[§432D-1]  Definitions.  For purposes ofthis chapter:

"Basic health care services" meansthe following medical services:  preventive care, emergency care, inpatient andoutpatient hospital and physician care, diagnostic laboratory services, anddiagnostic and therapeutic radiological services.  It does not include mentalhealth services, services for alcohol or drug abuse, dental or vision services,or long-term rehabilitation treatment, except as provided in chapter 431M.

"Capitated basis" means fixed permember per month payment or percentage of premium payment wherein the providerassumes the full risk for the cost of contracted services without regard to thetype, value, or frequency of services provided.  For purposes of thisdefinition, capitated basis includes the cost associated with operating staffmodel facilities.

"Carrier" means a health maintenanceorganization, an insurer, a nonprofit hospital and medical service corporation,a mutual benefit society, or other entity responsible for the payment ofbenefits or provision of services under a group contract.

"Commissioner" means the insurancecommissioner.

"Copayment" means an amount anenrollee must pay to receive a specific service which is not fully prepaid.

"Deductible" means the amount anenrollee is responsible to pay out-of-pocket before the health maintenanceorganization begins to pay the costs associated with treatment.

"Enrollee" means an individual who iscovered by a health maintenance organization.

"Evidence of coverage" means astatement of the essential features and services of the health maintenanceorganization coverage that is given to the subscriber by the health maintenanceorganization or by the group contract holder.

"Extension of benefits" means thecontinuation of coverage under a particular benefit provided under a contractfollowing termination with respect to an enrollee who is totally disabled onthe date of termination.

"Grievance" means a written complaintsubmitted in accordance with the health maintenance organization's formalgrievance procedure by or on behalf of the enrollee regarding any aspect of thehealth maintenance organization relative to the enrollee.

"Group contract" means a contract forhealth care services which by its terms limits eligibility to members of aspecified group.  The group contract may include coverage for dependents.

"Group contract holder" means theperson to which a group contract has been issued.

"Health maintenance organization"means any person that undertakes to provide or arrange for the delivery ofbasic health care services to enrollees on a prepaid basis, except for enrolleeresponsibility for copayments, deductibles, or both.

"Individual contract" means acontract for health care services issued to and covering an individual.  Theindividual contract may include dependents of the subscriber.

"Insolvent" or "insolvency"means that the health maintenance organization has been declared insolvent andplaced under an order of supervision, rehabilitation, or liquidation by a courtof competent jurisdiction.

"Managed hospital payment basis"means agreements wherein the financial risk is primarily related to the degreeof utilization rather than to the cost of services.

"Net worth" means the excess of totaladmitted assets over total liabilities, but the liabilities shall not includefully subordinated debt.

"Participating provider" means aprovider as defined in this section, who, under an express or implied contractwith the health maintenance organization or with its contractor orsubcontractor, has agreed to provide health care services to enrollees with anexpectation of receiving payment, other than copayment or deductible, directlyor indirectly from the health maintenance organization.

"Person" means any natural or artificialperson including but not limited to individuals, partnerships, associations,trusts, or corporations.

"Provider" means any physician,hospital, or other person licensed or otherwise authorized to furnish healthcare services.

"Replacement coverage" means thebenefits provided by a succeeding carrier.

"Subscriber" means an individualwhose employment or other status, except family dependency, is the basis foreligibility for enrollment in the health maintenance organization, or in thecase of an individual contract, the person in whose name the contract isissued.

"Uncovered expenditures" means thecosts to the health maintenance organization for health care services that arethe obligation of the health maintenance organization, for which an enrolleemay also be liable in the event of the health maintenance organization'sinsolvency, and for which no alternative arrangements have been made that areacceptable to the commissioner.  Uncovered expenditures do not includeexpenditures for services when a provider has agreed not to bill the enrolleeeven though the provider is not paid by the health maintenance organization, orfor services that are guaranteed, insured, or assumed by a person ororganization other than the health maintenance organization. [L 1995, c179, pt of §1]