Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 43.00 - Health Maintenance Organizations (HMOs) › Section 43.02 - Definitions

Current through Register 1525, July 5, 2024
As used in
				211 CMR 43.00, the following
				words mean:
Administrative Supervision
, action by
				the Commissioner to apply and carry out the provisions of M.G.L. c.
				175J.
Affiliate
, an affiliate of, or person
				affiliated with, a specific person, is a person that directly, or indirectly
				through one or more intermediaries, controls, or is controlled by, or is under
				common control with, the person specified.
Agent
, any person not employed by an
				HMO who is appointed as an agent of the HMO pursuant to M.G.L. c. 175, §
				162S and who markets or sells HMO benefits.
Bureau of Managed Care or Bureau
, the
				bureau in the Division of Insurance established by M.G.L. c. 176O, §
				2.
Commissioner
, the Commissioner of
				Insurance, appointed pursuant to M.G.L. c. 26, § 6 or his or her
				designee.
Control
, including controlling,
				controlled by and under common control with, the possession, direct or
				indirect, of the power to direct or cause the direction of the management and
				policies of a person, whether through the ownership of voting securities, by
				contract other than a commercial contract for goods or non-management services,
				or otherwise, unless the power is the result of an official position with or
				corporate office held by the person. Control shall be presumed to exist if any
				person, directly or indirectly, owns, controls, holds with the power to vote,
				or holds proxies representing, 10% or more of the voting securities of any
				other person. In the case of a person that is a charitable or nonprofit
				organization subject to M.G.L. c. 180, control shall be presumed to exist if
				any other person shall, directly or indirectly, own, control or hold, more than
				10% of the aggregate rights in any membership class or shall, directly or
				indirectly, have the right to appoint or elect more than 10% of the directors
				serving on the person's board of directors. Any of these aforementioned
				presumptions may be rebutted by a showing made in the manner provided with
				respect to HMOs under M.G.L. c. 176G, § 28(j) that control does not exist
				in fact. The Commissioner may determine, after furnishing all persons in
				interest notice an opportunity to be heard and making specific findings of fact
				to support such determination, that such control exists in fact,
				notwithstanding the absence of a presumption to that effect.
Division
, the Division of Insurance
				established pursuant to M.G.L. c. 26, § 1.
Emergency Medical Condition
, a medical
				condition, whether physical or mental, manifesting itself by symptoms of
				sufficient severity, including severe pain, that the absence of prompt medical
				attention could reasonably be expected by a prudent layperson who possesses an
				average knowledge of health and medicine, to result in placing the health of
				the insured or another person in serious jeopardy, serious impairment to body
				function, or serious dysfunction of any body organ or part, or, with respect to
				a pregnant woman, as further defined in section 1867(e)(1)(B) of the Social
				Security Act and
				42
				U.S.C. section
				1395dd(e)(1)(B).
Evidence of Coverage
, any certificate,
				contract, or agreement including riders, amendments and supplementary inserts,
				issued to a member in accordance with M.G.L. c. 176G, § 7 and
				211 CMR 52.00:
Managed Care Consumer Protections and Accreditation of
				Carriers
, specifying the benefits to which the member is
				entitled.
Finding of Neglect
, a written
				determination by the Commissioner that the HMO has failed to make and file the
				materials required by M.G.L. c. 176G, M.G.L. c. 176O,
				211 CMR 43.00 or
				52.00:
Managed Care
				Consumer Protections and Accreditation of Carriers
in the form and
				within the time required.
Foreign HMO
, an alien HMO, except
				where clearly noted otherwise, or an HMO formed by authority of any state or
				government other than the commonwealth and qualified to conduct business in the
				commonwealth.
Health Maintenance Organization
or
HMO
, a company organized under the laws of the
				commonwealth, or organized under the laws of another state and qualified to do
				business in the commonwealth, which:
(a) provides or arranges for the provision of health services
				to voluntarily enrolled members in exchange primarily for a prepaid per capita
				or aggregate fixed sum.
