Group or blanket insurance (including school insurance programs); or
b. Blue Cross, Blue Shield, group practice (including HMOs and PPOs), individual practice (including IPAs), or any other prepayment arrangement (including this program) when:
(1) An employer contributes any portion of the premium;
(2) An employer contracts for the group coverage on behalf of employees; or
(3) It is any labor-management trustee plan, union welfare plan, employer organization plan, or employee benefit organization plan.
2. The term "health plan" refers to each plan or program separately. It also refers to any portion of a plan or program that reserves the right to take into account benefits of other health plans when determining its own benefits. If a health plan has a coordination of benefits provision that applies to only part of its services, the terms of this section will be applied separately to that part and to any other part.
3. A prepaid health care services contract or accident or health plan meeting all the following conditions is not a health plan:
a. One that is individually underwritten;
b. One that is individually issued;
c. One that provides only for accident and sickness benefits; and
d. One that is paid for entirely by the subscriber. A contract or policy of the type described in subdivision 3 of this definition is not subject to coordination of benefits.
"Independent hearing officer" means an individual requested by the director of the department from a list maintained by the Executive Secretary of the Supreme Court of Virginia to arbitrate disputes that may arise in conjunction with these regulations or the health benefits program.
"Independent review organization" means an organization that, upon written request from the Department of Human Resource Management, examines the adverse health benefits claim decision made by the Commonwealth's Third Party Administrator (TPA). The independent review organization should determine whether the TPA's decision is objective, clinically valid, compatible with established principles of health care, and appropriate under the terms of the contractual obligations to the covered person.
"Insured arrangement" means an accident or health plan underwritten by an insurance company wherein the department's only obligation as it may relate to claims is the payment of insurance company premiums.
"Local employees" or "employees of local governments" means all officers and employees of the governing body of any county, city, or town, and the directing or governing body of any political entity, subdivision, branch, or unit of the Commonwealth or of any commission or public authority or body corporate created by or under an act of the General Assembly specifying the power or powers, privileges or authority capable of exercise by the commission or public authority or body corporate, as distinguished from §
15.2-1300
or
15.2-1303
of the Code of Virginia, or similar statutes, provided that the officers and employees of a social services department, welfare board, community services board, or behavioral health authority, or library board of a county, city, or town shall be deemed to be the employees of local government.
"Local employer" means any county, city, or town, school board, and the directing or governing body of any political entity, subdivision, branch or unit of the Commonwealth or of any commission or public authority or body corporate created by or under an act of the General Assembly specifying the power or powers, privileges or authority capable of exercise by the commission or public authority or body corporate, as distinguished from §
15.2-1300
or
15.2-1303
of the Code of Virginia, or similar statutes.
"Local officer" means the treasurer, registrar, commissioner of revenue, attorney for the Commonwealth, clerk of a circuit court, sheriff, or constable of any county or city or deputies or employees of any of the preceding local officers.
"Local retiree" means a former local employee who has met the terms and conditions for early, normal, or late retirement from a local employer.
"Open enrollment" means the period during which an employee may elect to commence, waive, or change membership or plans offered pursuant to the health benefits program.
"Part-time employee," as defined by each local employer, means an employee working less than full time but more than 20 hours per week whom a local employer has determined to be eligible to participate in the program. The conditions of participation for these employees shall be decided by the local employer in a nondiscriminatory manner.
"Participants" means individuals covered by the plan due to their relationship with the employer. They are not covered as dependents under the plan.
"Plan administrator" means the department.
"Preexisting condition" means a condition that, in the opinion of the plan's medical advisors, displayed signs or symptoms before the participant's effective date of coverage. These signs or symptoms must be ones of which the participant was aware or should reasonably have been aware. The condition is considered preexisting whether or not the participant was seen or treated for the condition. It is also considered preexisting whether or not the signs and symptoms of the condition were correctly diagnosed.
"Preferred provider organization" or "PPO" means an entity through which a group of health care providers, such as doctors, hospitals, and others, agree to provide specific medical and hospital care and some related services at a negotiated price.
"Primary coverage" means the health plan that will provide benefits first. It does not matter whether or not a claim has been filed for benefits with the primary health plan.
"Retiree" means any person who meets the definition of either a state retiree or a local retiree.
"Secondary coverage" means the health plan under which the benefits may be reduced to prevent duplicate or overlapping coverage.
"Self-funded arrangement" means a facility through which the plan sponsor agrees to assume the risk associated with the type of benefit provided without using an insurance company.
"Single membership" means coverage of the employee only under the health benefits program.
"State" means the Commonwealth of Virginia.
"State agency" means a court, department, institution, office, board, council, or other unit of state government located in the legislative, judicial, or executive departments or group of independent agencies, as shown in the Appropriation Act, and which is designated in the Appropriation Act by title and a three-digit agency code.
"State employee" means any person who is regularly employed full time on a salaried basis, whose tenure is not restricted as to temporary or provisional appointment, in the service of, and whose compensation is payable, no more often than biweekly, in whole or in part, by the Commonwealth or any department, institution, or agency thereof. "State employee" shall include the Governor, Lieutenant Governor, Attorney General, and members of the General Assembly. It includes "judge" as defined in §
51.1-301
of the Code of Virginia and judges, clerks, and deputy clerks of regional juvenile and domestic relations, county juvenile and domestic relations, and district courts of the Commonwealth.
"State retiree" means a former state employee who has met the terms and conditions for early, normal or late retirement from the Commonwealth.
"Teacher" means any employee of a county, city, or other local public school board.
