2009 Iowa Code
Title 13 - Commerce
Subtitle 1 - Insurance and Related Regulation
CHAPTER 513B - SMALL GROUP HEALTH COVERAGE
513B.2 - DEFINITIONS.

        513B.2  DEFINITIONS.
         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
      insurance coverages.
         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 for health insurance
      plans with the same or similar coverage.
         3.  "Basic health benefit plan" means a plan established by
      the board of the small employer health reinsurance program pursuant
      to section 513B.13, subsection 8, paragraph "a".
         4.  "Carrier" means an entity subject to the insurance laws
      and regulations of this state, or subject to the jurisdiction of the
      commissioner, that contracts or offers to contract to provide,
      deliver, arrange for, pay for, or reimburse any of the costs of
      health care services, including an insurance company offering
      sickness and accident plans, a health maintenance organization, a
      nonprofit health service corporation, or any other entity providing a
      plan of health insurance, health benefits, or health services.
         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 insurance
      coverages meet one or more of the following requirements:
         (1)  The coverages 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 coverages have been acquired from another small employer
      carrier as a distinct grouping of plans.
         (3)  The coverages are provided by a policy of group health
      insurance coverage through a bona fide association as provided in
      section 509.1, subsection 8, which meets the requirements for a class
      of business under section 513B.4.  A small employer carrier may
      condition coverages under such a policy of group health insurance
      coverage on any of the following requirements:
         (a)  Minimum levels of participation by employees of each member
      of a bona fide association that offers the coverage to its employees.

         (b)  Minimum levels of contribution by each member of a bona fide
      association that offers the coverage to its employees.
         (c)  A specified policy term, subject to annual premium rate
      adjustments as permitted by section 513B.4.
         (4)  The coverages are provided by a policy of group health
      insurance coverage through two or more bona fide associations as
      provided in section 509.1, subsection 8, which a small employer
      carrier has aggregated as a distinct grouping that meets the
      requirements for a class of business under section 513B.4.  After a
      distinct grouping of bona fide associations is established as a class
      of business, the small employer carrier shall not remove a bona fide
      association from the class based on the claims experience of that
      association.  A small employer carrier may condition coverages under
      such a policy of group health insurance coverage on any of the
      following requirements:
         (a)  Minimum levels of participation by employees of each member
      of a bona fide association in the class that offers the coverage to
      its employees.
         (b)  Minimum levels of contribution by each member of a bona fide
      association in the class that offers the coverage to its employees.
         (c)  A specified policy term, subject to annual premium rate
      adjustments as permitted by section 513B.4.
         b.  A small employer carrier may establish 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.  "Creditable coverage" means health benefits or coverage
      provided to an individual under any of the following:
         a.  A group health plan.
         b.  Health insurance coverage.
         c.  Part A or Part B Medicare pursuant to Tit. XVIII of the
      federal Social Security Act.
         d.  Medicaid pursuant to Tit. XIX of the federal Social
      Security Act, other than coverage consisting solely of benefits under
      section 1928 of that Act.
         e.  10 U.S.C. ch. 55.
         f.  A health or medical care program provided through the
      Indian health service or a tribal organization.
         g.  A state health benefits risk pool.
         h.  A health plan offered under 5 U.S.C. ch. 89.
         i.  A public health plan as defined under federal regulations.

