Code of Massachusetts Regulations
211 CMR - DIVISION OF INSURANCE
Title 211 CMR 151.00 - Certified Group Purchasing Cooperatives
Section 151.03 - Definitions
As used in 211 CMR 151.00, the following words mean:
Association: A chamber of commerce, trade association, or other organization, formed for purposes other than obtaining insurance.
Carrier: 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; or an organization entering into a preferred provider arrangement under M.G.L. c. 176I, but not including 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. As used in 211 CMR 151.00, Carrier shall not include any entity offering a policy, certificate or contract that provides coverage solely for dental care services or vision care services.
Commissioner: The Commissioner of Insurance appointed pursuant to M.G.L. c. 26, § 6.
Commonwealth Health Insurance Connector Authority or Connector: An authority established under M.G.L. c. 176Q to facilitate the availability, choice and adoption of private health insurance plans to Eligible Individuals and groups.
Covered Benefits or Benefits: Health Care Services to which an Insured is entitled under the terms of a Health Benefit Plan.
Division: The Division of Insurance established pursuant to M.G.L. c. 26, § 1.
Eligible Association Member: Any individual member of a Qualified Association who is a Massachusetts resident, who is also and Eligible Individual, and who meets all eligibility criteria of the Qualified Association of which he or she is a member, and who meets all eligibility criteria necessary to be offered a Health Benefit Plan through the Group Purchasing Cooperative of which the Qualified Association is a member.
Eligible Dependent: The spouse or child of an Eligible Employee or Eligible Association Member, subject to the applicable terms of the Health Benefit Plan covering such Eligible Employee or Eligible Association Member.
Eligible Employee: An employee who:
(a) works on a full-time basis with a normal work week of 30 or more hours, including an owner, a sole proprietor or a partner of a partnership; provided however, that such owner, sole proprietor or partner is included as an employee under a Health Benefit Plan of an Eligible Small Business; and provided, however, that Eligible Employee does not include an employee who works on a temporary or substitute basis; and
(b) is hired to work for a period of not less than five months, provided, however, that a Carrier shall not require that an employee must have worked for an unreasonable length of time in order to qualify as an Eligible Employee. For the purposes of 211 CMR 151.00, five months shall be deemed to be an unreasonable length of time when determining whether an employee is an Eligible Employee. Nothing in this definition shall exclude a sole proprietor from being determined to be an Eligible Employee, so long as that sole proprietor is otherwise eligible to be offered a Health Benefit Plan through a Group Purchasing Cooperative.
Eligible Individual: An individual who is a Massachusetts resident and who is not seeking health insurance coverage to replace an employer-sponsored health plan for which the individual is eligible and which provides coverage that is at least actuarially equivalent to minimum creditable coverage as defined by Connector regulation 956 CMR 5.00: Minimum Credible Coverage. For the purposes of 211 CMR 151.00, continuation coverage under M.G.L. c. 176J, § 9 or under the Consolidated Omnibus Budget Reconciliation Act of 1986 ("COBRA"), shall not be considered an employer-sponsored health plan
Eligible Small Business: Any sole proprietorship, firm, corporation, partnership, or association actively engaged in business which, on at least 50% of its working days during the preceding year, employed from among one to not more than 50 Eligible Employees, the majority of whom worked in Massachusetts; provided, however, that the sole proprietorship, firm, corporation, partnership or association need not have been in existence during the preceding year in order to qualify as an Eligible Small Business. An entity is considered to be one Eligible Small Business if it is eligible to file a combined tax return, or if its companies are affiliated companies through the same corporate parent. Except as otherwise specifically provided, provisions of 211 CMR 151.00 that apply to an Eligible Small Business will continue to apply through the end of the Rating Period in which such entity no longer meets the requirements of an Eligible Small Business.
Emergency Services: Services to treat a medical condition, whether physical or mental, manifesting itself by symptoms of sufficient severity, including severe pain, that the absence of prompt medical attention could reasonably be expected by a prudent layperson who possesses an average knowledge of health and medicine, to result in placing the health of an Insured or another person in serious jeopardy, serious impairment to body function, or serious dysfunction of any body organ or part, or, with respect to a pregnant woman, as further defined in § 1867(e)(1)(B) of the Social Security Act, 42 U.S.C. 1395dd(e)(1)(B).
Finding of Neglect: A written determination by the Commissioner that a Carrier has failed to complete or file required information in the form and/or within the time required by 211 CMR 151.00.
Group Purchasing Cooperative:
(a) A Massachusetts nonprofit or not-for-profit corporation; or
(b) an association, approved as a Qualified Association by the Commissioner, all the members of which are part of a Qualified Association which negotiates with one or more Carriers for the issuance of Health Benefit Plans that cover Eligible Employees and Eligible Dependents of the Qualified Association's members.
