Adverse determination - A determination, based upon a review of information provided, by a carrier or its designated utilization review organization, to deny, reduce, modify, or terminate an admission, continued inpatient stay, or the availability of any other health care services, for failure to meet the requirements for coverage based on medical necessity, appropriateness of health care setting and level of care, or effectiveness.
Benefit limit - A specified limit on the visits or dollars allowed for a specific covered service.
Carrier - An insurer licensed or otherwise authorized to transact accident and health insurance under M.G.L. chapter 175; a nonprofit hospital service corporation organized under M.G.L. chapter 176A; a non-profit medical service corporation organized under M.G.L. chapter 176B; or a health maintenance organization organized under M.G.L. chapter 176G.
Coinsurance - A percentage of the allowed charge, after a copayment, if any, that an insured will pay for covered services under a health benefit plan.
Commonwealth Care - Publicly subsidized health plans that are offered through the Health Connector and that are available to a qualified, uninsured Massachusetts resident who is 19 years old, makes under 300% of the federal poverty level, and is a U.S. citizens or legal permanent resident.
Commonwealth Choice - Commercial health plan for uninsured individuals and small groups not eligible for Commonwealth Care. Offered as of July 1, 2007 through the Health Connector with the Connector Seal of Approval that certifies the plans as products of good value to consumers.
Commonwealth Health Connector - A state agency that assists Massachusetts residents with the purchase of health insurance.
Copayment - A fixed dollar amount paid by an insured to a physician, hospital, pharmacy or other health care provider at the time the insured receives covered services.
Creditable coverage - Coverage of an individual under any of the following health plans with no lapse of coverage of more than 63 days:
- Group health plan
- Health plan, including, but not limited to, 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 M.G.L. chapter 15A or a qualifying student health program of another state
- Part A or Part B of Title XVIII of the Social Security Act
- Title XIX of the Social Security Act, other than coverage consisting solely of benefits under section 1928
- 10 U.S.C. 55
- Medical care program of the Indian Health Service or of a tribal organization
- State health benefits risk pool
- Health plan offered under 5 U.S.C. 89
- Public health plan as defined in federal regulations authorized by the Public Health Service Act, section 2701(c)(I)(I), as amended by Public Law 104-191
- Health benefit plan under the Peace Corps Act, 22 U.S.C. 2504(e)
- Coverage for young adults as offered under section 10 of chapter 176J; or,
- Any other qualifying coverage required by the Health Insurance Portability and Accountability Act of 1996, as it is amended, or by regulations promulgated under that act. This definition applies to creditable coverage for portability in relation to any pre-existing condition provision or waiting period. It is not intended to define creditable coverage as it is defined by the Connector Board for purposes of determining individual responsibility for maintaining health coverage.
Deductible - An annual dollar amount that must be paid by an insured for specified health care services that the insured uses before the health plan becomes obligated to pay for covered services. Some health plans may include separate prescription drug deductibles. The deductible amount does not include the premiums that the insured pays.
Eligible dependent - The spouse or child of an eligible person, individual or eligible employee, subject to the applicable terms of the health plan covering such individual or employee.
Eligible employee (in an eligible small business or group) - An employee who:
(a) Works on a full-time basis with a normal work week of 30 or more hours, and includes an owner, a sole proprietor or a partner of a partnership; provided however, that such owner, sole proprietor or partner is included as an employee under a health care plan of an eligible small business; and provided, however, that "eligible employee" does not include an employee who works on a temporary or substitute basis; and,
(b) Is hired to work for a period of not less than five months, provided, however, that a carrier cannot require that a person must have worked for an unreasonable length of time in order to qualify as an "eligible employee." For the purposes of 211 CMR 66.00, five months shall be deemed to be an unreasonable length of time when determining "eligible employee."
Eligible individual - An individual who is a resident of the commonwealth.
Eligible small business or group - Any sole proprietorship, firm, corporation, partnership or association actively engaged in business who, on at least 50% of its working days during the preceding year, employed from among one to not more than 50 eligible employees, the majority of whom worked in Massachusetts; provided, however, that the sole proprietorship, firm, corporation, partnership or association need not have been in existence during the preceding year in order to qualify as an "eligible small business or group." In determining the number of eligible employees, companies that are affiliated companies or are eligible to file a combined tax return for purposes of state taxation are considered to be one business A business shall be considered to be one eligible small business or group if: (1) it is eligible to file a combined tax return for purpose of state taxation, or (2) its companies are affiliated companies through the same corporate parent.
Federal poverty level (FPL) - Income guidelines set by the federal government annually. These levels are used to determine financial eligibility for many programs, including Commonwealth Care. Go to www.mass.gov/connector for information on the current federal poverty levels.
Late enrollee - An eligible employee or dependent who requests enrollment in an eligible small business' health insurance plan or insurance arrangement after the group's initial enrollment period, his or her initial eligibility date provided under the terms of the plan or arrangement, or the group's annual open enrollment period.
Mandated benefit - A health service or category of health service provider that a carrier is required by its licensing or other statute to include in its health plan.
Medical necessity or medically necessary - Health care services that are consistent with generally accepted principles of professional medical practice as determined by whether (a) the service is the most appropriate available supply or level of service for the insured in question considering potential benefits and harms to the individual; (b) is known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes; or (c) for services and interventions not in widespread use, is based on scientific evidence.
Minimum creditable coverage - The lowest threshold health plan that satisfies the legal requirement for a Massachusetts resident, over age 18, to have health coverage. See page 6 of this guide for a description of the current minimum creditable coverage standards.
Pre-existing condition - A condition that was present before the date of enrollment for the coverage, whether or not any medical advice, diagnosis, care or treatment was recommended or received before the date. Genetic information is not treated as a condition in the absence of a diagnosis of the condition related to that information. Pregnancy is not a pre-existing condition. Trade Act/HCTC-eligible persons are not subject to any pre-existing conditions provision. Health carriers that impose a pre-existing condition limitation must waive or reduce the period if an insured had prior creditable coverage up to 63 days before completing the application.
Preventive health services - Any periodic, routine, screening or other services designed for the prevention and early detection of illness that a carrier is required to provide pursuant to Massachusetts or federal law.
Rating period - The period for which premium rates established by a carrier are in effect, as determined by the carrier.
Resident - A natural person living in the commonwealth, but the confinement of a person in a nursing home, hospital or other institution shall not by itself be sufficient to qualify a person as a resident. A carrier may ask for reasonable evidence of residency.
Trade Act/HCTC-Eligible person: or TA/HCTC-eligible person - Any eligible trade adjustment assistance recipient or any eligible alternative trade adjustment assistance recipient as defined in section 35(c)(2) of section 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 - The time immediately after the effective date of an insured's coverage under a health plan during which time the plan does not pay for some or all hospital or medical expenses, but in all cases pays for emergency services. Trade Act/HCTC-eligible persons are not subject to any waiting period.
Young Adult Health Benefit Plan - A health plan offered as of July 1, 2007 to Massachusetts young adults between the nineteenth (19 th) birthday up until the day before the twenty-seventh (27 th) birthday who do not otherwise have access to a health benefits plan subsidized by the young adult's employer.