Section 26-A3599. DEFINITIONS

 

3599.1"Act" means the Health Maintenance Organization Act of 1996, effective April 9, 1997, D.C. Law 11-235, D.C. Code § 35-4500 et seq.

 

3599.2"Annual Dues Revenues" means sources of income received by the Health Maintenance Organization (HMO) for health services provided to members or in certain situations, non-members. These balances are found in the National Association of Insurance Commissioners' (NAIC) HMO annual statement blank.

 

3599.3"Annual Health Care Expenditures except those expenses paid on a capitated basis or managed hospital payment basis" means the health-related expenditures of the health maintenance organization which are paid on a fee-for-service or non-managed care basis annually. These balances are found in the National Association of Insurance Commissioners' (NAIC) HMO annual statement blank.

 

3599.4"Annual Health Care Expenditures paid on a capitated basis or managed hospital payment basis" means the health expenditures of the HMO used to provide covered services to its enrollees which are included within the capitated or contractual arrangement the HMO has with its providers and participating hospitals. These balances are found in the National Association of Insurance Commissioners' (NAIC) HMO annual statement blank.

 

3599.5"Annual Hospital Expenditures paid on a managed hospital payment basis" means the inpatient hospital costs of routine and ancillary services provided to members of the Health Maintenance Organization while confined to an acute care hospital. This excludes emergency room and out-of-area hospitalization. However, these expenditures may include and not be limited to capitation payments, diagnostic related group ("DRG") type payments, case rate type payments, discounted fee-for-service payments, per diem arrangements, and similar arrangements in which payment is not based on usual, reasonable and customary fees for services rendered. When filing rates, accompanied with an actuarial memorandum, the memorandum shall clearly state whether the definition of "annual hospital expenditures" is used in the rates that are filed. The actuary shall state which components of the definition are included and which are excluded from the rates that are filed. These balances are found in the National Association of Insurance Commissioners' (NAIC) HMO annual statement blank.

 

3599.6"Appointed producer" means a licensed HMO producer who conducts business within the scope of his or her license and who is appointed by an HMO to solicit, negotiate, effect, procure, deliver, renew or continue HMO membership contracts on behalf of the appointing HMO or who takes or transmits a membership fee or premium for such contract, other than for himself, or a person who advertises or otherwise holds himself or herself out to the public as an appointed producer.

 

3599.7"Basic Health Care Services" means preventive care, emergency care, inpatient and outpatient hospital and physician care, diagnostic laboratory and diagnostic and therapeutic radiological services, and services mandated under the Drug Abuse, Alcohol Abuse, and Mental Illness Insurance Coverage Act of 1986, effective February 28, 1987, D.C. Law 6-195, D.C. Code, § 35-2301 et seq.; the Newborn Health Insurance Act of 1979, effective October 20, 1979, D.C. Law 3-33, D.C. Code § 35-1101 et seq.; and the District of Columbia Cancer Prevention Act of 1990, effective March 7, 1991, D.C. Law 8-225, D.C. Code § 35-2402 et seq.

 

3599.8"Copayment" means either a dollar or percentage amount an enrollee must pay in order to receive a specific covered service which is not fully prepaid.

 

3599.9"Customer" means any person to whom an HMO producer sells or attempts to sell an HMO membership contract, or from whom an HMO producer accepts an application for such a contract.

 

3599.10"Deductible" means the amount an enrollee is responsible to pay out-of-pocket before the HMO begins to pay the costs or provide the services associated with treatment.

 

3599.11"Department" means the Department of Insurance and Securities Regulation.

 

3599.12"Emergency Care Services" means:

 

(a)Health care services furnished in the emergency department of a hospital for the treatment of a medical emergency;

 

(b)Ancillary services routinely available to the emergency department of a hospital for the treatment of a medical emergency; and

 

(c)Emergency medical services transportation.

 

3599.13"Enrollee" means an individual covered under a group or nongroup HMO contract.

 

3599.14"Evidence of Coverage" means a statement of the essential features and services covered of the HMO which is given to the enrollee by the HMO or by the group contract holder.

 

3599.15"Firm" means a health maintenance organization.

 

3599.16"Group Contract" means a contract issued and delivered in the District for health care services which by its terms limits eligibility to members of a specified group. The group contract may include coverage for dependents.

 

3599.17"Group Contract Holder" means the person to which a group contract has been issued.

 

3599.18"Health Maintenance Organization" or "HMO" means any person that undertakes to provide or arrange for the delivery of basic health care services to enrollees on a prepaid basis, except for enrollee responsibility for copayments and/or deductibles.

 

3599.19"HMO Producer" means a person who solicits, negotiates, effects, procures, delivers, renews or continues a policy or contract for HMO membership, or who takes or transmits a membership fee or premium for such a policy or contract, other than for himself or herself, or a person who advertises or otherwise holds himself or herself out to the public as an HMO Producer.

 

3599.20"Hospital" means a duly licensed institution which provides general and specialized inpatient medical care. The term "hospital" shall not include a convalescent facility, nursing home, or any institution or part thereof which is used principally as a convalescent facility, rest facility, nursing facility or facility for the aged.

 

3599.21"Individual" means a natural person.

 

3599.22"Individual contract" means a contract delivered in the District for health care services issued to and covering an individual enrollee. The individual contract may include dependents of the enrollee.

 

3599.23"License" means a document or certificate of authority issued by the Department authorizing a person to act as an HMO producer.

 

3599.24"Participating provider" means a provider who, under an express or implied contract with the HMO or with its contractor or subcontractor, has agreed to provide covered services to enrollees with an expectation of receiving payment, other than copayments or deductibles, directly or indirectly from the HMO.

 

3599.25"Person" means any natural person, corporation, association, partnership or other legal entity.

 

3599.26"Primary care provider" means a participating provider whom the enrollee has selected, or who has otherwise been assigned responsibility, for the coordination of covered services to the enrollee.

 

3599.27"Provider" means any hospital or health professional licensed or authorized by reciprocity or endorsement to practice a health occupation by the District pursuant to the Health Occupations Revision Act of 1985, effective March 25, 1986, D.C. Law 6-99, D.C. Code § 2-3301.1 et seq., or any state.

 

3599.28"Service area" means the District of Columbia.

 

3599.29"Subscriber contract" means an individual whose employment or other status, except family dependency, is the basis for eligibility for enrollment in the HMO, or in the case of an individual contract, the person in whose name the contract is issued.

 

3599.30"Text" means all printed matter except: the name and address of the HMO; the name, number, or title of the documents; the table of contents or index; the heading and captions; the defined terms; the proper nouns; and the declarations pages, schedules or tables.

 

3599.31"Uncovered Health Care Expenditures" means the cost of health-related expenditures that are the obligation of the health maintenance organization for which an enrollee may also be liable in the event of the HMO's insolvency.

 

source

Final Rulemaking published at 46 DCR 7291(September 17, 1999).