Section 220-RICR-90-00-1.4 - DefinitionsA. Wherever used in this Part, the following terms shall be construed as follows: 1. "Act" or "ACA" means Pub. Law 111-148, the Federal Patient Protection and Affordable Care Act as amended by Pub. Law 111-152, the Health Care and Education Reconciliation Act of 2010, and all Rules promulgated thereunder.2. "Advance payments of the premium tax credit" or "APTCs" means payments of the tax credits specified in 26 U.S.C. § 36B which are provided on an advance basis to an eligible individual enrolled in a Qualified Health Plan through the Exchange.3. "Annual open enrollment period" means the period during which a qualified individual may enroll in coverage through the Exchange for an upcoming Benefit Year.4. "Applicant" means an individual who is seeking eligibility for him or herself or for members of his or her household through an application submitted to the Exchange for at least one (1) of the following: a. Enrollment in a Qualified Health Plan;b. Advance payments of the premium tax credit and cost sharing reductions;c. Medicaid or "CHIP," if applicable;d. An employer or employee seeking eligibility for enrollment in a Qualified Health Plan through SHOP where applicable; ore. Exemption from the individual responsibility penalty or the shared responsibility payment penalty.5. "Benefit year" means a calendar year for which a health plan provides coverage for health benefits.6. "Cost sharing reductions" or "CSRs" means reductions in cost sharing for an eligible individual enrolled in a silver level plan, as defined by §1302(d)(1)(B) of the ACA, in the Exchange or for an individual who is an Indian enrolled in a Qualified Health Plan through the Exchange.7. "Dependent" means any individual who is or who may become eligible for coverage under the terms of a Qualified Health Plan because of a relationship to a qualified individual or enrollee.8. "Eligibility appeals" means appeals from an eligibility decision made by the Exchange in accordance with R.I. Gen. Laws § 42-157-12 and 45 C.F.R. § 155.505, incorporated above at § 1.3 of this Part, including: a. An initial determination of eligibility, including the amount of APTCs and the level of CSRs, made in accordance with standards specified in 45 C.F.R. §§ 155.305(a) through (h), incorporated above at § 1.3 of this Part;b. A redetermination of eligibility, including the amount of APTCs and level of CSRs, made in accordance with 45 C.F.R. §§ 155.330 and 155.335, incorporated above at § 1.3 of this Part;c. The failure by the Exchange to make such eligibility determination or redetermination in a timely manner; andd. A termination from QHP coverage or disenrollment from a QHP made by the Exchange in accordance with 45 C.F.R. § 155.430, incorporated above at § 1.3 of this Part.9. "Enrollee" means a qualified individual or qualified employee enrolled in a QHP.10. "EOHHS" means the Rhode Island Executive Office of Health and Human Services.11. "Exchange" means the Rhode Island Health Benefits Exchange, doing business as HealthSource RI.12. "Exchange appeals" means Eligibility Appeals, Exemption Appeals, Large Employer Appeals, and SHOP Appeals, as defined in these Regulations.13. "Exemption appeals" means appeals from a determination of eligibility for an exemption from the Individual Responsibility Penalty (IRP) made by the Exchange in accordance with §1311(d)(4)(H) of the ACA or from the shared responsibility payment penalty made by the Exchange in accordance with R.I. Gen. Laws § 42-157-11.14. "Federal regulations" means the regulations promulgated under the Act at 45 C.F.R. Parts 155, 156 and 157, incorporated above at § 1.3 of this Part.15. "FPL" means the most recently published Federal Poverty Level guidelines available as of the first (1st) day of the annual open enrollment period for coverage offered through the Exchange.16. "HHS" means the United States Department of Health and Human Services.17. "Indian" has the same meaning as the definition of Indian given in 45 C.F.R. § 155.300, incorporated above at § 1.3 of this Part.18. "Individual responsibility penalty" means the tax penalty associated with the failure of certain individuals to carry minimum essential coverage in accordance with the Internal Revenue Code, 26 U.S.C. § 5000A.19. "Issuer agreement" means the agreement between the QHP issuer and the Exchange that satisfies all applicable requirements of the Federal Regulations.20. "Large employer appeals" means appeals from a determination that an employer does not provide minimum essential coverage through an employer-sponsored plan or that the employer does provide that coverage, but it is not affordable with respect to an employee, as further set forth in 45 C.F.R. § 155.555, incorporated above at § 1.3 of this Part.21. "Lawfully present" has the same meaning given to the term in 45 C.F.R. § 155.305, incorporated above at § 1.3 of this Part.22. "Limited cost sharing plan" means, with respect to a QHP at any level of coverage, the variation of such QHP described in 45 C.F.R. § 156.420(b)(2), incorporated above at § 1.3 of this Part.23. "Premium" means the payment required to be paid for an enrollee to participate in a Qualified Health Plan.24. "Qualified employee" means an individual employed by a qualified employer who has been offered health insurance coverage by such qualified employer through the SHOP.25. "Qualified employer" means an employer that is eligible to participate in the SHOP Exchange and elects to make available health coverage to its employees through the SHOP Exchange.26. "Qualified health plan" or "QHP" means a health plan that has in effect a certification that it meets the standards described in 45 C.F.R. Part 156 Subpart C and such additional standards that may be prescribed, issued or recognized by the Exchange in accordance with the process described in 45 C.F.R. Part 155 Subpart K, incorporated above at § 1.3 of this Part.27. "Qualified individual" means, with respect to an Exchange, an individual who has been determined eligible to enroll through the Exchange in a Qualified Health Plan in the individual market.28. "Regulations" mean all parts of the Rules and Regulations Pertaining to HealthSource RI.29. "R.I. Gen. Laws" means the General Laws of Rhode Island, as amended.30. "Shared responsibility payment penalty" means the penalty associated with the failure of certain individuals to carry minimum essential coverage in accordance with R.I. Gen. Laws § 44-30-101.31. "SHOP appeals" means appeals by employers or employees of determinations of eligibility for the SHOP Exchange made by the Exchange in accordance with 45 C.F.R. § 155.715, incorporated above at § 1.3 of this Part, including the failure of the Exchange to make such eligibility determinations in a timely manner.32. "SHOP exchange" means the Small Business Health Options Program in accordance with §1311(b)(1)(B) of the ACA and 45 C.F.R. Part 155 Subpart H, incorporated above at § 1.3 of this Part, through which a qualified employer may provide its employees and their dependents participation in one (1) or more QHPs.33. "Special enrollment period" means a period during which a qualified individual or enrollee who experiences certain qualifying events may enroll in, or change enrollment in, a Qualified Health Plan through the Exchange outside of the initial and annual open enrollment periods.34. "Trust" means the HealthSource RI Trust established by the Exchange.35. "Zero cost sharing plan" means, with respect to a QHP at any level of coverage, the variation of such QHP described in 45 C.F.R. § 156.420(b)(1), incorporated above at § 1.3 of this Part.220 R.I. Code R. 220-RICR-90-00-1.4
Amended effective 12/22/2019
Amended effective 12/31/2020
Amended effective 4/2/2023