211 CMR 41.02 - Definitions
As used in 211 CMR 41.00, the following words mean:
Actuarial Opinion and Memorandum
: A
signed written statement by a member of the American Academy of Actuaries based
upon the person's examination, including a review of the appropriate records,
of the actuarial assumptions and methods utilized by a
Adjusted Composite Rate
: The
(a) Geographic differences in the cost of health care;
(b) The average age of eligible individuals enrolled in a
(c) Differences in benefit levels.
Alternative Benefits Plan
: A
Average Adjusted Composite Rate
: The
average of the adjusted composite rates filed by the Carriers as calculated by
the
Average Composite Rate
: The average of
the composite rates filed by Carriers as calculated by the
Base Premium Rate
: The midpoint rate
within a
Carrier
: An insurer licensed or
otherwise authorized to transact accident and health insurance under M.G.L. c.
175 or the laws of any other jurisdiction; a nonprofit hospital service
corporation organized under M.G.L. c. 176A or the laws of any other
jurisdiction; a nonprofit medical service corporation organized under M.G.L. c.
176B or the laws of any other jurisdiction; a health maintenance organization
organized under M.G.L. c. 176G or the laws of any other jurisdiction; and an
insured
Case Mix Adjustment
: The adjustment
based upon the diagnosis-related group grouper selected by the
Closed Guaranteed Issue Health Plan
: A
Closed Plan
: A Nongroup
Commissioner
: The
Composite Rate
: The average per member
per month premium rate for each type of
Connector
: The Commonwealth Health
Insurance
Creditable Coverage : Coverage of an individual under any of the following:
(a) A
(b) A
(c) Part A or Part B of Title XVIII of the Social Security Act;
(d) Title XIX of the Social Security Act, other than coverage consisting solely of benefits under § 1928;
(e) 10 U.S.C. c. 55;
(f) A medical care program of the Indian Health Service or of a tribal organization;
(g) A state health benefits risk pool;
(h) A
(i) A public
(j) A health benefit plan under the Peace Corps Acts, 22 U.S.C. 2504(e);
(k) Young Adult Coverage offered under M.G.L. c. 176J, § 10; or
(l) Any other qualifying coverage required by the Health Insurance Portability and Accountability Act of 1996.
Division
: The
Eligible Dependent
: The spouse or
children of an
Eligible Individual
: Between November
1, 2001 and June 30, 2007, any natural person who is a
Emergency Medical Condition : A medical condition, whether physical or mental, manifesting itself by symptoms of sufficient severity, including severe pain, that the absence ofprompt medical attention could reasonably be expected by a prudent layperson who possesses an average knowledge of health and medicine, to result in placing the health of an insured or another person in serious jeopardy, serious impairment to body function, or serious dysfunction of any body organ or part, or, with respect to a pregnant woman, as further defined in § 1867(e)(l)(B) of the Social Security Act, 42 U.S.C. § 1395dd(e)(1)(B).
Enhanced Benefits Plan
: AGuaranteed
Issue Managed Care Plan,
Group Health Plan :
(a) An employee welfare benefit plan, as defined in § 3(1) of the Employee Retirement Income Security Act of 1974, 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 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 41.00, 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 41.02(a)1.; and
