2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 87: DIRIGO HEALTH › Subchapter 1: GENERAL PROVISIONS › 24-A §6903. Definitions

§6903. Definitions
As used in this chapter, unless the context otherwise indicates, the following terms have the following meanings.   [PL 2003, c. 469, Pt. A, §8 (NEW).]
1.  Board.
"Board" means the Board of Trustees of Dirigo Health, as established in section 6904.
[PL 2007, c. 447, §3 (AMD).]
1-A.  Behavioral health care.
"Behavioral health care" means services to address mental health and substance use conditions.
[PL 2021, c. 603, Pt. A, §1 (NEW).]
2.  Child.
"Child" means a natural child, stepchild, adopted child or child placed for adoption with a plan enrollee.
[PL 2003, c. 469, Pt. A, §8 (NEW).]
3.  Dependent.
"Dependent" means a spouse, a domestic partner, an unmarried child under 19 years of age, a child who is a student under 23 years of age and is financially dependent upon a plan enrollee or a person of any age who is the child of a plan enrollee and is disabled and dependent upon that plan enrollee.
[PL 2021, c. 567, §40 (AMD).]
4.  Dirigo Health Insurance.
[PL 2005, c. 400, Pt. A, §3 (RP).]
4-A.  Dirigo Health Program.
"Dirigo Health Program" means the program of services provided by Dirigo Health that includes comprehensive health benefits coverage, subsidies, wellness programs and quality improvement initiatives.
[PL 2005, c. 400, Pt. A, §4 (NEW).]
5.  Eligible business.
"Eligible business" means a business that employs at least 2 but not more than 50 eligible employees, the majority of whom are employed in the State, including a municipality that has 50 or fewer employees.
After one year of operation of Dirigo Health, the board may, by rule, define "eligible business" to include larger public or private employers.
[PL 2003, c. 469, Pt. A, §8 (NEW).]
6.  Eligible employee.
"Eligible employee" means an employee of an eligible business who works at least 20 hours per week for that eligible business. "Eligible employee" does not include an employee who works on a temporary or substitute basis or who does not work more than 26 weeks annually.
[PL 2003, c. 469, Pt. A, §8 (NEW).]
7.  Eligible individual.
"Eligible individual" means:
A. A self-employed individual who:
(1) Works and resides in the State; and
(2) Is organized as a sole proprietorship or in any other legally recognized manner in which a self-employed individual may organize, a substantial part of whose income derives from a trade or business through which the individual has attempted to earn taxable income;   [PL 2003, c. 469, Pt. A, §8 (NEW).]
B. An unemployed individual who resides in this State; or   [PL 2003, c. 469, Pt. A, §8 (NEW).]
C. An individual employed in an eligible business that does not offer health insurance.   [PL 2003, c. 469, Pt. A, §8 (NEW).]
[PL 2003, c. 469, Pt. A, §8 (NEW).]
8.  Employer.
"Employer" means the owner or responsible agent of a business authorized to sign contracts on behalf of the business.
[PL 2003, c. 469, Pt. A, §8 (NEW).]
9.  Executive director.
"Executive director" means the Executive Director of Dirigo Health.
[PL 2003, c. 469, Pt. A, §8 (NEW).]
10.  Health insurance carrier.
"Health insurance carrier" means:
A. An insurance company licensed in accordance with this Title to provide health insurance;   [PL 2003, c. 469, Pt. A, §8 (NEW).]
B. A health maintenance organization licensed pursuant to chapter 56;   [PL 2003, c. 469, Pt. A, §8 (NEW).]
C. A preferred provider arrangement administrator registered pursuant to chapter 32;   [PL 2003, c. 469, Pt. A, §8 (NEW).]
D. A nonprofit hospital or medical service organization or health plan licensed pursuant to Title 24; or   [PL 2003, c. 469, Pt. A, §8 (NEW).]
E. An employee benefit excess insurance company licensed in accordance with this Title to provide property and casualty insurance that provides employee benefit excess insurance pursuant to section 707, subsection 1, paragraph C‑1.   [PL 2003, c. 469, Pt. A, §8 (NEW).]
