Rule 120-2-112-.03. Definitions

(1) "Advanced Premium Tax Credit" or "APTC" means payment of the tax credit authorized by 26 U.S.C. § 36B and otherwise defined as "advanced payment of the premium tax credits" in 45 C.F.R. § 155.20, which are provided on an advance basis to an eligible individual enrolled in a qualifying health plan through the Exchange in accordance with 42 U.S.C. § 18082. (2) "Catastrophic Health Plan" means a certified plan offered through the Exchange that covers essential health benefits and requires the highest cost sharing allowable for those benefits. (3) "Commissioner" means the Commissioner of Insurance. (4) "Direct Enrollment" or "DE" means an entity that the Commissioner permits to assist consumers with direct enrollment in qualified health plans and stand alone dental plans offered through the exchange. (5) "Dependent" has the same meaning as 26 C.F.R. § 54.9801-2 referring to any individual who is or who may become eligible for coverage under the terms of a qualifying health plan because of a relationship to a qualified individual or enrollee. (6) "Eligible Individual" means an individual or consumer who has been determined eligible to enroll through Georgia Access in a qualified health plan in the individual market. (7) "Enhanced Direct Enrollment" or "EDE" means a version of Direct Enrollment which allows consumers to complete all steps in the application, eligibility, and enrollment processes on an EDE Entity's website consistent with the requirements of 45 C.F.R. § 155.220, 155.221, 156.265 or 156.1230 using application programming interfaces as provided, owned, and maintained by CMS to transfer data between the Exchange and the EDE Entity's website. (8) "Exchange" means a state, federal, or partnership exchange or marketplace operating in Georgia pursuant to Section 1311 of the federal Patient Protection and Affordable Care Act, P.L. 111-148, as amended by the Health Care and Education Reconciliation Act of 2010, P.L. 111-152 (referred hereinafter as the "Federal Act"). (9) "Full-Time Employee" means a common-law employee as defined by 20 C.F.R. § 404.1007 that works an average of 30 hours per week or more. (10) "Georgia Access" means the State-based Exchange of the State of Georgia. (11) "Issuer" means an insurance company licensed by the Georgia Office of Commissioner of Insurance and Safety Fire to engage in the business of selling, soliciting, or negotiating insurance in Georgia. (12) "Open Enrollment" means the annual period when eligible individuals may enroll in an individual health or dental insurance plan for the upcoming year. (13) "Plan year" means the 12-month period of benefit coverage under a health or dental plan. For Georgia Access, a plan year begins January 1st of each year and rules through December 31st of the same year. (14) "Policy Manual" means the official policies for each plan year published by the Commissioner prior to open enrollment. Policies will be published at https://georgiaaccess.gov/about-georgia-access/policies/ (15) "Stand-alone dental plan" or "SADP" means a dental insurance plan certified by Georgia Access that is not included as part of a health plan. (16) "Special Enrollment Period" means a period, following a triggering event, during which a qualified individual or enrollee may enroll in, or change enrollment in, a qualifying health plan or stand-alone dental plan through the Exchange notwithstanding lapse of the Open Enrollment Period. (17) "Triggering Event" means an event specified in 45 C.F.R. § 155.420(d) and shall additionally include any event published by the Commissioner as a triggering event for a Special Enrollment Period. (18) "Qualified Health Plan" or "QHP" means a health or dental insurance plan that is certified by Georgia Access, which provides essential health benefits and follows established limits on cost sharing. Cite as Ga. Comp. R. & Regs. R. 120-2-112-.03
Authority: O.C.G.A. §§ 33-2-9; 50-13-21.
History. Original Rule entitled "Definitions" adopted. F. July 9, 2025; eff. July 29, 2025.
Amended: F. Sept. 12, 2025; eff. Oct. 2, 2025.