33-22-1501. Definitions. As used in this part, the following definitions apply:
     (1) "Association" means the comprehensive health association created by 33-22-1503.
     (2) "Association plan" means a policy of insurance coverage that is offered by the association and that is certified by the association as required by 33-22-1521.
     (3) "Association plan premium" means the charge determined pursuant to 33-22-1512 for membership in the association plan based on the benefits provided in 33-22-1521.
     (4) "Association portability plan" means a policy of insurance coverage that is offered by the association to a federally defined eligible individual.
     (5) "Association portability plan premium" means the charge determined by the association and approved by the commissioner for an association portability plan.
     (6) "Block of business" means a separate risk pool grouping of covered individuals, enrollees, and dependents as defined by rules of the commissioner.
     (7) (a) "Eligible person" means an individual who:
     (i) is a resident of this state and applies for coverage under the association plan;
     (ii) is not eligible for any other form of health insurance coverage or health service benefits, except:
     (A) for coverage consisting solely of excepted benefits, as defined in 33-22-140; or
     (B) subject to eligibility limitations adopted pursuant to 33-22-1502(1)(b), if the individual has coverage comparable to the association plan but is paying a premium or has received a renewal notice to pay a premium that is more than 150% of the average premium rate used to calculate the association plan premium rate pursuant to 33-22-1512(1); and
     (iii) meets one or more of the following criteria:
     (A) has, within 6 months prior to the date of application, been rejected for disability insurance or health service benefits by at least two insurers, societies, or health service corporations, unless the association waives this requirement; or
     (B) has had a restrictive rider or preexisting conditions limitation, which limitation is required by at least two insurers, societies, or health service corporations, that has the effect of substantially reducing coverage from that received by a person considered a standard risk.
     (b) The term does not apply to an individual who is certified as eligible for federal trade adjustment assistance or for pension benefit guarantee corporation assistance, as provided by the federal Trade Adjustment Assistance Reform Act of 2002, and is eligible for the association portability plan.
     (8) "Federally defined eligible individual" means a person who is an individual enrolling in the association portability plan:
     (a) for whom, as of the date on which the individual seeks coverage under the association portability plan, the aggregate of the periods of creditable coverage is 18 months or more and whose most recent prior creditable coverage was under a group health plan, governmental plan, or church plan;
     (b) who does not have other health insurance coverage;
     (c) who is not eligible for coverage under:
     (i) a group health plan;
     (ii) Title XVIII, part A or B, of the Social Security Act, 42 U.S.C. 1395c through 1395i-4 or 42 U.S.C. 1395j through 1395w-4; or
     (iii) a state plan under Title XIX of the Social Security Act, 42 U.S.C. 1396a through 1396u, or a successor program;
     (d) for whom the most recent coverage was not terminated for factors relating to nonpayment of premiums or fraud;
     (e) who, if offered the option of continuation coverage under a COBRA continuation provision or under a similar state program, elected that coverage; and
     (f) who has exhausted continuation coverage under the COBRA continuation provision or program described in subsection (8)(e) if the individual elected the continuation coverage described in subsection (8)(e).
     (9) "Health service corporation" means a corporation operating pursuant to Title 33, chapter 30, and offering or selling contracts of disability insurance.
     (10) "Insurance arrangement" means any plan, program, contract, or other arrangement to the extent not exempt from inclusion by virtue of the provisions of the federal Employee Retirement Income Security Act of 1974 under which one or more employers, unions, or other organizations provide to their employees or members, either directly or indirectly through a trust of a third-party administrator, health care services or benefits other than through an insurer.
     (11) "Insurer" means a company operating pursuant to Title 33, chapter 2 or 3, and offering or selling policies or contracts of disability insurance, as provided in Title 33, chapter 22.
     (12) "Lead carrier" means the licensed administrator or insurer selected by the association to administer the association plan.
     (13) "Medicare" means coverage under both parts A and B of Title XVIII of the Social Security Act, 42 U.S.C. 1395, et seq., as amended.
     (14) "Preexisting condition" means any condition for which an applicant for coverage under the association plan has received medical attention during the 3 years immediately preceding the filing of an application.
     (15) "Qualified TAA-eligible individual" means an individual and any dependent of that individual, in addition to meeting the requirements specified in subsection (17):
     (a) who has 3 months of prior creditable coverage;
     (b) whose application for association portability plan coverage is made within 63 days following termination of the applicant's most recent prior creditable coverage; and
     (c) who, if eligible for COBRA, is not required to elect or exhaust continuation coverage under the COBRA continuation provision or under a similar state program.
     (16) "Society" means a fraternal benefit society operating pursuant to Title 33, chapter 7, and offering or selling certificates of disability insurance.
     (17) "TAA-eligible individual" means an individual and any dependent of that individual enrolling in the association portability plan:
     (a) who is a resident of this state on the date of application to the pool;
     (b) who has been certified as eligible for federal trade adjustment assistance and a health insurance tax credit or for pension benefit guarantee corporation assistance, as provided by the federal Trade Adjustment Assistance Reform Act of 2002;
     (c) who does not have other health insurance coverage; and
     (d) who is not covered under a group health plan maintained by an employer, including a group health plan available through a spouse, if the employer contributes 50% or more to the total cost of coverage.

     History: En. Sec. 1, Ch. 595, L. 1985; amd. Sec. 15, Ch. 798, L. 1991; amd. Sec. 5, Ch. 357, L. 1995; amd. Sec. 17, Ch. 416, L. 1997; amd. Sec. 1, Ch. 173, L. 1999; amd. Sec. 1, Ch. 453, L. 2003.