2005 Idaho Code - 41-4703 — DEFINITIONS

                                  TITLE  41
                                  INSURANCE
                                  CHAPTER 47
                            SMALL EMPLOYER HEALTH
                          INSURANCE AVAILABILITY ACT
    41-4703.  DEFINITIONS. As used in this chapter:
    (1)  "Actuarial certification" means a written statement by a member of
the American academy of actuaries or other individual acceptable to the
director that a small employer carrier is in compliance with the provisions of
section 41-4706, Idaho Code, based upon the person's examination and including
a review of the appropriate records and the actuarial assumptions and methods
used by the small employer carrier in establishing premium rates for
applicable health benefit plans.
    (2)  "Affiliate" or "affiliated" means any entity or person who directly
or indirectly through one (1) or more intermediaries, controls or is
controlled by, or is under common control with, a specified entity or person.
    (3)  "Agent" means a producer as defined in section 41-1003(9)[(8)], Idaho
Code.
    (4)  "Base premium rate" means, for each class of business as to a rating
period, the lowest premium rate charged or that 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 benefit plans
with the same or similar coverage.
    (5)  "Board" means the board of directors of the small employer
reinsurance program and the individual high risk reinsurance pool as provided
for in section 41-5502, Idaho Code.
    (6)  "Carrier" means any entity that provides, or is authorized to
provide, health insurance in this state. For the purposes of this chapter,
carrier includes an insurance company, a hospital or professional service
corporation, a fraternal benefit society, a health  maintenance organization,
any entity providing health insurance coverage or benefits to residents of
this state as certificate holders under a group policy issued or delivered
outside of this state, and any other entity providing a plan of health
insurance or health benefits subject to state insurance regulation.
    (7)  "Case characteristics" means demographic or other objective
characteristics of a small employer that are considered by the small employer
carrier in the determination of premium rates for the small employer, provided
that claim experience, health  status and duration of coverage shall not be
case characteristics for the purposes of this chapter.
    (8)  "Catastrophic health benefit plan" means a higher limit health
benefit plan developed pursuant to section 41-4712, Idaho Code.
    (9)  "Class of business" means all or a separate grouping of small
employers established pursuant to section 41-4705, Idaho Code.
    (10) "Control" shall be defined in the same manner as in section
41-3801(2), Idaho Code.
    (11) "Dependent" means a spouse, an unmarried child under the age of
nineteen (19) years, an unmarried child who is a full-time student under the
age of twenty-three (23) years and who is financially dependent upon the
parent, and an unmarried child of any age who is medically certified as
disabled and dependent upon the parent.
    (12) "Director" means the director of the department of insurance of the
state of Idaho.
    (13) "Eligible employee" means an employee who works on a full-time basis
and has a normal work week of thirty (30) or more hours or, by agreement
between the employer and the carrier, an employee who works  between twenty
(20) and thirty (30) hours per week. 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, seasonal or substitute basis. The term
eligible employee may include public officers and public employees without
regard to the number of hours worked when designated by a small employer.
    (14) "Established geographic service area" means a geographic area, as
approved by the director and based on the carrier's certificate of authority
to transact insurance in this state, within which the carrier is authorized to
provide coverage.
    (15) "Health benefit plan" means any hospital or medical policy or
certificate, any subscriber contract provided by a hospital or professional
service corporation, or managed care organization subscriber contract. Health
benefit plan does not include policies or certificates of insurance for
specific disease, hospital confinement indemnity, accident-only, credit,
dental, vision, medicare supplement, long-term care, or disability income
insurance, student health benefits only coverage issued as a supplement to
liability insurance, worker's compensation or similar insurance, automobile
medical payment insurance or nonrenewable short-term coverage issues for a
period of twelve (12) months or less.
    (16) "Index rate" means, for each class of business as to a rating period
for small employers with similar case characteristics, the arithmetic average
of the applicable base premium rate and the corresponding highest premium
rate.
    (17) "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 during which the individual is entitled to enroll under the
terms of the health benefit plan, provided that the initial enrollment period
is a period of at least thirty (30) days. However, an eligible employee or
dependent shall not be considered a late enrollee if:
    (a)  The individual meets each of the following:
         (i)   The individual was covered under qualifying previous coverage
         at the time of the initial enrollment;
         (ii)  The individual lost coverage under qualifying previous coverage
         as a result of termination of employment or eligibility, or the
         involuntary termination of the qualifying previous coverage; and
         (iii) The individual requests enrollment within thirty (30) days
         after termination of the qualifying previous coverage.
