Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 51.00 - Preferred Provider Health Plans And Workers' Compensation Preferred Provider Arrangements › Section 51.02 - Definitions

Current through Register 1525, July 5, 2024
As used in
				211 CMR 51.00, the following
				words mean:
Benefit Level
, health benefits
				provided through a Preferred Provider Health Plan to Covered Persons, as
				opposed to the payments made to the provider, by the Health Benefit
				Plan.
Commissioner
, the Commissioner of
				Insurance, appointed pursuant to M.G.L. c. 26, § 6, or his or her
				designee.
Covered Person
, any policyholder,
				subscriber, member or dependent on whose behalf the insurer is obligated to pay
				for and/or provide Health Care Services, including those provided under a
				workers' compensation Preferred Provider Arrangement under the provisions of
				M.G.L. c. 152.
Covered Services
, Health Care Services
				that an insurer is obligated to pay for or provide under either a Health
				Benefit Plan or a workers' compensation insurance policy.
Emergency Care
, services provided in
				or by a hospital emergency facility to a Covered Person after the development
				of a medical condition, whether physical or mental, manifesting itself by
				symptoms of sufficient severity 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 Covered Person's or
				another person's health 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,
				42
				U.S.C. section
				1395dd(e)(1)(B).
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 Covered 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,
				42
				U.S.C. section
				1395dd(e)(1)(B).
Evidence of Coverage
, any certificate,
				contract, or agreement issued to a Covered Person, including any amendments,
				riders, or supplementary inserts, stating the health services and benefits to
				which the Covered Person is entitled under a Preferred Provider Health
				Plan.
Finding of Neglect
, a determination by
				the Commissioner that an Organization offering a Preferred Provider Health Plan
				has failed to make and file the materials required by M.G.L. c. 1760 or
				211 CMR 52.00:
Managed Care Consumer Protections and Accreditation of Carriers
in the form and within the time required.
Health Benefit Plan
, the health
				insurance policy, subscriber agreement, plan, certificate, agreement, or
				contract between the Covered Person or Health Care Purchaser and an
				Organization, which defines the Covered Services, and Benefit Levels
				available.
Health Care Provider
, a provider of
				Health Care Services licensed or registered pursuant to M.G.L. c. Ill ore.
				112.
Health Care Purchaser
, a person,
				partnership, association, or corporation that provides health care coverage to
				its employees or members and their dependents by reimbursing the Covered
				Persons directly for covered Health Care Services or by contracting with an
				Organization to provide, arrange for the provision of, reimburse and/or pay for
				covered Health Care Services.
Health Care Services
, services
				rendered or products sold by a Health Care Provider within the scope of the
				provider's license. The term includes, but is not limited to, hospital,
				medical, surgical, dental, vision, and pharmaceutical services or
				products.
Insured Health Benefit Plan
, a Health
				Benefit Plan in which the Organization assumes financial risk arising out of
				the contractual liability to pay for or reimburse Covered Persons for Covered
				Services. The term does not include a Health Benefit Plan in which an
				Organization functions solely as a third-party administrator.
Organization
, an entity authorized by
				the Commissioner to bear risk, including, but not limited to companies licensed
				or otherwise authorized to write accident and health insurance pursuant to
				M.G.L. c. 175, fraternal benefit societies licensed or otherwise authorized to
				write accident and health insurance pursuant to M.G.L c. 176, non-profit
				hospital service corporations organized under M.G.L. c. 176A, medical service
				corporations organized under M.G.L. c. 176B, dental service corporations
				organized under M.G.L. c. 176E, optometric service corporations organized under
				M.G.L. c. 176F, or health maintenance organizations licensed pursuant to M.G.L.
				c. 176G. For the purpose of Workers' Compensation Preferred Provider
				Arrangements only, "Organization" shall also include an authorized insurer,
				self-insurer, or self-insurance group as defined in M.G.L. c. 152 §§
				1, 25A and 25E, and any other corporate entity engaged in the delivery or
				administration of the delivery of health services that has requested approval
				of a Workers' Compensation Preferred Provider Arrangement on behalf of such
				insurer, self-insurer or self-insurance group which is acting on behalf of such
				entity.
Preferred Provider
, a Health Care
				Provider, group of Health Care Providers or a network of providers who have
				contracted with an Organization to provide specified Covered Services in the
				context of a Preferred Provider Arrangement.
Preferred Provider Arrangement
, a
				contract between or on behalf of an Organization and a Preferred Provider that
				complies with all the applicable requirements of M.G.L. c. 152, § 30, c.
				1761, and
				211 CMR 51.00.
Preferred Provider Health Plan
, an
				insured Health Benefit Plan offered by an Organization that provides incentives
				for Covered Persons to receive Health Care Services from Preferred Providers in
				the context of a Preferred Provider Arrangement. A Workers' Compensation
				Preferred Provider Arrangement shall not be considered a Preferred Provider
				Health Plan under this regulation.
Usual and Customary Charge
, the fees
				identified by a carrier as the usual fees charged by similar Health Care
				Providers in the same geographic area.
Workers' Compensation Preferred Provider
				Arrangement
, a Preferred Provider Arrangement between an insurer,
				self-insurer, or self-insurance group, as defined in M.G.L. c. 152,
				§§ 1,25A, or 25E, respectively, and a Preferred Provider to provide
				all or a specified portion of Health Care Services resulting from workers'
				compensation claims by Covered Persons against such insurer, self-insurer or
				self-insurance group under the provisions of M.G.L. c. 152, §
				30.