Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 151.00 - Certified Group Purchasing Cooperatives › Section 151.03 - Definitions

Current through Register 1525, July 5, 2024
As used in
				211 CMR 151.00, the
				following words mean:
Association
: A chamber of commerce,
				trade association, or other organization, formed for purposes other than
				obtaining insurance.
Carrier
: An insurer licensed or
				otherwise authorized to transact accident or 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; a health
				maintenance organization licensed under M.G.L. c. 176G; or an organization
				entering into a preferred provider arrangement under M.G.L. c. 176I, but not
				including an employer purchasing coverage or acting on behalf of its employees
				or the employees of one or more subsidiaries or affiliated corporations of the
				employer. As used in
				211 CMR 151.00, Carrier
				shall not include any entity offering a policy, certificate or contract that
				provides coverage solely for dental care services or vision care
				services.
Commissioner
: The Commissioner of
				Insurance appointed pursuant to M.G.L. c. 26, § 6.
Commonwealth Health Insurance Connector Authority
				or Connector
: An authority established under M.G.L. c. 176Q to
				facilitate the availability, choice and adoption of private health insurance
				plans to Eligible Individuals and groups.
Covered Benefits or Benefits
: Health
				Care Services to which an Insured is entitled under the terms of a Health
				Benefit Plan.
Division
: The Division of Insurance
				established pursuant to M.G.L. c. 26, § 1.
Eligible Association Member
: Any
				individual member of a Qualified Association who is a Massachusetts resident,
				who is also and Eligible Individual, and who meets all eligibility criteria of
				the Qualified Association of which he or she is a member, and who meets all
				eligibility criteria necessary to be offered a Health Benefit Plan through the
				Group Purchasing Cooperative of which the Qualified Association is a
				member.
Eligible Dependent
: The spouse or
				child of an Eligible Employee or Eligible Association Member, subject to the
				applicable terms of the Health Benefit Plan covering such Eligible Employee or
				Eligible Association Member.
Eligible Employee
: An employee
				who:
(a) works on a full-time basis with a normal work week of 30 or
				more hours, including an owner, a sole proprietor or a partner of a
				partnership; provided however, that such owner, sole proprietor or partner is
				included as an employee under a Health Benefit Plan of an Eligible Small
				Business; and provided, however, that Eligible Employee does not include an
				employee who works on a temporary or substitute basis; and
(b) is hired to work for a period of not less than five months,
				provided, however, that a Carrier shall not require that an employee must have
				worked for an unreasonable length of time in order to qualify as an Eligible
				Employee. For the purposes of
				211 CMR 151.00, five months
				shall be deemed to be an unreasonable length of time when determining whether
				an employee is an Eligible Employee. Nothing in this definition shall exclude a
				sole proprietor from being determined to be an Eligible Employee, so long as
				that sole proprietor is otherwise eligible to be offered a Health Benefit Plan
				through a Group Purchasing Cooperative.
Eligible Individual
: An individual who
				is a Massachusetts resident and who is not seeking health insurance coverage to
				replace an employer-sponsored health plan for which the individual is eligible
				and which provides coverage that is at least actuarially equivalent to minimum
				creditable coverage as defined by Connector regulation
				956
				CMR 5.00:
Minimum Credible Coverage
.
				For the purposes of
				211 CMR 151.00, continuation
				coverage under M.G.L. c. 176J, § 9 or under the Consolidated Omnibus
				Budget Reconciliation Act of 1986 ("COBRA"), shall not be considered an
				employer-sponsored health plan
Eligible Small Business
: Any sole
				proprietorship, firm, corporation, partnership, or association actively engaged
				in business which, on at least 50% of its working days during the preceding
				year, employed from among one to not more than 50 Eligible Employees, the
				majority of whom worked in Massachusetts; provided, however, that the sole
				proprietorship, firm, corporation, partnership or association need not have
				been in existence during the preceding year in order to qualify as an Eligible
				Small Business. An entity is considered to be one Eligible Small Business if it
				is eligible to file a combined tax return, or if its companies are affiliated
				companies through the same corporate parent. Except as otherwise specifically
				provided, provisions of
				211 CMR 151.00 that apply to
				an Eligible Small Business will continue to apply through the end of the Rating
				Period in which such entity no longer meets the requirements of an Eligible
				Small Business.
Emergency Services
: Services to treat
				a medical condition, whether physical or mental, manifesting itself by symptoms
				of sufficient severity, including severe pain, that the absence of prompt
				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)(1)(B) of the
				Social Security Act,
				42
				U.S.C.
