Code of Maryland Regulations › Title 14 - INDEPENDENT AGENCIES › Subtitle 35 - MARYLAND HEALTH BENEFIT EXCHANGE › Chapter 14.35.17 - State Reinsurance Program › Section 14.35.17.02 - Definitions

Current through Register Vol. 51, No. 14, July 12, 2024
A. In this chapter,
				the following terms have the meanings indicated.
B. Terms Defined.
(1) 'Affordable Care Act (ACA) " means the
				Patient Protection and Affordable Care Act of 2010 (Pub. I. 111-148), as
				amended, including by the Health Care and Education Reconciliation Act of 2010
				(Pub. I. 111-152), and the regulations issued under it.
(2) "Annual letter to Issuers " means a
				written communication, issued by the Individual and SHOP Exchange, that:
(a) Provides guidance on how the Exchange
				will interpret laws and regulations, issues reminders regarding requirements of
				and compliance with relevant laws and regulations, and provides notification of
				policy developments; and
(b)
				Instructs issuers on how to meet compliance with QHP certification standards,
				establishes timelines on implementation, and details Exchange expectations of
				issuer compliance with such certification standards.
(3) "Attachment point" means the threshold
				dollar amount for claims costs incurred by a health insurance carrier for an
				enrolled individual's covered benefits in a benefit year, after which threshold
				the claims costs for such benefits are eligible for reinsurance
				payments.
(4) "Benefit year" means
				a calendar year for which a health plan provides coverage for health
				benefits.
(5) "Board" has the
				meaning stated in Insurance Article, §
										31-101, Annotated Code of
				Maryland.
(6) "Carrier business
				agreement" means the annual agreement between the Exchange and the carrier that
				contains terms and conditions governing compliance with the Annotated Code of
				Maryland, and State and federal regulations.
(7) "Carrier Reference Manual" means the
				document developed by the Exchange that provides business rules and operational
				instructions to authorized carriers participating on the Individual and SHOP
				Exchange.
(8) "Carrier-specific
				adjustment factors" means a set of coefficients that modify payments under the
				State Reinsurance Program and that replicate the modified payments that would
				occur by applying the Dampening Factor to the Federal Risk Adjustment
				Program.
(9) "Claims-to-premium
				ratio" means the resulting ratio produced by dividing total claims incurred
				(less State Reinsurance Program payments, federal risk adjustment payments, and
				federal high risk pool reinsurance payments) by the premium amount collected
				for a reinsurance-eligible plan.
(10) "Coinsurance rate" means the rate at
				which the applicable reinsurance entity will reimburse the health insurance
				issuer for claims costs incurred for an enrolled individual's covered benefits
				in a benefit year after the attachment point and before the reinsurance
				cap.
(11) "Dampening factor" means
				a coefficient that modifies payments under the State Reinsurance Program to
				account for RA/RI program interaction to the extent that the claims-to-premium
				ratio between payers and receivers under the risk adjustment is
				normalized.
(12) "Individual
				Exchange" has the meaning stated in Insurance Article, §
										31-101(h),
				Annotated Code of Maryland.
(13)
				Payment Parameters.
(a) "Payment parameters"
				means the attachment point, coinsurance rate, and reinsurance cap for
				reinsurance payments.
(b) "Payment
				parameters" includes a dampening factor, if determined appropriate by the
				Board.
(14) "Qualified
				health plan (QHP) " has the meaning stated in Insurance Article, §
										31-101, Annotated Code of
				Maryland.
(15) "RA/RIprogram
				interaction" refers to payments received by a carrier for the enrolled
				population whose risk and claims experience would be eligible for payments
				under both the Federal Risk Adjustment Program and the State Reinsurance
				Program, such that the resulting full payment would result in a normalized
				claims-to-premium ratio, for the enrolled population identified in this
				definition, that is less than one.
(16) "Reinsurance cap" means the threshold
				dollar amount for total claims costs paid by a health insurance issuer for an
				enrolled individual's covered benefits, after which, the claims costs for such
				benefits are no longer eligible for reinsurance payments.
(17) "Reinsurance-eligible plan" means any
				health benefit plan offered in the individual market, except for the
				limitations and exceptions provided in Regulation . 03 of this
				chapter.
(18) "Risk adjustment
				covered plan" means, for the purpose of the risk adjustment program, any health
				insurance coverage offered in the individual or small group market with the
				exception of grandfathered health plans, group health insurance coverage
				described in 45 CFR §
											146.145(c), individual
				health insurance coverage described in
				45 CFR §
											148.220, and any plan determined not to be a
				risk adjustment covered plan in the applicable federally certified risk
				adjustment methodology.
(19)
				"Section 1332 State Innovation Waiver" means the waiver for state innovation
				filed by the State of Maryland, pursuant to 42 U.S. Code §
				18052.
(20) "State Reinsurance
				Program" means the market stabilization program identified in Insurance
				Article, §
										31-117, Annotated Code of
				Maryland.