    (b)  The individual is employed by an employer which offers multiple
    health benefit plans and the individual elects a different plan during an
    open enrollment period.
    (c)  A court has ordered coverage be provided for a spouse or minor or
    dependent child under a covered employee's health benefit plan and request
    for enrollment is made within thirty (30) days after issuance of the court
    order.
    (d)  The individual first becomes eligible.
    (e)  If an individual seeks to enroll a dependent during the first sixty
    (60) days of eligibility, the coverage of the dependent shall become
    effective:
         (i)   In the case of marriage, not later than the first day of the
         first month beginning after the date the completed request for
         enrollment is received;
         (ii)  In the case of a dependent's birth, as of the date of such
         birth; or
         (iii) In the case of a dependent's adoption or placement for
         adoption, the date of such adoption or placement for adoption.
    (18) "New business premium rate" means, for each class of business as to a
rating period, the lowest premium rate charged or offered or which could have
been 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.
    (19) "Plan of operation" means the plan of operation of the program
established pursuant to section 41-4711, Idaho Code.
    (20) "Plan year" means the year that is designated as the plan year in the
plan document of a group health benefit plan, except that if the plan document
does not designate a plan year or if there is no plan document, the year plan
is:
    (a)  The deductible/limit year used under the plan;
    (b)  If the plan does not impose deductibles or limits on a yearly basis,
    then the plan year is the policy year;
    (c)  If the plan does not impose deductibles or limits on a yearly basis
    or the insurance policy is not renewed on an annual basis, then the plan
    year is the employer's taxable year; or
    (d)  In any other case, the plan year is the calendar year.
    (21) "Premium" means all moneys paid by a small employer and eligible
employees as a condition of receiving coverage from a small employer carrier,
including any fees or other contributions associated with the health benefit
plan.
    (22) "Program" means the Idaho small employer reinsurance program created
in section 41-4711, Idaho Code.
    (23) "Qualifying previous coverage" and "qualifying existing coverage"
mean benefits or coverage provided under:
    (a)  Medicare or medicaid, civilian health and medical program for
    uniformed services (CHAMPUS), the Indian health service program, a state
    health benefit risk pool or any other similar publicly sponsored program;
    or
    (b)  Any other group or individual health insurance policy or health
    benefit arrangement whether or not subject to the state insurance laws,
    including coverage provided by a health maintenance organization, hospital
    or professional service corporation, or a fraternal benefit society, that
    provides benefits similar to or exceeding benefits  provided under the
    basic health benefit plan.
    (24) "Rating period" means the calendar period for which premium rates
established by a small employer carrier are assumed to be in effect.
    (25) "Reinsuring carrier" means a small employer carrier participating in
the reinsurance program pursuant to section 41-4711, Idaho Code.
    (26) "Restricted network provision" means any provision of a health
benefit plan that conditions the payment of benefits, in whole or in part, on
the use of health care providers that have entered into a contractual
arrangement with the carrier to provide health care services to covered
individuals.
    (27) "Risk-assuming carrier" means a small employer carrier whose
application is approved by the director pursuant to section 41-4710, Idaho
Code.
    (28) "Small employer" means any person, firm, corporation, partnership or
association that is actively engaged in business that employed an average of
at least two (2) but no more than fifty (50) eligible employees on business
days during the preceding calendar year and that employs at least two (2) but
no more than fifty (50) eligible employees on the first day of the plan year,
the majority of whom were and are employed within this state. In determining
the number of eligible employees, companies that are affiliated companies, or
that are eligible to file a combined tax return for purposes of state
taxation, shall be considered one (1) employer.
    (29) "Small employer basic health benefit plan" means a lower cost health
benefit plan developed pursuant to section 41-4712, Idaho Code.
    (30) "Small employer carrier" means a carrier that offers health benefit
plans covering eligible employees of one (1) or more small employers in this
state.
    (31) "Small employer catastrophic health benefit plan" means a higher
limit health benefit plan developed pursuant to section 41-4712, Idaho Code.
    (32) "Small employer standard health benefit plan" means a health benefit
plan developed pursuant to section 41-4712, Idaho Code.