§ 5101. Definitions

As used in this chapter:

(1) “Commissioner” means the Commissioner of Financial Regulation.

(2) “Health maintenance organization” means any person who furnishes, either directly or through arrangements with others, comprehensive health care services to an enrolled member in return for periodic payments; the amounts of said payments are agreed upon prior to the time during which the health care services may be furnished; and who is obligated to the member to arrange for or to provide directly available and accessible health care services.

(3) “Person” includes individuals, partnerships, associations, trusts, and corporations.

(4) “Health care services” means physician, hospitalization, laboratory, x-ray service, and medical equipment and supplies, which may include: medical, surgical, and dental care; psychological, obstetrical, osteopathic, optometric, optic, podiatric, chiropractic, nursing, physical therapy 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 of disease or conditions, or the maintenance of the physical and mental well-being of members.

(5) “Member” means any individual who has entered into a contract with a health maintenance organization for health care services or for services related to but not limited to processing, administering, or the payment of claims for health care services or on whose behalf such an arrangement has been made.

(6) “Evidence of coverage” means any certificate, agreement, or contract issued to a member setting out the coverage to which the member is entitled and the rates for that coverage.

(7) “Provider” means any physician, hospital, or other institution, organization, or other person who furnishes health care services.

(8) “Grievance” means a written complaint submitted to the Department or to the health maintenance organization in accordance with the health maintenance organization’s formal grievance procedure by or on behalf of a member regarding any aspect of the health maintenance organization relative to the member.

(9) “Uncovered expenditures” mean the costs to the health maintenance organization for health care services that are the obligation of the health maintenance organization, for which a member may also be liable in the event of the health maintenance organization’s impairment or insolvency, and for which no alternative arrangements for payment have been made that are acceptable to the Commissioner. (Added 1979, No. 117 (Adj. Sess.); amended 1989, No. 225 (Adj. Sess.), § 25; 1993, No. 30, §§ 1, 2, eff. May 21, 1993; 1995, No. 180 (Adj. Sess.), § 38 2011, No. 78 (Adj. Sess.), § 2, eff. April 2, 2012; 2013, No. 96 (Adj. Sess.), § 21; 2021, No. 105 (Adj. Sess.), § 238, eff. July 1, 2022.)