Code of Massachusetts Regulations
956 CMR - COMMONWEALTH HEALTH INSURANCE CONNECTOR AUTHORITY
Title 956 CMR 12.00 - Eligibility, Enrollment, and Hearing Process for Connector Programs
Section 12.03 - Definitions
Current through Register 1531, September 27, 2024
As used in 956 CMR 12.00, the following terms shall mean:
Advance Premium Tax Credit (or APTC). A payment made by the U.S. Department of Health and Human Services pursuant to 42 USC § 18082 on behalf of an eligible individual to reduce the amount of a Non-group Health Plan premium.
Appeal Representative. A person who:
(a) is sufficiently aware of an appellant's circumstances to assume responsibility for the accuracy of the statements made during the appeal process, and who has been provided with written authorization from the appellant to act on the appellant's behalf during the appeal process; or
(b) has, under applicable law, authority to act on behalf of an appellant in making decisions related to health care or payment for health care. An appeal representative may include, but is not limited to, an attorney or a non-attorney acting under an attorney's supervision, a guardian, conservator, executor, administrator, holder of power of attorney or health care proxy.
Appealable Action. Any of the actions listed in 956 CMR 12.13.
Applicant. An individual or a Small Employer who completes and submits an application for a Connector Program.
Application. A form prescribed by the Connector to be completed by an Applicant or on the Applicant's behalf, and submitted to the Connector or its designee as a request for a determination that the Applicant is eligible for a Connector Program.
Board. The Board of the Commonwealth Health Insurance Connector Authority, established by M.G.L. c. 176Q, § 2.
Commonwealth. The Commonwealth of Massachusetts.
Commonwealth Health Insurance Connector Authority or Connector. The entity established pursuant to M.G.L. c. 176Q, § 2 and authorized under M.G.L. c. 176, § 3 to perform all the duties and responsibilities required of an American Health Benefit Exchange, as that term is defined by the Patient Protection and Affordable Care Act, Pub. L. 111-148, as amended from time to time.
Connector Program. Any program administered by the Connector to allow individuals to enroll in Health Plans or Dental Plans, including with Financial Assistance, or to allow Small Employers to offer Health Plans or Dental Plans to their Employees and for Employees to enroll in those Health Plans or Dental Plans. Connector Programs include Non-Group Health Plans without Financial Assistance; Non-Group Health Plans with Financial Assistance; and Small Group Health Plans.
Connector Rules and Regulations. All regulations, bulletins and other written directives duly adopted or issued by the Connector relating to Connector Programs.
ConnectorCare. The program administered by the Connector pursuant to M.G.L. c. 176Q to provide Premium Assistance Payments and Cost Sharing Subsidies to Eligible Individuals at or below 500% of the Federal Poverty Level who are also eligible for Advance Premium Tax Credits.
Cost Sharing. A payment made by or billed to an Enrollee at the point of service including, but not be limited to, co-payments, co-insurance and deductibles.
Cost Sharing Subsidy. A payment made to a Health Plan by the Connector to reduce Cost Sharing expenses of ConnectorCare Enrollees. If applicable, Cost Sharing Subsidy may also encompass additional federal payments made to a Health Plan by the federal government to reduce Cost Sharing expenses of certain ConnectorCare enrollees under 45 CFR 156.410.
Covered Services. The range of medical services required to be provided by a Health Plan under its policy.
Day. A calendar day, unless a business day is specified.
Dental Carrier. Any dental insurance carrier that is contracted with the Connector to provide dental services to Connector Program Enrollees.
Dental Plan. Any individual or group policy of insurance issued by a Dental Carrier and offered through the Connector.
Eligible Individual. An individual who is a Resident of the Commonwealth and who is eligible to participate in a Connector Program for Non-group Health Plans in accordance with M.G.L. c. 176Q, and 956 CMR 12.04.
Eligible Small Employer. A Small Employer that is eligible to participate in a Connector Program for Small Group Health Plans, in accordance with 956 CMR 12.04.
Employee. Any individual who is an Employee as that term is defined by § 2791 of the Public Health Services Act.
Employer. Any Employer, as that term is defined in § 2791 of the Public Health Services Act, except that "Employer" includes employers with one or more employees.
Enrollee. An Eligible Individual enrolled by the Connector or its designee in a Health Plan after completing Enrollment. Enrollee also means an Employee enrolled in a Small Group Health Plan, and any dependent of such Employee also enrolled in such Small Group Health Plan, through the Connector, consistent with applicable law and the terms of the Small Group Health Plan. Provided that at least one Employee enrolls in a Small Group Health Plan through the Connector, Enrollee also means a business owner enrolled in a Small Group Health Plan through the Connector, or the dependent of a business owner enrolled in a Small Group Health Plan through the Connector.
