Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 30 - Health Insurance › Part 15 - Benefit Determination and Utilization Review › Section 230-RICR-20-30-15.3 - Definitions

Current through June 14, 2024
A. As used in this regulation:
1. "Actuarial value" means the level of
				  coverage provided by an issuer of a health insurance plan's benefits, as
				  further defined in 42 U.S.C.
				  §
												18022(d) and
				  regulations adopted thereunder.
2.
				  "Commissioner" means the Commissioner of the Office of the Health Insurance
				  Commissioner.
3. "Essential health
				  benefits" means health insurance plan coverage of the benefits required by
				  42 U.S.C §
												18022(b), including if
				  applicable any benchmark plan designated by the Commissioner on behalf of the
				  Governor;
4. "Exchange" means the
				  Rhode Island Health Benefits Exchange established by Executive Order No. 11-09,
				  issued on September 19, 2011.
5.
				  "Health insurance issuer" means any entity subject to the insurance laws and
				  regulations of this state, or subject to the jurisdiction of the Commissioner,
				  that contracts or offers to contract to provide, deliver, arrange for, pay for,
				  or reimburse any of the costs of health care services, including, without
				  limitation, an insurance company offering accident and sickness insurance, a
				  health maintenance organization licensed under R.I. Gen. Laws Chapter 27-41, a
				  non-profit hospital service corporation organized under R.I. Gen. Laws Chapter
				  27-19, a non-profit medical service corporation organized under R.I. Gen. Laws
				  Chapter 27-20, a non-profit dental service corporation organized under R.I.
				  Gen. Laws Chapter 27-20.1, a non-profit optometric service corporation
				  organized under R.I. Gen. Laws Chapter 27-20.2, a domestic insurance company
				  subject to R.I. Gen. Laws Chapter 27-1 that offers or provides health insurance
				  coverage in the state, and a foreign insurance company subject to R.I. Gen.
				  Laws Chapter 27-2 that offers or providers health insurance coverage in the
				  state.
6. "Health insurance plan"
				  means:
a. A policy, contract, certificate or
				  other evidence of agreement to provide "health insurance coverage," as defined
				  in R.I. Gen. Laws §§
												27-18.5-2(8) and
				  27-18.6-2(15), or
				  to provide a "health benefit plan," as defined in R.I. Gen. Laws §
												27-50-3(t),
				  including but not limited to an individual health insurance plan, a small group
				  health insurance plan, a large group market health insurance plan, a plan of
				  Medicare Supplemental insurance, and a plan of dental insurance. The term shall
				  include a qualified health plan offered on the Exchange, and a qualified health
				  plan offered on the Exchange by the Small Business Health Options Program. The
				  terms "individual health insurance plan", and "small group health insurance
				  plan" do not include a Medicare Supplement insurance plan or a dental insurance
				  plan.
b. The term shall include a
				  health insurance plan in which the certificate or other evidence of coverage is
				  offered, issued, delivered or renewed to an individual resident in this state,
				  or to the employees or members and their dependents of a small group or
				  employer located in this state where the health insurance plan is issued or
				  delivered outside of this state, and the plan offers or provides such coverage
				  through a trust association or other intermediary.
7. "Office of the Health Insurance
				  Commissioner" or "Office" means the agency established pursuant to R.I. Gen.
				  Laws §
											42-14.5-1 et seq.
8. "Qualified health plan" means a health
				  insurance plan that has been approved by the Office, certified by the Exchange,
				  and with respect to which the Issuer has been licensed by the Office and
				  certified by the Exchange, in accordance with 42 U.S.C. Chapter 157, Subchapter
				  III (§§
											18021  through  18063) and regulations adopted
				  thereunder.
9. "Risk adjustment and
				  reinsurance" means the programs authorized by
				  42 U.S.C. §
												18061 et seq.
10. "SERFF" means the System for Electronic
				  Rate and Form Filing administered under the auspices of the National
				  Association of Insurance Commissioners.
11. "Small Business Health Option Program" or
				  "SHOP" means the program authorized by
				  42 U.S.C §
												18031(b)(1)(B).