Wisconsin Administrative Code
Office of the Commissioner of Insurance
Chapter Ins 19 - Wisconsin Healthcare Stability Plan
Section Ins 19.02 - Definitions
Current through August 26, 2024
In addition to definitions contained in s. 601.80, Stats., the following definitions shall apply in this chapter:
(1) "Audit" has the meaning provided under s. 601.83(5) (f), Stats., and includes a verification and compliance audit conducted by OCI.
(2) "CMS" means the Centers for Medicare & Medicaid Services within the U.S. department of health and human services.
(3) "Commissioner" has the meaning provided under s. 600.03(11), Stats.
(4) "Compliant plan" means an individual health benefit plan offered by an eligible health carrier that conforms with regulations set forth in the Affordable Care Act, as applicable, or an individual health benefit plan that provides substantially similar benefits as required by the Affordable Care Act effective July 1, 2018, as defined by the office.
(5) "Eligible health carrier" means an insurer offering a compliant plan either on or off the federally facilitated marketplace that was issued after January 1, 2014, and is not a grandfathered plan or transitional plan. A transitional plan is a health plan in effect on October 1, 2013, and is in compliance with CMS and guidance issued by the office. A grandfathered plan is a health plan that has been continuously offered since March 23, 2010, and in compliance with CMS.
(6) "Enrolled individual" means an insured member of an eligible health carrier during the applicable benefit year for at least one day and who has paid all premium owed for the period in which claims eligible for reinsurance payment were incurred or the eligible health carrier is obligated to pay under law.
(7) "External Data Gathering Environment" or "EDGE server" means the server developed by the CMS in conjunction with the federally facilitated marketplace for health care insurers to submit claims information on enrolled individuals for claims paid for covered services or treatments.
(7m) "Office" or "OCI" has the meaning provided under s. 600.03(34), Stats.
(8) "Secure file transfer portal" or "FTP" means a manner of securely transferring requested information from the eligible health carrier to the commissioner in a manner specified by the commissioner.
(10) "Wisconsin Healthcare Stability Plan" or "WIHSP" means the Wisconsin healthcare stability plan created under s. 601.83, Stats.
