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General Laws

Section 1. As used in this chapter, the following words shall, unless the context clearly requires otherwise, have the following meanings:—

“Commissioner”, the commissioner of the division of insurance.

“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)(l)(B) of the Social Security Act, 42 U.S.C. 1395dd(e)(1)(B).

“Health plan”, any individual, general, blanket or group policy of health, accident and sickness insurance issued by an insurer licensed under chapter 175; a group hospital service plan issued by a nonprofit hospital service corporation under chapter 176A; a group medical service plan issued by a non profit medical service corporation under chapter 176B; a group health maintenance contract issued by a health maintenance organization under chapter 176G; provided, however, “health plan” shall not include accident only, credit-only, limited scope vision or dental benefits if offered separately, hospital indemnity insurance policies if offered as independent, non-coordinated benefits which under this chapter shall mean policies issued under chapter 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 section 1 of chapter 152, 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, disability income insurance, 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, insurance arising out of a workers’ compensation law or similar law, automobile medical payment insurance, 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, long-term care if offered separately, coverage supplemental to the coverage provided under 10 U.S.C. 55 if offered as a separate insurance policy, or any policy under chapter 176K. 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 section 18 of chapter 15A shall not be considered a health plan under this chapter and shall be governed by said chapter 15A and the regulations promulgated hereunder. The commissioner may by regulation define other health coverage as a health benefit plan for the purposes of this chapter.

“Late enrollee”, an eligible employee or dependent who requests enrollment in a group health plan or insurance arrangement after the plan initial enrollment period, their initial eligibility date provided under the terms of the plan or arrangement or the group’s annual open enrollment period; provided, however, that an insured shall not be considered a late enrollee if the request for enrollment to the insurer is made within 30 days after termination of coverage provided under another health insurance plan or arrangement where such coverage has ceased due to termination of the spouse’s employment or death of the spouse or if the request for enrollment is made pursuant to section 9A, 9C or 18 of chapter 118E.

“Out of state health plan”, any general, blanket, group or nongroup policy of health, accident and sickness insurance issued by an insurer meeting the requirements for licensure under chapter one hundred and seventy-five or the laws of any other jurisdiction; a group hospital service plan issued by a nonprofit hospital service corporation under chapter one hundred and seventy-six A or the laws of any other jurisdiction; a group medical service plan issued by a nonprofit hospital service corporation under chapter one hundred and seventy-six B or the laws of any other jurisdiction; a group health maintenance contract issued by a health maintenance organization meeting the requirements for licensure under chapter one hundred and seventy-six G or the laws of any other jurisdiction; or a preferred provider arrangement meeting the requirements for licensing under chapter one hundred and seventy-six I or the laws of any other jurisdiction which (i) is delivered or issued for delivery outside the commonwealth and (ii) covers any resident of the commonwealth.

“Qualifying health plan”, (i) any blanket or general policy of medical, surgical or hospital insurance described in subsection (A), (B) or (D) of section one hundred and ten of chapter one hundred and seventy-five; (ii) any policy of accident or sickness insurance as described in section one hundred and eight of chapter one hundred and seventy-five which provides hospital or surgical expense coverage; (iii) any nongroup medical, surgical or hospital insurance as described in chapter one hundred and seventy-five; (iv) any nongroup or group hospital or medical service plan issued by a nonprofit hospital or medical service corporation under chapters one hundred and seventy-six A and one hundred and seventy-six B; (v) any nongroup health maintenance contract issued by a health maintenance organization under chapter one hundred and seventy-six G; (vi) any self insured or self-funded employer group health plan; (vii) any health coverage provided to persons serving in the armed forces of the United States; or (viii) medicare or medical assistance provided under chapter one hundred and eighteen E. The commissioner may, by regulation, define other health coverage as a qualifying health plan for the purposes of this chapter.

“Waiting period”, a specified period immediately subsequent to the effective date of an eligible insured’s coverage under the health plan or out of state health plan during which the plan does not pay for some or all medical expenses.

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