2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 54-A: MAINE GUARANTEED ACCESS REINSURANCE ASSOCIATION ACT › 24-A §3952. Definitions

§3952. Definitions
As used in this chapter, unless the context otherwise indicates, the following terms have the following meanings.   [PL 2011, c. 90, Pt. B, §8 (NEW).]
1.  Association.
"Association" means the Maine Guaranteed Access Reinsurance Association under section 3953.
[PL 2011, c. 90, Pt. B, §8 (NEW).]
2.  Board.
"Board" means the Board of Directors of the Maine Guaranteed Access Reinsurance Association under section 3953, subsection 2.
[PL 2011, c. 90, Pt. B, §8 (NEW).]
3.  Covered person.
"Covered person" means an individual covered as a policyholder, participant or dependent under a plan, policy or contract of medical insurance.
[PL 2011, c. 90, Pt. B, §8 (NEW).]
4.  Dependent.
"Dependent" means a spouse, a domestic partner or a child under 26 years of age.
[PL 2021, c. 567, §36 (AMD).]
4-A.  Eligible claim.
"Eligible claim" means either:
A. For a high-priced item or service, a claim amount that is no greater than 200% of the allowed charge determined for the item or service under the original Medicare fee-for-service program under Part A and Part B of Title XVIII of the Social Security Act for the applicable year; or   [PL 2019, c. 653, Pt. B, §8 (NEW).]
B. For all other items or services, a claim paid by the member insurer in accordance with the terms of the policy.   [PL 2019, c. 653, Pt. B, §8 (NEW).]
[PL 2019, c. 653, Pt. B, §8 (NEW).]
5.  Health maintenance organization.
"Health maintenance organization" means an organization authorized under chapter 56 to operate a health maintenance organization in this State.
[PL 2011, c. 90, Pt. B, §8 (NEW).]
5-A.  High-priced item or service.
"High-priced item or service" means an item or service covered under the original Medicare fee-for-service program under Part A and Part B of Title XVIII of the Social Security Act that the board, in consultation with and based on analysis by the Department of Health and Human Services and Maine Health Data Organization, has identified in advance of a plan year that contributes to association costs and offers an opportunity for savings.
[PL 2019, c. 653, Pt. B, §9 (NEW).]
6.  Insurer.
"Insurer" means an entity that is authorized to write medical insurance or that provides medical insurance in this State. For the purposes of this chapter, "insurer" includes an insurance company, a nonprofit hospital and medical service organization, a fraternal benefit society, a health maintenance organization, a self-insured employer subject to state regulation as described in section 2848‑A, a 3rd-party administrator, a multiple-employer welfare arrangement, a reinsurer that reinsures health insurance in this State or a captive insurance company established pursuant to chapter 83 that insures the health coverage risks of its members.
[PL 2019, c. 653, Pt. B, §10 (AMD).]
7.  Medical insurance.
"Medical insurance" means a hospital and medical expense-incurred policy, nonprofit hospital and medical service plan, health maintenance organization subscriber contract or other health care plan or arrangement that pays for or furnishes medical or health care services whether by insurance or otherwise, whether sold as an individual or group policy. "Medical insurance" does not include accidental injury, specified disease, hospital indemnity, dental, vision, disability income, Medicare supplement, long-term care or other limited benefit health insurance or credit insurance; coverage issued as a supplement to liability insurance; insurance arising out of workers' compensation or similar law; automobile medical payment insurance; or insurance under which benefits are payable with or without regard to fault and that is statutorily required to be contained in any liability insurance policy or equivalent self-insurance.
[PL 2011, c. 90, Pt. B, §8 (NEW).]
8.  Medicare.
"Medicare" means coverage under both Parts A and B of Title XVIII of the federal Social Security Act, 42 United States Code, Section 1395 et seq., as amended.
[PL 2011, c. 90, Pt. B, §8 (NEW).]
9.  Member insurer.
"Member insurer" means an insurer that offers individual health plans and is actively marketing individual health plans in this State. In any calendar year in which the association reinsures small group health plans, "member insurer" also includes an insurer that offers small group health plans and is actively marketing small group health plans in this State.
[PL 2019, c. 653, Pt. B, §11 (AMD).]
10.  Producer.
"Producer" means a person who is licensed to sell health insurance in this State.
[PL 2011, c. 90, Pt. B, §8 (NEW).]
11.  Reinsurer.
"Reinsurer" means an insurer from whom a person providing health insurance for a resident procures insurance for itself with the insurer with respect to all or part of the medical insurance risk of the person. "Reinsurer" includes an insurer that provides employee benefits excess insurance.
[PL 2011, c. 90, Pt. B, §8 (NEW).]
12.  Resident.
"Resident" has the same meaning as in section 2736‑C, subsection 1, paragraph C‑2.
[PL 2011, c. 90, Pt. B, §8 (NEW).]
13.  Third-party administrator.
"Third-party administrator" means an entity that is paying or processing medical insurance claims for a resident.
[PL 2011, c. 90, Pt. B, §8 (NEW).]
SECTION HISTORY
PL 2011, c. 90, Pt. B, §8 (NEW). PL 2019, c. 653, Pt. B, §§8-11 (AMD). PL 2021, c. 567, §36 (AMD).