Section 21.54.500. Definitions.

In this chapter,
        (1) "aggregate lifetime limit" means a dollar limit on the total amount that may be paid for benefits under a health care insurance plan offered in the group market with respect to an individual or unit of coverage;
        (2) "annual limit" means a dollar limit on the total amount that may be paid for benefits in a 12-month period under the plan with respect to an individual or unit of coverage;
        (3) "beneficiary" has the meaning given under 29 U.S.C. 1002(8) (Employee Retirement Income Security Act of 1974);
        (4) "certification of coverage" means a written certification of
             (A) the period of creditable coverage of an individual under a health benefit plan or health care insurance plan offered in the group market, including coverage under a federal continuation provision; and
             (B) the waiting period imposed with respect to the individual for coverage under the health benefit plan or health care insurance plan offered in the group market;
        (5) "church plan" has the meaning given under 29 U.S.C. 1002(33) (Employee Retirement Income Security Act of 1974);
        (6) "creditable coverage" means, with respect to an individual, coverage, excluding excepted benefits, calculated as required under AS 21.54.120 and applicable under
             (A) a health care insurance plan;
             (B) a health benefit plan;
             (C) 42 U.S.C. 1395c or 1395j (Part A or Part B of Title XVIII of the Social Security Act);
             (D) 42 U.S.C. 1396 (Title XIX of the Social Security Act), other than coverage consisting solely of benefits under 42 U.S.C. 1396s;
             (E) 10 U.S.C. 1071 - 1090;
             (F) a medical care program of the Indian Health Service or of a tribal organization;
             (G) AS 21.55 or other state high risk pool;
             (H) 5 U.S.C. 8901 - 8914;
             (I) a public health plan as defined under federal law; or
             (J) a health benefit plan under 22 U.S.C. 2504(e) (Peace Corps Act);
        (7) "employee" has the meaning given under 29 U.S.C. 1002(6) (Employee Retirement Income Security Act of 1974);
        (8) "employer" has the meaning given under 29 U.S.C. 1002(5) (Employee Retirement Income Security Act of 1974); for purposes of this chapter, "employer" includes a large or small employer, including a person, firm, corporation, partnership, association, or political subdivision, that is actively engaged in business;
        (9) "enrollment date" means the date of enrollment of an individual in a health benefit plan or health care insurance plan offered in the group market or the first day of the waiting period for enrollment, whichever occurs first;
        (10) "federal continuation provision" means a "COBRA continuation provision" as defined in 42 U.S.C. 300gg-91(d) (Health Insurance Portability and Accountability Act of 1996);
        (11) "federal governmental plan" means a governmental plan established or maintained for employees of the United States government or by an agency or instrumentality of the United States government;
        (12) "governmental plan" has the meaning given under 29 U.S.C. 1002(32) (Employee Retirement Income Security Act of 1974);
        (13) "group market" means the health care insurance market in which individuals obtain health care insurance coverage on behalf of themselves and their dependents through a health benefit plan maintained by a large or small employer; "group market" includes a health benefit plan for a small employer in the group market that includes an arrangement under which
             (A) a portion of the premium or benefits is paid by a small employer;
             (B) a covered individual or dependent is reimbursed, through wage adjustments or otherwise, by or on behalf of a small employer for all or a portion of the premium; or
             (C) the health benefit plan is treated by the employer or any of the eligible employees or dependents as part of a plan or program for the purposes of 26 U.S.C. 106 or 26 U.S.C. 162 (Internal Revenue Code);
        (14) "health benefit plan" means an employee welfare benefit plan as defined in 29 U.S.C. 1002(1) (Employee Retirement Income Security Act of 1974), and includes a plan, fund, or program established or maintained by a partnership, to the extent that the plan, fund, or program provides medical care, including items and services paid for as medical care to employees, present or former partners, or their dependents, as defined under the terms of the plan, fund, or program, directly or through insurance, reimbursement, or other method;
        (15) "health care insurance plan" means a health care insurance policy or contract but does not include an excepted benefits policy or contract;
        (16) "health care insurer" means a person transacting the business of health care insurance, including an insurance company licensed under AS 21.09, a hospital or medical service corporation licensed under AS 21.87, a fraternal benefit society licensed under AS 21.84, a health maintenance organization licensed under AS 21.86, a multiple employer welfare arrangement, a church plan, and a governmental plan, except for a nonfederal governmental plan that elects to be excluded under 42 U.S.C. 300gg-21(b)(2) (Health Insurance Portability and Accountability Act of 1996);
        (17) "health status factor" means any of the factors described in AS 21.54.100(a);
        (18) "large employer" means an employer that employed an average of at least 51 employees on the business days during the preceding calendar year and that employs at least two employees on the first day of a health benefit plan year;
        (19) "late enrollee" means a participant or beneficiary who requests enrollment in an employer's health care insurance plan following the initial enrollment period for which the participant or beneficiary was eligible to enroll under the terms of a health care insurance plan, except that a participant or beneficiary may not be considered a late enrollee if
             (A) the individual requests enrollment within 30 days after the termination of the creditable coverage or the exhaustion of coverage, was covered under creditable coverage at the time of the initial enrollment, and
                  (i) has lost creditable coverage as a result of the termination of employer contributions toward coverage or the termination of eligibility, including death, divorce, dissolution of marriage, legal separation, or a reduction in number of hours of employment; or
                  (ii) had coverage under a federal continuation provision and the coverage under that provision was exhausted;
             (B) the individual is employed by an employer who offers multiple health care insurance plans and the individual elects a different health care insurance plan during an open enrollment period; or
             (C) a court has ordered coverage to be provided for a spouse or minor child under a covered employee's plan and request for enrollment is made within 30 days after issuance of the court order;
        (20) "medical and surgical benefits" means benefits provided for medical or surgical services, but does not include mental health benefits;
        (21) "mental health benefits" means benefits provided for mental health services as defined under the terms of the health care insurance plan, but does not include benefits for treatment of substance abuse or chemical dependency;
        (22) "network plan" means a health care insurance plan offered in the group market or by an insurer 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 insurer;
        (23) "participant" has the meaning given under 29 U.S.C. 1002(7) (Employee Retirement Income Security Act of 1974); "participant" includes a
             (A) partner in relation to a partnership; or
             (B) self-employed individual if the individual or the individual's beneficiaries are or may become eligible to receive benefits under a health benefit plan maintained by the self-employed individual;
        (24) "placed for adoption" means the assumption and retention by an individual of a legal obligation for total or partial support of a child in anticipation of adopting the child;
        (25) "plan sponsor" has the meaning given under 29 U.S.C. 1002(16)(B) (Employee Retirement Income Security Act of 1974);
        (26) "preexisting condition exclusion" means a limitation or exclusion of benefits relating to a physical or mental condition that was present before the enrollment date, regardless of whether medical advice, diagnosis, care, or treatment was recommended or received before the enrollment date;
        (27) "small employer" means an employer that employed an average of at least two but not more than 50 employees on the business days during the preceding calendar year and that employs at least two employees on the first day of a health benefit plan year;
        (28) "waiting period" means the period that must pass before an individual who is a potential participant or beneficiary in a health care insurance plan offered in the group market is eligible to be covered for benefits under the terms of the plan.

