) Prepaid Health Plan means a plan which offers a specified scope of benefits to an enrolled population for a predetermined prepaid annual rate.

(b) Health Maintenance Organization means any organization of providers of personal health services with a proven capacity to provide preventive and health maintenance services to a given population of enrolled consumers in a Prepaid Health Plan. Providers shall guarantee that quality services be available and accessible twenty-four (24) hours a day, seven (7) days a week. The definition of health maintenance organization under this Subdivision shall include, but not be limited to, “medical care foundations,” group practice prepayment organizations and health consumer organizations. Medical care foundation means any non-profit foundation whose physician membership is capable and guarantees to provide comprehensive health services to patients enrolled in a Prepaid Health Plan. Health consumer organization means any incorporated organization of citizens whose primary motive for organizing is to create a system of financing and arranging for the delivery of personal health services under circumstances which require sensitivity to the consumer’s desires in this field. A group practice prepayment organization means a formal, organized group of doctors and other providers in a group practice center with centralized management peer review, and a formal structure and organization.

(c) Fiscal Intermediary means any private insurance company which performs fiscal and administrative functions for any organization or provider of health care, or on behalf of consumers through a contract for health benefits.

(d) Peer Review-Medical Audit means an organized system for regular review of professional performance in or out of the hospital by a committee of peers. Such review is designed to judge the medical justification for case management to assure its quality.

(e) Utilization Review means an organized review by peers designed to control or eliminate unnecessary admissions to hospitals, and unwarranted length of stays in hospitals.

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(f) Provider Profiles means computer-assisted files of the performance of a provider over an extended period of time.

(g) Provider means any licensed individual or organization engaged in the providing of personal health service to the public.

(h) Health Commission means that body under which this legislation assumes powers and responsibility for activities related to providing personal health care to the public.

(i) Approved Hospital means a licensed hospital which meets the standards of performance as developed by the Health Commission to assure quality of care, safety of the patient and such other criteria as the Commission deems necessary.

(j) Health Facility means any licensed facility whose primary function is to deliver personal health service to the public. This includes, but is not limited to, out-patient clinics, hospitals, clinics, nursing homes, home care organizations and intermediate care facilities.

(k) Prepaid Capitation means an annual fixed premium per person paid in advance for a specified set of comprehensive health benefits.

(l) Benefit Period means the period of time during which an enrolled person is covered under a Prepaid Health Plan.

(m) Allied Health Professional means any professional person involved in the provision of skilled health service both directly or indirectly in support of physicians and health institutions engaged in the delivery of health care services.

(n) Out of Area Emergency Services means medical treatment for any sudden or unexpected illness, or the medical treatment of an injury or injuries. Such illnesses or injuries shall be those requiring medical services at a location outside the area of the patient’s own health maintenance organization, and requiring the medical services of another provider of health care services, so as to not compromise the quality of care or safety of the patient by delaying treatment. This shall include any emergency services provided to an enrollee while off-island.

(o) Enrollee means a person who has enrolled as a beneficiary of a health benefit plan.

SOURCE: GC § 9990.1.

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ARTICLE 2
ADMINISTRATION