Code of Massachusetts Regulations › 956 CMR - COMMONWEALTH HEALTH INSURANCE CONNECTOR AUTHORITY › Title 956 CMR 12.00 - Eligibility, Enrollment, and Hearing Process for Connector Programs › Section 12.03 - Definitions

Current through Register 1525, July 5, 2024
As used in
										956 CMR 12.00, the following terms shall mean:
Advance Premium Tax Credit (or APTC)
. A payment made
										by the U.S. Department of Health and Human Services pursuant to
										42 USC §
									18082 on
										behalf of an eligible individual to reduce the amount of a Non-group Health Plan premium.
Appeal Representative
. A person who:
(a) is sufficiently aware of an appellant's circumstances to assume
								 responsibility for the accuracy of the statements made during the appeal process, and who has been provided
								 with written authorization from the appellant to act on the appellant's behalf during the appeal process;
								 or
(b) has, under applicable law, authority to act on behalf of
								 an appellant in making decisions related to health care or payment for health care. An appeal representative
								 may include, but is not limited to, an attorney or a non-attorney acting under an attorney's supervision, a
								 guardian, conservator, executor, administrator, holder of power of attorney or health care proxy.
Appealable Action
. Any of the actions listed in
										956 CMR
										12.13.
Applicant
. An individual or a Small Employer who
										completes and submits an application for a Connector Program.
Application
. A form prescribed by the Connector to be
										completed by an Applicant or on the Applicant's behalf, and submitted to the Connector or its designee as a
										request for a determination that the Applicant is eligible for a Connector Program.
Board
. The Board of the Commonwealth Health Insurance
										Connector Authority, established by M.G.L. c. 176Q, § 2.
Commonwealth
. The Commonwealth of
										Massachusetts.
Commonwealth Health Insurance Connector Authority or
										Connector
. The entity established pursuant to M.G.L. c. 176Q, § 2 and authorized under
										M.G.L. c. 176, § 3 to perform all the duties and responsibilities required of an American Health Benefit
										Exchange, as that term is defined by the Patient Protection and Affordable Care Act,
Pub. L. 111-148
, as amended
										from time to time.
Connector Program
. Any program administered by the
										Connector to allow individuals to enroll in Health Plans or Dental Plans, including with Financial
										Assistance, or to allow Small Employers to offer Health Plans or Dental Plans to their Employees and for
										Employees to enroll in those Health Plans or Dental Plans. Connector Programs include Non-Group Health Plans
										without Financial Assistance; Non-Group Health Plans with Financial Assistance; and Small Group Health
										Plans.
Connector Rules and Regulations
. All regulations,
										bulletins and other written directives duly adopted or issued by the Connector relating to Connector
										Programs.
ConnectorCare
. The program administered by the
										Connector pursuant to M.G.L. c. 176Q to provide Premium Assistance Payments and Cost Sharing Subsidies to
										Eligible Individuals at or below 500% of the Federal Poverty Level who are also eligible for Advance Premium
										Tax Credits.
Cost Sharing
. A payment made by or billed to an
										Enrollee at the point of service including, but not be limited to, co-payments, co-insurance and
										deductibles.
Cost Sharing Subsidy
. A payment made to a Health Plan
										by the Connector to reduce Cost Sharing expenses of ConnectorCare Enrollees. If applicable,
Cost
										Sharing Subsidy
may also encompass additional federal payments made to a Health Plan by the
										federal government to reduce Cost Sharing expenses of certain ConnectorCare enrollees under
										45 CFR 156.410.
Covered Services
. The range of medical services
										required to be provided by a Health Plan under its policy.
Day
. A calendar day, unless a business day is
										specified.
Dental Carrier
. Any dental insurance carrier that is
										contracted with the Connector to provide dental services to Connector Program Enrollees.
Dental Plan
. Any individual or group policy of
										insurance issued by a Dental Carrier and offered through the Connector.
Eligible Individual
. An individual who is a Resident
										of the Commonwealth and who is eligible to participate in a Connector Program for Non-group Health Plans in
										accordance with M.G.L. c. 176Q, and
										956 CMR
										12.04.
Eligible Small Employer
. A Small Employer that is
										eligible to participate in a Connector Program for Small Group Health Plans, in accordance with
										956 CMR
										12.04.
Employee
. Any individual who is an Employee as that
										term is defined by § 2791 of the Public Health Services Act.
Employer
. Any Employer, as that term is defined in
										§ 2791 of the Public Health Services Act, except that "Employer" includes employers with one or more
										employees.
Enrollee
. An Eligible Individual enrolled by the
										Connector or its designee in a Health Plan after completing Enrollment. Enrollee also means an Employee
										enrolled in a Small Group Health Plan, and any dependent of such Employee also enrolled in such Small Group
										Health Plan, through the Connector, consistent with applicable law and the terms of the Small Group Health
										Plan. Provided that at least one Employee enrolls in a Small Group Health Plan through the Connector,
										Enrollee also means a business owner enrolled in a Small Group Health Plan through the Connector, or the
										dependent of a business owner enrolled in a Small Group Health Plan through the Connector.
