North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 16 - ACTUARIAL SERVICES DIVISION › Section .0600 - HEALTH MAINTENANCE ORGANIZATION FILINGS AND STANDARDS › Section 16 .0601 - DEFINITIONS

Current through Register Vol. 39, No. 2, July 15, 2024
(a) The definitions
				contained in
				G.S.
				58-67-5 shall apply in this
				Section.
(b) As used in this
				Section:
(1) "Adjusted community rating" means
				a rating method that allows an HMO to prospectively establish premium rates
				based upon the expected revenue requirements for individual groups and to take
				into account a group's historical utilization, intensity, or cost
				experience.
(2) "Capitated" means
				covered health care services are provided by an HMO, medical group, or
				institution based on a prepaid fixed amount per enrollee regardless of the
				actual value of those services.
(3)
				"Community rating" means a general method of establishing premiums for
				financing health care in which an individual's rate is based on the actual or
				anticipated average cost of health services used by all HMO members in a
				specified service area.
(4)
				"Community rating by class" means a modification of community rating whereby
				individual groups may have different rates depending on the composition by age,
				gender, number of family members covered, geographic area, or
				industry.
(5) "Contingency reserve"
				means the unassigned funds held over and above any known or estimated
				liabilities of an HMO for the protection of its enrollees against the
				insolvency of the HMO.
(6)
				"Contract type" means a classification of the members into categories, usually
				based on enrolled dependent status, such as subscriber only, subscriber with
				one dependent, and subscriber with two or more dependents.
(7) "Credibility rating" means a rating
				method that establishes premium rates based upon the assignment of a level of
				credibility to an HMO group's historical utilization, intensity, or cost
				experience.
(8) "Fee-for-service"
				means payment for health care services is made on a retrospective basis based
				on the actual value of those services.
(9) "Full-service HMO" means an HMO that
				provides a comprehensive range of medical services, including hospital and
				physician services.
(10) "HMO
				expansion request" means all materials submitted for the purpose of obtaining
				authority to operate an HMO in a new or expanded geographic area in this
				State.
(11) "HMO model type" means
				a classification that describes the manner in which physicians are affiliated
				with the HMO and the contractual and payment arrangements with hospitals, and
				includes types such as group, network, staff, independent practice association,
				and point-of-service.
(12) "HMO
				rate filing" means an initial HMO rate filing, an HMO expansion request, or an
				HMO rate revision filing.
(13) "HMO
				rate revision filing" means all materials submitted for the purpose of making a
				revision to an existing schedule of premiums.
(14) "Incurred loss ratio" means the ratio of
				total medical expenses, including the change in claim reserves to total earned
				premium revenues.
(15) "Initial HMO
				rate filing" means all materials submitted for the purpose of obtaining a
				certificate of authority to operate an HMO in this State.
(16) "Single-service HMO" means an HMO that
				undertakes to provide or arrange for the delivery of a single or limited type
				of health care service to a defined population on a prepaid basis.