As used in this chapter, unless the context otherwise indicates, the following terms have the following meanings. [1991, c. 709, §2 (NEW).]
1.Basic health care services. "Basic health care services" means health care services that an enrolled population might reasonably require in order to
be maintained in good health and includes, at a minimum, emergency care, inpatient hospital care, inpatient physician services,
outpatient physician services, ancillary services such as x-ray services and laboratory services and all benefits mandated
by statute and mandated by rule applicable to health maintenance organizations. The superintendent may adopt rules defining
"basic health care services" to be provided by health maintenance organizations. In adopting such rules, the superintendent
shall consider the coverages that have traditionally been provided by health maintenance organizations; the need for flexibility
in the marketplace; and the importance of providing multiple options to employers and consumers. The superintendent may not
require that all health benefit plans offered by health maintenance organizations meet or exceed each of the particular requirements
of standard or basic health plans specified in Bureau of Insurance Rule, Chapter 750. The superintendent may select required
services from among those set forth in Bureau of Insurance Rule, Chapter 750 and shall permit reasonable, but not excessive
or unfairly discriminatory, variations in the copayment, coinsurance, deductible and other features of such coverage, except
that these features must meet or exceed those required in benefits mandated by statute. Rules adopted pursuant to this subsection
are major substantive rules as defined in Title 5, chapter 375, subchapter II-A.
[
2001, c. 218, §1 (AMD)
.]
2.Capitated basis. "Capitated basis" has the following meanings.
A. "Capitated basis" means fixed per-member, per-month payments or percentage-of-premium payments pursuant to which the provider
assumes full risk for the cost of contracted services without regard to the type, value or frequency of services provided.
For purposes of this definition, capitated basis includes the cost associated with operating staff model facilities. [1991, c. 709, §2 (NEW).]
B. "Capitated basis," in the context of a point-of-service option plan, means prepayment that considers provision of in-plan
covered services as described in paragraph A and that considers out-of-plan indemnity benefits reimbursed pursuant to the
terms of a point-of-service product approved pursuant to section 4207-A. [1991, c. 709, §2 (NEW).]
[
1991, c. 709, §2 (NEW)
.]
3.Carrier. "Carrier" means a health maintenance organization, an insurer, a nonprofit hospital, a medical service corporation or any
other entity responsible for the payment of benefits or provision of services under a group contract.
[
1991, c. 709, §2 (NEW)
.]
4.Copayment. "Copayment" means an amount an enrollee must pay in order to receive a specific service that is not fully prepaid.
[
1991, c. 709, §2 (NEW)
.]
5.Deductible. "Deductible" means the amount an enrollee is responsible to pay out of pocket before a health maintenance organization begins
to pay the costs associated with treatment.
[
1991, c. 709, §2 (NEW)
.]
6.Enrollee. "Enrollee" means an individual who is enrolled in a health maintenance organization.
[
1991, c. 709, §2 (NEW)
.]
7.Evidence of coverage. "Evidence of coverage" means any certificate, agreement or contract issued to a group contract holder or an enrollee setting
out the coverage to which an enrollee is entitled.
[
1991, c. 709, §2 (NEW)
.]
8.Group contract holder. "Group contract holder" means an entity or person that has purchased coverage from a health maintenance organization that
provides, at a minimum, basic health care services to enrollees.
[
1991, c. 709, §2 (NEW)
.]
9.Health care services. "Health care services" means any services included in the furnishing of medical care, dental care or hospitalization to
an individual, or any services incident to the furnishing of that care or hospitalization, as well as the furnishing of any
other services to an individual to prevent, alleviate, cure or heal human illness or injury.
[
1991, c. 709, §2 (NEW)
.]
10.Health maintenance organization. "Health maintenance organization" means a public or private organization that is organized under the laws of the Federal
Government, this State, another state or the District of Columbia or a component of such an organization, and that:
A. Provides, arranges or pays for, or reimburses the cost of, health care services, including, at a minimum, basic health care
services to enrolled participants, except that health maintenance organizations contracting with the State Government or the
Federal Government to service Medicaid or Medicare populations may limit the services they provide under the contracts consistent
with the terms of those contracts if such basic health care services are provided to those populations by other means; [1995, c. 673, Pt. D, §1 (AMD).]
B. Is compensated, except for reasonable copayments, for basic health care services to enrolled participants solely on a predetermined
periodic rate basis, except that the organization is not prohibited from having a provision in a group contract allowing an
adjustment of premiums based upon the actual health services utilization of the enrollees covered under the contract, and
except that such a contract may not be sold to an eligible group subject to the community rating requirements of section 2808-B; [1993, c. 645, Pt. A, §5 (AMD).]