				1395dd(e)(1)(B).
Finding of Neglect
: A written
				determination by the Commissioner that a Carrier has failed to complete or file
				required information in the form and/or within the time required by
				211 CMR 151.00.
Group Purchasing Cooperative
:
(a) A Massachusetts nonprofit or not-for-profit corporation;
				or
(b) an association, approved as a Qualified Association by the
				Commissioner, all the members of which are part of a Qualified Association
				which negotiates with one or more Carriers for the issuance of Health Benefit
				Plans that cover Eligible Employees and Eligible Dependents of the Qualified
				Association's members.
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 non-profit hospital service corporation under
				M.G.L. c. 176A; an individual or group medical service plan issued by a
				nonprofit 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 if offered as
				independent, non-coordinated benefits which for the purposes of
				211
				CMR 66.00:
Small Group Health
				Insurance
shall mean policies issued under M.G.L. c. 175 which provide
				a benefit not to exceed $500 per day, as adjusted on an annual basis by the
				amount of increase in the average weekly wages in the commonwealth 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;
(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 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) a health plan issued, renewed or delivered within or
				without the commonwealth to an individual who is enrolled in a qualifying
				student health insurance program under M.G.L. c. 15A, § 18 shall not be
				considered a health plan for the purposes of
				211
				CMR 66.00:
Small Group Health
				Insurance
and shall be governed by said M.G.L. c. 15A.
Health Care Services
: Services for the
				diagnosis, prevention, treatment, cure or relief of a health condition,
				illness, injury or disease.
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.
Mandated Benefit
: A Health Care
				Service or category of health care provider which a Carrier is required by its
				licensing, or by law or regulation, to include as a Covered Benefit in its
				Health Benefit Plan.
Material Change
: A modification to any
				procedures or documents that substantially affects the rights or
				responsibilities of an Insured, Qualified Association, Group Purchasing
				Cooperative, Carrier or health care provider.
Network
: A grouping of health care
				providers who contract with a Carrier or affiliated Carriers to provide Health
				Care Services to Insureds covered by any or all of the Carrier's or affiliated
				Carrier's Health Benefit Plans.
Participation Rate
: The percentage of
				Eligible Employees electing to participate in any Health Benefit Plan offered
				by their Eligible Employer; or the percentage of the sum of Eligible Employees
				and Eligible Dependents electing to participate in any Health Benefit Plan
				offered by their Eligible Employer. For Eligible Association Members, it may be
				the percentage of the sum of Eligible Association Members and Eligible
				Dependents electing to participate in the Health Benefit Plan in which the
				Eligible Association Member is enrolled. In any case, the numbers used to
				calculate the percentage shall not include any Eligible Employee, Eligible
				Association Member, or Eligible Dependent who is enrolled in a Health Benefit
				Plan sponsored by a different employer.
Qualified Association
:
(a) A Massachusetts nonprofit or not-for-profit corporation;
				or
(b) any other entity domiciled inside or outside Massachusetts;
				organized and maintained for the purpose of advancing the occupational,
				professional, trade, or industry interests of Association members, other than
				that of obtaining health insurance, and which has been in active existence for
				at least five years, and which comprises at least 100 Association members, and
				membership in which is generally available to potential Association members of
				such occupation, profession, trade or industry without regard to the health
				condition or status of a prospective Association member, or the employees and
				dependents of a prospective Association member.
Qualified Association Member
: An
				individual member or small business that is actively enrolled or registered as
				a member of a Qualified Association according to the bylaws of the Qualified
				Association and, where necessary, has paid any dues that are required by the
				Qualified Association for membership.
Rating Period
: The period for which
				premium rates established by a Carrier are in effect, as determined by the
				Carrier.
Service Area
: The geographic area, as
				approved by the Commissioner, within which the Carrier has developed a Network
				of health care providers to afford adequate access to members for Covered
				Benefits.
Small Business Group Purchasing
				Cooperative
:
See
definition of Group Purchasing
				Cooperative.
Waiting Period
: A period immediately
				subsequent to the effective date of an Insured's coverage under a Health
				Benefit Plan during which the Health Benefit Plan does not pay for some or all
				Covered Benefits.
Wellness Program
: A program designed
				to measure and improve individual health by identifying risk factors through
				diagnostic testing, surveys, questionnaires, establishing plans to meet
				specific health goals which include appropriate preventive measures, and/or
				other programs or plans that are designed to enhance health.
Working Day
: A day when a sole
				proprietorship, firm, corporation, partnership or association is actively
				engaged in business, with one or more employees working.