Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 41.00 - Nongroup Health Insurance Rate And Policy Form Filings, Review, And Hearing Procedures Under M.g.l. C.176m › Section 41.02 - Definitions

Current through Register 1525, July 5, 2024
As used in
				211 CMR 41.00, the following
				words mean:
Actuarial Opinion and Memorandum
: A
				signed written statement by a member of the American Academy of Actuaries based
				upon the person's examination, including a review of the appropriate records,
				of the actuarial assumptions and methods utilized by a Carrier in establishing
				premium rates for Closed Guaranteed Issue Health Plans or by an Intervenor in
				evaluating proposed premium rates. The Actuarial Opinion and Memorandum must
				describe any rating methodology or evaluation in detail and must include all
				calculations, data, experience and rationale supporting each of the actuary's
				opinions and conclusions.
Adjusted Composite Rate
: The composite
				rate for each Closed Guaranteed Issue Health Plan issued by a Carrier adjusted
				pursuant to
				211 CMR
				41.04 and
				41.98
				to account for differences in premiums among Carriers that are the result
				of:
(a) Geographic differences in the cost of health care;
(b) The average age of eligible individuals enrolled in a
				Carrier's Closed Guaranteed Issue Health Plan; and
(c) Differences in benefit levels.
Alternative Benefits Plan
: A
				Guaranteed Issue Managed Care Plan, Guaranteed Issue Medical Plan or Guaranteed
				Issue Preferred Provider Plan with lower benefits or higher cost-sharing
				requirements than those contained in the Standard Benefits Plans as allowed by
				M.G.L. c. 176M, § 2(d).
Average Adjusted Composite Rate
: The
				average of the adjusted composite rates filed by the Carriers as calculated by
				the Commissioner pursuant to M.G.L. c. 176M, § 5.
Average Composite Rate
: The average of
				the composite rates filed by Carriers as calculated by the Commissioner.
Base Premium Rate
: The midpoint rate
				within a modified community rate band for each rate basis type of each Closed
				Guaranteed Issue Health Plan of a Carrier.
Carrier
: An insurer licensed or
				otherwise authorized to transact accident and health insurance under M.G.L. c.
				175 or the laws of any other jurisdiction; a nonprofit hospital service
				corporation organized under M.G.L. c. 176A or the laws of any other
				jurisdiction; a nonprofit medical service corporation organized under M.G.L. c.
				176B or the laws of any other jurisdiction; a health maintenance organization
				organized under M.G.L. c. 176G or the laws of any other jurisdiction; and an
				insured health plan that includes a preferred provider arrangement organized
				under M.G.L. c. 176I or the laws of any other jurisdiction. For the purposes of
				211 CMR 41.00, Carriers that
				are affiliated companies will be treated as one Carrier. Joint marketing
				ventures between Carriers do not constitute an affiliation.
Case Mix Adjustment
: The adjustment
				based upon the diagnosis-related group grouper selected by the Division of
				Health Care Finance and Policy established under M.G.L. c. 118G, § 2 and
				associated diagnosis related group weights calculated from Massachusetts data,
				and measuring the differential case mix compared to the case mix of all
				privately insured persons discharged from hospitals in Massachusetts, as
				determined by the Division of Health Care Finance and Policy, or as modified by
				the Commissioner to ensure that the methodology used is consistent with the
				most current knowledge and methodologies used for such purposes.
Closed Guaranteed Issue Health Plan
: A
				Guaranteed Issue Managed Care Plan, Guaranteed Issue Preferred Provider Plan or
				Guaranteed Issue Medical Plan issued by a Carrier to an individual, as well as
				any covered dependents, after October 1, 1997 but before July 1, 2007. A
				Carrier may permit an individual to continue to add new dependents to a policy
				issued under a Closed Guaranteed Issue Health Plan.
Closed Plan
: A Nongroup Health Plan
				issued by a Carrier to a natural person for that person, as well as any covered
				dependents, before October 1, 1997, the first day of the first open enrollment
				period specified in M.G.L. c. 176M, § 3(b). A Carrier may permit a natural
				person to continue to add new dependents to a policy issued under a Closed
				Plan.
