Current through Register 1531, September 27, 2024
(1) For the
purposes of 211 CMR 149.07 only, the following words shall mean:
(a)
Carrier or Health
Insurer: An insurer licensed or otherwise authorized to transact
accident or health insurance under M.G.L. c. 175; a nonprofit hospital service
corporation organized under M.G.L. c. 176A; a nonprofit medical service
corporation organized under M.G.L. c. 176B; a health maintenance organization
licensed under M.G.L. c. 176G; and an organization entering into a preferred
provider arrangement under M.G.L. c. 176I. Carrier or Health Insurer shall not
include any entity to the extent it offers a policy, certificate or contract
that does not qualify as creditable coverage as defined in M.G.L. c. 111M,
§1; provided, however, that "Carrier or Health Insurer" shall include an
entity that offers a policy, certificate or contract that provides coverage
solely for dental care services or vision care services. Carrier or Health
Insurer shall not include an employer purchasing coverage or acting on behalf
of its employees or the employees of one or more subsidiaries or affiliated
corporations of the employer, or any entity acting solely as a Third-party
Administrator.
(b)
Self-insured Customer: A Self-insured Group for which
a Third-party Administrator provides administrative services related to
receiving or collecting charges, contributions or premiums for, or adjusting of
settling claims on or for residents of the Commonwealth.
(c)
Self-insured Group
Plan: A self-insured or self-funded employment-based group health
plan.
(d)
Third-party
Administrator: A person domiciled inside or outside of the
Commonwealth who, on behalf of a Health Insurer or purchaser of health
benefits, receives or collects charges, contributions or premiums for, or
adjusts or settles claims on or for residents of the Commonwealth. Unless noted
otherwise, a purchaser of health benefits shall not include an entity to the
extent it offers a policy, certificate or contract that does not qualify as
creditable coverage as defined in M.G.L. c. 111M, § 1; provided, however,
that a purchaser of health benefits shall include an entity that offers a
policy, certificate or contract that provides coverage solely for dental care
services or vision care services. Third-party Administrator shall also include
pharmacy benefit managers and any other entity with claims data, eligibility
data, provider files and other information relating to health care provided to
residents of the Commonwealth and health care provided by health care providers
in the Commonwealth, except that Third-party Administrator shall not include an
entity that administers only claims data, eligibility data, provider files and
other information for its own employees and dependents.
(2) Any Carrier which is required to file an
Annual Comprehensive Financial Statement pursuant to M.G.L. c. 176O, §
21(a) and which provides administrative services to one or more Self-insured
Groups shall submit to the Division an appendix to the Annual Comprehensive
Financial Statement on a form approved by the Commissioner. The appendix to the
Annual Comprehensive Financial Statement shall be submitted electronically on
or before April 1st for the year ended December
31st immediately preceding and shall include the
following information:
(a) The number of the
Carrier's Self-insured Customers as of December
31st;
(b) The aggregate number of subscriber
members enrolled in the benefit plans administered for all of the Carrier's
Self-insured Customers, including:
1. Number
of subscriber members covered on December
31st;
2.
Number of subscriber member months covered in prior calendar year;
and
3. Average number of subscriber
members for prior calendar year; and
(c) The aggregate number of subscriber and
dependent lives covered in the benefit plans administered for all of the
Carrier's Self-insured Customers, including:
1. Number of total subscriber and dependent
covered lives on December 31st;
2. Number of total subscriber and dependent
covered life months covered in prior calendar year; and
3. Average number of subscriber and dependent
covered lives in prior calendar year.
(d) The aggregate value of direct premiums
earned for all of the Carrier's Self-insured Customers;
(e) The aggregate value of direct claims
incurred for all of the Carrier's Self-insured Customers;
(f) The aggregate Medical Loss Ratio for all
of the Carrier's Self-insured Customers;
(g) Net income;
(h) Accumulated surplus;
(i) Accumulated reserves;
(j) The percentage of the Carrier's
Self-insured Customers that include each of the benefits mandated for health
benefit plans under M.G.L. chs. 175, 176A, 176B and 176G;
(k) The aggregated administrative service
fees paid by all of the Carrier's Self-insured Customers; and
(l) Any other information requested by the
Commissioner.
(3) If a
Carrier is unable to provide any of the required information set forth in 211
CMR 149.07(2) in the appendix to its Annual Comprehensive Financial Statement,
the Carrier shall provide a detailed explanation, within the Annual
Comprehensive Financial Statement, of the reason(s) that such required
information is not available.
(4) A
Carrier that provides administrative services to one or more Self-insured
Groups and fails to submit the appendix to its Annual Comprehensive Financial
Statement to the Division on or before April 1st of
each year shall be assessed a late penalty by the Commissioner not to exceed
$100.00 per day.
