Code of Massachusetts Regulations › 940 CMR - OFFICE OF THE ATTORNEY GENERAL › Title 940 CMR 26.00 - Discount health plans and discount health plan organizations › Section 26.03 - Definitions

Current through Register 1525, July 5, 2024
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shall have the same
				meaning as set forth in
				940 CMR
				6.00.
Ancillary Services
shall include, but
				are not limited to, audiology, dental, vision, mental health, substance abuse,
				physical therapy, chiropractic and podiatry services.
Clear and Conspicuous
shall have the
				same meaning as set forth in
				940 CMR
				6.00.
Discount Health Plan
shall mean a
				business arrangement or contract in which a person, in exchange for fees, dues,
				charges or other consideration, offers access for its members to providers of
				medical, ancillary or pharmacy services and the right to receive discounts on
				medical, ancillary or pharmacy services provided under the discount health plan
				from those providers.
Discount Health Plan
does not
				include:
(a) any program offered by or through a governmental or
				government-sponsored program, including Medicaid, Medicare or
				state-administered prescription pharmacy programs;
(b) any insured health plan product offered by a health carrier
				including a product that includes a discount program offered to enrollees when
				the discount program is incidental to the insurance product; or
(c) a patient access program.
Discount Health Plan Organization
shall mean an entity that, in exchange for fees, dues, charges or other
				consideration, contracts with providers, provider networks or other discount
				health plan organizations to provide access for discount health plan members to
				providers to receive specified medical, ancillary or pharmacy services from
				those providers at a discount.
Health Carrier
shall mean an insurer
				licensed or otherwise authorized to transact accident or health insurance under
				M.G.L. c. 175; a nonprofit hospital service corporation organized under M.G.L.
				c. 176A; a nonprofit medical service corporation organized under M.G.L. c.
				176B; a dental service corporation organized under M.G.L. c. 176E; an
				optometric service corporation organized Under M.G.L. c. 176F; or a health
				maintenance organization organized under M.G.L. c. 176G.
Marketing Material
shall mean any
				material used to promote, sell or distribute a discount health plan, including
				by a private label entity that places its name on and markets or distributes a
				discount health plan pursuant to a marketing agreement with a discount health
				plan organization.
Medical Services
shall mean any
				maintenance care of, or preventive care for, the human body or care, service or
				treatment of an illness or dysfunction of, or injury to, the human body,
				including, not limited to, physician care, inpatient care, all surgical
				services, skilled nursing care, rehabilitative services, emergency services,
				ambulance services, laboratory services, diagnostic and imaging services and
				medical equipment and supplies. Medical Services does not include pharmacy
				services or ancillary services.
Member
shall mean any individual who
				pays fees, dues, charges or other consideration for the right to receive the
				benefits of a discount health plan. Member does not include any individual who
				enrolls in a patient access program.
Patient Access Program
shall mean a
				voluntary program sponsored by a pharmaceutical manufacturer, or a consortium
				of pharmaceutical manufacturers, that provides free or discounted health care
				products directly to low-income or uninsured individuals either through a
				discount card or direct shipment program.
Person
shall have the same meaning as
				set forth in
				940 CMR
				3.00.
Pharmacy Services
shall include
				pharmaceutical supplies and prescription drugs.
Prospective Member
shall mean any
				individual who has been solicited, orally or through advertisements, marketing
				material or brochures, to pay fees, dues, charges or other consideration for
				the right to receive the benefits of a discount medical plan or discount
				prescription drug plan.
Provider
shall mean any physician,
				pharmacist or other health care practitioner who is licensed, accredited or
				certified to perform specified medical, pharmaceutical or ancillary services
				within the scope of his or her license, accreditation, certification or other
				appropriate authority pursuant to the General Laws or any facility that has
				contracted, directly or indirectly, with a discount medical plan organization
				to provide medical, ancillary or pharmacy services to members.
Provider Network
shall mean an entity
				that negotiates directly or indirectly with a discount health plan organization
				on behalf of more than one provider to provide members with access to medical,
				ancillary or pharmacy services.