Article 32.--HEALTH MAINTENANCE ORGANIZATIONS AND MEDICARE PROVIDER ORGANIZATIONS
40-3202.Definitions.As used in this act:
(a) "Commissioner" means the commissioner ofinsurance of the state of Kansas.
(b) "Basic health care services" means but is not limited tousual physician, hospitalization, laboratory, x-ray, emergency and preventiveservices and out-of-area coverage.
(c) "Capitated basis" means a fixed per member per month payment orpercentage of premium payment wherein the provider assumes risk forthe cost of contracted services without regard to the type, value or frequencyof services provided. For purposes of this definition, capitated basisincludes the cost associated with operating staff model facilities.
(d) "Carrier" means a health maintenance organization, an insurer, anonprofit hospital and medical service corporation, or other entity responsiblefor the payment of benefits or provision of services under a groupcontract.
(e) "Certificate of coverage" means a statement of theessential featuresand services of the health maintenance organization coverage which is given tothe subscriber by the health maintenance organization, medicare providerorganization or by the group contractholder.
(f) "Copayment" means an amount an enrollee must pay inorder to receive aspecific service which is not fully prepaid.
(g) "Deductible" means an amount an enrollee is responsibleto payout-of-pocket before the health maintenance organization begins to pay thecosts associated with treatment.
(h) "Director" means the secretary of health andenvironment.
(i) "Disability" means an injury or illness that results ina substantialphysical or mental limitation in one or more major life activities such asworking or independent activities of daily living that a person was able to doprior to the injury or illness.
(j) "Enrollee" means a person who has entered into acontractualarrangement or on whose behalf a contractual arrangement has been enteredinto with a health maintenance organization or the medicare providerorganization for health care services.
(k) "Grievance" means a written complaint submitted inaccordance with theformal grievance procedure by or onbehalf ofthe enrollee regarding any aspect of the health maintenance organizationor the medicare provider organization relative to the enrollee.
(l) "Group contract" means a contract for health careservices which by itsterms limits eligibility to members of a specified group. The group contractmay include coverage for dependents.
(m) "Group contract holder" means the person to which agroup contract hasbeen issued.
(n) "Health care services" means basic health care servicesandotherservices, medical equipment and supplies which may include, but are notlimited to, medical, surgical and dental care; psychological, obstetrical,osteopathic, optometric, optic, podiatric, nursing, occupational therapyservices, physical therapyservices, chiropractic services and pharmaceutical services; healtheducation, preventive medical, rehabilitative and home health services;inpatient and outpatient hospital services, extended care, nursing homecare, convalescent institutional care, laboratory and ambulance services,appliances, drugs, medicines and supplies; and any other care, service ortreatment for the prevention, control or elimination of disease, thecorrection of defects or the maintenance of the physical or mentalwell-being of human beings.
(o) "Health maintenance organization" means an organizationwhich:
(1) Provides or otherwise makes available to enrollees health careservices, including at a minimum those basic health care services which aredetermined by the commissioner to be generally available on an insured orprepaid basis in the geographic area served;
(2) is compensated, except for reasonable copayments, for the provisionof basic health care services to enrollees solely on a predeterminedperiodic rate basis;
(3) provides physician services directly through physicians who areeither employees or partners of such organization or under arrangementswith a physician or any group of physicians or under arrangements as anindependent contractor with a physician or any group of physicians;
(4) is responsible for the availability, accessibility and quality ofthe health care services provided or made available.
(p) "Individual contract" means a contract for health careservices issuedto and covering an individual. The individual contract may include dependentsof the subscriber.
(q) "Individual practice association" means a partnership,corporation,association or other legal entity which delivers or arranges for the deliveryof basic health care services and which has entered into a services arrangementwith persons who are licensed to practice medicine and surgery,dentistry, chiropractic, pharmacy, podiatry, optometry or any other healthprofession and a majority of whom are licensed to practice medicine andsurgery. Such an arrangement shall provide:
(1) That such persons shall provide their professional services inaccordance with a compensation arrangement established by the entity; and
(2) to the extent feasible for the sharing by such persons of medical andother records, equipment, and professional, technical and administrative staff.
(r) "Medical group" or "staff model" means a partnership,association orother group:
(1) Which is composed of health professionals licensed to practice medicineand surgery and of such other licensed health professionals, including butnot limited to dentists, chiropractors, pharmacists, optometrists andpodiatrists as are necessary for the provision of health services for which thegroup is responsible;
(2) a majority of the members of which are licensed to practice medicine andsurgery; and
(3) the members of which: (A) As their principal professional activity over50% individually and as a group responsibility are engaged in the coordinatedpractice of their profession for a health maintenance organization; (B) pooltheir income and distribute it among themselves according to a prearrangedsalary or drawing account or other plan, or are salaried employees of thehealth maintenance organization; (C)share medical and other records and substantial portions of major equipment andof professional, technical and administrative staff; and (D) establish anarrangement whereby the enrollee's enrollment status is not known to themember of the group who provides health services to the enrollee.
