Actuarial Opinion. A signed written statement by a qualified member of the American Academy of Actuaries, which certifies that the actuarial assumptions, methods and contract forms utilized by the Carrier in establishing premium rates for Merged Market Health Benefit Plans comply with all the requirements of 211 CMR 66.00 and any other applicable law.
Affordable Care Act or ACA. The federal Patient Protection and Affordable Care Act, Public Law 111-148, adopted March 23, 2010, as amended by the federal Health Care and Education Reconciliation Act of 2010, Public Law 111-152, and federal regulations adopted pursuant to those acts.
Benefit Level Rate Adjustment Factor. A number that represents the ratio of the actuarial value of the Benefit Level of a Health Benefit Plan as compared to the average actuarial value of the Benefit Level of all Health Benefit Plans offered by the Carrier to Eligible Individuals and Eligible Small Groups in Massachusetts. The Benefit Level Rate Adjustment Factor is also referred to as "Plan Adjustment Factor" or "Pricing Actuarial Value".
Carrier. An insurer licensed or otherwise authorized to transact accident and health insurance under M.G.L. c. 175; a nonprofit hospital service corporation organized under M.G.L. c. 176A; a nonprofit medical service corporation organized under M.G.L. c. 176B; or a Health Maintenance Organization organized under M.G.L. c. 176G.
Catastrophic Health Benefit Plan. A Health Benefit Plan in accordance with the ACA that is offered to individuals who are younger than 30 years old or who have a hardship exemption from individual health plan penalty requirements.
Child-only Health Benefit Plan. A Health Benefit Plan in accordance with the ACA that is offered to individuals younger than 21 years old.
Commissioner. The Commissioner of Insurance appointed pursuant to M.G.L. c. 26, § 6, or his or her designee.
Connector. The Commonwealth Health Insurance Connector Authority created under M.G.L. c. 176Q.
Connector Seal of Approval. The approval given by the Connector to indicate that a Health Benefit Plan meets certain standards regarding quality and value.
Division. The Division of Insurance established pursuant to M.G.L. c. 26, § 1.
Eligible Child. An Eligible Individual who, as of the beginning of a plan year, has not attained 21 years of age and who is seeking to enroll in a Child-only Health Benefit Plan offered by a Carrier.
Eligible Dependent. The spouse or child of an Eligible Individual or Eligible Employee, subject to the applicable terms of the Health Benefit Plan covering such individual or employee. The child of an Eligible Individual or Eligible Employee shall be considered an Eligible Dependent until at least the child's 26th birthday.
Eligible Employee. Any individual employed by an employer, including seasonal and temporary staff, but excluding business owners and those holding more than 2% of stock ownership.
Eligible Individual. An individual who is a resident of the Commonwealth.
Eligible Small Business or Eligible Small Group. Any sole proprietorship, firm, corporation, partnership or association actively engaged in business who employed not more than 50 Eligible Employees; a business shall be considered to be an Eligible Small Business or Eligible Small Group if:
Exchange. Public entity that administers a website whereby consumers may purchase health insurance products pursuant to federal law and regulation. In Massachusetts, the Connector is the Exchange.
Financial Impairment. A condition in which, based on the overall condition of the Carrier as determined by the Commissioner, the Carrier is, or if subjected to the provisions of 211 CMR 66.00 could reasonably be expected to be, insolvent, or otherwise in an unsound financial condition such as to render its further transactions of business hazardous to the public or its policyholders or Members, or is compelled to compromise, or attempt to compromise, with its creditors or claimants on the grounds that it is financially unable to pay its claims.
Group Base Premium Rates. The base premium rate to be charged to Eligible Individuals and their dependents and Eligible Small Businesses for all Eligible Employees and Eligible Dependents prior to the application of Rating Adjustment Factors. These rates are equivalent to the calibrated plan adjusted index rate (CPAIR) as reported in the Federal Unified Rate Review Template.
Group Health Plan.
Health Benefit Plan. Any individual, general, blanket or group policy of health, accident and sickness insurance issued by an insurer licensed under M.G.L. c. 175; an individual or group hospital service plan issued by a nonprofit hospital service corporation under M.G.L. c. 176A; an individual or group nonprofit medical service plan issued by a medical service corporation under M.G.L. c. 176B; and an individual or group health maintenance contract issued by a Health Maintenance Organization under M.G.L. c. 176G.
Health Benefit Plans shall not include those plans whose benefits are for:
Health Maintenance Organization or HMO. An entity licensed to do business in Massachusetts under M.G.L. c. 176G.