         j.  A health benefit plan under section 5(e) of the federal
      Peace Corps Act, 22 U.S.C. § 2504(e).
         k.  An organized delivery system licensed by the director of
      public health.
         l.  A short-term limited duration policy.
         m.  The hawk-i program authorized by chapter 514I.
         9.  "Division" means the division of insurance.
         10.  "Eligible employee" means an employee who works on a
      full-time basis and has a normal workweek 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 health
      insurance coverage of a small employer, but does not include an
      employee who works on a part-time, temporary, or substitute basis.
         11. a.  "Group health plan" means an employee welfare benefit
      plan as defined in section 3(1) of the federal Employee Retirement
      Income Security Act of 1974, to the extent that the plan provides
      medical care 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.
         b.  For purposes of this subsection, "medical care" means
      amounts paid for any of the following:
         (1)  The diagnosis, cure, mitigation, treatment, or prevention of
      disease, or amounts paid for the purpose of affecting a structure or
      function of the body.
         (2)  Transportation primarily for and essential to medical care
      referred to in subparagraph (1).
         (3)  Insurance covering medical care referred to in subparagraph
      (1) or (2).
         c.  For purposes of this subsection, a partnership which
      establishes and maintains a plan, fund, or program to provide medical
      care to present or former partners in the partnership or to their
      dependents directly or through insurance, reimbursement, or other
      method, which would not be an employee benefit welfare plan but for
      this paragraph, shall be treated as an employee benefit welfare plan
      which is a group health plan.
         (1)  For purposes of a group health plan, an employer includes the
      partnership in relation to any partner.
         (2)  For purposes of a group health plan, the term
      "participant" also includes both of the following:
         (a)  An individual who is a partner in relation to a partnership
      which maintains a group health plan.
         (b)  An individual who is a self-employed individual in connection
      with a group health plan maintained by the self-employed individual
      where one or more employees are participants, if the individual is or
      may become eligible to receive a benefit under the plan or the
      individual's beneficiaries may be eligible to receive a benefit.
         12. a.  "Health insurance coverage" means benefits consisting
      of health care provided directly, through insurance or reimbursement,
      or otherwise and including items and services paid for as health care
      under a hospital or health service policy or certificate, hospital or
      health service plan contract, or health maintenance organization
      contract offered by a carrier.
         b.  "Health insurance coverage" does not include any of the
      following:
         (1)  Coverage for accident-only, or disability income insurance.
         (2)  Coverage issued as a supplement to liability insurance.
         (3)  Liability insurance, including general liability insurance
      and automobile liability insurance.
         (4)  Workers' compensation or similar insurance.
         (5)  Automobile medical-payment insurance.
         (6)  Credit-only insurance.
         (7)  Coverage for on-site medical clinic care.
         (8)  Other similar insurance coverage, specified in federal
      regulations, under which benefits for medical care are secondary or
      incidental to other insurance coverage or benefits.
         c.  "Health insurance coverage" does not include benefits
      provided under a separate policy as follows:
         (1)  Limited scope dental or vision benefits.
         (2)  Benefits for long-term care, nursing home care, home health
      care, or community-based care.
         (3)  Any other similar limited benefits as provided by rule of the
      commissioner.
         d.  "Health insurance coverage" does not include benefits
      offered as independent noncoordinated benefits as follows:
         (1)  Coverage only for a specified disease or illness.
         (2)  A hospital indemnity or other fixed indemnity insurance.
         e.  "Health insurance coverage" does not include Medicare
      supplemental health insurance as defined under § 1882(g)(1) of the
      federal Social Security Act, coverage supplemental to the coverage
      provided under 10 U.S.C. ch. 55, and similar supplemental coverage
      provided to coverage under group health insurance coverage.
         f.  "Group health insurance coverage" means health insurance
      coverage offered in connection with a group health plan.
         13.  "Index rate" means, for each class of business for small
      employers, the average of the applicable base premium rate and the
      corresponding highest premium rate.
         14.  "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 creditable coverage at the
      time of the initial enrollment.
         (2)  The individual lost creditable coverage as a result of
      termination of the individual's employment or eligibility, the
      involuntary termination of the creditable coverage, death of the
      individual's spouse, or the individual's divorce.
         (3)  The individual requests enrollment within thirty days after
      termination of the creditable coverage.
         b.  The individual is employed by an employer that offers
      multiple health insurance coverages and the individual elects a
      different coverage 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
      insurance coverage and the request for enrollment is made within
      thirty days after issuance of the court order.
         d.  The individual changes status and becomes an eligible
      employee and requests enrollment within sixty-three days after the
      date of the change in status.
         e.  The individual was covered under a mandated continuation
      of group health plan or group health insurance coverage plan until
      the coverage under that plan was exhausted.
         15.  "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 for newly
      issued health insurance coverages with the same or similar coverage.

         16.  "Preexisting conditions exclusion" means, with respect to
      health insurance 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 such coverage, whether or
      not any medical advice, diagnosis, care, or treatment was recommended
      or received before such date.
         17.  "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.
         18.  "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.
         19.  "Small employer carrier" means any carrier which offers
      health benefit plans covering the employees of a small employer.
         20.  "Standard health benefit plan" means a plan established
      by the board of the small employer health reinsurance program
      pursuant to section 513B.13, subsection 8, paragraph "a".  

         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; 97 Acts, ch 103,
      §2--11; 98 Acts, ch 1057, § 8; 2000 Acts, ch 1023, §20; 2001 Acts, ch
      69, §13, 39; 2007 Acts, ch 57, §3--5, 8; 2007 Acts, ch 215, §255;
      2009 Acts, ch 118, §20
         Referred to in § 135H.3, 509.1, 509.3, 509A.13B, 514A.3B, 514B.9A,
      514C.14, 514C.15, 514C.16, 514C.17, 514C.22, 514F.5
         Organized delivery systems, see 93 Acts, ch 158, §3