Commissioner
: The Commissioner of
				Insurance appointed pursuant to M.G.L. c. 26, § 6.
Composite Rate
: The average per member
				per month premium rate for each type of Closed Guaranteed Issue Health
				Plan.
Connector
: The Commonwealth Health
				Insurance Connector, established by M.G.L. c. 176Q, § 2(a).
Creditable Coverage
: Coverage of an
				individual under any of the following:
(a) A Group Health Plan;
(b) A Health Plan, including, but not limited to, a Health Plan
				issued, renewed or delivered within or without Massachusetts to a natural
				person who is enrolled in a qualifying student health insurance program
				pursuant to M.G.L. c. 15A, § 18 or a qualifying student health program of
				another state;
(c) Part A or Part B of Title XVIII of the Social Security
				Act;
(d) Title XIX of the Social Security Act, other than coverage
				consisting solely of benefits under § 1928;
(e) 10 U.S.C. c. 55;
(f) A medical care program of the Indian Health Service or of a
				tribal organization;
(g) A state health benefits risk pool;
(h) A health plan offered under 5 U.S.C. c. 89;
(i) A public health plan as defined in federal regulations
				authorized by the Public Health Service Act, § 2701(c)(1)(I), as amended
				by
				P.L.
				104-191;
(j) A health benefit plan under the Peace Corps Acts,
				22 U.S.C.
				2504(e);
(k) Young Adult Coverage offered under M.G.L. c. 176J, §
				10; or
(l) Any other qualifying coverage required by the Health
				Insurance Portability and Accountability Act of 1996.
Division
: The Division of Insurance
				established pursuant to M.G.L. c. 26, § 1.
Eligible Dependent
: The spouse or
				children of an Eligible Individual, subject to the applicable terms of the
				Health Plan covering such individuals.
Eligible Individual
: Between November
				1, 2001 and June 30, 2007, any natural person who is a resident of
				Massachusetts and who is not enrolled for coverage under Part A or Part B of
				Title XVIII of the federal Social Security Act, or a state plan under Title XIX
				of such act or any successor program.
Emergency Medical Condition
: A medical
				condition, whether physical or mental, manifesting itself by symptoms of
				sufficient severity, including severe pain, that the absence ofprompt medical
				attention could reasonably be expected by a prudent layperson who possesses an
				average knowledge of health and medicine, to result in placing the health of an
				insured or another person in serious jeopardy, serious impairment to body
				function, or serious dysfunction of any body organ or part, or, with respect to
				a pregnant woman, as further defined in § 1867(e)(l)(B) of the Social
				Security Act, 42 U.S.C. § 1395dd(e)(1)(B).
Enhanced Benefits Plan
: AGuaranteed
				Issue Managed Care Plan, Guaranteed Issue Medical Plan or Guaranteed Issue
				Preferred Provider Plan with additional benefits or lower cost-sharing
				requirements (enhancements) than those contained in the Standard Benefits Plans
				as allowed by M.G.L. c. 176M, § 2(c)(4).
Group Health Plan
:
(a) An employee welfare benefit plan, as defined in § 3(1)
				of the Employee Retirement Income Security Act of 1974, 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 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 41.00, 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 41.02(a)1.; and
3. Amounts paid for insurance covering medical care referred to
				in 211 CMR 41.02:
Group Health Plan
(a)1. and
				2.