(s) "Medicare provider organization" means an organizationwhich:
(1) Is a provider-sponsored organization as defined by Section 4001 of theBalanced Budget Act of 1997 (PL 105-33); and
(2) provides or otherwise makes available to enrollees basic health careservices pursuant to Section 4001 of the Balanced Budget Act of 1997 (PL105-33).
(t) "Net worth" means the excess of assets over liabilitiesasdeterminedbythe commissioner from the latest annual report filed pursuant to K.S.A. 40-3220and amendments thereto.
(u) "Person" means any natural or artificial personincludingbut notlimited to individuals, partnerships, associations, trusts or corporations.
(v) "Physician" means a person licensed to practicemedicine andsurgeryunder the healing arts act.
(w) "Provider" means any physician, hospital or otherpersonwhich islicensed or otherwise authorized in this state to furnish health careservices.
(x) "Uncovered expenditures" means the costs of health careservicesthat are covered by a health maintenance organization for which an enrolleewould also be liable in the event of the organization's insolvency asdetermined by the commissioner from the latest annual statement filedpursuant to K.S.A. 40-3220 and amendments thereto and which are notguaranteed, insured or assumed by any person or organization other than thecarrier.
Article 32.--HEALTH MAINTENANCE ORGANIZATIONS AND MEDICARE PROVIDER ORGANIZATIONS
40-3202.Definitions.As used in this act:
(a) "Commissioner" means the commissioner ofinsurance of the state of Kansas.
(b) "Basic health care services" means but is not limited tousual physician, hospitalization, laboratory, x-ray, emergency and preventiveservices and out-of-area coverage.
(c) "Capitated basis" means a fixed per member per month payment orpercentage of premium payment wherein the provider assumes risk forthe cost of contracted services without regard to the type, value or frequencyof services provided. For purposes of this definition, capitated basisincludes the cost associated with operating staff model facilities.
(d) "Carrier" means a health maintenance organization, an insurer, anonprofit hospital and medical service corporation, or other entity responsiblefor the payment of benefits or provision of services under a groupcontract.
(e) "Certificate of coverage" means a statement of theessential featuresand services of the health maintenance organization coverage which is given tothe subscriber by the health maintenance organization, medicare providerorganization or by the group contractholder.
(f) "Copayment" means an amount an enrollee must pay inorder to receive aspecific service which is not fully prepaid.
(g) "Deductible" means an amount an enrollee is responsibleto payout-of-pocket before the health maintenance organization begins to pay thecosts associated with treatment.
(h) "Director" means the secretary of health andenvironment.
(i) "Disability" means an injury or illness that results ina substantialphysical or mental limitation in one or more major life activities such asworking or independent activities of daily living that a person was able to doprior to the injury or illness.
(j) "Enrollee" means a person who has entered into acontractualarrangement or on whose behalf a contractual arrangement has been enteredinto with a health maintenance organization or the medicare providerorganization for health care services.
(k) "Grievance" means a written complaint submitted inaccordance with theformal grievance procedure by or onbehalf ofthe enrollee regarding any aspect of the health maintenance organizationor the medicare provider organization relative to the enrollee.
(l) "Group contract" means a contract for health careservices which by itsterms limits eligibility to members of a specified group. The group contractmay include coverage for dependents.
(m) "Group contract holder" means the person to which agroup contract hasbeen issued.
(n) "Health care services" means basic health care servicesandotherservices, medical equipment and supplies which may include, but are notlimited to, medical, surgical and dental care; psychological, obstetrical,osteopathic, optometric, optic, podiatric, nursing, occupational therapyservices, physical therapyservices, chiropractic services and pharmaceutical services; healtheducation, preventive medical, rehabilitative and home health services;inpatient and outpatient hospital services, extended care, nursing homecare, convalescent institutional care, laboratory and ambulance services,appliances, drugs, medicines and supplies; and any other care, service ortreatment for the prevention, control or elimination of disease, thecorrection of defects or the maintenance of the physical or mentalwell-being of human beings.