Health Benefit Plan: Any individual, general, blanket or group policy of health, accident and sickness insurance issued by an insurer licensed under M.G.L. c. 175; an individual or group hospital service plan issued by a non-profit hospital service corporation under M.G.L. c. 176A; an individual or group medical service plan issued by a nonprofit medical service corporation under M.G.L. c. 176B; and an individual or group health maintenance contract issued by a health maintenance organization under M.G.L. c. 176G.
Health benefit plans shall not include those plans whose benefits are for:
(a) accident only;
(b) credit only;
(c) limited scope vision or dental benefits if offered separately;
(d) hospital indemnity insurance policies if offered as independent, non-coordinated benefits which for the purposes of 211 CMR 66.00: Small Group Health Insurance shall mean policies issued under M.G.L. c. 175 which provide a benefit not to exceed $500 per day, as adjusted on an annual basis by the amount of increase in the average weekly wages in the commonwealth as defined in M.G.L. c. 152, § 1, to be paid to an insured or a dependent, including the spouse of an insured, on the basis of a hospitalization of the insured or a dependent;
(e) disability income insurance;
(f) coverage issued as a supplement to liability insurance;
(g) specified disease insurance that is purchased as a supplement and not as a substitute for a health plan and meets the requirements of 211 CMR 146.00: Specified Disease Insurance;
(h) insurance arising out of a workers' compensation law or similar law;
(i) automobile medical payment insurance;
(j) insurance under which benefits are payable with or without regard to fault and which is statutorily required to be contained in a liability insurance policy or equivalent self insurance;
(k) long-term care if offered separately;
(l) coverage supplemental to the coverage provided under 10 U.S.C. 55 if offered as a separate insurance policy;
(m) any policy subject to M.G.L. c. 176K or any similar policies issued on a group basis, Medicare Advantage plans or Medicare Prescription drug plans; or
(n) a health plan issued, renewed or delivered within or without the commonwealth to an individual who is enrolled in a qualifying student health insurance program under M.G.L. c. 15A, § 18 shall not be considered a health plan for the purposes of 211 CMR 66.00: Small Group Health Insurance and shall be governed by said M.G.L. c. 15A.
Health Care Services: Services for the diagnosis, prevention, treatment, cure or relief of a health condition, illness, injury or disease.
Insured: Any policyholder, certificate holder, subscriber, member or other person on whose behalf the Carrier is obligated to pay for and/or provide Health Care Services.
Mandated Benefit: A Health Care Service or category of health care provider which a Carrier is required by its licensing, or by law or regulation, to include as a Covered Benefit in its Health Benefit Plan.
Material Change: A modification to any procedures or documents that substantially affects the rights or responsibilities of an Insured, Qualified Association, Group Purchasing Cooperative, Carrier or health care provider.
Network: A grouping of health care providers who contract with a Carrier or affiliated Carriers to provide Health Care Services to Insureds covered by any or all of the Carrier's or affiliated Carrier's Health Benefit Plans.
Participation Rate: The percentage of Eligible Employees electing to participate in any Health Benefit Plan offered by their Eligible Employer; or the percentage of the sum of Eligible Employees and Eligible Dependents electing to participate in any Health Benefit Plan offered by their Eligible Employer. For Eligible Association Members, it may be the percentage of the sum of Eligible Association Members and Eligible Dependents electing to participate in the Health Benefit Plan in which the Eligible Association Member is enrolled. In any case, the numbers used to calculate the percentage shall not include any Eligible Employee, Eligible Association Member, or Eligible Dependent who is enrolled in a Health Benefit Plan sponsored by a different employer.
Qualified Association:
(a) A Massachusetts nonprofit or not-for-profit corporation; or
(b) any other entity domiciled inside or outside Massachusetts; organized and maintained for the purpose of advancing the occupational, professional, trade, or industry interests of Association members, other than that of obtaining health insurance, and which has been in active existence for at least five years, and which comprises at least 100 Association members, and membership in which is generally available to potential Association members of such occupation, profession, trade or industry without regard to the health condition or status of a prospective Association member, or the employees and dependents of a prospective Association member.
Qualified Association Member: An individual member or small business that is actively enrolled or registered as a member of a Qualified Association according to the bylaws of the Qualified Association and, where necessary, has paid any dues that are required by the Qualified Association for membership.
Rating Period: The period for which premium rates established by a Carrier are in effect, as determined by the Carrier.
Service Area: The geographic area, as approved by the Commissioner, within which the Carrier has developed a Network of health care providers to afford adequate access to members for Covered Benefits.
Small Business Group Purchasing Cooperative: See definition of Group Purchasing Cooperative.
Waiting Period: A period immediately subsequent to the effective date of an Insured's coverage under a Health Benefit Plan during which the Health Benefit Plan does not pay for some or all Covered Benefits.
Wellness Program: A program designed to measure and improve individual health by identifying risk factors through diagnostic testing, surveys, questionnaires, establishing plans to meet specific health goals which include appropriate preventive measures, and/or other programs or plans that are designed to enhance health.
Working Day: A day when a sole proprietorship, firm, corporation, partnership or association is actively engaged in business, with one or more employees working.
