Terms Used In Kansas Statutes > Chapter 40 > Article 32 - Health Maintenance Organizations and Medicare Provider Organizations

• Amendment: A proposal to alter the text of a pending bill or other measure by striking out some of it, by inserting new language, or both. Before an amendment becomes part of the measure, thelegislature must agree to it.
• Appeal: A request made after a trial, asking another court (usually the court of appeals) to decide whether the trial was conducted properly. To make such a request is "to appeal" or "to take an appeal." One who appeals is called the appellant.
• Appropriation: The provision of funds, through an annual appropriations act or a permanent law, for federal agencies to make payments out of the Treasury for specified purposes. The formal federal spending process consists of two sequential steps: authorization
• Assets: (1) The property comprising the estate of a deceased person, or (2) the property in a trust account.
• Balanced budget: A budget in which receipts equal outlays.
• Basic health care services: means but is not limited to usual physician, hospitalization, laboratory, x-ray, emergency and preventive services and out-of-area coverage. See Kansas Statutes 40-3202
• Beneficiary: A person who is entitled to receive the benefits or proceeds of a will, trust, insurance policy, retirement plan, annuity, or other contract. ^{Source: OCC}
• Capitated basis: means a fixed per member per month payment or percentage of premium payment wherein the provider assumes risk for the cost of contracted services without regard to the type, value or frequency of services provided. See Kansas Statutes 40-3202
• Carrier: means a health maintenance organization, an insurer, a nonprofit hospital and medical service corporation, or other entity responsible for the payment of benefits or provision of services under a group contract. See Kansas Statutes 40-3202
• Certificate of coverage: means a statement of the essential features and services of the health maintenance organization coverage which is given to the subscriber by the health maintenance organization, medicare provider organization or by the group contract holder. See Kansas Statutes 40-3202
• Commissioner: means the commissioner of insurance of the state of Kansas. See Kansas Statutes 40-3202
• Complaint: A written statement by the plaintiff stating the wrongs allegedly committed by the defendant.
• Contract: A legal written agreement that becomes binding when signed.
• Copayment: means an amount an enrollee must pay in order to receive a specific service which is not fully prepaid. See Kansas Statutes 40-3202
• Corporation: A legal entity owned by the holders of shares of stock that have been issued, and that can own, receive, and transfer property, and carry on business in its own name.
• Deductible: means an amount an enrollee is responsible to pay out-of-pocket before the health maintenance organization begins to pay the costs associated with treatment. See Kansas Statutes 40-3202
• Dependent: A person dependent for support upon another.
• Director: means the secretary of health and environment. See Kansas Statutes 40-3202
• Disability: means an injury or illness that results in a substantial physical or mental limitation in one or more major life activities such as working or independent activities of daily living that a person was able to do prior to the injury or illness. See Kansas Statutes 40-3202
• Enrollee: means a person who has entered into a contractual arrangement or on whose behalf a contractual arrangement has been entered into with a health maintenance organization or the medicare provider organization for health care services. See Kansas Statutes 40-3202
• Evidence: Information presented in testimony or in documents that is used to persuade the fact finder (judge or jury) to decide the case for one side or the other.
• Fair market value: The price at which an asset would change hands in a transaction between a willing, informed buyer and a willing, informed seller.
• Fiduciary: A trustee, executor, or administrator.
• Grievance: means a written complaint submitted in accordance with the formal grievance procedure by or on behalf of the enrollee regarding any aspect of the health maintenance organization or the medicare provider organization relative to the enrollee. See Kansas Statutes 40-3202
• Group contract: means a contract for health care services which by its terms limits eligibility to members of a specified group. See Kansas Statutes 40-3202
• Health care services: means basic health care services and other services, medical equipment and supplies which may include, but are not limited to, medical, surgical and dental care; psychological, obstetrical, osteopathic, optometric, optic, podiatric, nursing, occupational therapy services, physical therapy services, chiropractic services and pharmaceutical services; health education, preventive medical, rehabilitative and home health services; inpatient and outpatient hospital services, extended care, nursing home care, convalescent institutional care, laboratory and ambulance services, appliances, drugs, medicines and supplies; and any other care, service or treatment for the prevention, control or elimination of disease, the correction of defects or the maintenance of the physical or mental well-being of human beings. See Kansas Statutes 40-3202
• Health maintenance organization: means an organization which:

  (1) Provides or otherwise makes available to enrollees health care services, including at a minimum those basic health care services which are determined by the commissioner to be generally available on an insured or prepaid basis in the geographic area served;

  (2) is compensated, except for reasonable copayments, for the provision of basic health care services to enrollees solely on a predetermined periodic rate basis;

  (3) provides physician services directly through physicians who are either employees or partners of such organization or under arrangements with a physician or any group of physicians or under arrangements as an independent contractor with a physician or any group of physicians;

  (4) is responsible for the availability, accessibility and quality of the health care services provided or made available. See Kansas Statutes 40-3202

• Individual contract: means a contract for health care services issued to and covering an individual. See Kansas Statutes 40-3202
• Individual practice association: means a partnership, corporation, association or other legal entity which delivers or arranges for the delivery of basic health care services and which has entered into a services arrangement with persons who are licensed to practice medicine and surgery, dentistry, chiropractic, pharmacy, podiatry, optometry or any other health profession and a majority of whom are licensed to practice medicine and surgery. See Kansas Statutes 40-3202
• Lease: A contract transferring the use of property or occupancy of land, space, structures, or equipment in consideration of a payment (e.g., rent). ^{Source: OCC}
• Legislative session: That part of a chamber's daily session in which it considers legislative business (bills, resolutions, and actions related thereto).
• Liabilities: The aggregate of all debts and other legal obligations of a particular person or legal entity.
• Medicare provider organization: means an organization which:

  (1) Is a provider-sponsored organization as defined by Section 4001 of the Balanced Budget Act of 1997 (PL 105-33); and

  (2) provides or otherwise makes available to enrollees basic health care services pursuant to Section 4001 of the Balanced Budget Act of 1997 (PL 105-33). See Kansas Statutes 40-3202

• Month: means a calendar month, unless otherwise expressed. See Kansas Statutes 77-201
• Net worth: means the excess of assets over liabilities as determined by the commissioner from the latest annual report filed pursuant to Kan. See Kansas Statutes 40-3202
• Obligation: An order placed, contract awarded, service received, or similar transaction during a given period that will require payments during the same or a future period.
• Partnership: A voluntary contract between two or more persons to pool some or all of their assets into a business, with the agreement that there will be a proportional sharing of profits and losses.
• Person: means any natural or artificial person including but not limited to individuals, partnerships, associations, trusts or corporations. See Kansas Statutes 40-3202
• Physician: means a person licensed to practice medicine and surgery under the healing arts act. See Kansas Statutes 40-3202
• Property: includes personal and real property. See Kansas Statutes 77-201
• Provider: means any physician, hospital or other person which is licensed or otherwise authorized in this state to furnish health care services. See Kansas Statutes 40-3202
• Remainder: An interest in property that takes effect in the future at a specified time or after the occurrence of some event, such as the death of a life tenant.
• Service of process: The service of writs or summonses to the appropriate party.
• Settlement: Parties to a lawsuit resolve their difference without having a trial. Settlements often involve the payment of compensation by one party in satisfaction of the other party's claims.
• staff model: means a partnership, association or other group:

  (1) Which is composed of health professionals licensed to practice medicine and surgery and of such other licensed health professionals, including but not limited to dentists, chiropractors, pharmacists, optometrists and podiatrists as are necessary for the provision of health services for which the group is responsible;

  (2) a majority of the members of which are licensed to practice medicine and surgery; and

  (3) the members of which: (A) As their principal professional activity over 50% individually and as a group responsibility are engaged in the coordinated practice of their profession for a health maintenance organization; (B) pool their income and distribute it among themselves according to a prearranged salary or drawing account or other plan, or are salaried employees of the health maintenance organization; (C) share medical and other records and substantial portions of major equipment and of professional, technical and administrative staff; and (D) establish an arrangement whereby the enrollee's enrollment status is not known to the member of the group who provides health services to the enrollee. See Kansas Statutes 40-3202

• State: when applied to the different parts of the United States, includes the District of Columbia and the territories. See Kansas Statutes 77-201
• Statute: A law passed by a legislature.
• Trustee: A person or institution holding and administering property in trust.
• Uncovered expenditures: means the costs of health care services that are covered by a health maintenance organization for which an enrollee would also be liable in the event of the organization's insolvency as determined by the commissioner from the latest annual statement filed pursuant to Kan. See Kansas Statutes 40-3202