(b) Any plan, fund or program that would not be, but for §
				2721(e) of the federal Public Health Service Act, an employee welfare benefit
				plan, and which is established or maintained by a partnership, to the extent
				that such plan, fund or program provides medical care, including items and
				services paid for as medical care, to present or former partners in the
				partnership, or to their dependents, as defined under the terms of the plan,
				fund or program, directly or through insurance, reimbursement or otherwise,
				shall be treated, subject to 211 CMR 41.02:
Group Health
				Plan
(c), as an employee welfare benefit plan which is a Group
				Health Plan;
(c) In the case of a Group Health Plan, the term "employer"
				also includes the partnership in relation to any partner; and
(d) In the case of a Group Health Plan, the term "participant"
				also includes:
1. In connection with a Group Health Plan maintained by a
				partnership, an individual who is a partner in relation to the partnership;
				or
2. In connection with a Group Health Plan maintained by a
				self-employed individual, under which one or more employees are participants,
				the self-employed individual; if such individual is, or may become, eligible to
				receive a benefit under the plan or such individual's beneficiaries may be
				eligible to receive any such benefit.
Guaranteed Issue Managed Care Plan
: A
				Nongroup Health Plan, including a conversion Nongroup Health Plan, sold,
				issued, delivered, made effective or renewed by a Carrier, within or without
				Massachusetts pursuant to M.G.L. c. 176G or the laws of any other jurisdiction,
				to any eligible individual for said individual or his or her eligible
				dependents and for which the Carrier may not decline to offer to or deny
				enrollment of such eligible individual or his or her eligible dependents and
				which is to be renewed or continued in force at the option of the eligible
				individual or his or her eligible dependents, subject to the exclusions set
				forth in M.G.L. c. 176M, that provides the benefits specified in M.G.L. c.
				176M, § 2.
Guaranteed Issue Medical Plan
: A
				Nongroup Health Plan, including a conversion Nongroup Health Plan, sold,
				issued, delivered, made effective or renewed by a Carrier, within or without
				Massachusetts pursuant to M.G.L. c. 175, 176A or 176B or the laws of any other
				jurisdiction, to any eligible individual for said individual or his or her
				eligible dependents and for which the Carrier may not decline to offer to or
				deny enrollment of such eligible individual or his or her eligible dependents
				and which is to be renewed or continued in force at the option of the eligible
				individual or his or her eligible dependents, subject to the exclusions set
				forth in M.G.L. c. 176M, that provides the benefits specified in M.G.L. c.
				176M, § 2.
Guaranteed Issue Preferred Provider
				Plan
: A Nongroup Health Plan, including a conversion Nongroup
				Health Plan, sold, issued, delivered, made effective or renewed by a Carrier,
				within or without Massachusetts pursuant to M.G.L. c. 176I or the laws of any
				other jurisdiction, to any eligible individual for said individual or his or
				her eligible dependents and for which the Carrier may not decline to offer to
				or deny enrollment of such eligible individual or his or her eligible
				dependents and which is to be renewed or continued in force at the option of
				the eligible individual or his or her eligible dependents, subject to the
				exclusions set forth in M.G.L. c. 176M, that provides the benefits specified in
				M.G.L. c. 176M, § 2.
Health Plan
: Any individual, general,
				blanket, or group policy of health, accident or sickness insurance issued by an
				insurer licensed under M.G.L. c. 175 or the laws of any other jurisdiction; a
				hospital service plan issued by a nonprofit hospital service corporation
				pursuant to M.G.L. c. 176A or the laws of any other jurisdiction; a medical
				service plan issued by a nonprofit medical service corporation pursuant to
				M.G.L. c. 176B or the laws of any other jurisdiction; a health maintenance
				contract issued by a health maintenance organization pursuant to M.G.L. c. 176G
				or the laws of any other jurisdiction; and an insured health benefit plan that
				includes a preferred provider arrangement issued pursuant to M.G.L. c. 176I or
				the laws of any other jurisdiction. The words "health plan" shall not
				include:
(a) Accident only;
(b) Credit-only;
(c) Limited scope dental benefits if offered separately;
(d) Limited scope vision benefits if offered separately;
(e) Hospitalindemnityinsurance policies if offered as
				independent, non-coordinated benefits which, for the purposes of
				211 CMR 41.00, mean policies
				issued pursuant to M.G.L. c. 175 which provide a benefit not to exceed $500.00
				per day, as adjusted on an annual basis by the amount of increase in the
				average weekly wages in Massachusetts as defined in M.G.L. c. 152, § 1, to
				be paid to an insured or a dependent, including the spouse of an insured, on
				the basis of a hospitalization of the insured or a dependent;
(f) Disability income insurance;
(g) Coverage issued as a supplement to liability insurance;
				specified disease insurance that is purchased as a supplement and not as a
				substitute for a health plan and meets any requirements the Commissioner by
				regulation may set;
(h) Insurance arising out of a workers' compensation law or
				similar law;
(i) Automobile medical payment insurance;
(j) Insurance under which benefits are payable with or without
				regard to fault and which is statutorily required to be contained in a
				liability insurance policy or equivalent self insurance;
(k) Long-term care, if offered separately;
(l) Coverage supplemental to the coverage provided under 10
				U.S.C. c. 55 if offered as a separate insurance policy; or
(m) Any other policy subject to the provisions of M.G.L. c.
