As used in this subchapter, unless the context otherwise requires:
1. "Actuarial certification" means a written statement by a member of the American academy of actuaries or other individual acceptable to the commissioner that a small employer carrier is in compliance with the provisions of section 513B.4, based upon the person's examination, including a review of the appropriate records and of the actuarial assumptions and methods utilized by the small employer carrier in establishing premium rates for applicable health benefit plans.
2. "Base premium rate" means, for each class of business as to a rating period, the lowest premium rate charged or which could have been charged under a rating system for that class of business, by the small employer carrier to small employers with similar case characteristics for health insurance plans with the same or similar coverage.
3. "Basic health benefit plan" means a plan which is offered pursuant to section 513B.14.
4. "Carrier" means any person who provides health insurance in this state. For the purposes of this subchapter, carrier includes a licensed insurance company, a prepaid hospital or medical service plan, a health maintenance organization, a multiple employer welfare arrangement or any other person providing a plan of health insurance subject to state insurance regulation.
5. "Case characteristics" means demographic or other relevant characteristics of a small employer, as determined by a small employer carrier, which are considered by the insurer in the determination of premium rates for the small employer. Claim experience, health status, and duration of coverage since issue are not case characteristics for the purpose of this subchapter.
6. "Class of business" means all or a distinct grouping of small employers as shown on the records of the small employer carrier.
a. A distinct grouping may only be established by the small employer carrier on the basis that the applicable health benefit plans meet one or more of the following requirements:
(1) The plans are marketed and sold through individuals and organizations which are not participating in the marketing or sales of other distinct groupings of small employers for the small employer carrier.
(2) The plans have been acquired from another small employer carrier as a distinct grouping of plans.
(3) The plans are provided through an association with membership of not less than fifty small employers which has been formed for purposes other than obtaining insurance.
b. A small employer carrier may establish no more than two additional groupings under each of the subparagraphs in paragraph "a" on the basis of underwriting criteria which are expected to produce substantial variation in the health care costs.
c. The commissioner may approve the establishment of additional distinct groupings upon application to the commissioner and a finding by the commissioner that such action would enhance the efficiency and fairness of the small employer insurance marketplace.
7. "Commissioner" means the commissioner of insurance.
8. "Division" means the division of insurance.
9. "Eligible employee" means an employee who works on a full-time basis and has a normal work week of thirty or more hours. The term includes a sole proprietor, a partner of a partnership, and an independent contractor, if the sole proprietor, partner, or independent contractor is included as an employee under a health benefit plan of a small employer, but does not include an employee who works on a part-time, temporary, or substitute basis.
10. a. "Health benefit plan" or "plan" means any hospital or medical expense incurred policy or certificate, major medical expense insurance, hospital or medical service plan contract, or health maintenance organization subscriber contract.
b. "Health benefit plan" does not include accident-only, credit, dental, Medicare supplement, long-term care, or disability income insurance, coverage issued as a supplement to liability insurance, workers' compensation or similar insurance, or automobile medical-payment insurance.
c. "Health benefit plan" also does not include policies or certificates of specified disease, hospital confinement indemnity, or limited benefit health insurance if the carrier offering such policies or certificates complies with all of the following:
(1) The carrier files on or before March 1 of each year a certification with the commissioner that contains the following statement and information:
(a) A statement from the carrier certifying that policies or certificates described in this paragraph "c" are being offered and marketed as supplemental health insurance and not as a substitute for hospital or medical expense insurance or major medical expense insurance.
(b) A summary description of each policy or certificate described in this paragraph "c" including the average annual premium rates or range of premium rates in cases where premiums vary by age, gender, or other factors, which are to be charged for such policies and certificates in this state.
(2) If a policy or certificate described in this paragraph "c" is offered for the first time in this state on or after July 1, 1993, the carrier files with the commissioner the information and statement required in subparagraph (1) at least thirty days prior to the date such policy or certificate is issued or delivered in this state.
11. "Index rate" means for each class of business for small employers with similar case characteristics the average of the applicable base premium rate and the corresponding highest premium rate.
12. "Late enrollee" means an eligible employee or dependent who requests enrollment in a health benefit plan of a small employer following the initial enrollment period for which such individual is entitled to enroll under the terms of the health benefit plan, provided the initial enrollment period is a period of at least thirty days. An eligible employee or dependent shall not be considered a late enrollee if any of the following apply:
a. The individual meets all of the following:
(1) The individual was covered under qualifying previous coverage at the time of the initial enrollment.
(2) The individual lost coverage under qualifying previous coverage as a result of termination of the individual's employment or eligibility, the involuntary termination of the qualifying previous coverage, death of the individual's spouse, or the individual's divorce.
(3) The individual requests enrollment within thirty days after termination of the qualifying previous coverage.
b. The individual is employed by an employer that offers multiple health benefit plans and the individual elects a different plan during an open enrollment period.
c. A court has ordered that coverage be provided for a spouse or minor or dependent child under a covered employee's health benefit plan and the request for enrollment is made within thirty days after issuance of the court order.
13. "New business premium rate" means, for each class of business as to a rating period, the lowest premium rate charged or offered by the small employer carrier to small employers with similar case characteristics for newly issued health benefit plans with the same or similar coverage.
14. "Qualifying previous coverage" and "qualifying existing coverage" mean benefits or coverage provided under any of the following:
a. Medicaid pursuant to Title XIX of the Social Security Act, medicare pursuant to Title XVIII of the Social Security Act, or coverage pursuant to the person's service as a member of a branch of the armed forces of the United States.
b. An employer-based health insurance or health benefit arrangement that provides benefits similar to or exceeding benefits provided under a basic health benefit plan.
c. An individual health insurance policy or contract issued by a carrier which provides benefits similar to or exceeding the benefits provided under the basic health benefit plan, provided the policy or contract has been in effect for a period of at least one year.
15. "Rating period" means the calendar period for which premium rates established by a small employer carrier are assumed to be in effect, as determined by the small employer carrier.
16. "Small employer" means a person actively engaged in business who, on at least fifty percent of the employer's working days during the preceding year, employed not less than two and not more than fifty full-time equivalent eligible employees. In determining the number of eligible employees, companies which are affiliated companies or which are eligible to file a combined tax return for purposes of state taxation are considered one employer.
17. "Small employer carrier" means any carrier which offers health benefit plans covering the employees of a small employer.
18. "Standard health benefit plan" means a plan which is offered pursuant to section 513B.14.
91 Acts, ch 244, § 2; 92 Acts, ch 1167, § 1; 93 Acts, ch 80, § 2, 3; 94 Acts, ch 1176, §9; 95 Acts, ch 185, §9
Referred to in § 513B.10
© 1997 Cornell College and League of Women Voters of Iowa
Last update: Mon Jan 27 16:05:08 CST 1997