Nebraska State Statutes (as of 4/17/07)

Small Employer Health Insurance Availability Act

Contact: Nebraska Department of Insurance

(402) 471-4742

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Section 44-5223
Act, how cited.

Sections 44-5223 to 44-5267 shall be known and may be cited as the Small Employer Health Insurance Availability Act.

Source:

Laws 1994, LB 1222, ? 1
Laws 1997, LB 862, ? 30
Laws 2000, LB 1253, ? 33
Laws 2002, LB 1139, ? 29

Section 44-5224
Purposes of act.

The purposes of the Small Employer Health Insurance Availability Act are to promote the availability of health insurance coverage to small employers regardless of their health status or claims experience, to prevent abusive rating practices, to require disclosure of rating practices to purchasers, to establish rules regarding renewability of coverage, to establish limitations on the use of preexisting condition exclusions, to provide for development of basic and standard health benefit plans to be offered to all small employers, to provide for establishment of a reinsurance program, and to improve the overall fairness and efficiency of the small group health insurance market. The act is not intended to provide a comprehensive solution to the problem of affordability of health care or health insurance.

Source:

Laws 1994, LB 1222, ? 2

Section 44-5225
Definitions, where found.

For purposes of the Small Employer Health Insurance Availability Act, the definitions found in sections 44-5226 to 44-5255.01 shall be used.

Source:

Laws 1994, LB 1222, ? 3
Laws 1997, LB 862, ? 31
Laws 2000, LB 1253, ? 34
Laws 2002, LB 1139, ? 30

Section 44-5226
Actuarial certification, defined.

Actuarial certification shall mean 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 44-5258 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.

Source:

Laws 1994, LB 1222, ? 4

Section 44-5227
Affiliate or affiliated, defined.

Affiliate or affiliated shall mean any entity or person who directly or indirectly, through one or more intermediaries, controls or is controlled by, or is under common control with, a specified entity or person.

Source:

Laws 1994, LB 1222, ? 5

Section 44-5227.01
Affiliation period, defined.

Affiliation period means a period of time that must expire before health insurance coverage provided by a carrier becomes effective and during which the carrier is not required to provide benefits.

Source:

Laws 2002, LB 1139, ? 31

Section 44-5228
Agent, defined.

Agent shall have the same meaning as insurance producer in section 44-103.

Source:

Laws 1994, LB 1222, ? 6
Laws 2001, LB 51, ? 36

Section 44-5229
Base premium rate, defined.

Base premium rate shall mean 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.

Source:

Laws 1994, LB 1222, ? 7

Section 44-5230
Basic health benefit plan, defined.

Basic health benefit plan shall mean a lower cost health benefit plan developed pursuant to section 44-5262.

Source:

Laws 1994, LB 1222, ? 8

Section 44-5231
Board, defined.

Board shall mean the board of directors of the Nebraska Small Employer Health Reinsurance Program.

Source:

Laws 1994, LB 1222, ? 9

Section 44-5232
Broker, defined.

Broker shall have the same meaning as insurance producer in section 44-103.

Source:

Laws 1994, LB 1222, ? 10
Laws 2001, LB 51, ? 37

Section 44-5233
Transferred to section 44-5242.01.

Section 44-5234
Case characteristics, defined.

Case characteristics shall mean 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. Claim experience, health status, and duration of coverage shall not be case characteristics for purposes of the Small Employer Health Insurance Availability Act.

Source:

Laws 1994, LB 1222, ? 12

Section 44-5234.01
Church plan, defined.

Church plan shall mean a plan as defined under 29 U.S.C. 1002.

Source:

Laws 1997, LB 862, ? 32

Section 44-5235
Class of business, defined.

Class of business shall mean all or a separate grouping of small employers established pursuant to section 44-5257.

Source:

Laws 1994, LB 1222, ? 13

Section 44-5236
Committee, defined.

Committee shall mean the Health Benefit Plan Committee established pursuant to section 44-5262.

Source:

Laws 1994, LB 1222, ? 14

Section 44-5237
Control, defined.

Control shall have the same meaning as in section 44-2121.

Source:

Laws 1994, LB 1222, ? 15

Section 44-5237.01
Creditable coverage, defined.

