Rhode Island Code of Regulations › Title 220 - Department of Administration › Chapter 90 - Health Benefits Exchange › Subchapter 00 - N/A › Part 2 - Rules and Regulations Pertaining to the Rhode Island Reinsurance Program › Section 220-RICR-90-00-2.3 - Definitions

Current through June 14, 2024
A. The following definitions shall apply to
				 this regulation:
1. "Attachment point" means
				 the threshold dollar amount, adopted by the Director, after which point the
				 claims costs of an insured individual's covered benefits under a
				 reinsurance-eligible health benefit plan in a benefit year are eligible for
				 reinsurance payments.
2. "Benefit
				 year" means a calendar year beginning on or after January 1, 2020, for which a
				 reinsurance eligible health benefit plan provides health insurance
				 coverage.
3. "Coinsurance rate"
				 means the rate at which the Director may reimburse a reinsurance eligible
				 health benefit plan for claims costs incurred after the attachment point and
				 before the reinsurance cap for an insured individual's covered benefits in a
				 benefit year. The coinsurance rate is set by the Director at an initial
				 estimated value but is subject to change in accordance with §
											2.6(B)(2)     of
				 this Part.
4. "Director" means the
				 Director of the Rhode Island health benefit exchange, or his/her
				 designee(s).
5. "Health insurance
				 carrier" or "carrier" means the same as it does in R.I. Gen. Laws §
											27-18.5-2.
6. "Health insurance coverage" means the same
				 as it does in R.I. Gen. Laws §
											27-18.5-2.
7. "Individual market" means the same as it
				 does in R.I. Gen. Laws §
											27-18.5-2.
8. "Program" means the Rhode Island
				 reinsurance program established by the Director pursuant to R.I. Gen. Laws
				 §
											42-157.1-3.
9. "Regulations" means all parts of the Rules
				 and Regulations Pertaining to the Rhode Island Reinsurance Program.
10. "Reinsurance cap" means the threshold
				 dollar amount, adopted by the Director, for claims costs incurred by a
				 reinsurance eligible health benefit plan for an insured individual's covered
				 benefits in a benefit year, after which threshold the claims costs for the
				 benefits are no longer eligible for reinsurance payments.
11. "Reinsurance eligible claim" means a
				 claim for services covered under a reinsurance eligible health benefit plan
				 that is incurred by a reinsurance eligible issuer during the applicable benefit
				 year and within the period of eligibility for the member, that is paid by the
				 reinsurance eligible issuer before June 1 of the following year. A reinsurance
				 eligible claim shall not be adjusted for risk nor for pharmacy rebates. A
				 reinsurance eligible claim does not include a claim for certain abortion
				 services, as defined in
				  45 C.F.R. §
												156.280(d)(1). In the event
				 a single reinsurance eligible claim for inpatient services spans multiple
				 consecutive dates of service and extends across benefit years, the reinsurance
				 eligible claim is deemed incurred on the discharge date.
12. "Reinsurance eligible health benefit
				 plan" means health insurance coverage offered on the individual market,
				 irrespective of whether it is offered through the Rhode Island health benefit
				 exchange, that:
a. constitutes minimum
				 essential coverage, as set forth in
				  26 U.S. C. §
													5000A(f);
b. is approved by the state's health
				 insurance commissioner;
c. is
				 delivered or issued for delivery by a carrier in the state; and d. is not a
				 grandfathered health plan as defined in § 1251 of the Patient Protection
				 and Affordable Care Act.
13. "Reinsurance eligible individual" means
				 an individual who is insured in a reinsurance eligible health benefit plan on
				 or after January 1, 2020.
14.
				 "Reinsurance eligible issuer" means a health insurance carrier that offers a
				 reinsurance eligible health benefit plan to reinsurance eligible
				 individuals.
15. "Reinsurance
				 payment" means payments issued to a reinsurance eligible issuer in accordance
				 with §
											2.6     of this Part.
16. "State" means the State of Rhode
				 Island.