Rhode Island Code of Regulations › Title 220 - Department of Administration › Chapter 90 - Health Benefits Exchange › Subchapter 00 - N/A › Part 1 - Rules and Regulations Pertaining to HealthSource RI › Section 220-RICR-90-00-1.4 - Definitions

Current through June 14, 2024
A. Wherever used in this Part, the following
				 terms shall be construed as follows:
1. "Act"
				 or "ACA" means Pub. Law 111-148, the Federal Patient Protection and Affordable
				 Care Act as amended by Pub. Law 111-152, the Health Care and Education
				 Reconciliation Act of 2010, and all Rules promulgated thereunder.
2. "Advance payments of the premium tax
				 credit" or "APTCs" means payments of the tax credits specified in  26 U.S.C. §
												36B  which are provided on an advance basis to an eligible individual
				 enrolled in a Qualified Health Plan through the Exchange.
3. "Annual open enrollment period" means the
				 period during which a qualified individual may enroll in coverage through the
				 Exchange for an upcoming Benefit Year.
4. "Applicant" means an individual who is
				 seeking eligibility for him or herself or for members of his or her household
				 through an application submitted to the Exchange for at least one (1) of the
				 following:
a. Enrollment in a Qualified
				 Health Plan;
b. Advance payments of
				 the premium tax credit and cost sharing reductions;
c. Medicaid or "CHIP," if
				 applicable;
d. An employer or
				 employee seeking eligibility for enrollment in a Qualified Health Plan through
				 SHOP where applicable; or
e.
				 Exemption from the individual responsibility penalty or the shared
				 responsibility payment penalty.
5. "Benefit year" means a calendar year for
				 which a health plan provides coverage for health benefits.
6. "Cost sharing reductions" or "CSRs" means
				 reductions in cost sharing for an eligible individual enrolled in a silver
				 level plan, as defined by §1302(d)(1)(B) of the ACA, in the Exchange or
				 for an individual who is an Indian enrolled in a Qualified Health Plan through
				 the Exchange.
7. "Dependent" means
				 any individual who is or who may become eligible for coverage under the terms
				 of a Qualified Health Plan because of a relationship to a qualified individual
				 or enrollee.
8. "Eligibility
				 appeals" means appeals from an eligibility decision made by the Exchange in
				 accordance with R.I. Gen. Laws §
											42-157-12 and  45 C.F.R. §
												155.505,
				 incorporated above at §
											1.3     of this Part, including:
a. An initial determination of eligibility,
				 including the amount of APTCs and the level of CSRs, made in accordance with
				 standards specified in  45 C.F.R. §§
													155.305(a) through (h),
				 incorporated above at §
												1.3     of this Part;
b. A redetermination of eligibility,
				 including the amount of APTCs and level of CSRs, made in accordance with  45 C.F.R. §§
													155.330 and  155.335, incorporated above at §
												1.3     of
				 this Part;
c. The failure by the
				 Exchange to make such eligibility determination or redetermination in a timely
				 manner; and
d. A termination from
				 QHP coverage or disenrollment from a QHP made by the Exchange in accordance
				 with  45 C.F.R. §
													155.430, incorporated above at §
												1.3     of this
				 Part.
9. "Enrollee" means
				 a qualified individual or qualified employee enrolled in a QHP.
10. "EOHHS" means the Rhode Island Executive
				 Office of Health and Human Services.
11. "Exchange" means the Rhode Island Health
				 Benefits Exchange, doing business as HealthSource RI.
12. "Exchange appeals" means Eligibility
				 Appeals, Exemption Appeals, Large Employer Appeals, and SHOP Appeals, as
				 defined in these Regulations.
13.
				 "Exemption appeals" means appeals from a determination of eligibility for an
				 exemption from the Individual Responsibility Penalty (IRP) made by the Exchange
				 in accordance with §1311(d)(4)(H) of the ACA or from the shared
				 responsibility payment penalty made by the Exchange in accordance with R.I.
				 Gen. Laws §
											42-157-11.
14.
				 "Federal regulations" means the regulations promulgated under the Act at 45 C.F.R. Parts 155, 156 and 157, incorporated above at §
											1.3     of this
				 Part.