(1) Creditable coverage shall mean, with respect to an individual, coverage of the individual under any of the following:

(a) A group health plan;

(b) Health insurance coverage;

(d) Title XIX of the Social Security Act, 42 U.S.C. 1396 et seq., other than coverage consisting solely of benefits under section 1928 of the act, 42 U.S.C. 1396s;

(e) 10 U.S.C. chapter 55, as such chapter existed on January 1, 2003;

(f) A medical care program of the Indian Health Service or of a tribal organization;

(g) A state health benefits risk pool;

(h) A health plan offered under 5 U.S.C. 8901 et seq.;

(i) A public health plan as defined under regulations promulgated by the federal Secretary of Health and Human Services; and

(j) A health benefit plan under 22 U.S.C. 2504.

(2) Creditable coverage shall not include any coverage that occurs before a significant break in coverage. For purposes of this section, a significant break in coverage shall mean any period of sixty-three consecutive days during all of which the individual does not have any creditable coverage, except that neither a waiting period nor an affiliation period shall be taken into account in determining a significant break in coverage.

(3) Creditable coverage shall not include coverage consisting solely of coverage of excepted benefits as that term is defined in the federal Health Insurance Portability and Accountability Act of 1996, 29 U.S.C. 1191b, and regulations adopted pursuant to the act and in effect on April 19, 1998.

Source:

Laws 1997, LB 862, ? 33
Laws 1998, LB 1035, ? 11
Laws 2003, LB 6, ? 2

Section 44-5238
Dependent, defined.

Dependent shall mean a spouse, an unmarried child under the age of nineteen years, an unmarried child who is a full-time student under the age of twenty-three 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.

Source:

Laws 1994, LB 1222, ? 16

Section 44-5239
Director, defined.

Director shall mean the Director of Insurance.

Source:

Laws 1994, LB 1222, ? 17

Section 44-5240
Eligible employee, defined.

Eligible employee shall mean an employee who works on a full-time basis and has a normal workweek of thirty or more hours. The term shall include a sole proprietor, a partner of a partnership, a member of a limited liability company, and an independent contractor, if the sole proprietor, partner, member, or independent contractor is included as an employee under a health benefit plan of a small employer, but shall not include an employee who works on a part-time, temporary, or substitute basis.

Source:

Laws 1994, LB 1222, ? 18

Section 44-5240.01
Enrollment date, defined.

Enrollment date means the first day of coverage in the health benefit plan or, if earlier, the first day of the waiting period.

Source:

Laws 2000, LB 1253, ? 35

Section 44-5241
Established geographic service area, defined.

Established geographic service area shall mean a geographic area, as approved by the director and based on the carrier's certificate of authority to transact insurance business in this state, within which the carrier is authorized to provide coverage.

Source:

Laws 1994, LB 1222, ? 19

Section 44-5241.01
Governmental plan, defined.

Governmental plan shall mean a plan as defined under 29 U.S.C. 1002 and any plan maintained for its employees by the United States Government or by any agency or instrumentality of the United States Government.

Source:

Laws 1997, LB 862, ? 34

Section 44-5241.02
Group health plan, defined.

Group health plan shall mean an employee welfare benefit plan as defined by 29 U.S.C. 1002 to the extent that the plan provides any hospital, surgical, or medical expense benefits to employees or their dependents, as defined under the terms of the plan, directly or through insurance, reimbursement, or otherwise.

Source:

Laws 1997, LB 862, ? 35

Section 44-5242
Health benefit plan, defined.

(1) Health benefit plan shall mean any hospital or medical policy or certificate, major medical expense insurance, or health maintenance organization subscriber contract.

(2) Health benefit plan shall not include one or more, or any combination, of the following:

(a) Coverage only for accident or disability income insurance, or any combination thereof;

(b) Coverage issued as a supplement to liability insurance;

(d) Workers' compensation or similar insurance;

(e) Automobile medical payment insurance;

(f) Credit-only insurance;

(g) Coverage for onsite medical clinics; and

(h) Other similar insurance coverage, specified in federal regulations, under which benefits for medical care are secondary or incidental to other insurance benefits.

