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The Vermont Statutes Online



Title

08

:
Banking and Insurance






Chapter

139

:
HEALTH MAINTENANCE ORGANIZATION











 

§

5101. Definitions

As used in this

chapter:

(1)

"Commissioner" means the Commissioner of Financial Regulation.

(2) "Health

maintenance organization" means any person who furnishes, either directly

or through arrangements with others, comprehensive health care services to an

enrolled member in return for periodic payments; the amounts of said payments

are agreed upon prior to the time during which the health care services may be

furnished; and who is obligated to the member to arrange for or to provide

directly available and accessible health care services.

(3)

"Person" includes individuals, partnerships, associations, trusts,

and corporations.

(4) "Health

care services" means physician, hospitalization, laboratory, x-ray

service, and medical equipment and supplies, which may include: medical,

surgical, and dental care; psychological, obstetrical, osteopathic, optometric,

optic, podiatric, chiropractic, nursing, physical therapy services, and

pharmaceutical services; health education; preventive medical, rehabilitative,

and home health services; inpatient and outpatient hospital services, extended

care, nursing home care, convalescent institutional care, laboratory and

ambulance services, appliances, drugs, medicines, and supplies; and any other

care, service, or treatment of disease or conditions, or the maintenance of the

physical and mental well-being of members.

(5)

"Member" means any individual who has entered into a contract with a

health maintenance organization for health care services or for services

related to but not limited to processing, administering, or the payment of

claims for health care services or in whose behalf such an arrangement has been

made.

(6)

"Evidence of coverage" means any certificate, agreement, or contract

issued to a member setting out the coverage to which he or she is entitled and

the rates therefor.

(7)

"Provider" means any physician, hospital, or other institution,

organization, or other person who furnishes health care services.

(8)

"Grievance" means a written complaint submitted to the Department or

to the health maintenance organization in accordance with the health

maintenance organization's formal grievance procedure by or on behalf of a

member regarding any aspect of the health maintenance organization relative to

the member.

(9)

"Uncovered expenditures" mean the costs to the health maintenance

organization for health care services that are the obligation of the health

maintenance organization, for which a member may also be liable in the event of

the health maintenance organization's impairment or insolvency, and for which

no alternative arrangements for payment have been made that are acceptable to

the Commissioner. (Added 1979, No. 117 (Adj. Sess.); amended 1989, No. 225

(Adj. Sess.), § 25; 1993, No. 30, §§ 1, 2, eff. May 21, 1993; 1995, No. 180

(Adj. Sess.), § 38 2011, No. 78 (Adj. Sess.), § 2, eff. April 2, 2012; 2013,

No. 96 (Adj. Sess.), § 21.)