Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 153.00 - Continuity Of Care Access To Comprehensive Cancer Centers, Pediatric Hospitals, And Pediatric Specialty Units For Small Group Health Benefit Plans That Utilize Limited, Regional Or Tiered Provider Networks › Section 153.02 - Definitions

Current through Register 1525, July 5, 2024
As used in
				211 CMR 153.00, the
				following words mean:
Active Course of Medical Treatment
:
				treatment that is:
(a) delivered following an inpatient stay or outpatient
				procedure and designed to assure recovery/rehabilitation; or
(b) continuing care for a Serious Disease that requires
				periodic diagnostic studies or adjustment of medications or treatments at least
				every six months.
An Active Course of Medical Treatment does not include services
				considered preventive in nature, or services provided for the monitoring or
				surveillance of the patient's condition following the completion of the
				treatment protocol for the Serious Disease, nor does it include clinical
				trials, experimental treatments, off-label use for products, or products not
				approved by the Food and Drug Administration, except insofar as coverage is
				mandated as set forth in M.G.L. c. 175, § 110L, c. 176A, § 8X, c.
				176B, § 4X and c. 176G, § 4P.
Adverse Determination
: a
				determination, based upon a review of information provided, by a Carrier or its
				designated utilization review organization, to deny, reduce, modify, or
				terminate an admission, continued inpatient stay, or the availability of any
				other Health Care Services, for failure to meet the requirements for coverage
				based on medical necessity, appropriateness of health care setting and level of
				care, or effectiveness.
Carrier
: an insurer licensed or
				otherwise authorized to transact accident and health insurance under M.G.L. c.
				175; a nonprofit hospital service corporation organized under M.G.L. c. 176A; a
				non-profit medical service corporation organized under M.G.L. c. 176B; or a
				health maintenance organization organized under M.G.L. c. 176G.
Commissioner
: the Commissioner of
				Insurance appointed pursuant to M.G.L. c. 26, § 6, or his or her
				designee.
Comprehensive Cancer Center
the term
				Comprehensive Cancer Center shall have the same meaning as that term is defined
				in M.G.L. c. 118G, §1, but shall be limited in
				211 CMR 153.00 to only those
				entities in Massachusetts.
Commonwealth
: the Commonwealth of
				Massachusetts.
Eligible Individual
: an individual who
				is a resident of the Commonwealth and who is not seeking individual coverage to
				replace an employment-based Health Benefit Plan for which the individual or
				individual's dependent is eligible and which provides coverage that is at least
				actuarially equivalent to minimum creditable coverage as defined by
				956
				CMR 5.00:
Minimum Creditable
				Coverage
, provided, however, that any person enrolled in an individual
				Health Benefit Plan before September 30, 2010 shall be considered an Eligible
				Individual so long as such person continues to be a resident of the
				Commonwealth and maintains enrollment in an individual Health Benefit
				Plan.
Eligible Small Business or Group
: any
				sole proprietorship, firm, corporation, partnership or association actively
				engaged in business who, 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 or Group. A business shall be considered to be one eligible
				small business or group if:
(a) it is eligible to file a combined tax return for purpose of
				state taxation; or
(b) its companies are affiliated companies through the same
				corporate parent.
Except as otherwise specifically provided, provisions of
				211 CMR 153.00 which apply
				to an eligible small business will continue to apply through the end of the
				rating period in which an eligible small business no longer meets the
				requirements of Eligible Small Business or Group. An eligible small business
				that exists within a Multiple Employer Welfare Arrangement (MEWA) shall be
				subject to
				211 CMR 153.00.
Evidence of Coverage
: any certificate,
				contract or agreement of health insurance including riders, amendments,
				endorsements and any other supplementary inserts or a summary plan description
				pursuant to § 104(b)(1) of the Employee Retirement Income Security Act of
				1974, 29 U.S.C. § 1024(b), issued to an Insured specifying the benefits to
				which the Insured is entitled.
General Provider Network
: the most
				comprehensive provider network offered by a Carrier in its Massachusetts
				Service Area.
Health Benefit Plan
: the term Health
				Benefit Plan shall have the same meaning as that term is defined in M.G.L. c.
				176J, § 1.
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.
Limited Provider Network
: a reduced or
				selective Provider Network, not a Regional Provider Network, which is smaller
				than a Carrier's General Provider Network and from which the Carrier may choose
				to exclude from participation other providers who participate in the Carrier's
				Regional Provider Network or General Provider Network.
Pediatric Hospital
: the term Pediatric
				Hospital shall have the same meaning as that term is defined in M.G.L. c. 118G,
				§ 1, but shall be limited in
				211 CMR 153.00 to only those
				entities in Massachusetts.
Pediatric Specialty Unit
: the term
				Pediatric Secialty Unit shall have the same meaning as that term is defined in
				M.G.L. c. 118G, § 1, but shall be limited in
				211 CMR 153.00 to only those
				entities in Massachusetts.
Plan Year
: the 12-month period
				beginning on a newly enrolled subscriber's initial effective date of coverage
				for health insurance coverage under a Health Benefit Plan with a Limited,
				Tiered, or Regional Provider Network.
Provider Network
: a group of Health
				Care Providers contracted with a Carrier or affiliate to provide Health Care
				Services to Insureds covered by any or all of the Carrier's or affiliate's
				Health Benefit Plans, policies, contracts or other arrangements. Provider
				Network shall not mean those participating providers that provide services to
				subscribers of a nonprofit hospital service corporation organized under M.G.L.
				c. 176A, or a nonprofit medical service corporation organized under M.G.L. c.
				176B, but shall include network providers that are subject to M.G.L. c.
				176I.
Regional Provider Network
: a Provider
				Network for a defined geographic area within Massachusetts that is smaller than
				the Carrier's Service Area and includes only those providers that have agreed
				to participate in the Carrier's Health Benefit Plan in a limited geographic
				area within the Commonwealth. A Regional Provider Network may be a geographic
				subset of the Carrier's General Provider Network.
Serious Disease
: a condition that is
				life threatening or is likely to lead to serious or permanent disability if
				left untreated.
Service Area
: the geographical area,
				as approved bythe Commissioner, within which the Carrier has developed a
				Provider Network to afford adequate access to Insureds for covered
				benefits.
Tiered Provider Network
: a Provider
				Network in which a Carrier assigns providers to different benefit tiers based
				on the Carrier's assessment of a provider's relative cost and, where available,
				quality and in which Insureds pay the cost-sharing (copayment, coinsurance or
				deductible) associated with a provider's assigned benefit tiers.
Undue Hardship
: circumstances
				that:
(a) could endanger life, cause suffering or pain, or cause
				physical deformity or malfunction; or
(b) require the Insured to undertake a substantial change in
				recommended treatment for covered Health Care Services; or
(c) require the Insured to receive covered Health Care Services
				from multiple providers/ facilities in an uncoordinated manner which will
				significantly worsen the Insured's Serious Disease.