Code of Massachusetts Regulations
211 CMR - DIVISION OF INSURANCE
Title 211 CMR 41.00 - Nongroup Health Insurance Rate And Policy Form Filings, Review, And Hearing Procedures Under M.g.l. C.176m
Section 41.02 - Definitions
As used in 211 CMR 41.00, the following words mean:
Actuarial Opinion and Memorandum: A signed written statement by a member of the American Academy of Actuaries based upon the person's examination, including a review of the appropriate records, of the actuarial assumptions and methods utilized by a Carrier in establishing premium rates for Closed Guaranteed Issue Health Plans or by an Intervenor in evaluating proposed premium rates. The Actuarial Opinion and Memorandum must describe any rating methodology or evaluation in detail and must include all calculations, data, experience and rationale supporting each of the actuary's opinions and conclusions.
Adjusted Composite Rate: The composite rate for each Closed Guaranteed Issue Health Plan issued by a Carrier adjusted pursuant to 211 CMR 41.04 and 41.98 to account for differences in premiums among Carriers that are the result of:
(a) Geographic differences in the cost of health care;
(b) The average age of eligible individuals enrolled in a Carrier's Closed Guaranteed Issue Health Plan; and
(c) Differences in benefit levels.
Alternative Benefits Plan: A Guaranteed Issue Managed Care Plan, Guaranteed Issue Medical Plan or Guaranteed Issue Preferred Provider Plan with lower benefits or higher cost-sharing requirements than those contained in the Standard Benefits Plans as allowed by M.G.L. c. 176M, § 2(d).
Average Adjusted Composite Rate: The average of the adjusted composite rates filed by the Carriers as calculated by the Commissioner pursuant to M.G.L. c. 176M, § 5.
Average Composite Rate: The average of the composite rates filed by Carriers as calculated by the Commissioner.
Base Premium Rate: The midpoint rate within a modified community rate band for each rate basis type of each Closed Guaranteed Issue Health Plan of a Carrier.
Carrier: An insurer licensed or otherwise authorized to transact accident and health insurance under M.G.L. c. 175 or the laws of any other jurisdiction; a nonprofit hospital service corporation organized under M.G.L. c. 176A or the laws of any other jurisdiction; a nonprofit medical service corporation organized under M.G.L. c. 176B or the laws of any other jurisdiction; a health maintenance organization organized under M.G.L. c. 176G or the laws of any other jurisdiction; and an insured health plan that includes a preferred provider arrangement organized under M.G.L. c. 176I or the laws of any other jurisdiction. For the purposes of 211 CMR 41.00, Carriers that are affiliated companies will be treated as one Carrier. Joint marketing ventures between Carriers do not constitute an affiliation.
Case Mix Adjustment: The adjustment based upon the diagnosis-related group grouper selected by the Division of Health Care Finance and Policy established under M.G.L. c. 118G, § 2 and associated diagnosis related group weights calculated from Massachusetts data, and measuring the differential case mix compared to the case mix of all privately insured persons discharged from hospitals in Massachusetts, as determined by the Division of Health Care Finance and Policy, or as modified by the Commissioner to ensure that the methodology used is consistent with the most current knowledge and methodologies used for such purposes.
Closed Guaranteed Issue Health Plan: A Guaranteed Issue Managed Care Plan, Guaranteed Issue Preferred Provider Plan or Guaranteed Issue Medical Plan issued by a Carrier to an individual, as well as any covered dependents, after October 1, 1997 but before July 1, 2007. A Carrier may permit an individual to continue to add new dependents to a policy issued under a Closed Guaranteed Issue Health Plan.
Closed Plan: A Nongroup Health Plan issued by a Carrier to a natural person for that person, as well as any covered dependents, before October 1, 1997, the first day of the first open enrollment period specified in M.G.L. c. 176M, § 3(b). A Carrier may permit a natural person to continue to add new dependents to a policy issued under a Closed Plan.
Commissioner: The Commissioner of Insurance appointed pursuant to M.G.L. c. 26, § 6.
Composite Rate: The average per member per month premium rate for each type of Closed Guaranteed Issue Health Plan.
Connector: The Commonwealth Health Insurance Connector, established by M.G.L. c. 176Q, § 2(a).
