Maine Revised Statutes > Title 24-A > Chapter 56-A > Subchapter 1 – Health Plan Requirements
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Terms Used In Maine Revised Statutes > Title 24-A > Chapter 56-A > Subchapter 1 - Health Plan Requirements
- Adult: means a person who has attained the age of 18 years. See Maine Revised Statutes Title 1 Sec. 72
- Adverse health care treatment decision: includes a rescission determination and an initial coverage eligibility determination, consistent with the requirements of the federal Affordable Care Act. See Maine Revised Statutes Title 24-A Sec. 4301-A
- 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.
- Attachment: A procedure by which a person's property is seized to pay judgments levied by the court.
- Authorized representative: means :
A. See Maine Revised Statutes Title 24-A Sec. 4301-ABehavioral health care service: means a health care service or treatment to address mental health and substance use conditions. See Maine Revised Statutes Title 24-A Sec. 4301-A 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 Carrier: means :
A. See Maine Revised Statutes Title 24-A Sec. 4301-AClinical peer: means a physician or other licensed health care practitioner who holds a nonrestricted license in a state of the United States, is board certified in the same or similar specialty as typically manages the medical condition, procedure or treatment under review and whose compensation does not depend, directly or indirectly, upon the quantity, type or cost of the medical condition, procedure or treatment that the physician or other licensed health care practitioner approves or denies on behalf of a carrier. See Maine Revised Statutes Title 24-A Sec. 4301-A 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. Damages: Money paid by defendants to successful plaintiffs in civil cases to compensate the plaintiffs for their injuries. Dependent: A person dependent for support upon another. Donor: The person who makes a gift. Emergency medical condition: means the sudden and, at the time, unexpected onset of a physical or mental health condition, including severe pain, manifesting itself by symptoms of sufficient severity, regardless of the final diagnosis that is given, that would lead a prudent layperson, possessing an average knowledge of medicine and health, to believe:
A. See Maine Revised Statutes Title 24-A Sec. 4301-AEmergency service: means a health care item or service furnished or required to evaluate and treat an emergency medical condition that is provided in an emergency facility or setting. See Maine Revised Statutes Title 24-A Sec. 4301-A Enrollee: means an individual who is enrolled in a health plan or a managed care plan. See Maine Revised Statutes Title 24-A Sec. 4301-A 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. federal Affordable Care Act: means the federal Patient Protection and Affordable Care Act, Public Law 111-148, as amended by the federal Health Care and Education Reconciliation Act of 2010, Public Law 111-152, and any amendments to or regulations or guidance issued under those acts. See Maine Revised Statutes Title 24-A Sec. 14 Fraud: Intentional deception resulting in injury to another. Gift: A voluntary transfer or conveyance of property without consideration, or for less than full and adequate consideration based on fair market value. Health care treatment decision: means a decision regarding diagnosis, care or treatment when medical services are provided by a health plan, or a benefits decision involving determinations regarding medically necessary health care, preexisting condition determinations and determinations regarding experimental or investigational services. See Maine Revised Statutes Title 24-A Sec. 4301-A health insurance: means insurance of human beings against bodily injury, disablement or death by accident or accidental means, or the expense thereof, or against disablement or expense resulting from sickness, and every insurance appertaining thereto, including provision for the mental and emotional welfare of human beings by defraying the costs of legal services only to the extent provided for in chapter 38. See Maine Revised Statutes Title 24-A Sec. 704 Health plan: means a plan offered or administered by a carrier that provides for the financing or delivery of health care services to persons enrolled in the plan, other than a plan that provides only accidental injury, specified disease, hospital indemnity, Medicare supplement, disability income, long-term care or other limited benefit coverage not subject to the requirements of the federal Affordable Care Act. See Maine Revised Statutes Title 24-A Sec. 4301-A in writing: include printing and other modes of making legible words. See Maine Revised Statutes Title 1 Sec. 72 Indemnification: In general, a collateral contract or assurance under which one person agrees to secure another person against either anticipated financial losses or potential adverse legal consequences. Source: