Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 156.00 - Dental Insurance › Section 156.03 - Definitions

Current through Register 1525, July 5, 2024
Actual Dental Loss Ratio
. Incurred
				Claims during a specified period for covered dental services plus Qualified
				Quality Improvement Activity expenses, which is then divided by earned dental
				premiums reduced by Federal and State Taxes, Assessments, and Licensing or
				Regulatory Fees.
Actuarial Opinion
. A signed written
				statement by a qualified actuary, which certifies that the actuarial
				assumptions, methods, and contract forms utilized by the Carrier in
				establishing premium rates for Dental Benefit Plans comply with all the
				requirements of M.G.L. c. 176X, 211 CMR 156.00, and any other applicable law or
				regulation.
Base Rates or Group Product Base
				Rates
. The rate to be charged to Individuals and their Dependents
				and/or Businesses for all Eligible Employees and Eligible Dependents prior to
				the application of Rating Adjustment Factors.
Carrier
. An insurer or other entity
				offering insured Dental Benefit Plans in the Commonwealth, which may include 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 medical service corporation organized under
				M.G.L. c. 176B; or a dental service corporation organized under M.G.L. c.
				176E.
Commissioner
. The Commissioner of
				Insurance appointed pursuant to M.G.L. c. 26, § 6, or their
				designee.
Connector
. The Commonwealth Health
				Insurance Connector Authority, established by M.G.L. c. 176Q.
Dental Benefit Plan or Plan
. Any
				insured Stand-alone Dental Benefit Plan that covers oral surgical care, Dental
				Services, dental procedures, or benefits covered by any individual, general,
				blanket, or group policy of insurance issued by a Carrier.
Dental Care
. The diagnosis or
				treatment (preventive or otherwise) of dental disease of teeth and/or their
				supporting structures.
Dental Provider
. A practitioner that
				is appropriately licensed to provide Dental Services.
Dental Service
. The dental services
				ordinarily provided by registered dentists and dental practices in accordance
				with accepted practices in the community where the services are
				rendered.
Division
. The Division of Insurance
				established pursuant to M.G.L. c. 26, § 1.
Eligible Dependent
. The spouse or
				child of an Individual or Business' Eligible Employee, subject to the
				applicable terms of the Dental Benefit Plan covering such Individual or
				Eligible Employee. The child of an Individual or Eligible Employee shall be
				considered an Eligible Dependent until at least the child's
				26th birthday or without regard to age, so long as
				the dependent, who is covered under the membership of their parent as a member
				of a family group, is mentally or physically incapable of earning their own
				living due to disability.
Eligible Employee
. Any person employed
				by an employer, including seasonal and temporary staff, but excluding business
				owners and those holding more than 2% of stock ownership.
Employer Group or Business
. Any sole
				proprietorship, firm, corporation, partnership, or other entity that employs
				Eligible Employees.
Financial Impairment
. A condition in
				which, based on the overall condition of the Carrier as determined by the
				Commissioner, the Carrier is, or if subjected to the provisions of 211 CMR
				156.00 could reasonably be expected to be, insolvent, or otherwise in an
				unsound financial condition such as to render its further transactions of
				business hazardous to the public or its policyholders or Members, or is
				compelled to compromise, or attempt to compromise, with its creditors or
				claimants on the grounds that it is financially unable to pay its
				claims.
Federal and State Taxes, Assessments and Licensing
				or Regulatory Fees
. Incurred federal and state income, premium or
				other taxes and assessments, and licensing or regulatory fees associated with a
				Carrier's Dental Benefit Plans.
Fraud, Waste, and Abuse Recoveries
.
				The amount of claims payments recovered through fraud, waste, and abuse
				reduction efforts, not to exceed the amount of fraud, waste, and abuse
				reduction expenses.
Group Association
. A group formed as
				an association or a trust, which may obtain insurance coverage for the benefit
				of members of one or more associations.
Incurred Claims
. Dental Services
				costs, including eligible Fraud, Waste, and Abuse Recoveries, incurred in a
				reporting period by a Dental Benefit Plan to be paid to Dental Providers or
				covered persons for activities by a Dental Provider.
Individual
. An individual who is a
				Resident of the Commonwealth.
Insured
. Any policyholder, certificate
				holder, subscriber, Member, or other person on whose behalf the Carrier is
				obligated to pay for and/or provide Dental Care services.
Large Group
. Employer Groups that
				employ 51 or more Eligible Employees.
Market
. The Individual, Group
				Association, Small Group, and/or Large Group Market(s) in which a Carrier
				offers a Dental Benefit Plan.
Member
. Any person enrolled in a
				Dental Benefit Plan.
Minimum Dental Loss Ratio
. The Minimum
				Dental Loss Ratio for insured Dental Benefit Plans issued or renewed in
				Massachusetts is 83%.
Projected Dental Loss Ratio
. Projected
				Incurred Claims for a specified period for covered Dental Care services plus
				projected Qualified Quality Improvement Activity expenses, which is then
				divided by projected earned dental premiums reduced by projected Federal and
				State Taxes, Assessments, and Licensing or Regulatory Fees.
Qualified Quality Improvement Activity or
				QIA
. An activity designed to improve dental quality that is
				performed equitably, including activities performed by or through a provider
				that are primarily designed to improve dental outcomes, including, but not
				limited to, activities with a likelihood of reducing disparities among
				specified populations or which promote and enhance dental wellness. A QIA is
				directed to individual patients or incurred for the benefit of specified
				segments of patients, increases the likelihood of desired clinical outcomes
				that are capable of being objectively measured and/or which produce verifiable
				results, requires expertise, increases wellness and promotes health activities,
				and is directed toward individual Members of a Carrier's plans or segments of
				Members, as well as populations other than Members (as long as no additional
				costs are incurred for the non-Members, and as long as the activity can be
				supported by evidence-based medicine, best clinical practices, or criteria
				issued by professional associations that meet all the requirements of
				45 CFR
				158.150(b)). A QIA does not
				include any activities that are identified under
				45 CFR
				158.150(c); that have any
				overlap with administrative expense items specified under M.G.L. c. 176X,
				§ 2(b)(i) through (x); that have any marketing component that displays the
				name of the Carrier; or which are paid for by the Carrier to any affiliate of
				the Carrier in any way, directly or indirectly.
Rating Adjustment Factor
. A factor
				that is based on actuarial principles of risk segmentation, that is not
				restricted by any state or federal rule, and that is used to derive the premium
				that is charged to a particular Individual or Employer Group.
Rating Period
. The period for which
				premium rates established by a Carrier are in effect.
Resident
. A natural person living in
				the Commonwealth, but the confinement of a person in a nursing home, hospital,
				or other institution shall not by itself be sufficient to qualify a person as a
				Resident.
Small Group
. Employer Group that
				employs 50 or fewer Eligible Employees.
Stand-alone Dental Benefit Plan
. An
				insured dental plan issued by a Carrier to cover Dental Services that is
				otherwise not reported through medical loss ratio requirements under state or
				federal law.
Trend in Dental Care Expenses
. The
				projected change in Dental Care Costs.