Md. Code Regs. 31.10.31.02

Current through Register Vol. 51, No. 18, September 6, 2024

Section 31.10.31.02 - Definitions

A. In this chapter, the following terms have the meanings indicated.

B. Terms Defined.

(1) Behavioral Health Care Administrative Expenses.

(a) "Behavioral health care administrative expenses" means any expenses that are for administrative functions including:

(i) Billing and collection expenses;

(ii) Accounting and financial reporting expenses;

(iii) Quality assurance and utilization management program or activity expenses;

(iv) Promotion and marketing expenses;

(v) Taxes, fees, and assessments;

(vi) Legal expenses;

(vii) Salary expenses for employees that are not related to the delivery of behavioral health care services to patients;

(viii) Computer expenses;

(ix) Provider credentialing;

(x) Collection and administrative review of treatment plans;

(xi) Auditing the financial report submitted to the Commissioner under Insurance Article, § 15-127, Annotated Code of Maryland;

(xii) Debt payment and debt service; and

(xiii) Other general and administrative expenses.

(b) "Behavioral health care administrative expenses" does not include expenses incurred for behavioral health care services.

(2) Behavioral Health Care Services.

(a) "Behavioral health care services" means procedures or services rendered by a health care provider for the treatment of mental illness, emotional disorders, drug abuse, or alcohol abuse.

(b) "Behavioral health care services" includes any quality assurance or utilization management activities or treatment plan reviews that are clinical in nature.

(c) "Behavioral health care services" does not include administrative functions.

(3) "Carrier" means:

(a) A health insurer;

(b) A nonprofit health service plan;

(c) A health maintenance organization;

(d) A preferred provider organization;

(e) A third party administrator; or

(f) Except for a managed care organization as defined in Health-General Article, Title 15, Subtitle 1, Annotated Code of Maryland, any other person that provides health benefit plans subject to regulation by the State.

(4) "Direct behavioral health care expenses" means any payment to a health care provider by a managed behavioral health care organization for the provision of behavioral health care services to a member.

(5) "Direct payments" means the money that a carrier disburses to a managed behavioral health care organization for the provision of behavioral health care services to a member.

(6) "Managed behavioral health care organization" means a company, organization, private review agent, or subsidiary that:

(a) Contracts with a carrier to provide, undertake to arrange, or administer behavioral health care services to members; or

(b) Otherwise makes behavioral health care services available to members through contracts with health care providers.

(7) Member.

(a) "Member" means an individual entitled to behavioral health care services from a carrier or a managed behavioral health care organization under a policy or plan issued or delivered in the State.

(b) "Member" includes a subscriber.

(8) "Provider" means a person licensed, certified, or otherwise authorized under Health Occupations Article, or Health-General Article, Annotated Code of Maryland, to provide health care services.

Md. Code Regs. 31.10.31.02