Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 4.000 - Health Insurance Open Enrollment Waivers › Section 4.020 - Definitions

Current through Register 1525, July 5, 2024
As used in 958 CMR 4.000 the following words shall have the following meanings:
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. For the purposes of 958 CMR 4.000,
Carrier
also means an agent of a carrier that reviews or processes enrollment applications, including but not limited to, the Connector.
Connector
the Commonwealth Health Insurance Connector Authority established by M.G.L. c. 176Q, § 2(a).
Creditable Coverage
coverage of an individual under any of the following health plans with no lapse of coverage of more than 63 days:
(a) a group health plan;
(b) a health plan, including, but not limited to, 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 or a qualifying student health program of another state;
(c) Part A or Part B of Title XVIII of the Social Security Act;
(d) Title XIX of the Social Security Act, other than coverage consisting solely of benefits under § 1928;
(e) 10 U.S.C. 55;
(f) a medical care program of the Indian Health Service or of a tribal organization;
(g) a state health benefits risk pool;
(h) a health plan offered under 5 U.S.C. 89;
(i) a public health plan as defined in federal regulations authorized by the Public Health Service Act, § 2701(c)(I)(I), as amended by Public Law 104-191;
(j) a health benefit plan under the Peace Corps Act, 22 U.S.C. 2504(e);
(k) any other qualifying coverage required by the Health Insurance Portability and Accountability Act of 1996, as it is amended, or by regulations promulgated under that act; or
(l) any other minimum essential coverage as defined under the Patient Protection and Affordable Care Act, Public Law 111-148, and any rules, regulations or guidance issued thereunder.
Creditable Coverage
is used as a criterion for eligibility for enrollment outside of the open enrollment period as defined in M.G.L. c. 176J and 211 CMR 66.00:
Small Group Health Insurance
. It is different from
Minimum Creditable Coverage
as defined by the Connector pursuant to 956 CMR 5.00:
Minimum Creditable Coverage
.
Eligible Individual
an individual who is a resident of Massachusetts.
Enrollment Waiver
permission granted to an eligible individual by the Office of Patient Protection to enable such individual to enroll in a nongroup health benefit plan outside of the open enrollment period.
Health Benefit Plan or Health Plan
as defined at M.G.L. c. 176J, §1, a policy, contract, certificate or agreement entered into, offered or issued by a carrier to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services.
Intentionally Forgo Enrollment
an individual turned down the opportunity to enroll in or failed to apply for a health benefit plan or any plan offering creditable coverage when the individual was eligible for enrollment.
Minimum Creditable Coverage
the lowest threshold health benefit plan as determined by the Connector pursuant to 956 CMR 5.00:
Minimum Creditable Coverage
that a resident must purchase in order to satisfy the legal requirement to avoid paying a penalty to the Department of Revenue pursuant to M.G.L. c. 111M, § 2.
Minimum Creditable Coverage
is different from
Creditable Coverage
.
Nongroup Health Plan
a health benefit plan offered pursuant to M.G.L. c. 176J to an eligible individual.
Office of Patient Protection
the office within the Health Policy Commission established by M.G.L. c. 6D, § 16.
Open Enrollment or Open Enrollment Period
the mandatory period established by M.G.L. c. 176J, § 4(a)(3). For the purposes of 958 CMR 4.000,
Open Enrollment
also means the period of time prior to December 1, 2010 during which individuals could enroll in a nongroup health plan at any time.
Resident
a natural person living in Massachusetts, but the confinement of person in a nursing home, hospital or other institution shall not by itself be sufficient to qualify a person as a resident.