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