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  • PART I ADMINISTRATION OF THE GOVERNMENT
  • TITLE XXII CORPORATIONS
  • CHAPTER 176Q COMMONWEALTH HEALTH INSURANCE CONNECTOR
  • Section 1 Definitions

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

“Authority”, the commonwealth health insurance connector authority.

“Board”, the board of the commonwealth health insurance connector, established by section 2.

“Business entity”, a corporation, association, partnership, limited liability company, limited liability partnership or other legal entity.

“Carrier”, an insurer licensed or otherwise authorized to transact accident and health insurance under chapter 175; a nonprofit hospital service corporation organized under chapter 176A; a nonprofit medical service corporation organized under chapter 176B; a health maintenance organization organized under chapter 176G; a dental service corporation organized under chapter 176E; a nonprofit optometric service plan organized under chapter 176F.

“Catastrophic plan”, a health benefits plan limited exclusively for sale to eligible individuals who also meet the requirements of eligibility for catastrophic plans as defined in 42 U.S.C. § 18022(e) with premium rates that are consistent with section 3 of chapter 176J.

“Child-only plan”, a health benefits plan limited exclusively for sale to eligible children pursuant to 42 U.S.C. § 300gg-6(c) and U.S.C. § 18022(f) with premium rates that are consistent with section 3 of chapter 176J.

“Commissioner”, the commissioner of insurance.

“Commonwealth care health insurance program”, the program administered under chapter 118H.

“Commonwealth care health insurance program enrollees”, individuals and their dependents eligible to enroll in the commonwealth care health insurance program.

“Connector”, the commonwealth health insurance connector.

“Connector seal of approval”, the approval given by the board of the connector to indicate that a health benefit plan meets certain standards regarding quality and value.

“Dependent”, the spouse and children of any employee if such persons would qualify for dependent status under the Internal Revenue Code or for whom a support order could be granted under chapters 208, 209 or 209C.

“Eligible child”, an eligible individual who, as of the beginning of a plan year, has not attained the age of 21 and who is seeking to enroll in a child-only plan offered by a carrier.

“Eligible individual”, an individual who is a resident of the commonwealth and who is not seeking individual 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.

“Eligible small groups”, groups, any sole proprietorship, labor union, educational, professional, civic, trade, church, not-for-profit or social organization or firms, corporations, partnerships or associations actively engaged in business that on at least 50 per cent of its working days during the preceding year employed at least one but not more than 50 employees.

“Fiscal year”, the 12 month period during which a hospital keeps its accounts and which ends in the calendar year by which it is identified.

“Free care”, the following medically necessary services provided to individuals determined to be financially unable to pay for their care, in whole or in part, under applicable regulations of the connector: (1) services provided by acute hospitals; (2) services provided by community health centers; and (3) patients in situations of medical hardship in which major expenditures for health care have depleted or can reasonably be expected to deplete the financial resources of the individual to the extent that medical services cannot be paid, as determined by regulations of the connector.

“Health benefit 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 non-profit 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; a coverage for young adults health insurance plan under section 10 of chapter 176J. The words “health benefit 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 for the purposes of 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. section 55 if offered as a separate insurance policy, or any policy subject to chapter 176K or any similar policies issued on a group basis, Medicare Advantage plans or Medicare Prescription drug plans. 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 for the purposes of this chapter and shall be governed by said chapter 15A. The commissioner may by regulation define other health coverage as a health benefit plan for the purposes of this chapter.

“Mandated benefits”, a health service or category of health service provider which a carrier is required by its licensing or other statute to include in its health benefit plan.

“Medically necessary services”, medically necessary inpatient and outpatient services as mandated under Title XIX of the Federal Social Security Act; provided, that “medically necessary services” shall not include: (1) non-medical services, such as social, educational and vocational services; (2) cosmetic surgery; (3) canceled or missed appointments; (4) telephone conversations and consultations; (5) court testimony; (6) research or the provision of experimental or unproven procedures including, but not limited 1 to, treatment related to sex-reassignment surgery and pre-surgery hormone therapy; and (7) the provision of whole blood; and provided, further, that “Medically necessary services” shall include administrative and processing costs associated with the provision of blood and its derivatives.

“Non-providing employer”, an employer of a state-funded employee, as defined in this section; provided, however, that the term “non-providing employer” shall not include: (i) an employer who complies with chapter 151F for such employee; (ii) an employer that is signatory to or obligated under a negotiated, bona fide collective bargaining agreement between such employer and bona fide employee representative which agreement governs the employment conditions of such person receiving free care; (iii) an employer who participates in the insurance reimbursement program; or (iv) an employer that employs not more than 10 employees; provided, further, that for the purposes of this definition, an employer shall not be considered to pay for or arrange for the purchase of health care services provided by acute hospitals and ambulatory surgical centers by making or arranging for any payments to the uncompensated care pool.

“Participating institution”, an eligible group that purchases health benefit plans through the connector.

“Payments from non-providing employers”, all amounts paid to the Uncompensated Care Trust Fund or the General Fund or any successor fund by non-providing employers.

“Point-of-service cost-sharing subsidy”, a payment made to a carrier or an individual by the connector to offset point-of-service cost-sharing expenses of an individual which shall include, but not be limited to, copayments, coinsurance and deductibles.

“Premium assistance payment”, a payment made to a carrier or an individual by the connector to offset the value of a health benefit plan premium.

“Rating factor”, characteristics including, but not limited to, age, industry, rate basis type, geography, wellness program usage or tobacco usage.

“Stand-alone dental plan”, a nonprofit dental service plan offered by a licensed dental service corporation, as those terms are defined in section 1 of chapter 176E, offered independently of a health benefit plan offered through the connector or offered by: (i) an insurer licensed or otherwise authorized to transact accident and health insurance under chapter 175; (ii) a nonprofit hospital service corporation organized under chapter 176A; or (iii) a nonprofit medical service corporation organized under chapter 176B.

“Stand-alone vision plan”, a nonprofit optometric service plan offered by a licensed optometric service corporation, as those terms are defined in section 1 of chapter 176F, offered independently of a health benefit plan offered through the connector or offered by: (i) an insurer licensed or otherwise authorized to transact accident and health insurance under chapter 175; (ii) a nonprofit hospital service corporation organized under chapter 176A; or (iii) a nonprofit medical service corporation organized under chapter 176B.

“State-funded employee”, any employed person, or dependent of such person, who receives, on more than 3 occasions during any hospital fiscal year, health services paid for as free care; or any employed persons, or dependents of such persons, of a company that has 5 or more occurrences of health services paid for as free care by all employees in aggregate during any fiscal year; provided, that an occurrence shall include all healthcare related services incurred during a single visit to a health care professional.

“Sub-connector”, a locally incorporated and governed organization, with demonstrated experience in the small business health insurance and benefit market and which has been authorized to function in conjunction with the board of the connector.

“Uninsured patient”, a patient who is not covered by a health insurance plan, a self-insurance health plan or a medical assistance program.