957 CMR 10.02 - Definitions
All defined terms in 957 CMR 10.00 are capitalized. As used in 957 CMR 10.00, unless the context otherwise requires, terms have the following meanings:
Administrative Service Fees. The fees earned by a Payer for the full administration of a Self-insured Health Plan, excluding any premiums collected for stop-loss coverage.
Affiliated Payers. Any two or more Payers which, directly or indirectly, are in control of one another, are controlled by each other, or are under common control.
Allowed Claims. The total cost of claims after the provider or network discount, if any. Allowed Claims are equal to Incurred Claims plus member cost sharing and include medical claims, drug claims, capitation payments, and all other payments to providers, including those paid outside of the claims system. This value includes incurred but not reported (IBNR) estimates resulting in approximated completed claims for periods that are not yet considered complete.
Audit. An examination of a Payer's health care data, information and supporting documentation against internal and external data sources to evaluate the accuracy of such health care data and information and to also ensure consistency in reporting.
Average Employer Size. For a given category, the number of covered employees divided by the number of employers.
Benefit Design Type. Non-mutually exclusive groupings of Private Commercial Plan membership based on benefit, network, and/or product design, including but not limited to high-deductible health plans (HDHPs) and health plans that utilize tiered or limited provider networks.
Calendar Year. The period beginning January 1st and ending December 31st.
Center. The Center for Health Information and Analysis established under M.G.L. c. 12C.
Data Submission Manual. A data submission manual containing detailed specifications and submission guidelines.
Health Care Services. Supplies, care and services of a medical, surgical, optometric, dental, podiatric, chiropractic, psychiatric, therapeutic, diagnostic, preventative, rehabilitative, supportive, or geriatric nature including, but not limited to, inpatient and outpatient acute hospital care and services, services provided by a community health center or by a sanatorium, as included in the definition of "hospital" in Title XVIII of the federal Social Security Act, and treatment and care compatible with such services or by a health maintenance organization.
Health Insurance Plan. An individual or group contract or other plan providing coverage of Health Care Services and which is issued by a Payer, a hospital service corporation, a medical service corporation or a health maintenance organization.
Health Insurance Premiums. The gross premiums earned for providing health insurance coverage, including any portion of the premium that is paid to a third party.
Incurred Claims. The total cost of claims, after the provider/network discount (if any) and after member cost sharing. Incurred claims include medical claims, drug claims, and capitation payments, and all other payments to providers including those paid outside of the claims system. This value should include incurred but not reported estimates resulting in approximated completed claims for periods that are not yet considered complete.
Insurance Funding Type. A mutually exclusive grouping of Private Commercial Plan membership based on whether the Payer is financially responsible for paying covered members' medical claims or whether the employer is financially responsible for paying members' claims.
Member. A person covered by an individual contract or a certificate under a group arrangement contracted with a Payer, or their covered dependents.
Member Months. The number of months during which Members are covered, over a specified period of time.
Private Commercial Plans. All primary, medical Health Insurance Plans or Self-insured Health Plans, provided by Private Health Care Payers, with contract situs or administration based in Massachusetts. The following types of business are not considered to be Private Commercial Plans under 957 CMR 10.00: Medicare Advantage, Commonwealth Care, Medicaid Managed Care, Medicare Supplement, Federal Employee Health Benefit Plan (FEHBP), Medical Security Program, and other non-primary, non-medical business.
Private Health Care Payer ("Payer"). A private entity that contracts to provide, deliver, arrange for, pay for, or reimburse any of the costs of Health Care Services. A Private Health Care Payer includes a carrier authorized to transact accident and health insurance under M.G.L. c. 175, a nonprofit hospital service corporation licensed under M.G.L. c. 176A, a nonprofit medical service corporation licensed under M.G.L. c. 176B, a dental service corporation organized under M.G.L. c. 176E, an optometric service corporation organized under M.G.L. c. 176F, a Self-insured Health Plan, a Third-party Administrator, or a health maintenance organization licensed under M.G.L. c. 176G.
Product Type. A mutually exclusive breakdown of Private Commercial Plans into categories including but not limited to those with closed networks of providers, those with preferred networks of providers, and those without networks of preferred providers.
Rating Factors. Factors that are applied to base rates to develop Health Insurance Premiums, including but not limited to age/gender, area, group size, retention, and contract type.
Reporting Year. The Calendar Year in which the Payer reports.
Self-insured Health Plan. A plan which provides health benefits to the employees of an employer, which is not a health insurance plan, and in which the employer is liable for the actual costs of the Health Care Services provided by the plan and Administrative Service Fees.
Third-party Administrator. Any person or entity that receives or collects charges or contributions for, or adjusts or settles claims for, Self-insured Health Plans with contract situs in Massachusetts.
Website. The website of the Center for Health Information and Analysis located at www.chiamass.gov .
Notes
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