Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 149.00 - Annual Comprehensive Financial Statements Pursuant To M.g.l. C. 1760, Section 21 › Section 149.07 - Information Relative to Administrative Services Provided to Self-insured Groups

Current through Register 1525, July 5, 2024
(1) For the
			 purposes of 211 CMR 149.07 only, the following words shall mean:
(a)
Carrier or 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. Carrier or Health Insurer shall not
			 include any entity to the extent it offers a policy, certificate or contract
			 that does not qualify as creditable coverage as defined in M.G.L. c. 111M,
			 §1; provided, however, that "Carrier or Health Insurer" shall include an
			 entity that offers a policy, certificate or contract that provides coverage
			 solely for dental care services or vision care services. Carrier or 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, or any entity acting solely as a Third-party
			 Administrator.
(b)
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 of
			 settling claims on or for residents of the Commonwealth.
(c)
Self-insured Group
			 Plan
: A self-insured or self-funded employment-based group health
			 plan.
(d)
Third-party
			 Administrator
: A person 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 does not qualify as
			 creditable coverage as defined in M.G.L. c. 111M, § 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. 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 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.