Ga. Comp. R. & Regs. R. 120-2-81-.03 - Definitions

(1) For the purpose of this Regulation Chapter, the following definitions shall apply:

(a) "Assignment System" shall mean the Georgia Health Insurance Assignment System (GHIAS) and the Georgia Health Benefits Assignment System (GHBAS) as established by O.C.G.A. § 33-29A-1 et seq. and this Regulation Chapter.

(b) "Continuation Coverage" shall mean any coverage under the Consolidated Omnibus Budget Reconciliation Act of 1986 (COBRA).

(c) "Eligible Dependent" shall mean a dependent of a qualifying eligible individual, including a spouse, covered under the qualifying eligible individual's most recent group health plan, or continuation coverage thereof, who meets the requirements of subparagraphs (f)(1) through (6) below. Eligible dependents shall include any dependents who would otherwise not qualify for coverage because they have less than eighteen (18) months previous creditable coverage, provided:

(1) they were born, adopted, or placed for adoption during coverage under the most recent group health plan or continuation coverage of the qualifying eligible individual; and

(2) were enrolled under such coverage within 31 days of birth, adoption, or placement for adoption.

(d) "Group Health Plan" shall mean creditable coverage under an employer sponsored health benefit arrangement which does not provide benefits through a group health insurance policy or contract, or a group health insurance policy or contract subject to the laws of another state and not required to issue conversion policies pursuant to O.C.G.A. § 33-24-21.1.

(e) "Individual Health Insurance" or "Individual Health Benefits" shall mean any creditable coverage offered by a health insurer or managed care organization in the individual market as defined in Section 2791(e)(1) of the federal Public Health Service Act, issued or actively marketed to an individual in Georgia through a policy or certificate of coverage approved by the Commissioner or otherwise permitted by state law or the Rules and Regulations of the Office of Commissioner of Insurance, and as determined by the Commissioner pursuant to O.C.G.A. 33-29A-1et seq. and Rule 120-2-81-.17, but, in any case, not including:

(1) limited benefit insurance as defined in O.C.G.A. § 33-24-21.1(I) or excepted benefits pursuant to 45 CFR 148.220; and

(2) certificates issued to individuals through a true association as defined in O.C.G.A. § 33-30-1(b).

(f) "Qualifying Eligible Individual" shall mean any Georgia domiciliary who meets all of the following:

(1) As of the date on which the individual seeks coverage under this section, the aggregate period of previous creditable coverage is 18 months or more;

(2) The individual's most recent coverage was under a group health plan, or continuation coverage thereof;

(3) The individual's insurance under the group health plan has been terminated for any reason, including discontinuance of the group health plan in its entirety or with respect to a class, except for non-payment of premium contribution pertaining to the qualifying eligible individual;

(4) With regard to such an individual's coverage under a group health plan or continuation thereof, a qualifying event has occurred on or after October 30, 1997;

(5) The individual is not eligible for, or has not declined, any of the following:

(a) Coverage under a group health insurance policy or contract, or other group health plan, including continuation coverage under COBRA or O.C.G.A. §§ 33-24-21.1 or 33-24-21.2;

(b) Medicare;

(c) The state plan under Medicaid or any successor program; or

(d) Enhanced conversion coverage offered in accordance with O.C.G.A. § 33-24-21.1 and the Rules and Regulations of the Office of Commissioner of Insurance;

(6) The individual is not enrolled in or covered under any other creditable health insurance coverage, including individual health insurance policies or blanket accident and sickness insurance pertaining to student health coverage; and

(7) The individual is one of the following:

(a) A current or former employee, member, or enrollee covered under the group health plan or continuation coverage thereof, if applicable;

(b) The surviving spouse, if any, of a deceased covered employee, member, or enrollee, with or without dependents;

(c) The spouse, or a former spouse, with or without dependents, of a covered employee, member, or enrollee upon a qualifying event of the spouse while the employee, member, or enrollee remains insured under the group health plan or continuation thereof, by ceasing to be a qualified family member under the group health plan, such as a result of a valid decree of divorce; or

(d) An otherwise eligible dependent upon reaching limiting age or otherwise losing dependent status under the group health plan or continuation thereof, or under coverage issued to another qualifying eligible individual in the assignment system.

(g) "Qualifying Event" shall mean loss of creditable coverage resulting from either:

(1) Exhaustion of continuation coverage to the maximum extent eligible under federal law; or

(2) Termination of coverage under a group health plan, in the event such a qualifying eligible individual is not eligible for continuation coverage.

(h) "Schedule of Benefits" shall mean the outline of benefit levels for a policy or plan, including but not limited to the types of benefits covered and associated cost-sharing provisions.

(2) All other terms shall have the same meaning as in O.C.G.A. § 33-29A-1 et seq. and Section 2791 of the Federal Public Health Service Act.

Notes

Ga. Comp. R. & Regs. R. 120-2-81-.03

O.C.G.A. Secs. 33-2-9, 33-29A-1, et seq.

ER. 120-2-81-0.8 adopted. F. Dec. 31, 1997; eff. Jan. 2, 1998, to remain in effect for a period of 120 days or until the effective date of a permanent Rule covering the same subject matter superseding the ER, is adopted, as specified by the Agency. Amended: Permanent Rule entitled "Definitions" adopted. F. Apr. 29, 1998; eff. May 19, 1998.