Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 66.00 - Small Group Health Insurance › Section 66.03 - Definitions

Current through Register 1525, July 5, 2024
Actuarial Opinion
. A signed written
				statement by a qualified member of the American Academy of Actuaries, which
				certifies that the actuarial assumptions, methods and contract forms utilized
				by the Carrier in establishing premium rates for Merged Market Health Benefit
				Plans comply with all the requirements of
				211 CMR
				66.00 and any other applicable law.
Affordable Care Act
or
ACA
. The federal Patient Protection and Affordable
				Care Act, Public Law
				111-148, adopted March 23, 2010, as amended by the
				federal Health Care and Education Reconciliation Act of 2010,
				Public Law
				111-152, and federal regulations adopted pursuant
				to those acts.
Benefit Level Rate Adjustment Factor
.
				A number that represents the ratio of the actuarial value of the Benefit Level
				of a Health Benefit Plan as compared to the average actuarial value of the
				Benefit Level of all Health Benefit Plans offered by the Carrier to Eligible
				Individuals and Eligible Small Groups in Massachusetts. The Benefit Level Rate
				Adjustment Factor is also referred to as "Plan Adjustment Factor" or "Pricing
				Actuarial Value".
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
				nonprofit medical service corporation organized under M.G.L. c. 176B; or a
				Health Maintenance Organization organized under M.G.L. c. 176G.
Catastrophic Health Benefit Plan
. A
				Health Benefit Plan in accordance with the ACA that is offered to individuals
				who are younger than 30 years old or who have a hardship exemption from
				individual health plan penalty requirements.
Child-only Health Benefit Plan
. A
				Health Benefit Plan in accordance with the ACA that is offered to individuals
				younger than 21 years old.
Commissioner
. The Commissioner of
				Insurance appointed pursuant to M.G.L. c. 26, § 6, or his or her
				designee.
Connector
. The Commonwealth Health
				Insurance Connector Authority created under M.G.L. c. 176Q.
Connector Seal of Approval
. The
				approval given by the Connector to indicate that a Health Benefit Plan meets
				certain standards regarding quality and value.
Division
. The Division of Insurance
				established pursuant to M.G.L. c. 26, § 1.
Eligible Child
. An Eligible Individual
				who, as of the beginning of a plan year, has not attained 21 years of age and
				who is seeking to enroll in a Child-only Health Benefit Plan offered by a
				Carrier.
Eligible Dependent
. The spouse or
				child of an Eligible Individual or Eligible Employee, subject to the applicable
				terms of the Health Benefit Plan covering such individual or employee. The
				child of an Eligible Individual or Eligible Employee shall be considered an
				Eligible Dependent until at least the child's 26th
				birthday.
Eligible Employee
. Any individual
				employed by an employer, including seasonal and temporary staff, but excluding
				business owners and those holding more than 2% of stock ownership.
Eligible Individual
. An individual who
				is a resident of the Commonwealth.
Eligible Small Business
or
Eligible Small Group
. Any sole proprietorship, firm,
				corporation, partnership or association actively engaged in business who
				employed not more than 50 Eligible Employees; a business shall be considered to
				be an Eligible Small Business or Eligible Small 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
			 66.00 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
			 Eligible Small Group. An Eligible Small Business that exists within a MEWA
			 shall be subject to
			 211 CMR
			 66.00. Nothing within this definition or within any
			 other provision of
			 211 CMR
			 66.00 shall preclude other employer-entities
			 including, but not limited to, government municipalities, from being offered
			 Health Benefit Plans in accordance with
			 211 CMR
			 66.00.
Exchange
. Public entity that
				administers a website whereby consumers may purchase health insurance products
				pursuant to federal law and regulation. In Massachusetts, the Connector is the
				Exchange.
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
				66.00 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.
Group Base Premium Rates
. The base
				premium rate to be charged to Eligible Individuals and their dependents and
				Eligible Small Businesses for all Eligible Employees and Eligible Dependents
				prior to the application of Rating Adjustment Factors. These rates are
				equivalent to the calibrated plan adjusted index rate (CPAIR) as reported in
				the Federal Unified Rate Review Template.
Group Health Plan
.
(a) An employee welfare benefit plan, as
			 defined in the Employee Retirement Income Security Act of 1974, § 3(1),
			 29 U.S.C.
			 1002, to the extent that the plan provides
			 Medical Care, and including items and services paid for as Medical Care to plan
			 participants, including employees or their dependents, as defined under the
			 terms of the plan directly or through insurance, reimbursement or otherwise.
			 For the purposes of
			 211 CMR
			 66.00, Medical Care means amounts paid for:
1. the diagnosis, cure, mitigation, treatment
			 or prevention of disease, or amounts paid for the purpose of affecting any
			 structure or function of the body;
2. amounts paid for transportation primarily
			 for and essential to Medical Care referred to in
			 211
			 CMR 66.03:
Group Health
			 Plan
(a)1.; and
3.
			 amounts paid for insurance covering Medical Care referred to in
			 211
			 CMR 66.03:
Group Health
			 Plan
(a)1. and 2.