FDIC Independent review organization: means an entity that conducts independent external reviews of adverse health care treatment decisions. See Maine Revised Statutes Title 24-A Sec. 4301-A Infant: means a person who has not attained the age of 18 years. See Maine Revised Statutes Title 1 Sec. 72 Judgement: The official decision of a court finally determining the respective rights and claims of the parties to a suit. Jurisdiction: (1) The legal authority of a court to hear and decide a case. Concurrent jurisdiction exists when two courts have simultaneous responsibility for the same case. (2) The geographic area over which the court has authority to decide cases. Liabilities: The aggregate of all debts and other legal obligations of a particular person or legal entity. Managed care plan: means a plan offered or administered by a carrier that provides for the financing or delivery of health care services to persons enrolled in the plan through:
A. See Maine Revised Statutes Title 24-A Sec. 4301-AMedically necessary health care: means health care services or products provided to an enrollee for the purpose of preventing, diagnosing or treating an illness, injury or disease or the symptoms of an illness, injury or disease in a manner that is:
A. See Maine Revised Statutes Title 24-A Sec. 4301-AMonth: means a calendar month. See Maine Revised Statutes Title 1 Sec. 72 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. Ordinary care: means , in the case of a carrier, the degree of care that a carrier of ordinary prudence would use under the same or similar circumstances. See Maine Revised Statutes Title 24-A Sec. 4301-A Oversight: Committee review of the activities of a Federal agency or program. Participating provider: means a licensed or certified provider of health care services, including mental health services, or health care supplies that has entered into an agreement with a carrier to provide those services or supplies to an individual enrolled in a managed care plan. See Maine Revised Statutes Title 24-A Sec. 4301-A Peer-reviewed medical literature: means scientific studies published in at least 2 articles from major peer-reviewed medical journals that present supporting data that the proposed use of a drug or device is safe and effective. See Maine Revised Statutes Title 24-A Sec. 4301-A Plan sponsor: means an employer, association, public agency or any other entity providing a health plan. See Maine Revised Statutes Title 24-A Sec. 4301-A Provider: means a practitioner or facility licensed, accredited or certified to perform specified health care services consistent with state law. See Maine Revised Statutes Title 24-A Sec. 4301-A Provider profiling program: means a program that uses provider data in order to rate or rank provider quality, cost or efficiency of care by the use of a grade, star, tier, rating or any other form of designation that provides an enrollee with an incentive to use a designated provider based on quality, cost or efficiency of care. See Maine Revised Statutes Title 24-A Sec. 4301-A Public law: A public bill or joint resolution that has passed both chambers and been enacted into law. Public laws have general applicability nationwide. Religious nonmedical provider: means a provider who provides only religious nonmedical treatment or religious nonmedical nursing care. See Maine Revised Statutes Title 24-A Sec. 4301-A Rescission: The cancellation of budget authority previously provided by Congress. The Impoundment Control Act of 1974 specifies that the President may propose to Congress that funds be rescinded. If both Houses have not approved a rescission proposal (by passing legislation) within 45 days of continuous session, any funds being withheld must be made available for obligation. 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. Special condition: means a condition or disease that is life-threatening, degenerative or disabling and requires specialized medical care over a prolonged period of time. See Maine Revised Statutes Title 24-A Sec. 4301-A Specialist: means an appropriately licensed and credentialed health care provider with specialized training and clinical expertise. See Maine Revised Statutes Title 24-A Sec. 4301-A Standard reference compendia: means :
A. See Maine Revised Statutes Title 24-A Sec. 4301-ATranscript: A written, word-for-word record of what was said, either in a proceeding such as a trial or during some other conversation, as in a transcript of a hearing or oral deposition. Trial: A hearing that takes place when the defendant pleads "not guilty" and witnesses are required to come to court to give evidence. United States: includes territories and the District of Columbia. See Maine Revised Statutes Title 1 Sec. 72 Urgent care: means health care or treatment provided in response to exigent circumstances. See Maine Revised Statutes Title 24-A Sec. 4301-A Year: means a calendar year, unless otherwise expressed. See Maine Revised Statutes Title 1 Sec. 72