this section, a waiting 9 |
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350 | 350 | | period shall not be considered a gap in coverage. 10 |
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351 | 351 | | (mm) “Wellness health benefit plan” means a plan developed pursuant to § 27-50-10. 11 |
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352 | 352 | | (nn) “Health insurance commissioner” or “commissioner” means that individual appointed 12 |
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353 | 353 | | pursuant to § 42-14.5-1 and afforded those powers and duties as set forth in §§ 42-14.5-2 and 42-13 |
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354 | 354 | | 14.5-3. 14 |
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355 | 355 | | (oo) “Low-wage firm” means those with average wages that fall within the bottom quartile 15 |
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356 | 356 | | of all Rhode Island employers. 16 |
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357 | 357 | | (pp) “Wellness health benefit plan” means the health benefit plan offered by each small 17 |
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358 | 358 | | employer carrier pursuant to § 27-50-7. 18 |
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359 | 359 | | (qq) “Commissioner” means the health insurance commissioner. 19 |
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360 | 360 | | SECTION 2. This act shall take effect upon passage. 20 |
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361 | 361 | | ======== |
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362 | 362 | | LC001085 |
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363 | 363 | | ======== |
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364 | 364 | | |
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365 | 365 | | |
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366 | 366 | | LC001085 - Page 11 of 11 |
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367 | 367 | | EXPLANATION |
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368 | 368 | | BY THE LEGISLATIVE COUNCIL |
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369 | 369 | | OF |
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370 | 370 | | A N A C T |
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371 | 371 | | RELATING TO INSURANCE -- SMALL EMPLOYER HEALTH INSURANCE |
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372 | 372 | | AVAILABILITY ACT |
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373 | 373 | | *** |
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374 | 374 | | This act would amend the definition of "small employer" for purposes of the small 1 |
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375 | 375 | | employer health insurance availability act to mean a business employing less than one hundred 2 |
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376 | 376 | | (100) employees rather than fifty (50) employees. 3 |
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377 | 377 | | This act would take effect upon passage. 4 |
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378 | 378 | | ======== |
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379 | 379 | | LC001085 |
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380 | 380 | | ======== |
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