[PL 2003, c. 469, Pt. A, §8 (NEW).]
11.  Health plan in Medicaid.
"Health plan in Medicaid" means a health insurance carrier that meets the requirements of 42 Code of Federal Regulations, Part 438 (2002) and has a contract with the Department of Health and Human Services to provide MaineCare-covered services to individuals enrolled in MaineCare.
[PL 2003, c. 469, Pt. A, §8 (NEW); PL 2003, c. 689, Pt. B, §6 (REV).]
12.  Participating employer.
"Participating employer" means an eligible business that contracts with Dirigo Health pursuant to section 6910, subsection 4, paragraph B and that has employees enrolled in the Dirigo Health Program.
[PL 2005, c. 400, Pt. C, §3 (AMD).]
13.  Plan enrollee.
"Plan enrollee" means an eligible individual or eligible employee who enrolls in the Dirigo Health Program through Dirigo Health. "Plan enrollee" includes an eligible employee who is eligible to enroll in MaineCare.
[PL 2005, c. 400, Pt. C, §3 (AMD).]
13-A.  Practitioner-specific quality data.
"Practitioner-specific quality data" means material in electronic or paper format that provides information about the professional performance of a health care practitioner licensed to provide health care in the State. "Practitioner-specific quality data" includes, but is not limited to, records, reports, working papers, drafts, analyses, e-mail, interoffice and intraoffice memoranda and other data collected, used, produced or maintained by the Maine Quality Forum, established in section 6951, for the purposes of measuring a health care practitioner's professional performance against consensus best practices and local and national patterns of health care.
[PL 2005, c. 615, §1 (NEW).]
13-B.  Primary care.
"Primary care" means regular check‑ups, wellness and general health care provided by a provider with whom a patient has initial contact for a health issue, not including an urgent care or emergency health issue, and by whom the patient may be referred to a specialist.
[PL 2019, c. 244, §1 (NEW).]
14.  Provider.
"Provider" means any person, organization, corporation or association that provides health care services and products and is authorized to provide those services and products under the laws of this State.
[PL 2003, c. 469, Pt. A, §8 (NEW).]
15.  Reinsurance or reinsurer.
"Reinsurance" and "reinsurer" have the same meanings as in section 741.
[PL 2003, c. 469, Pt. A, §8 (NEW).]
16.  Resident.
"Resident" has the same meaning as in section 2736‑C, subsection 1, paragraph C‑2.
[PL 2003, c. 469, Pt. A, §8 (NEW).]
17.  Subsidy.
"Subsidy" means a subsidy as described in section 6912.
[PL 2003, c. 469, Pt. A, §8 (NEW).]
18.  Third-party administrator.
"Third-party administrator" means any person who, on behalf of any person who establishes a health insurance plan covering residents, receives or collects charges, contributions or premiums for or settles claims on residents in connection with any type of health benefit provided in or as an alternative to insurance as defined by section 704, other than:
A. Any person listed in section 1901, subsection 1, paragraphs A to C and paragraphs E to O; or   [PL 2003, c. 469, Pt. A, §8 (NEW).]
B. A person who provides those services in connection with a group health plan sponsored by an agricultural cooperative association located outside of this State that provides health insurance coverage to members and employees of agricultural cooperative associations located within this State.   [RR 2021, c. 2, Pt. A, §87 (COR).]
[RR 2021, c. 2, Pt. A, §87 (COR).]
19.  Unemployed individual.
"Unemployed individual" means an individual who does not work more than 20 hours a week for any single employer.
[PL 2003, c. 469, Pt. A, §8 (NEW).]
SECTION HISTORY
PL 2003, c. 469, §A8 (NEW). PL 2003, c. 689, §B6 (REV). PL 2005, c. 400, §§A3,4,C3 (AMD). PL 2005, c. 615, §1 (AMD). PL 2007, c. 447, §3 (AMD). PL 2019, c. 244, §1 (AMD). PL 2021, c. 567, §40 (AMD). PL 2021, c. 603, Pt. A, §1 (AMD). RR 2021, c. 2, Pt. A, §87 (COR).