3. Amounts paid for insurance covering medical care referred to in 211 CMR 41.02: Group Health Plan (a)1. and 2.
(b) Any plan, fund or program that would not be, but for §
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 such 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 41.02:
Group Health
Plan
(c), as an employee welfare benefit plan which is a
(c) In the case of a
(d) In the case of a
1. In connection with a
2. In connection with a
Guaranteed Issue Managed Care Plan
: A
Nongroup
Guaranteed Issue Medical Plan
: A
Nongroup
Guaranteed Issue Preferred Provider
Plan
: A Nongroup
Health Plan
: Any individual, general,
blanket, or group policy of health, accident or sickness insurance issued by an
insurer licensed under M.G.L. c. 175 or the laws of any other jurisdiction; a
hospital service plan issued by a nonprofit hospital service corporation
pursuant to M.G.L. c. 176A or the laws of any other jurisdiction; a medical
service plan issued by a nonprofit medical service corporation pursuant to
M.G.L. c. 176B or the laws of any other jurisdiction; a health maintenance
contract issued by a health maintenance organization pursuant to M.G.L. c. 176G
or the laws of any other jurisdiction; and an insured health benefit plan that
includes a preferred provider arrangement issued pursuant to M.G.L. c. 176I or
the laws of any other jurisdiction. The words "
(a) Accident only;
(b) Credit-only;
(c) Limited scope dental benefits if offered separately;
(d) Limited scope vision benefits if offered separately;
(e) Hospitalindemnityinsurance policies if offered as independent, non-coordinated benefits which, for the purposes of 211 CMR 41.00, mean policies issued pursuant to M.G.L. c. 175 which provide a benefit not to exceed $500.00 per day, as adjusted on an annual basis by the amount of increase in the average weekly wages in Massachusetts as defined in M.G.L. c. 152, § 1, 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;
(f) Disability income insurance;
(g) Coverage issued as a supplement to liability insurance;
specified disease insurance that is purchased as a supplement and not as a
substitute for a
(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, if offered separately;
(l) Coverage supplemental to the coverage provided under 10 U.S.C. c. 55 if offered as a separate insurance policy; or
(m) Any other policy subject to the provisions of M.G.L. c. 176K.
Hearing
: The part of a
Hearing Request: A request by a
Information Request
: A written request
made to a
Intervenor
: A person, agency or
organization substantially and specifically affected by a
Loss Ratio : The ratio of the incurred costs of hospital, medical, or health care services for the relevant period to the premium earned for the same period.
Minimum Credible Coverage
: The lowest
threshold health benefit plan that an individual must purchase in order to
satisfy the legal requirement that a Massachusetts
Modified Community Rate
: A rate
resulting from a rating methodology in which the premium for all persons within
the same
Nongroup Health Plan
: Any
Papers
: All documents filed in a
Party
: A
Pre-existing Condition Limitation
:
With respect to coverage, a limitation or exclusion of benefits relating to a
condition based on the fact that the condition was present before the date of
enrollment for such coverage, whether or not any medical advice, diagnosis,
care or treatment was recommended or received before such date. Genetic
information shall not be treated as a condition in the absence of a diagnosis
of the condition related to such information. No
Premium Payment Mode
: The method by
which premiums for a
Presiding Officer
: The
Proceeding
: The adjudicatory process
initiated by a
Rate Basis Type
: Each category of
individual or family composition for which separate rates are charged for a
Rate Filing
:
Rating Factor
: Characteristics
including, but not limited to age, occupation, sex, geography,
Record Request
: A request, made to a
Resident
: A natural person living in
Massachusetts; however, the confinement of a person in a nursing home, hospital
or other institution is not by itself sufficient to qualify that person as a
Responsive Filing
:
Revised Rate Filing
:
Service Area : The geographic area within which a health maintenance organization or preferred provider plan has developed a network of providers who provide covered health services in accordance with 211 CMR 43.00 or 211 CMR 51.00.
Standard Benefits Plan
: The minimum
level of benefits to be provided in each
Standard Deviation
: The square root of
the average of the squares of the differences between each
State Rating Bureau
: The rating bureau
in the
Statutory Intervenor
: A person, agency
or organization, including, but not limited to, the Attorney General, which has
a statutory right to appear as an
Subsidization Factor
: A factor to be
applied to the rates, based upon individual or household income and assets
criteria which are used by the
Trade Act/Health Coverage Tax Credit-eligible
Person
: Any eligible Trade Adjustment Assistance recipient as
defined in 35(c)(2) of § 201 of Title II of
Public
Law
Waiting Period : A period immediately subsequent to the effective date of an insured's coverage under a health benefit plan during which the plan does not pay for some or all hospital or medical expenses.
Notes
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