211 CMR, § 66.03

Current through Register 1533, October 25, 2024

Section 66.03 - Definitions

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 26^th 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:

(a) it is eligible to file a combined tax return for purpose of state taxation; or

(b) its companies are affiliated companies through the same corporate parent. Except as otherwise specifically provided, provisions of 211 CMR 66.00 which apply to an Eligible Small Business will continue to apply through the end of the Rating Period in which an Eligible Small Business no longer meets the requirements of Eligible Small Business or Eligible Small Group. An Eligible Small Business that exists within a MEWA shall be subject to 211 CMR 66.00. Nothing within this definition or within any other provision of 211 CMR 66.00 shall preclude other employer-entities including, but not limited to, government municipalities, from being offered Health Benefit Plans in accordance with 211 CMR 66.00.

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.

(a) An employee welfare benefit plan, as defined in the Employee Retirement Income Security Act of 1974, § 3(1), 29 U.S.C. 1002, to the extent that the plan provides Medical Care, and including items and services paid for as Medical Care to plan participants, including employees or their dependents, as defined under the terms of the plan directly or through insurance, reimbursement or otherwise. For the purposes of 211 CMR 66.00, Medical Care means amounts paid for:

1. the diagnosis, cure, mitigation, treatment or prevention of disease, or amounts paid for the purpose of affecting any structure or function of the body;

2. amounts paid for transportation primarily for and essential to Medical Care referred to in 211 CMR 66.03: Group Health Plan (a)1.; and

3. amounts paid for insurance covering Medical Care referred to in 211 CMR 66.03: Group Health Plan (a)1. and 2.

(b) Any plan, fund or program which would not be, but for section 2721(e) of the federal Public Health Service Act, an employee welfare benefit plan, and which is established or maintained by a partnership, to the extent that the plan, fund or program provides Medical Care, including items and services paid for as Medical Care, to present or former partners in the partnership, or to their dependents, as defined under the terms of the plan, fund or program, directly or through insurance, reimbursement or otherwise, shall be treated, subject to 211 CMR 66.03: Group Health Plan (c), as an employee welfare benefit plan which is a Group Health Plan.

(c) In a Group Health Plan the term participant, as referenced in 211 CMR 66.03Group Health Plan (a), also includes:

1. in connection with a Group Health Plan maintained by a partnership, an individual who is a partner of the partnership; or

2. in connection with a Group Health Plan maintained by a self-employed individual, under which one or more employees are participants, the self-employed individual if that individual is, or may become, eligible to receive a benefit under the plan or that individual's beneficiaries may be eligible to receive any benefit.

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:

(a) accident only;

(b) credit only;

(c) limited scope vision or dental benefits if offered separately;

(d) hospital indemnity insurance policies that provide a benefit to be paid to an Insured or a dependent, including the spouse of an Insured, on the basis of a hospitalization of the Insured or a dependent, that are sold as a supplement and not as a substitute for a Health Benefit Plan and that meet standards consistent with those identified for hospital indemnity insurance within 211 CMR 42.00: The Form and Contents of Individual Accident and Sickness Insurance;

(e) disability income insurance;

(f) coverage issued as a supplement to liability insurance;

(g) specified disease insurance that is purchased as a supplement and not as a substitute for a health plan and meets the requirements of 211 CMR 146.00: Specified Disease Insurance;

(h) insurance arising out of a workers' compensation law or similar law;

(i) automobile medical payment insurance;

(j) insurance under which benefits are payable with or without regard to fault and which is statutorily required to be contained in a liability insurance policy or equivalent self insurance;

(k) long-term care insurance if offered separately;

(l) coverage supplemental to the coverage provided under 10 U.S.C. 55 if offered as a separate insurance policy;

(m) any policy subject to M.G.L. c. 176K or any similar policies issued on a group basis, Medicare Advantage plans or Medicare Prescription drug plans; or

(n) travel insurance which is insurance coverage for personal risks incident to planned travel including, but not limited to:

1. interruption or cancellation of trip or event;

2. loss of baggage or personal effects;

3. damages to accommodations or rental vehicles; or

4. sickness, accident, disability or death occurring during travel, provided that the health benefits are not offered on a stand-alone basis and are incidental to other coverages and shall not include major medical plans, which provide comprehensive medical protection for travelers with trips lasting six months or longer, including for example, those working overseas as an ex-patriot or military personnel being deployed; or

(o) a health plan issued, renewed or delivered within or without the Commonwealth to an individual who is enrolled in a student health insurance program under M.G.L. c. 15A, § 18 shall not be considered a Health Benefit Plan for the purposes of 211 CMR 66.00, but shall be governed by said M.G.L. c. 15A and the ACA, where applicable.

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:

(a) a fully-insured Multiple Employer Welfare Arrangement as defined in §§ 3 and 514 of the Employee Retirement Income Security Act (ERISA) of 1974, §§ 3 and 514, 29 USC 1002 and 1144; or

(b) an entity holding itself out to be a MEWA, Multiple Employer Welfare Arrangement or Multiple Employer Trust which is not fully insured and, therefore, shall be required to be licensed under M.G.L. c. 175. An arrangement that constitutes a MEWA is considered a separate Group Health Plan with respect to each employer maintaining the arrangement agreement.

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:

(a) any Eligible Employee or Eligible Dependent who is ineligible to enroll in the Eligible Small Business' Health Benefit Plan according to the Carrier's service plan requirements; and

(b) any Eligible Employee or Eligible Dependent who does not participate in the Eligible Small Business' Health Benefit Plan, but who is enrolled in another Health Benefit Plan through a source other than the Eligible Small Business.

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

Amended by Mass Register Issue 1349, eff. 10/6/2017.

Amended by Mass Register Issue 1487, eff. 1/20/2023.