02-031 C.M.R. ch. 940, § 4 - Definitions

Current through 2022-14, April 6, 2022

A. "ACA" means the federal Patient Protection and Affordable Care Act, Public Law 111-148, as amended by the federal Health Care and Education Reconciliation Act of 2010, Public Law 111-152, and any amendments to or regulations or guidance issued under those acts.

B. "Carrier" means any insurance company, nonprofit hospital and medical service organization, or health maintenance organization authorized to issue health coverage in this State.

C. "Community rate" means the rate to be charged for a specific benefit plan, family structure (e.g., individual, couple, one-parent family, family), and group size (in the case of small group rates), prior to any adjustments for age, industry, occupation, geographic area, or tobacco use.

D. "Covered person" means a policyholder, certificate holder, subscriber, member, enrollee, dependent, or other individual entitled to benefits under a health benefit plan.

E. "MLR" means the medical loss ratio as defined by the ACA.

F. "Potentially unreasonable" means a rate filing which exceeds the threshold requiring review pursuant to Section 2794(a)(2) of the federal Public Health Service Act.

G. "Pure loss ratio" means the ratio of incurred claims to earned premiums for a given period, as determined in accordance with accepted actuarial principles and practices, and subject to the following provisions. For the purposes of this calculation, incurred claims do not include any claim adjustment expenses or cost containment expenses. Any savings offset payments, access payments, or reinsurance assessments paid pursuant to Title 24-A M.R.S.A. § 6913, § 6917, or § 3957, and any assessments for transitional reinsurance pursuant to the ACA, are treated as incurred claims. Except in situations where the assuming carrier is responsible for 100% of the ceding carrier's financial risk and administration of the policies, earned premiums and incurred claims must be stated on a direct basis without regard to commercial reinsurance. Reimbursements pursuant to the transitional reinsurance pursuant to the ACA shall be deducted from incurred claims. For individual health plans subject to Title 24-A M.R.S.A. § 2736-C, reinsurance premiums pursuant to Title 24-A M.R.S.A. § 3958 shall be deducted from earned premiums and reimbursements pursuant to Title 24-A M.R.S.A. § 3958 shall be deducted from incurred claims.

H. "Small group" refers to small group health plans as defined by Title 24-A M.R.S.A. § 2808-B.

I. "Transitional coverage" means a non-grandfathered individual or small group policy issued before January 1, 2014 and subject to the federal transitional policy announced in November 2013 and extended in March, 2014 and in February, 2016.

Notes

02-031 C.M.R. ch. 940, § 4