Code of Massachusetts Regulations › 957 CMR - CENTER FOR HEALTH INFORMATION AND ANALYSIS › Title 957 CMR 10.00 - HEALTH CARE PAYERS PREMIUMS AND CLAIMS DATA REPORTING REQUIREMENTS › Section 10.02 - Definitions

Current through Register 1525, July 5, 2024
All defined terms in 957 CMR 10.00 are capitalized. As used in
				957 CMR 10.00, unless the context otherwise requires, terms have the following
				meanings:
Administrative Service Fees
. The fees
				earned by a Payer for the full administration of a Self-insured Health Plan,
				excluding any premiums collected for stop-loss coverage.
Affiliated Payers
. Any two or more
				Payers which, directly or indirectly, are in control of one another, are
				controlled by each other, or are under common control.
Allowed Claims
. The total cost of
				claims after the provider or network discount, if any. Allowed Claims are equal
				to Incurred Claims plus member cost sharing and include medical claims, drug
				claims, capitation payments, and all other payments to providers, including
				those paid outside of the claims system. This value includes incurred but not
				reported (IBNR) estimates resulting in approximated completed claims for
				periods that are not yet considered complete.
Audit
. An examination of a Payer's
				health care data, information and supporting documentation against internal and
				external data sources to evaluate the accuracy of such health care data and
				information and to also ensure consistency in reporting.
Average Employer Size
. For a given
				category, the number of covered employees divided by the number of
				employers.
Benefit Design Type
. Non-mutually
				exclusive groupings of Private Commercial Plan membership based on benefit,
				network, and/or product design, including but not limited to high-deductible
				health plans (HDHPs) and health plans that utilize tiered or limited provider
				networks.
Calendar Year
. The period beginning
				January 1st and ending December
				31st.
Center
. The Center for Health
				Information and Analysis established under M.G.L. c. 12C.
Data Submission Manual
. A data
				submission manual containing detailed specifications and submission
				guidelines.
Health Care Services
. Supplies, care
				and services of a medical, surgical, optometric, dental, podiatric,
				chiropractic, psychiatric, therapeutic, diagnostic, preventative,
				rehabilitative, supportive, or geriatric nature including, but not limited to,
				inpatient and outpatient acute hospital care and services, services provided by
				a community health center or by a sanatorium, as included in the definition of
				"hospital" in Title XVIII of the federal Social Security Act, and treatment and
				care compatible with such services or by a health maintenance
				organization.
Health Insurance Plan
. An individual
				or group contract or other plan providing coverage of Health Care Services and
				which is issued by a Payer, a hospital service corporation, a medical service
				corporation or a health maintenance organization.
Health Insurance Premiums
. The gross
				premiums earned for providing health insurance coverage, including any portion
				of the premium that is paid to a third party.
Incurred Claims
. The total cost of
				claims, after the provider/network discount (if any) and after member cost
				sharing. Incurred claims include medical claims, drug claims, and capitation
				payments, and all other payments to providers including those paid outside of
				the claims system. This value should include incurred but not reported
				estimates resulting in approximated completed claims for periods that are not
				yet considered complete.
Insurance Funding Type
. A mutually
				exclusive grouping of Private Commercial Plan membership based on whether the
				Payer is financially responsible for paying covered members' medical claims or
				whether the employer is financially responsible for paying members'
				claims.
Member
. A person covered by an
				individual contract or a certificate under a group arrangement contracted with
				a Payer, or their covered dependents.
Member Months
. The number of months
				during which Members are covered, over a specified period of time.
Private Commercial Plans
. All primary,
				medical Health Insurance Plans or Self-insured Health Plans, provided by
				Private Health Care Payers, with contract situs or administration based in
				Massachusetts. The following types of business are not considered to be Private
				Commercial Plans under 957 CMR 10.00: Medicare Advantage, Commonwealth Care,
				Medicaid Managed Care, Medicare Supplement, Federal Employee Health Benefit
				Plan (FEHBP), Medical Security Program, and other non-primary, non-medical
				business.
Private Health Care Payer ("Payer")
. A
				private entity that contracts to provide, deliver, arrange for, pay for, or
				reimburse any of the costs of Health Care Services. A Private Health Care Payer
				includes a carrier authorized to transact accident and health insurance under
				M.G.L. c. 175, a nonprofit hospital service corporation licensed under M.G.L.
				c. 176A, a nonprofit medical service corporation licensed under M.G.L. c. 176B,
				a dental service corporation organized under M.G.L. c. 176E, an optometric
				service corporation organized under M.G.L. c. 176F, a Self-insured Health Plan,
				a Third-party Administrator, or a health maintenance organization licensed
				under M.G.L. c. 176G.
Product Type
. A mutually exclusive
				breakdown of Private Commercial Plans into categories including but not limited
				to those with closed networks of providers, those with preferred networks of
				providers, and those without networks of preferred providers.
Rating Factors
. Factors that are
				applied to base rates to develop Health Insurance Premiums, including but not
				limited to age/gender, area, group size, retention, and contract type.
Reporting Year
. The Calendar Year in
				which the Payer reports.
Self-insured Health Plan
. A plan which
				provides health benefits to the employees of an employer, which is not a health
				insurance plan, and in which the employer is liable for the actual costs of the
				Health Care Services provided by the plan and Administrative Service
				Fees.
Third-party Administrator
. Any person
				or entity that receives or collects charges or contributions for, or adjusts or
				settles claims for, Self-insured Health Plans with contract situs in
				Massachusetts.
Website
. The website of the Center for
				Health Information and Analysis located at
www.chiamass.gov
.