Creditable Coverage: Coverage of an individual under any of the following:
(a) A Group Health Plan;
(b) A Health Plan, including, but not limited to, a Health Plan issued, renewed or delivered within or without Massachusetts to a natural person who is enrolled in a qualifying student health insurance program pursuant to M.G.L. c. 15A, § 18 or a qualifying student health program of another state;
(c) Part A or Part B of Title XVIII of the Social Security Act;
(d) Title XIX of the Social Security Act, other than coverage consisting solely of benefits under § 1928;
(e) 10 U.S.C. c. 55;
(f) A medical care program of the Indian Health Service or of a tribal organization;
(g) A state health benefits risk pool;
(h) A health plan offered under 5 U.S.C. c. 89;
(i) A public health plan as defined in federal regulations authorized by the Public Health Service Act, § 2701(c)(1)(I), as amended by P.L. 104-191;
(j) A health benefit plan under the Peace Corps Acts, 22 U.S.C. 2504(e);
(k) Young Adult Coverage offered under M.G.L. c. 176J, § 10; or
(l) Any other qualifying coverage required by the Health Insurance Portability and Accountability Act of 1996.
Division: The Division of Insurance established pursuant to M.G.L. c. 26, § 1.
Eligible Dependent: The spouse or children of an Eligible Individual, subject to the applicable terms of the Health Plan covering such individuals.
Eligible Individual: Between November 1, 2001 and June 30, 2007, any natural person who is a resident of Massachusetts and who is not enrolled for coverage under Part A or Part B of Title XVIII of the federal Social Security Act, or a state plan under Title XIX of such act or any successor program.
Emergency Medical Condition: A medical condition, whether physical or mental, manifesting itself by symptoms of sufficient severity, including severe pain, that the absence ofprompt 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)(l)(B) of the Social Security Act, 42 U.S.C. § 1395dd(e)(1)(B).
Enhanced Benefits Plan: AGuaranteed Issue Managed Care Plan, Guaranteed Issue Medical Plan or Guaranteed Issue Preferred Provider Plan with additional benefits or lower cost-sharing requirements (enhancements) than those contained in the Standard Benefits Plans as allowed by M.G.L. c. 176M, § 2(c)(4).
Group Health Plan:
(a) An employee welfare benefit plan, as defined in § 3(1) of the Employee Retirement Income Security Act of 1974, 29 U.S.C. § 1002, to the extent that the plan provides medical care, and including items and services paid for as medical care to employees or their dependents, as defined under the terms of the plan directly or through insurance, reimbursement or otherwise. For the purposes of 211 CMR 41.00, medical care means amounts paid for:
1. The diagnosis, cure, mitigation, treatment or prevention of disease, or amounts paid for the purpose of affecting any structure or function of the body;
2. Amounts paid for transportation primarily for and essential to medical care referred to in 211 CMR 41.02(a)1.; and
3. Amounts paid for insurance covering medical care referred to in 211 CMR 41.02: Group Health Plan (a)1. and 2.
(b) Any plan, fund or program that would not be, but for § 2721(e) of the federal Public Health Service Act, an employee welfare benefit plan, and which is established or maintained by a partnership, to the extent that such plan, fund or program provides medical care, including items and services paid for as medical care, to present or former partners in the partnership, or to their dependents, as defined under the terms of the plan, fund or program, directly or through insurance, reimbursement or otherwise, shall be treated, subject to 211 CMR 41.02: Group Health Plan (c), as an employee welfare benefit plan which is a Group Health Plan;
(c) In the case of a Group Health Plan, the term "employer" also includes the partnership in relation to any partner; and
(d) In the case of a Group Health Plan, the term "participant" also includes:
1. In connection with a Group Health Plan maintained by a partnership, an individual who is a partner in relation to the partnership; or
2. In connection with a Group Health Plan maintained by a self-employed individual, under which one or more employees are participants, the self-employed individual; if such individual is, or may become, eligible to receive a benefit under the plan or such individual's beneficiaries may be eligible to receive any such benefit.
Guaranteed Issue Managed Care Plan: A Nongroup Health Plan, including a conversion Nongroup Health Plan, sold, issued, delivered, made effective or renewed by a Carrier, within or without Massachusetts pursuant to M.G.L. c. 176G or the laws of any other jurisdiction, to any eligible individual for said individual or his or her eligible dependents and for which the Carrier may not decline to offer to or deny enrollment of such eligible individual or his or her eligible dependents and which is to be renewed or continued in force at the option of the eligible individual or his or her eligible dependents, subject to the exclusions set forth in M.G.L. c. 176M, that provides the benefits specified in M.G.L. c. 176M, § 2.