(3) Health benefit plan shall not include the following benefits if they are provided under a separate policy, certificate, or contract of insurance or are otherwise not an integral part of the plan:

(a) Limited-scope dental or vision benefits;

(b) Benefits for long-term care, nursing home care, home health care, community-based care, or any combination thereof; and

(4) Health benefit plan shall not include the following benefits if the benefits are provided under a separate policy, certificate, or contract of insurance, there is no coordination between the provision of the benefits and any exclusion of benefits under any group health benefit plan maintained by the same plan sponsor, and such benefits are paid with respect to an event without regard to whether benefits are provided with respect to such an event under any group health plan maintained by the same plan sponsor:

(a) Coverage only for a specified disease or illness; and

(b) Hospital indemnity or other fixed indemnity insurance.

(5) Health benefit plan shall not include the following if it is offered as a separate policy, certificate, or contract of insurance:

(a) Medicare supplemental health insurance as defined under section 1882(g)(1) of the Social Security Act;

(b) Coverage supplemental to the coverage provided under 10 U.S.C. chapter 55, as such chapter existed on January 1, 2003; and

Source:

Laws 1994, LB 1222, ? 20
Laws 1997, LB 862, ? 36
Laws 2003, LB 6, ? 3

Section 44-5242.01
Health carrier or carrier, defined.

Health carrier or carrier shall mean any entity that provides health insurance in this state. Health carrier or carrier shall include an insurance company, a fraternal benefit society, a health maintenance organization, and any other entity providing a plan of health insurance or health benefits subject to state insurance regulation.

Source:

Laws 1994, LB 1222, ? 11
R.S.Supp.,1996, ? 44-5233
Laws 1997, LB 862, ? 37

Section 44-5242.02
Health-status-related factor, defined.

Health-status-related factor shall mean any of the following factors:

(1) Health status;

(2) Medical condition, including both physical and mental illnesses;

(3) Claims experience;

(4) Receipt of health care;

(5) Medical history;

(6) Genetic information;

(7) Evidence of insurability, including conditions arising out of acts of domestic violence; and

(8) Disability.

Source:

Laws 1997, LB 862, ? 38

Section 44-5242.03
Health maintenance organization, defined.

Health maintenance organization means a person that undertakes to provide or arrange for the delivery of basic health care services to enrollees on a prepaid basis, except for enrollee responsibility for copayments or deductibles or both.

Source:

Laws 2002, LB 1139, ? 32

Section 44-5243
Index rate, defined.

Index rate shall mean, 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.

Source:

Laws 1994, LB 1222, ? 21

Section 44-5244
Late enrollee, defined.

Late enrollee shall mean 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 if 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:

(1) The individual meets the following:

(a) The individual was covered under creditable coverage at the time of the initial enrollment;

(b) The individual lost coverage under creditable coverage as a result of termination of employment or eligibility, reduction in the number of hours of employment, the involuntary termination of the creditable coverage, the death of a spouse, divorce, or legal separation; and

(2) 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;

(3) A court has ordered coverage be provided for a spouse or a minor or dependent child under a covered employee's health benefit plan and the request for enrollment is made within thirty days after issuance of the court order; or

(4) The individual had coverage under a COBRA continuation provision and the coverage under that provision was exhausted.

Source:

Laws 1994, LB 1222, ? 22
Laws 1997, LB 862, ? 39

Section 44-5244.01
Medical care, defined.

Medical care shall mean amounts paid for:

(1)(a) The diagnosis, care, mitigation, treatment, or prevention of disease or (b) the purpose of affecting any structure or function of the body;

(2) Transportation primarily for and essential to medical care referred to in subdivision (1) of this section; and

(3) Insurance covering medical care referred to in subdivisions (1) and (2) of this section.

Source:

Laws 1997, LB 862, ? 40

Section 44-5244.02
Network plan, defined.

Network plan shall mean health insurance coverage offered by a health carrier under which the financing and delivery of medical care including items and services paid for as medical care are provided, in whole or in part, through a defined set of providers under contract with the health carrier.

Source:

Laws 1997, LB 862, ? 41

Section 44-5245
New business premium rate, defined.

New business premium rate shall mean, 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.

Source:

Laws 1994, LB 1222, ? 23

Section 44-5246
Plan of operation, defined.

Plan of operation shall mean the plan of operation of the Nebraska Small Employer Health Reinsurance Program.