15. "FPL" means the most
				 recently published Federal Poverty Level guidelines available as of the first
				 (1st) day of the annual open enrollment period for
				 coverage offered through the Exchange.
16. "HHS" means the United States Department
				 of Health and Human Services.
17.
				 "Indian" has the same meaning as the definition of Indian given in  45 C.F.R. §
												155.300, incorporated above at §
											1.3     of this Part.
18. "Individual responsibility penalty" means
				 the tax penalty associated with the failure of certain individuals to carry
				 minimum essential coverage in accordance with the Internal Revenue Code,  26 U.S.C. §
												5000A.
19. "Issuer
				 agreement" means the agreement between the QHP issuer and the Exchange that
				 satisfies all applicable requirements of the Federal Regulations.
20. "Large employer appeals" means appeals
				 from a determination that an employer does not provide minimum essential
				 coverage through an employer-sponsored plan or that the employer does provide
				 that coverage, but it is not affordable with respect to an employee, as further
				 set forth in  45 C.F.R. §
												155.555, incorporated above at §
											1.3     of this
				 Part.
21. "Lawfully present" has
				 the same meaning given to the term in  45 C.F.R. §
												155.305, incorporated
				 above at §
											1.3     of this Part.
22. "Limited cost sharing plan" means, with
				 respect to a QHP at any level of coverage, the variation of such QHP described
				 in  45 C.F.R. §
												156.420(b)(2), incorporated above at §
											1.3     of this
				 Part.
23. "Premium" means the
				 payment required to be paid for an enrollee to participate in a Qualified
				 Health Plan.
24. "Qualified
				 employee" means an individual employed by a qualified employer who has been
				 offered health insurance coverage by such qualified employer through the
				 SHOP.
25. "Qualified employer"
				 means an employer that is eligible to participate in the SHOP Exchange and
				 elects to make available health coverage to its employees through the SHOP
				 Exchange.
26. "Qualified health
				 plan" or "QHP" means a health plan that has in effect a certification that it
				 meets the standards described in  45 C.F.R. Part 156  Subpart C and such
				 additional standards that may be prescribed, issued or recognized by the
				 Exchange in accordance with the process described in  45 C.F.R. Part 155  Subpart
				 K, incorporated above at §
											1.3     of this Part.
27. "Qualified individual" means, with
				 respect to an Exchange, an individual who has been determined eligible to
				 enroll through the Exchange in a Qualified Health Plan in the individual
				 market.
28. "Regulations" mean all
				 parts of the Rules and Regulations Pertaining to HealthSource RI.
29. "R.I. Gen. Laws" means the General Laws
				 of Rhode Island, as amended.
30.
				 "Shared responsibility payment penalty" means the penalty associated with the
				 failure of certain individuals to carry minimum essential coverage in
				 accordance with R.I. Gen. Laws §
											44-30-101.
31. "SHOP appeals" means appeals by employers
				 or employees of determinations of eligibility for the SHOP Exchange made by the
				 Exchange in accordance with  45 C.F.R. §
												155.715, incorporated above at
				 §
											1.3     of this Part, including the failure of the Exchange to make such
				 eligibility determinations in a timely manner.
32. "SHOP exchange" means the Small Business
				 Health Options Program in accordance with §1311(b)(1)(B) of the ACA and
				  45 C.F.R. Part 155  Subpart H, incorporated above at §
											1.3     of this Part,
				 through which a qualified employer may provide its employees and their
				 dependents participation in one (1) or more QHPs.
33. "Special enrollment period" means a
				 period during which a qualified individual or enrollee who experiences certain
				 qualifying events may enroll in, or change enrollment in, a Qualified Health
				 Plan through the Exchange outside of the initial and annual open enrollment
				 periods.
34. "Trust" means the
				 HealthSource RI Trust established by the Exchange.
35. "Zero cost sharing plan" means, with
				 respect to a QHP at any level of coverage, the variation of such QHP described
				 in  45 C.F.R. §
												156.420(b)(1), incorporated above at §
											1.3     of this
				 Part.