C. Provides physicians' services primarily directly through physicians who are either employees or partners of that organization
or through arrangements with individual physicians or one or more groups of physicians organized on a group-practice or individual-practice
basis under which those physicians or groups are provided effective incentives to avoid unnecessary or unduly costly utilization,
regardless of whether a physician is individually compensated primarily on a fee-for-service basis or otherwise. The organization
may discharge its obligation through a point-of-service option product by reimbursing out-of-plan providers pursuant to the
terms contained in the group contract holder's group contract. Receipt of out-of-plan covered services by an enrollee does
not obligate the organization for an enrollee's responsibilities to meet copayments or deductibles; and [1991, c. 709, §2 (NEW).]
D. Ensures the availability, accessibility and quality, including effective utilization, of the health care services that it
provides or makes available through clearly identifiable focal points of legal and administrative responsibility. [1991, c. 709, §2 (NEW).]
Nothing in this subsection prevents a health maintenance organization from providing fee-for-service health care services
as well as health maintenance organization services. A health care provider or affiliated entity that does not offer health
insurance or health benefit plans may not be or become a health maintenance organization subject to this chapter solely by
reason of arrangements with insurers or hospital or medical service organizations for reimbursement in whole or in part on
a capitated basis, the financial risk to the provider or affiliated entity associated with reimbursement arrangements with
such 3rd-party payors or the furnishing by the provider or affiliated entity of utilization or case management services.
[
1995, c. 673, Pt. D, §1 (AMD)
.]
11.In-plan covered services. "In-plan covered services" means covered health care services obtained from providers who are employed by, under contract
with, referred by or otherwise affiliated with the health maintenance organization. "In-plan covered services" includes emergency
services.
[
1991, c. 709, §2 (NEW)
.]
12.Nonprofit hospital or medical service organization. "Nonprofit hospital or medical service organization" means any organization defined in and authorized to act under Title
24, chapter 19.
[
1991, c. 709, §2 (NEW)
.]
12-A.NCQA accreditation survey report. "NCQA accreditation survey report" means the unpublished, detailed survey report to a health maintenance organization by
the National Committee for Quality Assurance upon completion of NCQA's accreditation survey of the health maintenance organization.
[
1999, c. 256, Pt. Q, §1 (NEW)
.]
13.Out-of-plan covered services. "Out-of-plan covered services" means nonemergency, covered health care services obtained without a referral from providers
who are not otherwise employed by, under contract with or otherwise affiliated with the health maintenance organization or
from affiliated specialists.
[
1991, c. 709, §2 (NEW)
.]
14.Participating provider. "Participating provider" means a provider as defined in subsection 18 that, under an express or implied contract with a
health maintenance organization, has agreed to provide health care services to enrollees with an expectation of receiving
payment, other than copayment, directly or indirectly from the health maintenance organization.
[
1991, c. 709, §2 (NEW)
.]
15.Person. "Person" means an individual, firm, partnership, corporation, association, syndicate, organization, society, business trust,
attorney-in-fact or any legal entity.
[
1991, c. 709, §2 (NEW)
.]
16.Point-of-service option. "Point-of-service option" means a health maintenance organization product that allows an enrollee to select either the comprehensive
health care benefits of the health maintenance organization or care from a provider of the enrollee's choice outside the health
maintenance organization network with traditional indemnity benefits. A point-of-service option in which the risk for out-of-plan
covered services of a health maintenance organization is shared with a reinsurer must meet the requirements of this chapter
applicable to the indemnity benefits provided by a health maintenance organization.
[
1991, c. 709, §2 (NEW)
.]
17.Point-of-service product. "Point-of-service product" means a product that includes both in-plan covered services and out-of-plan covered services.
[
1991, c. 709, §2 (NEW)
.]
18.Provider. "Provider" means a physician, hospital or person that is licensed or otherwise authorized in this State to furnish health
care services.
[
1991, c. 709, §2 (NEW)
.]
19.Superintendent. "Superintendent" means the Superintendent of Insurance.
[
1991, c. 709, §2 (NEW)
.]
20.Uncovered expenditures. "Uncovered expenditures" means costs to a health maintenance organization for health care services that are the obligation
of the health maintenance organization for which an enrollee may also be liable.
[
1991, c. 709, §2 (NEW)
.]
SECTION HISTORY
1991, c. 709, §2 (NEW).
1993, c. 645, §A5 (AMD).
1995, c. 673, §D1 (AMD).
1999, c. 222, §1 (AMD).
1999, c. 256, §Q1 (AMD).
2001, c. 218, §1 (AMD).
Data for this page extracted on 11/09/2009 11:20:25.