§4202-A. Definitions






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 shall permit reasonable, but not excessive or unfairly discriminatory, variations
in the copayment, coinsurance, deductible and other features of coverage, except that these features must meet or exceed those required in benefits
mandated by statute. The superintendent shall permit deductible, coinsurance and copayment levels consistent
with the deductible levels permitted for policies issued pursuant to chapter 33 or
35. Rules adopted pursuant to this subsection are major substantive rules as defined
in Title 5, chapter 375, subchapter 2-A.


[
2011, c. 90, Pt. F, §4 (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).
2011, c. 90, Pt. F, §4 (AMD).