Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 148.00 - Registration And Reporting Requirements For Third-party Administrators › Section 148.02 - Definitions

Current through Register 1525, July 5, 2024
As used in
				211 CMR 148.00, the
				following words mean:
Accumulated Surplus
. Unassigned Funds
				(Surplus), defined as the undistributed and unappropriated amounts of surplus,
				in Statement of Statutory Accounting Principle No. 72 of the
NAIC
				Accounting Practices and Procedure Manual
of March 2011.
Commissioner
. The Commissioner of
				Insurance appointed pursuant to M.G.L. c. 26, § 6, or his or her
				designee.
Direct Claims Incurred
. Paid claims
				during the year, plus net change in the direct claim liability, plus the change
				in direct claim reserves, plus the change in direct contract reserves, plus
				incurred medical incentive pools, plus change in net healthcare receivables and
				net reinsurance recoverables, as calculated in the Supplemental Health Care
				Exhibit as adopted by the NAIC on August 17, 2010.
Division
. The Division of Insurance
				established pursuant to M.G.L. c. 26, § 1.
Health Insurer
. An insurer licensed or
				otherwise authorized to transact accident or health insurance under M.G.L. c.
				175; a nonprofit hospital service corporation organized under M.G.L. c. 176A; a
				nonprofit medical service corporation organized under M.G.L. c. 176B; a health
				maintenance organization licensed under M.G.L. c. 176G; and an organization
				entering into a preferred provider arrangement under M.G.L. c. 176I.
Health Insurer
shall not include an employer
				purchasing coverage or acting on behalf of its employees or the employees of
				one or more subsidiaries or affiliated corporations of the employer.
Health Insurer
also shall not include any entity to
				the extent it offers a policy, certificate or contract that is not a health
				benefit plan, as defined in M.G.L. c. 176J, § 1.
Medical Loss Ratio
. The ratio of the
				incurred loss (or incurred claims) plus the loss adjustment expense (or change
				in contract reserves) to earned premiums, according to current National
				Association of Insurance Commissioners' methodology, or as otherwise determined
				by the Commissioner. The Medical Loss Ratio shall be calculated and submitted
				to the Division pursuant to
				211 CMR 147.00:
Methodology for Calculating and Reporting Medical Loss Ratios (MLRSs)
				of Health Benefit Plans
.
NAIC
. National Association of
				Insurance Commissioners.
Self-insured Customer
. A Self-insured
				Group for which a Third-party Administrator provides administrative services
				related to receiving or collecting charges, contributions or premiums for, or
				adjusting or settling claims on or for residents of the Commonwealth.
Self-insured Group Plan
. A
				self-insured or self-funded employment based group health plan.
Third-party Administrator
. A person or
				entity domiciled inside or outside of the Commonwealth who, on behalf of a
				Health Insurer or purchaser of health benefits, receives or collects charges,
				contributions or premiums for, or adjusts or settles claims on or for residents
				of the Commonwealth. Unless noted otherwise, a purchaser of health benefits
				shall not include an entity to the extent it offers a policy, certificate or
				contract that is not a health benefit plan, as defined in M.G.L. c. 176J,
				§ 1; provided, however, that a purchaser of health benefits shall include
				an entity that offers a policy, certificate or contract that provides coverage
				solely for dental care services or vision care services. The Third-party
				Administrator shall also include pharmacy benefit managers and any other entity
				with claims data, eligibility data, provider files and other information
				relating to health care provided to residents of the Commonwealth and health
				care provided by health care providers in the Commonwealth, except that the
				Third-party Administrator shall not include an entity that administers only
				claims data, eligibility data, provider files and other information for its own
				employees and dependents. The Third-party Administrator further shall not
				include "intermediary", as defined in M.G.L. c. 176J, § 1 and
				211 CMR
				66.04:
Definitions
.