Guaranteed Issue Medical Plan: A Nongroup Health Plan, including a conversion Nongroup Health Plan, sold, issued, delivered, made effective or renewed by a Carrier, within or without Massachusetts pursuant to M.G.L. c. 175, 176A or 176B or the laws of any other jurisdiction, to any eligible individual for said individual or his or her eligible dependents and for which the Carrier may not decline to offer to or deny enrollment of such eligible individual or his or her eligible dependents and which is to be renewed or continued in force at the option of the eligible individual or his or her eligible dependents, subject to the exclusions set forth in M.G.L. c. 176M, that provides the benefits specified in M.G.L. c. 176M, § 2.
Guaranteed Issue Preferred Provider Plan: A Nongroup Health Plan, including a conversion Nongroup Health Plan, sold, issued, delivered, made effective or renewed by a Carrier, within or without Massachusetts pursuant to M.G.L. c. 176I or the laws of any other jurisdiction, to any eligible individual for said individual or his or her eligible dependents and for which the Carrier may not decline to offer to or deny enrollment of such eligible individual or his or her eligible dependents and which is to be renewed or continued in force at the option of the eligible individual or his or her eligible dependents, subject to the exclusions set forth in M.G.L. c. 176M, that provides the benefits specified in M.G.L. c. 176M, § 2.
Health Plan: Any individual, general, blanket, or group policy of health, accident or sickness insurance issued by an insurer licensed under M.G.L. c. 175 or the laws of any other jurisdiction; a hospital service plan issued by a nonprofit hospital service corporation pursuant to M.G.L. c. 176A or the laws of any other jurisdiction; a medical service plan issued by a nonprofit medical service corporation pursuant to M.G.L. c. 176B or the laws of any other jurisdiction; a health maintenance contract issued by a health maintenance organization pursuant to M.G.L. c. 176G or the laws of any other jurisdiction; and an insured health benefit plan that includes a preferred provider arrangement issued pursuant to M.G.L. c. 176I or the laws of any other jurisdiction. The words "health plan" shall not include:
(a) Accident only;
(b) Credit-only;
(c) Limited scope dental benefits if offered separately;
(d) Limited scope vision benefits if offered separately;
(e) Hospitalindemnityinsurance policies if offered as independent, non-coordinated benefits which, for the purposes of 211 CMR 41.00, mean policies issued pursuant to M.G.L. c. 175 which provide a benefit not to exceed $500.00 per day, as adjusted on an annual basis by the amount of increase in the average weekly wages in Massachusetts 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;
(f) Disability income insurance;
(g) Coverage issued as a supplement to liability insurance; specified disease insurance that is purchased as a supplement and not as a substitute for a health plan and meets any requirements the Commissioner by regulation may set;
(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. c. 55 if offered as a separate insurance policy; or
(m) Any other policy subject to the provisions of M.G.L. c. 176K.
Hearing: The part of a Proceeding consisting of testimony of witnesses and oral and written argument of the Parties.
Hearing Request: A request by a Carrier for a Proceeding to consider its proposed rates for a Closed Guaranteed Issue Health Plan following disapproval by the Commissioner after further review.
Information Request: A written request made to a party for production of documents or tangible things or answers to interrogatories.
Intervenor: A person, agency or organization substantially and specifically affected by a Carrier's proposed rate who has been granted permission to appear as a Party in a Proceeding, including, unless otherwise specified, the State Rating Bureau and all Statutory Intervenors.
Loss Ratio: The ratio of the incurred costs of hospital, medical, or health care services for the relevant period to the premium earned for the same period.
Minimum Credible Coverage: The lowest threshold health benefit plan that an individual must purchase in order to satisfy the legal requirement that a Massachusetts resident have health coverage so as to avoid paying a penalty to the Department of Revenue pursuant to M.G.L. c. 111M, § 2.
Modified Community Rate: A rate resulting from a rating methodology in which the premium for all persons within the same rate basis type who are covered under a Closed Guaranteed Issue Health Plan is the same without regard to health status; provided, however, that premiums may vary due to age, geographic area or premium payment mode for each rate basis type as permitted by M.G.L. c. 176M and 211 CMR 41.00. The modified community rate is the rate resulting from a rating methodology in which the premium for all persons within the same rate basis type who are covered under a guaranteed issue health plan is the same without regard to health status; provided, however, that premiums may varydue to age, geographic area, premium payment mode or benefit level for each rate basis type as permitted by M.G.L. c. 176M and 211 CMR 41.00.
