Md. Code Regs. 31.10.42.02

Current through Register Vol. 51, No. 22, November 1, 2024

Section 31.10.42.02 - Definitions

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

B. Terms Defined.

(1) "Carrier" means:

(a) An insurer authorized to sell health insurance;

(b) A nonprofit health service plan;

(c) A health maintenance organization;

(d) A dental plan organization; or

(e) Any other entity providing a plan of health insurance, health benefits, or health services authorized under the Insurance Article of the Annotated Code of Maryland or the Affordable Care Act.

(2) "Enrollee" means a:

(a) Person entitled to health care benefits from a carrier; or

(b) Program recipient who is enrolled in a managed care organization.

(3) "Health benefit plan" has the meaning stated in Insurance Article, § 15-140, Annotated Code of Maryland.

(4) "Managed care organization " means:

(a) A certified health maintenance organization that is authorized to receive medical assistance prepaid capitation payments;

(b) A corporation that:

(i) Is a managed care system that is authorized to receive medical assistance prepaid capitation payments;

(ii) Enrolls only Program recipients or individuals or families served under the Maryland Children's Health Program; and

(iii) Is subject to the requirements of Health-General Article, §15-102.4, Annotated Code of Maryland; or

(c) A prepaid dental plan that receives fees to manage dental services.

(5) "Program recipient" means an individual who receives benefits under the Maryland Medical Assistance Program.

(6) "Receiving carrier" means the carrier that issues the new health benefit plan when an enrollee transitions from another carrier or a managed care organization.

(7) "Receiving managed care organization" means the managed care organization that accepts the enrollee when the enrollee transitions from another managed care organization or a carrier

(8) "Relinquishing carrier" means a carrier that issued the prior health benefit plan when an enrollee transitions to a new carrier or a managed care organization.

(9) "Relinquishing managed care organization" means a managed care organization in which an enrollee had been enrolled prior to the enrollee's transition to a new managed care organization or a carrier

(10) "Transitioning enrollee " means an enrollee:

(a) Who has an effective date of coverage with a receiving carrier or a receiving managed care organization on or after January 1, 2015, under a contract that is issued or renewed on or after January 1, 2015; and

(b) Whose coverage under the receiving carrier or receiving managed care organization began within 1 month of the date coverage terminated under the:

(i) Health benefit plan with a relinquishing carrier; or

(ii) Relinquishing managed care organization.

Md. Code Regs. 31.10.42.02

Regulations .02 adopted as an emergency provision effective January 1, 2015 (42:1 Md. R. 16)
Regulation .02 adopted effective 42:8 Md. R. 608, eff.4/27/2015