Definitions

As used in 956 CMR 5.00, the following words shall have the following meanings, except where the context clearly indicates otherwise: Ambulatory Patient Services. All outpatient services, regardless of the setting. Annual Maximum Benefit. A maximum amount that a Health Benefit Plan will pay per year for covered services for an individual or family. Co-insurance. A percentage of the allowed charge, after any applicable Deductible, that a covered person will pay for covered services received under a Health Benefit Plan. Connector. The Commonwealth Health Insurance Connector Authority. Connector Board. The Board of the Connector established by M.G.L. c. 176Q, § 2(b). Co-payment. A fixed dollar amount, after any applicable Deductible, paid by a Covered Person to a physician, hospital, pharmacy, or other health care provider at the time the Covered Person receives covered services. Core Services. Physician services, inpatient acute care services, day surgery, and diagnostic procedures and tests. Covered Person. An individual who is covered under a Health Benefit Plan. Covered Services. The healthcare services, supplies and drugs that are paid for under the Health Benefit Plan. Deductible. An annual dollar amount that must be paid by a Covered Person for specified health care services that a Covered Person uses before the Health Benefit Plan becomes obligated to pay for covered services. Some Health Benefit Plans may include separate prescription drug Deductibles. The Deductible amount does not include the Premiums that a Covered Person pays or any Co-payments or Co-insurance that may apply after the Deductible. Essential Health Benefits. The health benefits listed in 42 U.S.C. § 18022(b), and health benefits defined as essential in regulations promulgated pursuant to 42 U.S.C. § 18022(b). (Mass. Register #1511, 12/22/2023) Health Benefit Plan. Any individual, general, blanket or group policy of health, accident and sickness insurance issued by an insurer licensed under M.G.L. c. 175; a group hospital service plan issued by a nonprofit hospital service corporation under M.G.L. c. 176A; a group medical service plan issued by a nonprofit medical service corporation under M.G.L. c. 176B; a group health maintenance contract issued by a health maintenance organization under M.G.L. c. 176G; coverage for young adults health insurance plan under M.G.L. c. 176J, § 10; any self-funded health plan, including a self-funded health plan which is an ERISA "employee welfare benefit plan" providing medical, surgical or hospital benefits, as that term is defined in 29 U.S.C. § 1002; and any individual, general, blanket or group policy of health, accident and sickness insurance issued in any state within the United States of America other than the Commonwealth of Massachusetts by an insurer that is licensed or otherwise statutorily authorized to transact business in such other state. Indemnity Schedule of Benefits. A fixed dollar amount per service, set forth in the subscriber's certificate of coverage as the maximum amount that a health plan is required to pay to the beneficiary or to reimburse the provider of that service. Multi-employer Health Benefit Plan. A Health Benefit Plan to which more than one employer is required to contribute, which is maintained pursuant to one or more collective bargaining agreements between one or more employee organizations and more than one employer, and there is evidence that such employer contributions to the Multi-employer Health Benefit Plan were the subject of good faith bargaining between such employee representatives and such employers. Out-of-pocket Maximum. The annual dollar limit that a Covered Person will pay for covered services under a Health Benefit Plan, not including premiums. Premium. A monthly payment made by, or on behalf of, a Covered Person to purchase and maintain a Health Benefit Plan, regardless of whether the Covered Person uses health care services or not. Preventive Health Services. The services that are defined in 42 U.S.C. § 300gg-13. Resident. As defined in M.G.L. c. 111M, § 1.