				176K.
Hearing
: The part of a Proceeding
				consisting of testimony of witnesses and oral and written argument of the
				Parties.
Hearing Request
: A request by a
				Carrier for a Proceeding to consider its proposed rates for a Closed Guaranteed
				Issue Health Plan following disapproval by the Commissioner after further
				review.
Information Request
: A written request
				made to a party for production of documents or tangible things or answers to
				interrogatories.
Intervenor
: A person, agency or
				organization substantially and specifically affected by a Carrier's proposed
				rate who has been granted permission to appear as a Party in a Proceeding,
				including, unless otherwise specified, the State Rating Bureau and all
				Statutory Intervenors.
Loss Ratio
: The ratio of the incurred
				costs of hospital, medical, or health care services for the relevant period to
				the premium earned for the same period.
Minimum Credible Coverage
: The lowest
				threshold health benefit plan that an individual must purchase in order to
				satisfy the legal requirement that a Massachusetts resident have health
				coverage so as to avoid paying a penalty to the Department of Revenue pursuant
				to M.G.L. c. 111M, § 2.
Modified Community Rate
: A rate
				resulting from a rating methodology in which the premium for all persons within
				the same rate basis type who are covered under a Closed Guaranteed Issue Health
				Plan is the same without regard to health status; provided, however, that
				premiums may vary due to age, geographic area or premium payment mode for each
				rate basis type as permitted by M.G.L. c. 176M and
				211 CMR 41.00. The modified
				community rate is the rate resulting from a rating methodology in which the
				premium for all persons within the same rate basis type who are covered under a
				guaranteed issue health plan is the same without regard to health status;
				provided, however, that premiums may varydue to age, geographic area, premium
				payment mode or benefit level for each rate basis type as permitted by M.G.L.
				c. 176M and
				211 CMR 41.00.
Nongroup Health Plan
: Any health plan,
				issued, renewed or delivered within or without Massachusetts to a natural
				person who is a resident of Massachusetts, including a certificate issued to an
				eligible natural person which evidences coverage under a policy or contract
				issued to a trust or association, for that person and his or her spouse and
				other dependents; provided, that a health plan issued, renewed or delivered
				within or without Massachusetts to a natural person who is enrolled in a
				qualifying student health insurance program pursuant to M.G.L. c. 15A, §
				18 will not be considered a Nongroup Health Plan for the purposes of
				211 CMR 41.00 and will be
				governed by the provisions of M.G.L. c. 15A and the regulations promulgated
				thereunder. Nongroup Health Plan includes a conversion Nongroup Health Plan as
				defined in M.G.L. c. 176M, but does not include a health benefit plan issued or
				renewed to a natural person pursuant to M.G.L. c. 176J.
Papers
: All documents filed in a
				Proceeding, including Rate Filings, Responsive Filings, motions, pleadings,
				briefs, memoranda and other communications.
Party
: A Carrier submitting a hearing
				request, the State Rating Bureau, Statutory Intervenors and Intervenors.
