Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 850 - HEALTH PLAN ACCOUNTABILITY › Section 031-850-5 - Definitions

Current through 2024-29, July 17, 2024
For purposes of this rule:
A. "Adverse benefit determination" means any
				of the following, including but not limited to adverse health care treatment
				decisions: a denial, reduction, or termination of, or a failure to provide or
				make payment (in whole or in part) for, a benefit, including an action based on
				a determination of a participant's or beneficiary's ineligibility to
				participate in a plan.
DRAFTING NOTE:
The term "adverse benefit
				  determination" includes both adverse health care treatment (medical) decisions
				  and adverse (non-medical) benefit determinations. Adverse health care treatment
				  (medical) decisions are subject to section
				  8 of this rule. Adverse (non-medical)
				  benefit determinations are subject to section
				  9 of this rule. All adverse benefit
				  determinations are subject to section
				  10 of this rule.
A-1. "Adverse health care treatment decision"
				means a health care treatment decision made by or on behalf of a carrier
				offering a health plan denying in whole or in part payment for or provision of
				otherwise covered services requested by or on behalf of an enrollee. "Health
				care treatment decision" means a decision regarding diagnosis, care, or
				treatment when medical services are provided by a health plan, or a benefits
				decision involving determinations regarding medically necessary health care,
				preexisting condition determinations and determinations regarding experimental
				or investigational services. "Adverse health care treatment decision" includes
				a rescission determination and an initial coverage eligibility determination,
				consistent with the requirements of the federal Affordable Care Act.
B. "Ambulatory review" means utilization
				review of health care services performed or provided in an outpatient
				setting.
C. "Ancillary Services"
				means appropriately licensed ancillary non-physician services which may include
				but are not limited to home health care, durable medical equipment, physical
				therapy, chiropractic, podiatry, certified nurse midwifery, pharmacy, home
				care, alcohol and chemical dependency services, and mental health services
				provided by psychologists, social workers, counseling professionals and
				psychiatric nurses in inpatient, outpatient treatment and residential treatment
				settings, as appropriate in each case. The listing of a particular service or
				category of provider in this definition does not function to mandate that
				coverage for that service or category of provider is required.
D. "Appeals procedure" means a formal process
				whereby a covered person, a representative of a covered person, or attending
				physician, facility or health care provider on a covered person's behalf, can
				contest an adverse health care treatment decision rendered by the health
				carrier or its designee utilization review entity (URE), which results in the
				denial, reduction without further opportunity for additional services or
				termination of coverage of a requested health care service.
E. "Carrier" or "health carrier" means:
1) An insurance company licensed in
				accordance with Title 24-A to provide health insurance;
2) A health maintenance organization licensed
				pursuant to Title 24-A Chapter 56;
3) A preferred provider arrangement
				administrator registered pursuant to Title 24-A Chapter 32;
4) A fraternal benefit society, as defined by
				 24-A M.R.S.A.
				§4101;
5) A nonprofit hospital or medical service
				organization or health plan licensed pursuant to Title 24;
6) A multiple-employer welfare arrangement
				licensed pursuant to 24-A M.R.S.A. Chapter 81;
7) A self-insured employer subject to state
				regulation as described in
				24-A M.R.S.A.
				§2848-A; or
8) Notwithstanding any other provision of
				Title 24-A, an entity offering coverage in this State that is subject to the
				requirements of the federal Affordable Care Act.
An employer exempted from the applicability of 24-A M.R.S.A.
				  Chapter 56-A under the federal Employee Retirement Income Security Act of 1974,
				  29 United States
				  Code, Sections 1001 to
				  1461
				  (1988) is not considered a carrier.