211 Mass. Reg. 156.03
Actual Dental Loss Ratio. Incurred Claims during a specified period for covered dental services plus Qualified Quality Improvement Activity expenses, which is then divided by earned dental premiums reduced by Federal and State Taxes, Assessments, and Licensing or Regulatory Fees.
Actuarial Opinion. A signed written statement by a qualified actuary, which certifies that the actuarial assumptions, methods, and contract forms utilized by the Carrier in establishing premium rates for Dental Benefit Plans comply with all the requirements of M.G.L. c. 176X, 211 CMR 156.00, and any other applicable law or regulation.
Base Rates or Group Product Base Rates. The rate to be charged to Individuals and their Dependents and/or Businesses for all Eligible Employees and Eligible Dependents prior to the application of Rating Adjustment Factors.
Carrier. An insurer or other entity offering insured Dental Benefit Plans in the Commonwealth, which may include an insurer licensed or otherwise authorized to transact accident and health insurance under M.G.L. c. 175; a nonprofit hospital service corporation organized under M.G.L. c. 176A; a medical service corporation organized under M.G.L. c. 176B; or a dental service corporation organized under M.G.L. c. 176E.
Commissioner. The Commissioner of Insurance appointed pursuant to M.G.L. c. 26, § 6, or their designee.
Connector. The Commonwealth Health Insurance Connector Authority, established by M.G.L. c. 176Q.
Dental Benefit Plan or Plan. Any insured Stand-alone Dental Benefit Plan that covers oral surgical care, Dental Services, dental procedures, or benefits covered by any individual, general, blanket, or group policy of insurance issued by a Carrier.
Dental Care. The diagnosis or treatment (preventive or otherwise) of dental disease of teeth and/or their supporting structures.
Dental Provider. A practitioner that is appropriately licensed to provide Dental Services.
Dental Service. The dental services ordinarily provided by registered dentists and dental practices in accordance with accepted practices in the community where the services are rendered.
Division. The Division of Insurance established pursuant to M.G.L. c. 26, § 1.
Eligible Dependent. The spouse or child of an Individual or Business' Eligible Employee, subject to the applicable terms of the Dental Benefit Plan covering such Individual or Eligible Employee. The child of an Individual or Eligible Employee shall be considered an Eligible Dependent until at least the child's 26th birthday or without regard to age, so long as the dependent, who is covered under the membership of their parent as a member of a family group, is mentally or physically incapable of earning their own living due to disability.
Eligible Employee. Any person employed by an employer, including seasonal and temporary staff, but excluding business owners and those holding more than 2% of stock ownership.
Employer Group or Business. Any sole proprietorship, firm, corporation, partnership, or other entity that employs Eligible Employees.
Financial Impairment. A condition in which, based on the overall condition of the Carrier as determined by the Commissioner, the Carrier is, or if subjected to the provisions of 211 CMR 156.00 could reasonably be expected to be, insolvent, or otherwise in an unsound financial condition such as to render its further transactions of business hazardous to the public or its policyholders or Members, or is compelled to compromise, or attempt to compromise, with its creditors or claimants on the grounds that it is financially unable to pay its claims.
Federal and State Taxes, Assessments and Licensing or Regulatory Fees. Incurred federal and state income, premium or other taxes and assessments, and licensing or regulatory fees associated with a Carrier's Dental Benefit Plans.
Fraud, Waste, and Abuse Recoveries. The amount of claims payments recovered through fraud, waste, and abuse reduction efforts, not to exceed the amount of fraud, waste, and abuse reduction expenses.
Group Association. A group formed as an association or a trust, which may obtain insurance coverage for the benefit of members of one or more associations.
Incurred Claims. Dental Services costs, including eligible Fraud, Waste, and Abuse Recoveries, incurred in a reporting period by a Dental Benefit Plan to be paid to Dental Providers or covered persons for activities by a Dental Provider.
Individual. An individual who is a Resident of the Commonwealth.
Insured. Any policyholder, certificate holder, subscriber, Member, or other person on whose behalf the Carrier is obligated to pay for and/or provide Dental Care services.
Large Group. Employer Groups that employ 51 or more Eligible Employees.
Market. The Individual, Group Association, Small Group, and/or Large Group Market(s) in which a Carrier offers a Dental Benefit Plan.
Member. Any person enrolled in a Dental Benefit Plan.
Minimum Dental Loss Ratio. The Minimum Dental Loss Ratio for insured Dental Benefit Plans issued or renewed in Massachusetts is 83%.
Projected Dental Loss Ratio. Projected Incurred Claims for a specified period for covered Dental Care services plus projected Qualified Quality Improvement Activity expenses, which is then divided by projected earned dental premiums reduced by projected Federal and State Taxes, Assessments, and Licensing or Regulatory Fees.
Qualified Quality Improvement Activity or QIA. An activity designed to improve dental quality that is performed equitably, including activities performed by or through a provider that are primarily designed to improve dental outcomes, including, but not limited to, activities with a likelihood of reducing disparities among specified populations or which promote and enhance dental wellness. A QIA is directed to individual patients or incurred for the benefit of specified segments of patients, increases the likelihood of desired clinical outcomes that are capable of being objectively measured and/or which produce verifiable results, requires expertise, increases wellness and promotes health activities, and is directed toward individual Members of a Carrier's plans or segments of Members, as well as populations other than Members (as long as no additional costs are incurred for the non-Members, and as long as the activity can be supported by evidence-based medicine, best clinical practices, or criteria issued by professional associations that meet all the requirements of 45 CFR 158.150(b)). A QIA does not include any activities that are identified under 45 CFR 158.150(c); that have any overlap with administrative expense items specified under M.G.L. c. 176X, § 2(b)(i) through (x); that have any marketing component that displays the name of the Carrier; or which are paid for by the Carrier to any affiliate of the Carrier in any way, directly or indirectly.
Rating Adjustment Factor. A factor that is based on actuarial principles of risk segmentation, that is not restricted by any state or federal rule, and that is used to derive the premium that is charged to a particular Individual or Employer Group.
Rating Period. The period for which premium rates established by a Carrier are in effect.
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.
Small Group. Employer Group that employs 50 or fewer Eligible Employees.
Stand-alone Dental Benefit Plan. An insured dental plan issued by a Carrier to cover Dental Services that is otherwise not reported through medical loss ratio requirements under state or federal law.
Trend in Dental Care Expenses. The projected change in Dental Care Costs.
211 CMR 156.03