02-031-380 Me. Code R. § 4

Current through 2024-46, November 13, 2024

Section 031-380-4 - DEFINITIONS

Terms defined in 24-A M.R.S.A. §4301-A have the same meanings when used in this Rule. At the time of adoption of this Rule, the following terms have the following statutory definitions:

1. "Carrier" means:

A. An insurance company licensed in accordance with the Maine Insurance Code (Title 24-A M.R.S.A.) to provide health insurance;

B. A health maintenance organization licensed pursuant to chapter 56 of the Insurance Code;

C. A preferred provider arrangement administrator registered pursuant to chapter 32 of the Insurance Code;

D. A fraternal benefit society, as defined by 24-A M.R.S.A. §4101;

E. A nonprofit hospital or medical service organization or health plan licensed pursuant to Title 24 M.R.S.A.;

F. A multiple-employer welfare arrangement licensed pursuant to chapter 81 of the Insurance Code;

G. A self-insured employer subject to state regulation as described in 24-A M.R.S.A. §2848-A; or

H. Notwithstanding any other provision of the Insurance Code, an entity offering coverage in this State that is subject to the requirements of the federal Affordable Care Act.

2. "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. A plan that is subject to the requirements of the federal Affordable Care Act and offered in this State by a carrier, including, but not limited to, a qualified health plan offered on an American Health Benefit Exchange or a SHOP Exchange established pursuant to the federal Affordable Care Act, is a health plan for purposes of this Rule.

3. "Provider" means a practitioner or facility licensed, accredited, or certified to perform specified health care services consistent with state law.

4. "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.

02-031 C.M.R. ch. 380, § 4