Code of Maine Rules › 90 - INDEPENDENT AGENCIES › 590 - MAINE HEALTH DATA ORGANIZATION › Chapter 10 - DETERMINATION OF ASSESSMENTS › Section 590-10-1 - Definitions

Current through 2024-29, July 17, 2024
A.
Carrier
. "Carrier" means an
				insurance company licensed in accordance with Title 24-A M.R.S.A., including a
				health maintenance organization, a multiple employer welfare arrangement
				licensed pursuant to Title 24-A M.R.S.A., chapter 81, a preferred provider
				organization, a fraternal benefit society, or a nonprofit hospital or medical
				service organization or health plan licensed pursuant to 24 M.R.S.A. 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.
B.
Health Care Claims Processed or Paid
. "Health care claims
				processed or paid" by third-party administrators or carriers that provide
				administrative services only do not include claims for specified disease,
				accident, injury, hospital indemnity, long term care, disability income, or
				other limited benefits.
C.
Health Care Premiums
. "Health care premiums" means the dollar
				amount charged for any policies offered by health insurance entities which
				partially or fully cover the cost of health care services but do not include
				policies issued for specified disease, accident, injury, hospital indemnity,
				long term care, disability income, or other limited benefit health insurance
				policies.
D.
Health Care
				Provider
. "Health care provider" is a hospital or a non-hospital health
				care facility. Riverview Psychiatric Center and Dorothea Dix Psychiatric Center
				are excluded.
E.
Health
				Insurance Entity
. "Health insurance entity" means a health insurance
				company, a health maintenance organization, or a nonprofit hospital or medical
				services organization with greater than $ 500,000 of premiums written per year
				in Maine that is licensed by the Maine Bureau of Insurance under Title 24-A
				M.R.S.A. All preferred payor organizations licensed by the Maine Bureau of
				Insurance under Title 24-A M.R.S.A. are excluded.
F.
Hospital
. "Hospital" means
				any acute care institution required to be licensed pursuant to 22 M.R.S.A.,
				chapter 405.
G.
MHDO
.
				"MHDO" means the Maine Health Data Organization.
H.
M.R.S.A.
" M.R.S.A. " means
				Maine Revised Statutes Annotated.
I.
Non-Hospital Health Care Facility
. "Non-hospital health care
				facility" means a public or private, proprietary or not-for-profit entity or
				institution providing health services licensed or certified under Title 22
				M.R.S.A., including, but not limited to, a radiological facility licensed under
				chapter 160, a health care facility licensed under chapter 405, an independent
				radiological service center, a federally qualified health center certified by
				the United States Department of Health and Human Services, Health Resources
				Service Administration, a rural health clinic, or rehabilitative agency,
				certified, or otherwise approved by the Division of Licensing within the
				Department of Health and Human Services, a home health care provider licensed
				under chapter 419, a residential care facility licensed under chapter 1663, a
				hospice provider licensed under chapter 1681, a state institution as defined
				under Title 34-B M.R.S.A., chapter 1 and a mental health facility licensed
				under Title 34-B M.R.S.A., chapter 1, and a retail store drug outlet licensed
				under Title 32 M.R.S.A., chapter 117.
J.
Pharmacy Benefits Manager
.
				"Pharmacy benefits manager" means an entity that performs pharmacy benefits
				management as defined in
				24-A MRSA
				§1913.
K.
Plan Sponsor
. "Plan sponsor"
				means any person, other than an insurer, who establishes or maintains a plan
				covering residents of this State, including, but not limited to, plans
				established or maintained by 2 or more employers or jointly by one or more
				employers and one or more employee organizations, the association, committee,
				joint board of trustees or other similar group of representatives of the
				parties that establish or maintain the plan.
L.
Retail Store Drug Outlet
.
				"Retail store drug outlet" means any pharmacy located in a retail store in this
				state which is engaged in dispensing, delivering, or distributing prescription
				drugs.
M.
Third-Party
				Administrator
. "Third-party administrator" means any person licensed by
				the Maine Bureau of Insurance under Title 24-A M.R.S.A., chapter 18 who, on
				behalf of a plan sponsor, health care service plan, nonprofit hospital or
				medical service organization, health maintenance organization or insurer,
				receives or collects charges, contributions or premiums for, or adjusts or
				settles claims on residents of this State that in aggregate exceeds $500,000
				per year in Maine.
N.
Total
				Net Patient Service Revenue
. "Total net patient service revenue" means
				gross charges for patient services less contractual adjustments, charity care
				and bad debt costs as provided in the standardized accounting templates
				submitted in accordance the requirements of 90-590 CMR, Chapter 300: Uniform
				Reporting System for Hospital Financial Data.