Nongroup Health Plan: Any health plan, issued, renewed or delivered within or without Massachusetts to a natural person who is a resident of Massachusetts, including a certificate issued to an eligible natural person which evidences coverage under a policy or contract issued to a trust or association, for that person and his or her spouse and other dependents; provided, that a health plan issued, renewed or delivered within or without Massachusetts to a natural person who is enrolled in a qualifying student health insurance program pursuant to M.G.L. c. 15A, § 18 will not be considered a Nongroup Health Plan for the purposes of 211 CMR 41.00 and will be governed by the provisions of M.G.L. c. 15A and the regulations promulgated thereunder. Nongroup Health Plan includes a conversion Nongroup Health Plan as defined in M.G.L. c. 176M, but does not include a health benefit plan issued or renewed to a natural person pursuant to M.G.L. c. 176J.
Papers: All documents filed in a Proceeding, including Rate Filings, Responsive Filings, motions, pleadings, briefs, memoranda and other communications.
Party: A Carrier submitting a hearing request, the State Rating Bureau, Statutory Intervenors and Intervenors.
Pre-existing Condition Limitation: With respect to coverage, a limitation or exclusion of benefits relating to a condition based on the fact that the condition was present before the date of enrollment for such coverage, whether or not any medical advice, diagnosis, care or treatment was recommended or received before such date. Genetic information shall not be treated as a condition in the absence of a diagnosis of the condition related to such information. No Trade Act/Health Coverage Tax Credit-eligible person shall be subject to a Pre-existing Condition Limitation.
Premium Payment Mode: The method by which premiums for a Closed Guaranteed Issue Health Plan or Closed Plan are paid or the frequency of premium payment installments.
Presiding Officer: The Commissioner, or any person or persons designated by the Commissioner, who conducts Proceedings pursuant to 211 CMR 41.00.
Proceeding: The adjudicatory process initiated by a Hearing Request by which a Presiding Officer considers a proposed rate for a Closed Guaranteed Issue Health Plan, including pre-hearing, discovery, hearing and post-hearing matters.
Rate Basis Type: Each category of individual or family composition for which separate rates are charged for a Closed Guaranteed Issue Health Plan as determined by the Carrier. Carriers must offer a minimum of four rate basis type categories for which separate rates are charged. One required category must be for a single parent with dependents.
Rate Filing: Papers constituting a Carrier's submission of a proposed rate for a particular Closed Guaranteed Issue Health Plan or Closed Plan.
Rating Factor: Characteristics including, but not limited to age, occupation, sex, geography, premium payment mode, actual or expected health condition, medical history, claims history, or duration of coverage.
Record Request: A request, made to a Party during the course of a Proceeding, for production of documents or tangible things or answers to interrogatories.
Resident: A natural person living in Massachusetts; however, the confinement of a person in a nursing home, hospital or other institution is not by itself sufficient to qualify that person as a Resident.
Responsive Filing: Papers by which an Intervenor introduces its evidence concerning a Rate Filing and identifies issues which it intends to raise in the Proceeding.
Revised Rate Filing: Papers by which a Rate Filing is revised to respond to issues upon which the Rate Filing was disapproved, as set forth in a Decision and Order issued by the Presiding Officer.
Service Area: The geographic area within which a health maintenance organization or preferred provider plan has developed a network of providers who provide covered health services in accordance with 211 CMR 43.00 or 211 CMR 51.00.
Standard Benefits Plan: The minimum level of benefits to be provided in each Guaranteed Issue Managed Care Plan, Guaranteed Issue Medical Plan and Guaranteed Issue Preferred Provider Plan on a reasonably actuarially equivalent basis, as determined pursuant to M.G.L. c. 176M, § 2.
Standard Deviation: The square root of the average of the squares of the differences between each adjusted composite rate and the average adjusted composite rate.
State Rating Bureau: The rating bureau in the Division established pursuant to M.G.L. c. 26, § 8E.
Statutory Intervenor: A person, agency or organization, including, but not limited to, the Attorney General, which has a statutory right to appear as an Intervenor in a Proceeding.
Subsidization Factor: A factor to be applied to the rates, based upon individual or household income and assets criteria which are used by the Carrier to assess economic need.
Trade Act/Health Coverage Tax Credit-eligible Person: Any eligible Trade Adjustment Assistance recipient as defined in 35(c)(2) of § 201 of Title II of Public Law 107-210, eligible alternative Trade Adjustment Assistance recipient as defined in § 35(c)(2) of § 201 of Title II of Public Law 107-210, or an eligible Pension Benefit Guarantee Corporation pension recipient who is at least 55 years old and who has qualified health coverage, does not have other specified coverage, and is not imprisoned, under Public Law 107-210.
Waiting Period: A period immediately subsequent to the effective date of an insured's coverage under a health benefit plan during which the plan does not pay for some or all hospital or medical expenses.
