Pennsylvania Code › Title 31 - INSURANCE › Part X - Health Maintenance Organization › Chapter 301 - HEALTH MAINTENANCE ORGANIZATION › Subchapter A - GENERAL INFORMATION › Section 301.2 - Definitions

Current through Register Vol. 54, No. 28, July 13, 2024
(a) No contract or
				  evidence of coverage delivered or issued for delivery to a person by an HMO
				  established or operating in this Commonwealth may contain definitions
				  respecting the matters in subsections (b) and (c) unless the definitions are
				  consistent with this section.
(b)
				  Definitions other than those in this section may be used as appropriate if they
				  do not contradict the definitions in this subsection. Definitions used in the
				  contracts or evidence of coverage shall be in alphabetical order.
(c) The following words and terms, when used
				  in this chapter, have the following meanings, unless the context clearly
				  indicates otherwise:
Act
-The Health Maintenance Organization
					 Act (40 P. S. §§
												1551-1567).
Affiliated provider
or
participating provider
-A provider that has entered into a
					 contractual agreement either directly or indirectly with an HMO to provide
					 health care services to members.
Certificate of authority
-The document
					 issued jointly by the Secretary and the Commissioner permitting a corporation
					 to establish, maintain and operate a health maintenance organization.
Commissioner
-The Insurance Commissioner of
					 the Commonwealth.
Contractholder
-An entity consisting of
					 employes or members which has purchased a group contract from an HMO for the
					 provision of specific health care services to its eligible employes or
					 members.
Department
-The Insurance Department of
					 the Commonwealth.
Evidence of coverage
-A certificate,
					 agreement or contract issued to a subscriber setting out the coverage to which
					 the member is entitled.
Federally qualified health maintenance
					 organization
-An entity which has been found by the Secretary of the
					 United States Department of Health and Human Services to meet the requirements
					 of section 1301 of the Public Health Service Act (42 U.S.C.A. §
												300e).
Group contract
-A contract for health care
					 services which by its terms limits eligibility to members of a specified group.
HMO-health maintenance organization
-An
					 organized system which combines the delivery and financing of health care and
					 which provides basic health services to voluntarily enrolled members for a
					 fixed prepaid fee.
Impaired organization
-An organization
					 which is deemed by the Commissioner, under sections 5.1(b)(2) and 10
					 (40
					 P. S. §§
												1555.1(b)(2) and
					 1560), to be no longer able
					 to operate in a financially sound manner, but which is not insolvent.
Individual contract
or
nongroup
					 contract
-A contract for health care services issued to and covering an
					 individual or family member.
Insolvent
-The point at which an HMO's
					 liabilities exceed its assets, as defined in section 403 of The Insurance
					 Company Law of 1921 (40 P. S. §
												503).
Medical necessity
or
medically
					 necessary
-Appropriate and necessary services as determined by the HMO
					 which are rendered to a member for a condition requiring, according to
					 generally accepted principles of good medical practice, the diagnosis or direct
					 care and treatment of an illness or injury and which are not provided only as a
					 convenience.
Member
or
enrollee
-An
					 individual who is contractually entitled to receive basic health services from
					 an HMO.
Net worth
-The excess of total admitted
					 assets over total liabilities, but not including fully subordinated
					 debt.
Primary care physician
-A physician who
					 supervises, coordinates and provides initial and basic care to members;
					 initiates their referral for specialist care and maintains continuity of
					 patient care.
Provider
-A physician, hospital or other
					 person licensed and practicing within the scope of the license or otherwise
					 authorized in this Commonwealth to furnish health care services.
Secretary
-The Secretary of Health of the
					 Commonwealth.
Service area
-The geographical area as
					 approved by the Commissioner within which the HMO provides or arranges for
					 health services for members.
Subordinated debt
-The debt which is
					 subordinated to all other obligations of the HMO and which meets the
					 requirements of this section.
Subscriber
-A member whose employment or
					 other status, except for family dependency, is the basis for eligibility for
					 enrollment in the HMO.
The provisions of this §
												301.2 amended under sections 206,
						506, 1501 and 1502 of The Administrative Code of 1929 (71 P. S.
						§§
													66,
						186,
						411 and
						412); and the Health
						Maintenance Organization Act (40 P. S. §§
													1551-1567).