(o) "Health maintenance organization" means an organizationwhich:
(1) Provides or otherwise makes available to enrollees health careservices, including at a minimum those basic health care services which aredetermined by the commissioner to be generally available on an insured orprepaid basis in the geographic area served;
(2) is compensated, except for reasonable copayments, for the provisionof basic health care services to enrollees solely on a predeterminedperiodic rate basis;
(3) provides physician services directly through physicians who areeither employees or partners of such organization or under arrangementswith a physician or any group of physicians or under arrangements as anindependent contractor with a physician or any group of physicians;
(4) is responsible for the availability, accessibility and quality ofthe health care services provided or made available.
(p) "Individual contract" means a contract for health careservices issuedto and covering an individual. The individual contract may include dependentsof the subscriber.
(q) "Individual practice association" means a partnership,corporation,association or other legal entity which delivers or arranges for the deliveryof basic health care services and which has entered into a services arrangementwith persons who are licensed to practice medicine and surgery,dentistry, chiropractic, pharmacy, podiatry, optometry or any other healthprofession and a majority of whom are licensed to practice medicine andsurgery. Such an arrangement shall provide:
(1) That such persons shall provide their professional services inaccordance with a compensation arrangement established by the entity; and
(2) to the extent feasible for the sharing by such persons of medical andother records, equipment, and professional, technical and administrative staff.
(r) "Medical group" or "staff model" means a partnership,association orother group:
(1) Which is composed of health professionals licensed to practice medicineand surgery and of such other licensed health professionals, including butnot limited to dentists, chiropractors, pharmacists, optometrists andpodiatrists as are necessary for the provision of health services for which thegroup is responsible;
(2) a majority of the members of which are licensed to practice medicine andsurgery; and
(3) the members of which: (A) As their principal professional activity over50% individually and as a group responsibility are engaged in the coordinatedpractice of their profession for a health maintenance organization; (B) pooltheir income and distribute it among themselves according to a prearrangedsalary or drawing account or other plan, or are salaried employees of thehealth maintenance organization; (C)share medical and other records and substantial portions of major equipment andof professional, technical and administrative staff; and (D) establish anarrangement whereby the enrollee's enrollment status is not known to themember of the group who provides health services to the enrollee.
(s) "Medicare provider organization" means an organizationwhich:
(1) Is a provider-sponsored organization as defined by Section 4001 of theBalanced Budget Act of 1997 (PL 105-33); and
(2) provides or otherwise makes available to enrollees basic health careservices pursuant to Section 4001 of the Balanced Budget Act of 1997 (PL105-33).
(t) "Net worth" means the excess of assets over liabilitiesasdeterminedbythe commissioner from the latest annual report filed pursuant to K.S.A. 40-3220and amendments thereto.
(u) "Person" means any natural or artificial personincludingbut notlimited to individuals, partnerships, associations, trusts or corporations.
(v) "Physician" means a person licensed to practicemedicine andsurgeryunder the healing arts act.
(w) "Provider" means any physician, hospital or otherpersonwhich islicensed or otherwise authorized in this state to furnish health careservices.
(x) "Uncovered expenditures" means the costs of health careservicesthat are covered by a health maintenance organization for which an enrolleewould also be liable in the event of the organization's insolvency asdetermined by the commissioner from the latest annual statement filedpursuant to K.S.A. 40-3220 and amendments thereto and which are notguaranteed, insured or assumed by any person or organization other than thecarrier.
Article 32.--HEALTH MAINTENANCE ORGANIZATIONS AND MEDICARE PROVIDER ORGANIZATIONS
40-3202.Definitions.As used in this act:
(a) "Commissioner" means the commissioner ofinsurance of the state of Kansas.
(b) "Basic health care services" means but is not limited tousual physician, hospitalization, laboratory, x-ray, emergency and preventiveservices and out-of-area coverage.
(c) "Capitated basis" means a fixed per member per month payment orpercentage of premium payment wherein the provider assumes risk forthe cost of contracted services without regard to the type, value or frequencyof services provided. For purposes of this definition, capitated basisincludes the cost associated with operating staff model facilities.
(d) "Carrier" means a health maintenance organization, an insurer, anonprofit hospital and medical service corporation, or other entity responsiblefor the payment of benefits or provision of services under a groupcontract.
(e) "Certificate of coverage" means a statement of theessential featuresand services of the health maintenance organization coverage which is given tothe subscriber by the health maintenance organization, medicare providerorganization or by the group contractholder.
(f) "Copayment" means an amount an enrollee must pay inorder to receive aspecific service which is not fully prepaid.
(g) "Deductible" means an amount an enrollee is responsibleto payout-of-pocket before the health maintenance organization begins to pay thecosts associated with treatment.
(h) "Director" means the secretary of health andenvironment.
(i) "Disability" means an injury or illness that results ina substantialphysical or mental limitation in one or more major life activities such asworking or independent activities of daily living that a person was able to doprior to the injury or illness.
