Section 220-RICR-90-00-2.3 - DefinitionsA. The following definitions shall apply to this regulation:1. "Attachment point" means the threshold dollar amount, adopted by the Director, after which point the claims costs of an insured individual's covered benefits under a reinsurance-eligible health benefit plan in a benefit year are eligible for reinsurance payments.2. "Benefit year" means a calendar year beginning on or after January 1, 2020, for which a reinsurance eligible health benefit plan provides health insurance coverage.3. "Coinsurance rate" means the rate at which the Director may reimburse a reinsurance eligible health benefit plan for claims costs incurred after the attachment point and before the reinsurance cap for an insured individual's covered benefits in a benefit year. The coinsurance rate is set by the Director at an initial estimated value but is subject to change in accordance with § 2.6(B)(2) of this Part.4. "Director" means the Director of the Rhode Island health benefit exchange, or his/her designee(s).5. "Health insurance carrier" or "carrier" means the same as it does in R.I. Gen. Laws § 27-18.5-2.6. "Health insurance coverage" means the same as it does in R.I. Gen. Laws § 27-18.5-2.7. "Individual market" means the same as it does in R.I. Gen. Laws § 27-18.5-2.8. "Program" means the Rhode Island reinsurance program established by the Director pursuant to R.I. Gen. Laws § 42-157.1-3.9. "Regulations" means all parts of the Rules and Regulations Pertaining to the Rhode Island Reinsurance Program.10. "Reinsurance cap" means the threshold dollar amount, adopted by the Director, for claims costs incurred by a reinsurance eligible health benefit plan for an insured individual's covered benefits in a benefit year, after which threshold the claims costs for the benefits are no longer eligible for reinsurance payments.11. "Reinsurance eligible claim" means a claim for services covered under a reinsurance eligible health benefit plan that is incurred by a reinsurance eligible issuer during the applicable benefit year and within the period of eligibility for the member, that is paid by the reinsurance eligible issuer before June 1 of the following year. A reinsurance eligible claim shall not be adjusted for risk nor for pharmacy rebates. A reinsurance eligible claim does not include a claim for certain abortion services, as defined in 45 C.F.R. § 156.280(d)(1). In the event a single reinsurance eligible claim for inpatient services spans multiple consecutive dates of service and extends across benefit years, the reinsurance eligible claim is deemed incurred on the discharge date.12. "Reinsurance eligible health benefit plan" means health insurance coverage offered on the individual market, irrespective of whether it is offered through the Rhode Island health benefit exchange, that:a. constitutes minimum essential coverage, as set forth in 26 U.S. C. § 5000A(f);b. is approved by the state's health insurance commissioner;c. is delivered or issued for delivery by a carrier in the state; and d. is not a grandfathered health plan as defined in § 1251 of the Patient Protection and Affordable Care Act.13. "Reinsurance eligible individual" means an individual who is insured in a reinsurance eligible health benefit plan on or after January 1, 2020.14. "Reinsurance eligible issuer" means a health insurance carrier that offers a reinsurance eligible health benefit plan to reinsurance eligible individuals.15. "Reinsurance payment" means payments issued to a reinsurance eligible issuer in accordance with § 2.6 of this Part.16. "State" means the State of Rhode Island.220 R.I. Code R. 220-RICR-90-00-2.3
Adopted effective 12/4/2019