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



"Basic health care services" means
the following medical services:  preventive care, emergency care, inpatient and
outpatient hospital and physician care, diagnostic laboratory services, and
diagnostic and therapeutic radiological services.  It does not include mental
health 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 per
member per month payment or percentage of premium payment wherein the provider
assumes the 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.



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



"Commissioner" means the insurance
commissioner.



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



"Deductible" means the amount an
enrollee is responsible to pay out-of-pocket before the health maintenance
organization begins to pay the costs associated with treatment.



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



"Evidence of coverage" means a
statement of the essential features and services of the health maintenance
organization coverage that is given to the subscriber by the health maintenance
organization or by the group contract holder.



"Extension of benefits" means the
continuation of coverage under a particular benefit provided under a contract
following termination with respect to an enrollee who is totally disabled on
the date of termination.



"Grievance" means a written complaint
submitted in accordance with the health maintenance organization's formal
grievance procedure by or on behalf of the enrollee regarding any aspect of the
health maintenance organization relative to the enrollee.



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



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



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



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



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



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



"Net worth" means the excess of total
admitted assets over total liabilities, but the liabilities shall not include
fully subordinated debt.



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



"Person" means any natural or artificial
person 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 health
care services.



"Replacement coverage" means the
benefits provided by a succeeding carrier.



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



"Uncovered expenditures" means the
costs to the health maintenance organization for health care services that are
the obligation of the health maintenance organization, for which an enrollee
may also be liable in the event of the health maintenance organization's
insolvency, and for which no alternative arrangements have been made that are
acceptable to the commissioner.  Uncovered expenditures do not include
expenditures for services when a provider has agreed not to bill the enrollee
even though the provider is not paid by the health maintenance organization, or
for services that are guaranteed, insured, or assumed by a person or
organization other than the health maintenance organization. [L 1995, c
179, pt of §1]