Pre-existing Condition Limitation
:
				With respect to coverage, a limitation or exclusion of benefits relating to a
				condition based on the fact that the condition was present before the date of
				enrollment for such coverage, whether or not any medical advice, diagnosis,
				care or treatment was recommended or received before such date. Genetic
				information shall not be treated as a condition in the absence of a diagnosis
				of the condition related to such information. No Trade Act/Health Coverage Tax
				Credit-eligible person shall be subject to a Pre-existing Condition
				Limitation.
Premium Payment Mode
: The method by
				which premiums for a Closed Guaranteed Issue Health Plan or Closed Plan are
				paid or the frequency of premium payment installments.
Presiding Officer
: The Commissioner,
				or any person or persons designated by the Commissioner, who conducts
				Proceedings pursuant to
				211 CMR 41.00.
Proceeding
: The adjudicatory process
				initiated by a Hearing Request by which a Presiding Officer considers a
				proposed rate for a Closed Guaranteed Issue Health Plan, including pre-hearing,
				discovery, hearing and post-hearing matters.
Rate Basis Type
: Each category of
				individual or family composition for which separate rates are charged for a
				Closed Guaranteed Issue Health Plan as determined by the Carrier. Carriers must
				offer a minimum of four rate basis type categories for which separate rates are
				charged. One required category must be for a single parent with
				dependents.
Rate Filing
: Papers constituting a
				Carrier's submission of a proposed rate for a particular Closed Guaranteed
				Issue Health Plan or Closed Plan.
Rating Factor
: Characteristics
				including, but not limited to age, occupation, sex, geography, premium payment
				mode, actual or expected health condition, medical history, claims history, or
				duration of coverage.
Record Request
: A request, made to a
				Party during the course of a Proceeding, for production of documents or
				tangible things or answers to interrogatories.
Resident
: A natural person living in
				Massachusetts; however, the confinement of a person in a nursing home, hospital
				or other institution is not by itself sufficient to qualify that person as a
				Resident.
Responsive Filing
: Papers by which an
				Intervenor introduces its evidence concerning a Rate Filing and identifies
				issues which it intends to raise in the Proceeding.
Revised Rate Filing
: Papers by which a
				Rate Filing is revised to respond to issues upon which the Rate Filing was
				disapproved, as set forth in a Decision and Order issued by the Presiding
				Officer.
Service Area
: The geographic area
				within which a health maintenance organization or preferred provider plan has
				developed a network of providers who provide covered health services in
				accordance with
				211 CMR 43.00 or
				211 CMR 51.00.
Standard Benefits Plan
: The minimum
				level of benefits to be provided in each Guaranteed Issue Managed Care Plan,
				Guaranteed Issue Medical Plan and Guaranteed Issue Preferred Provider Plan on a
				reasonably actuarially equivalent basis, as determined pursuant to M.G.L. c.
				176M, § 2.
Standard Deviation
: The square root of
				the average of the squares of the differences between each adjusted composite
				rate and the average adjusted composite rate.
State Rating Bureau
: The rating bureau
				in the Division established pursuant to M.G.L. c. 26, § 8E.
Statutory Intervenor
: A person, agency
				or organization, including, but not limited to, the Attorney General, which has
				a statutory right to appear as an Intervenor in a Proceeding.
Subsidization Factor
: A factor to be
				applied to the rates, based upon individual or household income and assets
				criteria which are used by the Carrier to assess economic need.
Trade Act/Health Coverage Tax Credit-eligible
				Person
: Any eligible Trade Adjustment Assistance recipient as
				defined in 35(c)(2) of § 201 of Title II of
				Public
				Law 107-210, eligible alternative Trade Adjustment
				Assistance recipient as defined in § 35(c)(2) of § 201 of Title II of
				Public
				Law 107-210, or an eligible Pension Benefit
				Guarantee Corporation pension recipient who is at least 55 years old and who
				has qualified health coverage, does not have other specified coverage, and is
				not imprisoned, under
				Public
				Law 107-210.
Waiting Period
: A period immediately
				subsequent to the effective date of an insured's coverage under a health
				benefit plan during which the plan does not pay for some or all hospital or
				medical expenses.