Enrollment. The selection of a Health Plan and, if applicable, the payment of the Premium for that Health Plan by the deadline established by the Connector.
Household. A single household for purposes of eligibility for a Non-group Health Plan with Financial Assistance, which means the tax filer and the individuals for whom a tax filer properly expects to claim a personal exemption under the Internal Revenue Code.
Federal Poverty Level (FPL). The most recently published Federal poverty level, updated periodically in the Federal Register by the Secretary of Health and Human Services under the authority of 42 USC 9902(2), as of the first day of the annual open enrollment period for coverage in a Health Plan through the Connector, as specified in 45 CFR 155.410.
Financial Assistance. Any subsidy provided to an Eligible Individual enrolled in a Health Plan, including plans with APTC only, Premium Assistance provided through ConnectorCare, or Cost Sharing Subsidies.
Fraud. An intentional deception or misrepresentation made by a person or corporation with the knowledge that the deception could result in some unauthorized benefit under a Connector Program to the person, the corporation, or some other person. It also includes any act that constitutes fraud under applicable Federal or state health care fraud laws. Examples of Enrollee fraud include, but are not limited to: improperly obtaining prescriptions for controlled substances and card sharing.
Health Carrier. Any managed care organization or insurance carrier that is contracted with the Connector to provide Covered Services to Connector Program Enrollees.
Health Plan. Any individual or group policy of insurance issued by a Health Carrier and offered through the Connector.
Hearing. An administrative, adjudicatory proceeding pursuant to 801 CMR 1.02: Informal/Fair Hearing Rules and 45 CFR 155.500 et seq. to determine the legal rights, duties, benefits or privileges of Applicants (in certain, limited circumstances) and Enrollees pertaining to eligibility for Connector Programs; enrollment in a Health Plan; and decisions regarding requests to waive or reduce a ConnectorCare Premium for extreme financial hardship.
Modified Adjusted Gross Income (MAGI). Income used to determine eligibility for Financial Assistance, as defined in the Internal Revenue Code at 26 USC § 36B(d)(2)(B).
Non-group Health Plan. A Health Plan sold to an Eligible Individual, consistent with M.G.L. c. 176J, § 1.
Plan Type. A type of coverage for ConnectorCare Enrollees with income within a certain range. Plan Types differ in terms of the amount of Premium Assistance payment and Cost Sharing Subsidy provided.
Premium. An Enrollee's or Small Employer's required periodic payment for coverage under a Connector Program, paid to the Connector.
Premium Assistance. A periodic payment made to a Health Carrier by the Connector on behalf of a ConnectorCare Enrollee to reduce the amount of a Premium paid by the individual.
Resident. For an individual who:
(a) is 21 years of age or older, a Resident is a person who is not living in an institution as defined in 42 CFR 435.403(b), is capable of indicating intent, and is not receiving an optional State supplementary payment as addressed in 42 CFR 435.403(f). Such an individual is a Resident if the individual is living and intends to reside, including without a fixed address, or has entered with a job commitment or is seeking employment (whether or not currently employed) within the Commonwealth;
(b) is younger than 21 years old, a Resident is an individual who is not living in an institution as defined in 42 CFR 435.403(b), is not eligible for Medicaid based on receipt of assistance under title IV-E of the Social Security Act as addressed in 42 CFR 435.403(g), is not emancipated, and is not receiving an optional State supplementary payment as addressed in 42 CFR 435.403(f). Such an individual is a Resident if the individual resides in the Commonwealth, including without a fixed address, or if the individual's parent or caretaker with whom the individual resides is a Resident of the Commonwealth;
(c) is not described in 956 CMR 12.03: Resident (a) or (b), the individual shall be a Resident if the individual satisfies the residency requirements described in 42 CFR 435.403; or
(d) is a member of a Household where at least one other member is a Resident under 956 CMR 12.03: Resident (a), (b), or (c), then that individual shall also be treated as a Resident, except where that individual is a tax dependent of married spouses who enroll in a Health Plan through a single Exchange other than the Connector.
Small Employer. An Employer with at least one but not more than 50 Employees. The number of Employees is determined using the method set forth in Internal Revenue Code § 4980H(c)(2).
Small Group Health Plan. A Health Plan sold to an eligible small business or group, as defined in M.G.L. c. 176J, § 1.
