Alabama Administrative Code › Title 482 - ALABAMA DEPARTMENT OF INSURANCE › Chapter 482-1-083 - GOVERNING RULES OF THE ALABAMA HEALTH MAINTENANCE ORGANIZATION GUARANTY ASSOCIATION › Section 482-1-083-.02 - Definitions

Current through Register Vol. 42, No. 9, June 28, 2024
As used in this chapter:
(a) ASSOCIATION. The Health Maintenance
			 Organization Guaranty Association created under Section
			 27-21A-12(i),
Code of Ala. 1975
.
(b) COMMISSIONER. The Commissioner of
			 Insurance of this state.
(c)
			 CONTRACTUAL OBLIGATION. Any covered health care services owed to an enrollee
			 residing in Alabama and arising from an evidence of coverage issued in the
			 State of Alabama to which this chapter applies, issued or assumed by a member
			 HMO which becomes an insolvent HMO after the effective date of this chapter. A
			 contractual obligation shall not include an amount in excess of $300,000 in the
			 aggregate under one or more evidence(s) of coverage on any one enrollee; nor
			 shall a contractual obligation include any debt or amounts owed by the
			 insolvent HMO to any provider of health care services, or other goods and
			 services except to the extent that any enrollee of the insolvent HMO may be
			 held legally accountable to such provider for the reasonable amount of such
			 debt. The Association shall be not liable for any amount claimed by owners or
			 officers of the insolvent HMO. An amount owed by the insolvent HMO to a
			 provider of health care services whose agreement with the HMO included a
			 "hold-harmless" provision that sought to prevent such provider from looking to
			 the enrollee for payment shall not be a contractual obligation for purposes of
			 this chapter but may be considered a claim against the estate.
(d) COVERED HEALTH CARE SERVICES. Those
			 services provided to the enrollee by the evidence of coverage, including any
			 conditions or limitations on those services, by the insolvent HMO.
(e) ENROLLEE. Any subscriber or covered
			 dependent of an individual who is enrolled in a member health maintenance
			 organization.
(f) EVIDENCE OF
			 COVERAGE. Any contract or certificate of coverage issued to a group or
			 individual, as defined by Section
			 27-21A-1(5),
Code of Ala. 1975
, which is required by Section
			 27-21A-7 and which is within the
			 scope of this chapter and is in force and issued by a member HMO which becomes
			 insolvent after the effective date of this chapter.
(g) HOLD HARMLESS AGREEMENT. The requirement
			 specified in Section
			 27-21A-3(b)(4)
			 that all contracts for basic health care services contain a provision that
			 providers shall hold the enrollee harmless for the payment of the cost of
			 health care services in any event including, but not limited to, nonpayment of
			 the health maintenance organization, or the health maintenance organizations
			 insolvency.
(h) IMPAIRED HEALTH
			 MAINTENANCE ORGANIZATION. A member health maintenance organization which, after
			 the effective date of this chapter, is not an insolvent health maintenance
			 organization, and (a) is deemed by the Commissioner to be potentially unable to
			 fulfill its contractual obligations and (b) is placed under an order of
			 rehabilitation or conservation by a court of competent jurisdiction.
(i) INSOLVENCY INSURANCE PROTECTION. Those
			 provisions in reinsurance contracts which provide that after the HMO is found
			 to be insolvent the enrollees will have their coverages continued for at least
			 the period of time for which their premiums have been paid, that the plans
			 benefits will be continued for enrollees who are confined in an acute care
			 hospital or skilled nursing facility until their discharge, and that the
			 reinsurer will make available to all enrollees for a period of thirty-one (31)
			 days after the date of insolvency without evidence of insurability replacement
			 health conversion insurance coverage of the same benefit schedule and rates as
			 it is then offering to other prospective insureds within Alabama, as outlined
			 in Chapter 482-1-080. Insolvency insurance protection also includes any
			 agreement between the HMO and an Alabama licensed insurer or nonprofit health
			 service plan under which the insurer or nonprofit health service plan agrees to
			 issue to enrollees in the HMO a plan of hospital, medical and surgical
			 insurance at standard conversion premium rates without any underwriting or
			 other requirement, other than an application and payment of the first monthly
			 premium by the enrollee, in the event the HMO is unable to continue in
			 operation, as required by Chapter 482-1-079.
(j) INSOLVENT HEALTH MAINTENANCE
			 ORGANIZATION. A member HMO which, after the effective date of this Plan, is
			 placed under an order of liquidation by a court of competent jurisdiction with
			 a finding of insolvency.
(k) MEMBER
			 HEALTH MAINTENANCE ORGANIZATION (HMO). Any health maintenance organization
			 authorized by the Commissioner to transact the business of a health maintenance
			 organization in this state to which Section
			 27-21A-1
et
seq
.,
Code of
			 Ala. 197
5 applies.
(l)
			 Other terms expressed in this chapter shall have the meanings as defined in
			 Sections 27-21A-1
et
seq
.,
Code of
			 Ala. 1975
.
Author:
Commissioner of Insurance
Statutory Authority:
Code of Ala.
				  1975
, §§
										27-2-17,
				  27-21A-19,
				  27-21A-12(i).