Authorities

18.09.990;21.06.085;21.07.250;21.09.270;21.36.480;21.36.485;21.36.495;21.42.145;21.42.347;21.42.351;21.42.397;21.42.599;21.51.500;21.55.500;21.56.110;21.56.250;21.85.500;21.86.900;23.50.099

Notes

Recent Bills that will modify this

HB 372 OMNIBUS INSURANCE

References

3 AAC 28.510
3 AAC 31.549
AS 18.09.990 Definitions.
AS 21.06.085 Uniform data and procedures for health claims.
AS 21.07.250 Definitions.
AS 21.09.270 Retaliation.
AS 21.36.480 Genetic information nondiscrimination.
AS 21.36.485 Coverage of children.
AS 21.36.495 Prompt payment of health care insurance claims.
AS 21.42.145 Stop-loss insurance provisions.
AS 21.42.347 Coverage for costs of birth.
AS 21.42.351 Coverage for well-baby exams.
AS 21.42.397 Coverage for autism spectrum disorders.
AS 21.42.599 Definitions.
AS 21.51.500 Definitions.
AS 21.55.500 Definitions.
AS 21.56.110 Applicability.
AS 21.56.250 Definitions.
AS 21.85.500 Definitions.
AS 21.86.900 Definitions.
AS 23.50.099 Definitions.

History

(Sec. 59 ch 81 SLA 1997; am Sec. 12, 13 ch 72 SLA 2000; am Sec. 28, 29 ch 41 SLA 2009; am Sec. 80 ch 23 SLA 2011; am Sec. 64 ch 41 SLA 2016)