Enrollment
. The selection of a Health Plan and, if
										applicable, the payment of the Premium for that Health Plan by the deadline established by the
										Connector.
Household
. A single household for purposes of
										eligibility for a Non-group Health Plan with Financial Assistance, which means the tax filer and the
										individuals for whom a tax filer properly expects to claim a personal exemption under the Internal Revenue
										Code.
Federal Poverty Level (FPL)
. The most recently
										published Federal poverty level, updated periodically in the
Federal Register
by the
										Secretary of Health and Human Services under the authority of
										42 USC
										9902(2), as of the first day of the annual open enrollment
										period for coverage in a Health Plan through the Connector, as specified in
										45
										CFR 155.410.
Financial Assistance
. Any subsidy provided to an
										Eligible Individual enrolled in a Health Plan, including plans with APTC only, Premium Assistance provided
										through ConnectorCare, or Cost Sharing Subsidies.
Fraud
. An intentional deception or misrepresentation
										made by a person or corporation with the knowledge that the deception could result in some unauthorized
										benefit under a Connector Program to the person, the corporation, or some other person. It also includes any
										act that constitutes fraud under applicable Federal or state health care fraud laws. Examples of Enrollee
										fraud include, but are not limited to: improperly obtaining prescriptions for controlled substances and card
										sharing.
Health Carrier
. Any managed care organization or
										insurance carrier that is contracted with the Connector to provide Covered Services to Connector Program
										Enrollees.
Health Plan
. Any individual or group policy of
										insurance issued by a Health Carrier and offered through the Connector.
Hearing
. An administrative, adjudicatory proceeding
										pursuant to
										801 CMR 1.02:
Informal/Fair
										Hearing Rules
and 45 CFR
										155.500
et seq
. to determine the legal rights, duties,
										benefits or privileges of Applicants (in certain, limited circumstances) and Enrollees pertaining to
										eligibility for Connector Programs; enrollment in a Health Plan; and decisions regarding requests to waive or
										reduce a ConnectorCare Premium for extreme financial hardship.
Modified Adjusted Gross Income (MAGI)
. Income used to
										determine eligibility for Financial Assistance, as defined in the Internal Revenue Code at
										26 USC §
									36B(d)(2)(B).
Non-group Health Plan
. A Health Plan sold to an
										Eligible Individual, consistent with M.G.L. c. 176J, § 1.
Plan Type
. A type of coverage for ConnectorCare
										Enrollees with income within a certain range. Plan Types differ in terms of the amount of Premium Assistance
										payment and Cost Sharing Subsidy provided.
Premium
. An Enrollee's or Small Employer's required
										periodic payment for coverage under a Connector Program, paid to the Connector.
Premium Assistance
. A periodic payment made to a
										Health Carrier by the Connector on behalf of a ConnectorCare Enrollee to reduce the amount of a Premium paid
										by the individual.
Resident
. For an individual who:
(a) is 21 years of age or older, a Resident is a person who is not living
								 in an institution as defined in
								 42 CFR
								 435.403(b), is capable of indicating intent, and is not
								 receiving an optional State supplementary payment as addressed in
								 42 CFR
								 435.403(f). Such an individual is a Resident if the
								 individual is living and intends to reside, including without a fixed address, or has entered with a job
								 commitment or is seeking employment (whether or not currently employed) within the Commonwealth;
(b) is younger than 21 years old, a Resident is an individual who is not
								 living in an institution as defined in
								 42 CFR
								 435.403(b), is not eligible for Medicaid based on receipt
								 of assistance under title IV-E of the Social Security Act as addressed in
								 42 CFR
								 435.403(g), is not emancipated, and is not receiving an
								 optional State supplementary payment as addressed in
								 42 CFR
								 435.403(f). Such an individual is a Resident if the
								 individual resides in the Commonwealth, including without a fixed address, or if the individual's parent or
								 caretaker with whom the individual resides is a Resident of the Commonwealth;
(c) is not described in 956 CMR 12.03:
Resident
(a) or (b), the individual shall be a Resident if the individual satisfies the residency requirements
								 described in 42 CFR
								 435.403; or
(d) is a member of a
								 Household where at least one other member is a Resident under 956 CMR 12.03:
Resident
(a), (b), or (c), then that individual shall also be treated as a Resident,
								 except where that individual is a tax dependent of married spouses who enroll in a Health Plan through a
								 single Exchange other than the Connector.
Small Employer
. An Employer with at least one but not
										more than 50 Employees. The number of Employees is determined using the method set forth in Internal Revenue
										Code § 4980H(c)(2).
Small Group Health Plan
. A Health Plan sold to an
										eligible small business or group, as defined in M.G.L. c. 176J, § 1.