Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 109 - QUALITY OVERSIGHT FOR COMMERCIAL HMOs › Section 144-109-1.02 - DEFINITIONS

Current through 2024-29, July 17, 2024
Unless otherwise indicated, the following terms shall have
				  the following meanings:
1.02-1
				Accessibility is the extent to which a member of an HMO can obtain available
				services at the time they are needed. This refers to telephone access, the
				ability to schedule an appointment and to physical, language and other barriers
				to obtaining the service.
1.02-2
				Acute Condition is an illness or health problem of a short-term or episodic
				nature.
1.02-3 Availability is the
				extent to which the HMO has practitioners of the appropriate type and number
				distributed geographically to meet the needs of its membership.
1.02-4 Benchmark is the measure of best
				performance, set externally to the HMO, for a particular indicator or
				performance goal in the health maintenance organization industry.
1.02-5 Chronic Condition is a disease or
				condition, usually of slow progress and long continuance, requiring ongoing
				care. Examples include asthma, hypertension, and diabetes.
1.02-6 Commissioner is the Commissioner of
				the Department of Human Services.
1.02-7 Continuity of Care is the provision of
				care by the same set of practitioners to a member over time, or if the same
				practitioners are not available over time, a mechanism to provide appropriate
				clinical information in a timely fashion to other practitioners who continue to
				provide the same type and level of care.
1.02-8 Coordination of Care describes the
				mechanisms assuring that the member and practitioners have access to, and take
				into consideration, all the required information on the member's conditions and
				treatments to assure that the member receives appropriate health care
				services.
1.02-9 Department is the
				Department of Human Services.
1.02-10 Facility is an institution providing
				health care services or a health care setting, including but not limited to
				appropriately licensed or certified hospitals and other inpatient centers,
				ambulatory surgical or treatment centers, skilled nursing centers, residential
				treatment centers, diagnostic, laboratory and imaging centers, and
				rehabilitation and other therapeutic health settings.
1.02-11 Governing Body is the board of
				directors, or other body, with ultimate authority and responsibility for the
				overall operations of the HMO, or its designee.
1.02-12 Guideline is a systematically
				developed descriptive tool or standardized specification for care to assist
				practitioner and patient decisions about appropriate health care for specific
				clinical circumstances.
1.02-13
				Health Care Services are services for the diagnosis, prevention, treatment,
				cure or relief of a health condition, illness, injury or disease, including
				mental illness and alcohol and chemical dependency.
1.02-14 Health Maintenance Organization (HMO)
				is an entity licensed pursuant to Title 24-A, M.R.S.A. Chapter 56.
1.02-15 HEDIS Effectiveness of Care Measures
				is that portion of the Health Plan Employer Data and Information Set (HEDIS)
				that measures the outcomes of care and care processes, as defined by National
				Committee for Quality Assurance. HEDIS is a set of standardized performance
				measures designed to allow for reliable comparison of the performance of
				managed health care plans.
1.02-16
				Intervention is an action taken by the HMO to increase the probability that a
				desired outcome will occur.
1.02-17
				Measure is a quantifiable element of performance that can be compared to the
				same element of other performances, such as a dimension of a function, process,
				or outcome. Measures can be of activities, events, occurrences, or outcomes for
				which data can be collected to allow comparison with a threshold, a benchmark,
				or prior performance.
1.02-18
				Member is a policyholder, subscriber, enrollee, or other individual entitled to
				benefits under an HMO benefit plan.
1.02-19 National Committee for Quality
				Assurance (NCQA) is a national organization that accredits quality assurance
				programs in prepaid managed care organizations.
1.02-20 NCQA Accreditation Survey Report is
				the detailed survey report reported to the HMO by NCQA upon completion of
				NCQA's survey of the HMO. The NCQA accreditation survey report is not the
				accreditation summary report that is published by NCQA.
1.02-21 Participating, with respect to a
				provider, is one who is under contract with the HMO, an intermediary, or with
				the HMO's contractor or subcontractor, who has agreed to provide health care
				services to members with an expectation of receiving payment, other than
				coinsurance, copayments or deductibles, directly or indirectly from the
				HMO.
1.02-22 Performance Goal is
				the desired level of achievement set for itself by an HMO.
1.02-23 Physician is a licensed doctor of
				medicine or osteopathy practicing within the scope of a license.
1.02-24 Practitioner is a physician or other
				person licensed, accredited or certified to perform specified health care
				services consistent with state law. This definition applies to individual
				practitioners, not corporate "persons."
1.02-25 Preventive Health Services are health
				care services designed for the prevention and early detection of illness in
				asymptomatic people, generally including routine physical examinations, tests,
				and immunizations.
1.02-26 Primary
				Care is the level of care that encompasses routine care of individuals with
				common health problems and chronic illnesses that can be managed on an
				outpatient basis, traditionally provided by family practice, pediatrics,
				general practitioners, internal medicine, and obstetricians/
				gynecologists.
1.02-27 Primary Care
				Practitioner (PCP) is a practitioner under contract with an HMO to supervise,
				coordinate, and provide primary care health care services to members; maintain
				continuity of member patient care; and initiate member patient referrals for
				specialist care.
1.02-28 Provider
				is a practitioner or facility.
1.02-29 Quality is the degree to which a
				health care service or health care services, or the availability,
				accessibility, continuity or coordination of care meet established professional
				or regulatory standards, or judgments of value to the consumer.
1.02-30 Quality Management Program (QMP) is
				that program prescribed by Section
				1.03.
1.02-31 Quality of Care relates to the
				quality or appropriateness of health care services, including preventive health
				services.
1.02-32 Quality of
				Service relates to the availability, accessibility, continuity or coordination
				of care and to the satisfaction of members with the quality of care, and the
				availability, accessibility, continuity and coordination of care.
1.02-33 Quality-related Function is a
				function that is related to the quality of care, the quality of service,
				quality management program, or any other function that relates to the quality
				of health care services or health care delivery.
1.02-34 Superintendent is the Superintendent
				of the Bureau of Insurance.
1.02-35
				Utilization Review is any program or practice by which the HMO seeks to review
				the utilization, clinical necessity, appropriateness, efficacy or efficiency of
				health care services, procedures, or providers.