1."Basic health care services" means the following medically necessary services:
preventive care, emergency care, inpatient and outpatient hospital and physician care,
diagnostic laboratory, and diagnostic and therapeutic radiological services.
2."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.
3."Carrier" means a health maintenance organization, an insurer, a nonprofit hospital
and medical service corporation, or other entity responsible for the payment of benefits
or provision of s
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1. "Basic health care services" means the following medically necessary services:
preventive care, emergency care, inpatient and outpatient hospital and physician care,
diagnostic laboratory, and diagnostic and therapeutic radiological services.
2. "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.
3. "Carrier" means a health maintenance organization, an insurer, a nonprofit hospital
and medical service corporation, or other entity responsible for the payment of benefits
or provision of services under a group contract.
4. "Copayment" means an amount an enrollee must pay in order to receive a specific
service which is not fully prepaid.
5. "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.
6. "Enrollee" means an individual who is covered by a health maintenance organization.
7. "Evidence of coverage" means a statement of the essential features and services of
the health maintenance organization coverage which is given to the subscriber by the
health maintenance organization or by the group contractholder.
8. "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.
9. "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.
10. "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.
11. "Group contractholder" means the person to which a group contract has been issued.
12. "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 or deductibles or both. However, a
qualified program of all-inclusive care for the elderly is not a health maintenance
organization.
13. "Health maintenance organization producer" means an insurance producer, as defined
in section 26.1-26-02, who solicits, negotiates, effects, procures, delivers, renews, or
continues a policy or contract for health maintenance organization membership, or
who takes or transmits a membership fee or premium for such a policy or contract,
other than for that person, or a person who advertises or otherwise holds out to the
public as such.
14. "Individual contract" means a contract for health care services issued to and covering
an individual. The individual contract may include dependents of the subscriber.
15. "Insolvent" or "insolvency" means that the organization has been declared insolvent
and placed under an order of liquidation by a court of competent jurisdiction.
16. "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.
17. "Net worth" means the excess of total admitted assets over total liabilities, but the
liabilities do not include fully subordinated debt.
18. "Participating provider" means a provider as defined in subsection 19 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.
19. "Provider" means any physician, hospital, or other person licensed or otherwise
authorized to furnish health care services.
20. "Qualified program of all-inclusive care for the elderly" means a program that:
a. Is sponsored by a religious or charitable organization that is itself or is controlled
by an entity organized under section 501(c)(3) of the Internal Revenue Code [26
U.S.C. 501(c)(3)];
b. Has been approved by the centers for Medicare and Medicaid services of the
United States department of health and human services to operate, and is
currently operating as, a program of all-inclusive care for the elderly; and
c. Has revenues from private pay sources which do not exceed ten percent of the
program's total revenues.
21. "Replacement coverage" means the benefits provided by a succeeding carrier.
22. "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.
23. "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.