(b) demonstrates to the satisfaction of the commissioner proof
				of its capability to provide its members protection against loss of prepaid
				fees or unavailability of covered health services resulting from its insolvency
				or bankruptcy or from other financial impairment of its obligations to its
				members.
Health Maintenance Organization Holding Company
				System
, a health maintenance organization holding company system
				consists of two or more affiliates, one or more of which is an HMO.
Health Services
, at least reasonably
				comprehensive inpatient, outpatient, and emergency care services including:
				preventive services, such as immunizations; periodic health exams for adults;
				prenatal maternity care; well child care including vision and auditory
				screening; voluntary family planning; nutrition counseling, and health
				education; and also including pediatric care; and a minimum of 100 days in a
				12-month period or 365 lifetime days of noncustodial care in a skilled nursing
				facility; and which may include, but not be limited to chiropractic services;
				optometric services; and podiatric services.
Managed Hospital Payment Basis
, an
				agreement or collection of agreements wherein the financial risk is primarily
				related to the degree of utilization rather than to the cost of the
				services.
Member
, any individual who has entered
				into a health maintenance contract, or on whose behalf such an arrangement has
				been made, with an HMO or carrier or both for health services and any dependent
				of such individual who is covered by the same contract; provided that in M.G.L.
				c. 176G, §§ 25 through 29,
Enrolled Member
shall mean any such individual, and
Member
shall have
				the same meaning as set forth in M.G.L. c. 180.
NAIC
, the National Association of
				Insurance Commissioners.
Net Worth
, the excess of total
				admitted assets over total liabilities, but the liabilities shall not include
				fully subordinated debt pursuant to M.G.L. c. 176G, §25(d). References
				herein to the term "surplus" shall include "net worth."
Organization
, an individual,
				corporation, partnership, business trust, association, organized group of
				persons whether incorporated or not, or any line of business division,
				department, subsidiary or affiliate of any thereof and any receiver, trustee or
				other liquidating agent of any of the foregoing while acting in such
				capacity.
Person
, any individual, corporation,
				association, partnership, reciprocal exchange, inter-insurer, Lloyds insurer,
				fraternal benefit society, operators of any medical service plan and hospital
				service plan as defined in M.G.L. c. 176A, c. 176B, c. 176C, c. 176E and c.
				176F, carriers and HMOs as defined in M.G.L. c. 176G, insurers and sponsors of
				a legal services plan as defined in M.G.L. c. 176H, any other legal entity or
				self insurer which is engaged in the business of insurance, including
				producers, and adjusters, the Massachusetts Insurers Insolvency Fund and any
				joint underwriting association established pursuant to law. For purposes of
				211 CMR 43.00, operators of
				any such medical and hospital service plans and carriers and such HMOs shall be
				engaged in the business of insurance. For purposes of M.G.L. c. 176G,
				§§ 27 through 29,
Person
, shall have the
				meaning set forth in M.G.L. c. 175, § 206.
Principal Executive Officer,
any chief
				executive officer, chief operating officer, chief financial officer, treasurer,
				secretary, controller, and any other individual performing functions
				corresponding to those performed by the foregoing officers under whatever
				title.
Provider
, any professional person,
				organization, health facility, or other person or institution licensed by the
				state to deliver or furnish health care services.
Service Area
, the geographical area as
				approved by the Commissioner within which the HMO has developed a network of
				providers to afford adequate access to members for covered health
				services.
Subsidiary
, an affiliate controlled by
				a person directly or indirectly through one or more intermediaries.
Uncovered Expenditures
, the cost to an
				HMO for health care services that are the obligation of such an HMO, for which
				an enrollee may also be liable in the event of the HMOs' insolvency and for
				which no alternative arrangements have been made to cover such costs that are
				acceptable to the Commissioner.