Insured. Any policyholder, certificate holder, subscriber, Member or other person on whose behalf the Carrier is obligated to pay for and/or provide health care services.
Intermediary. A chamber of commerce, trade association, or other organization, formed for purposes other than obtaining insurance, which has complied with the requirements of 211 CMR 66.12(3), and which offers its members the option of purchasing a Health Benefit Plan.
Late Enrollee. An Eligible Employee or dependent who requests enrollment in an Eligible Small Business' health insurance plan or insurance arrangement after the Group's initial enrollment period, his or her initial eligibility date provided under the terms of the plan or arrangement, or the Group's annual open enrollment period, provided however, that an Eligible Employee or Dependent shall not be considered a late enrollee if the request for enrollment to the insurer is made within 30 days after termination of coverage provided under another health insurance plan or arrangement where such coverage has ceased due to termination of the spouse's employment or death of the spouse.
Mandated Benefit. A health service or category of health service provider which a Carrier is required by its licensing or other statute to include in its Health Benefit Plan.
Member. Any person enrolled in a Health Benefit Plan.
Merged Market. The combined market of Eligible Individuals and Eligible Small Groups.
MEWA or Multiple Employer Welfare Arrangement or Multiple Employer Trust. Either:
Office of Patient Protection. The office in the Health Policy Commission established by M.G.L. c. 6D, § 16(a).
Participation Rate. The percentage of Eligible Employees electing to participate in a Health Benefit Plan out of all Eligible Employees, or the percentage of the sum of Eligible Employees and Eligible Dependents electing to participate in a Health Benefit Plan out of the sum of all Eligible Employees and Eligible Dependents, at the election of the Carrier, as referenced in 211 CMR 66.04(1)(j). In either case, the numbers used to compute these percentages shall not include:
Participation Requirement. A policy provision, or a Carrier's underwriting guideline if there is no such policy provision, that requires that a group attain a certain Participation Rate in order for a Carrier to accept the group for enrollment in the Health Benefit Plan, as referenced in 211 CMR 66.04(1)(j). For groups of five or fewer eligible persons, a Carrier may require a Participation Rate up to 100%. For groups of six or more eligible persons, a Carrier may require a Participation Rate up to 75%.
Qualifying Health Plan. Any blanket or general policy of medical, surgical or hospital insurance described in M.G.L. c. 175, § 110(A), (C) or (D); policy of accident or sickness insurance as described in M.G.L. c. 175, § 108 which provides hospital or surgical expense coverage; nongroup or group hospital or medical service plan issued by a nonprofit hospital or medical service corporation under M.G.L. c. 176A and M.G.L. c. 176B; nongroup or group health maintenance contract issued by an HMO under M.G.L. c. 176G; nongroup or group preferred provider plan issued under M.G.L. c. 176I; self-insured or self-funded health plans offered by an employer or union health and welfare fund; health coverage provided to persons serving in the armed forces of the United States; or government-sponsored health coverage including, but not limited to, Medicare and medical assistance provided under M.G.L. c. 118E.
Rating Adjustment Factor. A factor permitted by state law and by the Center for Medicare & Medicaid Services that is applied to a Group Base Premium Rate to derive the premium that is charged to a particular Eligible Individual or Eligible Small Business.
Rating Period. The period for which premium rates established by a Carrier are in effect.
Resident. A natural person living in the Commonwealth, but the confinement of a person in a nursing home, hospital or other institution shall not by itself be sufficient to qualify a person as a Resident.
Small Business Group Purchasing Cooperative or Group Purchasing Cooperative. A Massachusetts nonprofit or not-for-profit corporation or an association that is approved as a qualified association by the Commissioner, all the members of which are part of a qualified association under M.G.L. c. 176J, § 12, that has been certified by the Commissioner as a Group Purchasing Cooperative that negotiates with one or more Carriers for the issuance of Health Benefit Plans that cover Eligible Employees, and the Eligible Dependents of the qualified association's members.
Tobacco Product. A product that contains tobacco in any of its forms including, but not limited to, cigarettes, bidi cigarettes, clove cigarettes, cigars, pipe tobacco, smokeless tobacco, chewing tobacco, or snuff.
Trend in Health Plan Expenses. The projected change in health plan expenses.
Wellness Program. An organized system designed to improve the overall health of participants through activities that may include, but shall not be limited to, education, health risk assessment, lifestyle coaching, behavior modification and targeted disease management.
211 CMR 66.03