Code of Massachusetts Regulations › 956 CMR - COMMONWEALTH HEALTH INSURANCE CONNECTOR AUTHORITY › Title 956 CMR 5.00 - Minimum Creditable Coverage › Section 5.02 - Definitions

Current through Register 1525, July 5, 2024
As used in
				956 CMR
				5.00, the following words shall have the following
				meanings, except where the context clearly indicates otherwise:
Ambulatory Patient Services
. All
				outpatient services, regardless of the setting.
Annual Maximum Benefit
. A maximum
				amount that a Health Benefit Plan will pay per year for covered services for an
				individual or family.
Co-insurance
. A percentage of the
				allowed charge, after any applicable Deductible, that a covered person will pay
				for covered services received under a Health Benefit Plan.
Connector
. The Commonwealth Health
				Insurance Connector Authority.
Connector Board
. The Board of the
				Connector established by M.G.L. c. 176Q, § 2(b).
Co-payment
. A fixed dollar amount,
				after any applicable Deductible, paid by a Covered Person to a physician,
				hospital, pharmacy, or other health care provider at the time the Covered
				Person receives covered services.
Core Services
. Physician services,
				inpatient acute care services, day surgery, and diagnostic procedures and
				tests.
Covered Person
. An individual who is
				covered under a Health Benefit Plan.
Covered Services
. The healthcare
				services, supplies and drugs that are paid for under the Health Benefit
				Plan.
Deductible
. An annual dollar amount
				that must be paid by a Covered Person for specified health care services that a
				Covered Person uses before the Health Benefit Plan becomes obligated to pay for
				covered services. Some Health Benefit Plans may include separate prescription
				drug Deductibles. The Deductible amount does not include the Premiums that a
				Covered Person pays or any Co-payments or Co-insurance that may apply after the
				Deductible.
Essential Health Benefits
. The health
				benefits listed in 42 U.S.C.
				§
									18022(b), and health
				benefits defined as essential in regulations promulgated pursuant to
				42 U.S.C. §
									18022(b).
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; a group hospital service
				plan issued by a nonprofit hospital service corporation under M.G.L. c. 176A; a
				group medical service plan issued by a nonprofit medical service corporation
				under M.G.L. c. 176B; a group health maintenance contract issued by a health
				maintenance organization under M.G.L. c. 176G; coverage for young adults health
				insurance plan under M.G.L. c. 176J, § 10; any self-funded health plan,
				including a self-funded health plan which is an ERISA "employee welfare benefit
				plan" providing medical, surgical or hospital benefits, as that term is defined
				in 29 U.S.C. §
									1002; and any individual, general, blanket or
				group policy of health, accident and sickness insurance issued in any state
				within the United States of America other than the Commonwealth of
				Massachusetts by an insurer that is licensed or otherwise statutorily
				authorized to transact business in such other state.
Indemnity Schedule of Benefits
. A
				fixed dollar amount per service, set forth in the subscriber's certificate of
				coverage as the maximum amount that a health plan is required to pay to the
				beneficiary or to reimburse the provider of that service.
Multi-employer Health Benefit Plan
. A
				Health Benefit Plan to which more than one employer is required to contribute,
				which is maintained pursuant to one or more collective bargaining agreements
				between one or more employee organizations and more than one employer, and
				there is evidence that such employer contributions to the Multi-employer Health
				Benefit Plan were the subject of good faith bargaining between such employee
				representatives and such employers.
Out-of-pocket Maximum
. The annual
				dollar limit that a Covered Person will pay for covered services under a Health
				Benefit Plan, not including premiums.
Premium
. A monthly payment made by, or
				on behalf of, a Covered Person to purchase and maintain a Health Benefit Plan,
				regardless of whether the Covered Person uses health care services or
				not.
Preventive Health Services
. The
				services that are defined in 42 U.S.C. §
									300gg-13.
Resident
. As defined in M.G.L. c.
				111M, § 1.