(j) "Enrollee" means a person who has entered into acontractualarrangement or on whose behalf a contractual arrangement has been enteredinto with a health maintenance organization or the medicare providerorganization for health care services.
(k) "Grievance" means a written complaint submitted inaccordance with theformal grievance procedure by or onbehalf ofthe enrollee regarding any aspect of the health maintenance organizationor the medicare provider organization relative to the enrollee.
(l) "Group contract" means a contract for health careservices which by itsterms limits eligibility to members of a specified group. The group contractmay include coverage for dependents.
(m) "Group contract holder" means the person to which agroup contract hasbeen issued.
(n) "Health care services" means basic health care servicesandotherservices, medical equipment and supplies which may include, but are notlimited to, medical, surgical and dental care; psychological, obstetrical,osteopathic, optometric, optic, podiatric, nursing, occupational therapyservices, physical therapyservices, chiropractic services and pharmaceutical services; healtheducation, preventive medical, rehabilitative and home health services;inpatient and outpatient hospital services, extended care, nursing homecare, convalescent institutional care, laboratory and ambulance services,appliances, drugs, medicines and supplies; and any other care, service ortreatment for the prevention, control or elimination of disease, thecorrection of defects or the maintenance of the physical or mentalwell-being of human beings.
(o) "Health maintenance organization" means an organizationwhich:
(1) Provides or otherwise makes available to enrollees health careservices, including at a minimum those basic health care services which aredetermined by the commissioner to be generally available on an insured orprepaid basis in the geographic area served;
(2) is compensated, except for reasonable copayments, for the provisionof basic health care services to enrollees solely on a predeterminedperiodic rate basis;
(3) provides physician services directly through physicians who areeither employees or partners of such organization or under arrangementswith a physician or any group of physicians or under arrangements as anindependent contractor with a physician or any group of physicians;
(4) is responsible for the availability, accessibility and quality ofthe health care services provided or made available.
(p) "Individual contract" means a contract for health careservices issuedto and covering an individual. The individual contract may include dependentsof the subscriber.
(q) "Individual practice association" means a partnership,corporation,association or other legal entity which delivers or arranges for the deliveryof basic health care services and which has entered into a services arrangementwith persons who are licensed to practice medicine and surgery,dentistry, chiropractic, pharmacy, podiatry, optometry or any other healthprofession and a majority of whom are licensed to practice medicine andsurgery. Such an arrangement shall provide:
(1) That such persons shall provide their professional services inaccordance with a compensation arrangement established by the entity; and
(2) to the extent feasible for the sharing by such persons of medical andother records, equipment, and professional, technical and administrative staff.
(r) "Medical group" or "staff model" means a partnership,association orother group:
(1) Which is composed of health professionals licensed to practice medicineand surgery and of such other licensed health professionals, including butnot limited to dentists, chiropractors, pharmacists, optometrists andpodiatrists as are necessary for the provision of health services for which thegroup is responsible;
(2) a majority of the members of which are licensed to practice medicine andsurgery; and
(3) the members of which: (A) As their principal professional activity over50% individually and as a group responsibility are engaged in the coordinatedpractice of their profession for a health maintenance organization; (B) pooltheir income and distribute it among themselves according to a prearrangedsalary or drawing account or other plan, or are salaried employees of thehealth maintenance organization; (C)share medical and other records and substantial portions of major equipment andof professional, technical and administrative staff; and (D) establish anarrangement whereby the enrollee's enrollment status is not known to themember of the group who provides health services to the enrollee.
(s) "Medicare provider organization" means an organizationwhich:
(1) Is a provider-sponsored organization as defined by Section 4001 of theBalanced Budget Act of 1997 (PL 105-33); and
(2) provides or otherwise makes available to enrollees basic health careservices pursuant to Section 4001 of the Balanced Budget Act of 1997 (PL105-33).
(t) "Net worth" means the excess of assets over liabilitiesasdeterminedbythe commissioner from the latest annual report filed pursuant to K.S.A. 40-3220and amendments thereto.
(u) "Person" means any natural or artificial personincludingbut notlimited to individuals, partnerships, associations, trusts or corporations.
(v) "Physician" means a person licensed to practicemedicine andsurgeryunder the healing arts act.
(w) "Provider" means any physician, hospital or otherpersonwhich islicensed or otherwise authorized in this state to furnish health careservices.
(x) "Uncovered expenditures" means the costs of health careservicesthat are covered by a health maintenance organization for which an enrolleewould also be liable in the event of the organization's insolvency asdetermined by the commissioner from the latest annual statement filedpursuant to K.S.A. 40-3220 and amendments thereto and which are notguaranteed, insured or assumed by any person or organization other than thecarrier.
