D.C. Mun. Regs. tit. 26, r. 26-A4799

Current through Register 71, No. 45, November 7, 2024

Rule 26-A4799 - DEFINITIONS

4799.1

For purposes of this chapter, the following terms and phrases shall have the meanings ascribed:

"Access Plan" - a document consisting of policies and procedures for assuring the ongoing sufficiency of provider networks, developed in accordance with § 4702 of this chapter.

"Active course of treatment" -

(a) An ongoing course of treatment for a life-threatening condition, defined as a disease or condition for which likelihood of death is probable unless the course of the disease or condition is interrupted;

(b) An ongoing course of treatment for a serious acute condition, defined as a disease or condition requiring complex ongoing care which the covered person is currently receiving, such as chemotherapy, radiation therapy, or post-operative visits;

(c) The second or third trimester of pregnancy, through the postpartum period; or

(d) An ongoing course of treatment for a health condition for which a treating physician or health care provider attests that discontinuing care by that physician or health care provider would worsen the condition or interfere with anticipated outcomes.

"Authorized representative" -

(a) A person to whom a covered person has given express written consent to represent the interests of the covered person;

(b) A person authorized by law to provide substituted consent for a covered person; or

(c) The covered person's treating health care professional, but only when the covered person or a family member of the covered person is unable to provide consent.

"Balance billing" - the practice of a provider billing the covered person for the difference between the provider's charge and the health carrier's allowed reimbursement rate.

"Commissioner" - the Commissioner of the Department of Insurance, Securities and Banking.

"Covered benefit" or "benefit" - the health care services to which a covered person is entitled under the terms of a health benefit plan.

"Covered person" - a policyholder or other person participating in a health benefit plan.

"Emergency medical condition" - a physical, mental, or behavioral health condition that manifests itself by acute symptoms of sufficient severity, including severe pain, that would lead a prudent layperson, possessing an average knowledge of medicine and health, to reasonably expect, in the absence of immediate medical attention, would result in:

(a) Serious jeopardy to the individual's physical, mental, or behavioral health or, with respect to a pregnant woman, her unborn child's health;

(b) Serious impairment to a bodily function;

(c) Serious impairment of any bodily organ or part; or

(d) With respect to a pregnant woman who is having contractions:

(1) That there is inadequate time to affect a safe transfer to another hospital before delivery; or

(2) That transfer to another hospital may pose a threat to the health or safety of the woman or unborn child.

"Emergency services" - a medical or mental health screening examination that is within the capability of the emergency department of a hospital, including ancillary services routinely available to the emergency department to evaluate the emergency medical condition; and shall include any further medical or mental health examination and treatment to the extent they are within the capabilities of the staff and facilities available at the hospital to stabilize the patient.

"Facility" - an institution licensed pursuant to D.C. Official Code §§ 44-501et seq.

"Health benefit plan" -- the same meaning as provided in D.C. Official Code § 31-3301.01(20).

"Health care professional" - a physician or other health care provider who is licensed, accredited, or certified to perform specified physical, mental, or behavioral health care services consistent with their scope of practice pursuant to D.C. Official Code §§3-1201et seq.

"Health care provider" or "provider" - a "provider" as defined by D.C. Official Code § 31-3131(7).

"Health care services" - services for the diagnosis, prevention, treatment, cure, or relief of a physical, mental, or behavioral health condition, illness, injury, or disease, including mental health and substance use disorders.

"Health carrier" or "carrier" - a "health insurer," as defined by D.C. Official Code § 31-3131(5).

"Intermediary" - a person not employed by a carrier or by a provider but who is otherwise authorized to negotiate and execute provider contracts with health carriers on behalf of health care providers or on behalf of a network.

"Limited scope dental plan" - a plan that is provided under a separate policy, certificate, or contract of insurance, or is otherwise not an integral part of a health benefit plan, which provides coverage generally limited to treatment of the mouth, including any organ or structure within the mouth.

"Limited scope vision plan" - a plan that is provided under a separate policy, certificate, or contract of insurance, or is otherwise not an integral part of a health benefit plan, which provides coverage generally limited to treatment of the eye.

"Network" - the group or groups of participating providers and facilities rendering services under a network plan.

"Network plan" - a health benefit plan that requires, or creates incentives for, a covered person to use health care providers that are under contract with, or managed, owned, or employed by the health carrier.

"Participating provider" - a provider who has contractually agreed to provide health care services to covered persons with an expectation of receiving payment, other than coinsurance, copayments, or deductibles, directly or indirectly from the health carrier.

"Person" - an individual, a corporation, a partnership, an association, a joint venture, a joint stock company, a trust, an unincorporated organization, any similar entity, or any combination of the foregoing.

"Primary care" - health care services for a range of common physical, mental, or behavioral health conditions provided by a physician or non-physician primary care professional.

"Primary care professional" - a participating health care professional designated by the health carrier to supervise, coordinate or provide initial or continuing care to a covered person, and who may also be required by the health carrier to initiate a referral for specialty care and maintain overall supervision of the health care services rendered to the covered person.

"Specialist" - a physician or non-physician health care professional who:

(a) Focuses on a specific area of physical, mental, or behavioral health or a group of patients;

(b) Has successfully completed required training and is recognized by the state in which he or she practices as providing specialty care; and

(c) Includes a subspecialist who has additional training and recognition above and beyond his or her specialty training.

"Specialty care" - advanced medically necessary care and treatment of specific physical, mental, or behavioral health conditions, or health conditions which may manifest in particular ages or subpopulations, that are provided by a specialist, preferably in coordination with a primary care professional or other health care professional.

"Telemedicine" - health care services provided through telecommunications technology by a health care professional who is at a location other than where the covered person is located, in accordance with the definition of telehealth as provided in D.C. Official Code §§ 31-3861et seq.

"Tiered network" - a network that allows for different provider reimbursement, covered person cost-sharing, or provider access requirements, or any combination thereof, for the same services, as a result of grouping some or all types of providers and facilities.

"To stabilize" - with respect to an emergency medical condition, to provide medical treatment of the condition as may be necessary to ensure, within a reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the individual to or from a facility, or with respect to an emergency birth without complications that would result in a continued emergency, to deliver the child and the placenta.

"Transfer" - the movement, including the discharge, of an individual from a hospital's facilities at the direction of any person directly or indirectly employed by, or affiliated or associated with, the hospital, but does not include the movement of an individual who:

(a) Has been declared dead; or

(b) Leaves the facility without the permission of any such person.

D.C. Mun. Regs. tit. 26, r. 26-A4799

Final Rulemaking published at 70 DCR 2231 (2/17/2023)