20 Del. Admin. Code § 101-3.0 - Definitions
The following definitions shall apply to this regulation:
"Attachment point" means the threshold dollar amount, adopted by the Executive 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.
"Benefit year" means a calendar year beginning on or after January 1, 2020 for which reinsurance eligible health benefit plan provides health insurance coverage.
"Cabinet Secretary" means the Cabinet Secretary of Delaware Health and Social Services.
"Coinsurance rate" means the rate at which the Executive 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.
"Commission" or "DHCC" mean the Delaware Health Care Commission created pursuant to 16 Del.C. § 9902.
"DHSS" means Department of Health and Social Services.
"DOI" means Department of Insurance.
"Executive Director" means the Executive Director of the Delaware Health Care Commission or designee.
"Health insurance carrier" or "carrier" means any entity that provides health insurance in this State. For the purposes of this regulation, carrier includes an insurance company, health service corporation, health maintenance organization, managed care organization, and any other entity providing a plan of health insurance or health benefits subject to state insurance regulation. The entities providing insurance under the following types of plans do not meet the definition of carrier, per this regulation: plans of health insurance or health benefits designed for issuance to persons eligible for coverage under Titles XVIII, XIX, and XXI of the Social Security Act (42 U.S.C. §§ 1395 et seq., 1396 et seq., and 1397aa et seq.), known as Medicare, Medicaid; Chapter 52 of Title 29 of the Delaware Code; or any other similar coverage under state or federal governmental plans. Additionally, this regulation shall not apply to stand-alone dental insurance, stand-alone vision insurance, long-term care insurance, disability income insurance and all accident-only insurance.
"Health insurance coverage" means legal entitlement to payment or reimbursement for health care costs, generally under a contract with a health insurance company or a group health plan offered in connection with employment.
"Program" means the Delaware Health Insurance Individual Market Stabilization Reinsurance Program created by 16 Del.C. § 9903 (g).
"Regulations" mean all parts of the Rules and Regulations pertaining to the Delaware Health Insurance Individual Market Stabilization Reinsurance Program.
"Reinsurance cap" means the threshold dollar amount, adopted by the Executive 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.
"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 include a claim for certain abortion services, as defined in 45 C.F.R. § 156.280(d)(1).
"Reinsurance eligible health benefit plan" means health insurance coverage offered on the individual market that:
1. Constitutes minimum essential coverage, as set forth in 26 U.S.C. § 5000 A(f);
2. Is approved by the State's Insurance Commissioner;
3. Is delivered or issued for delivery by a carrier in the State; and
4. Is not a grandfathered plan as defined in §1251 of the Patient Protection and Affordable Care Act, 29 CFR § 2590.715-1251.
"Reinsurance eligible individual" means an individual who is insured in a reinsurance eligible health benefit plan on or after January 1, 2020.
"Reinsurance eligible issuer" means a health insurance carrier that offers a reinsurance eligible health benefit plan to reinsurance eligible individuals.
"Reinsurance payment" means payments issued to a reinsurance eligible issuer in accordance with Section 6.0.
"State" means the State of Delaware.
Notes
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