Code of Massachusetts Regulations
211 CMR - DIVISION OF INSURANCE
Title 211 CMR 43.00 - Health Maintenance Organizations (HMOs)
Section 43.02 - Definitions

As used in 211 CMR 43.00, the following words mean:

Administrative Supervision, action by the Commissioner to apply and carry out the provisions of M.G.L. c. 175J.

Affiliate, an affiliate of, or person affiliated with, a specific person, is a person that directly, or indirectly through one or more intermediaries, controls, or is controlled by, or is under common control with, the person specified.

Agent, any person not employed by an HMO who is appointed as an agent of the HMO pursuant to M.G.L. c. 175, § 162S and who markets or sells HMO benefits.

Bureau of Managed Care or Bureau, the bureau in the Division of Insurance established by M.G.L. c. 176O, § 2.

Commissioner, the Commissioner of Insurance, appointed pursuant to M.G.L. c. 26, § 6 or his or her designee.

Control, including controlling, controlled by and under common control with, the possession, direct or indirect, of the power to direct or cause the direction of the management and policies of a person, whether through the ownership of voting securities, by contract other than a commercial contract for goods or non-management services, or otherwise, unless the power is the result of an official position with or corporate office held by the person. Control shall be presumed to exist if any person, directly or indirectly, owns, controls, holds with the power to vote, or holds proxies representing, 10% or more of the voting securities of any other person. In the case of a person that is a charitable or nonprofit organization subject to M.G.L. c. 180, control shall be presumed to exist if any other person shall, directly or indirectly, own, control or hold, more than 10% of the aggregate rights in any membership class or shall, directly or indirectly, have the right to appoint or elect more than 10% of the directors serving on the person's board of directors. Any of these aforementioned presumptions may be rebutted by a showing made in the manner provided with respect to HMOs under M.G.L. c. 176G, § 28(j) that control does not exist in fact. The Commissioner may determine, after furnishing all persons in interest notice an opportunity to be heard and making specific findings of fact to support such determination, that such control exists in fact, notwithstanding the absence of a presumption to that effect.

Division, the Division of Insurance established pursuant to M.G.L. c. 26, § 1.

Emergency Medical Condition, a medical condition, whether physical or mental, manifesting itself by symptoms of sufficient severity, including severe pain, that the absence of prompt medical attention could reasonably be expected by a prudent layperson who possesses an average knowledge of health and medicine, to result in placing the health of the insured or another person in serious jeopardy, serious impairment to body function, or serious dysfunction of any body organ or part, or, with respect to a pregnant woman, as further defined in section 1867(e)(1)(B) of the Social Security Act and 42 U.S.C. section 1395dd(e)(1)(B).

Evidence of Coverage, any certificate, contract, or agreement including riders, amendments and supplementary inserts, issued to a member in accordance with M.G.L. c. 176G, § 7 and 211 CMR 52.00: Managed Care Consumer Protections and Accreditation of Carriers, specifying the benefits to which the member is entitled.

Finding of Neglect, a written determination by the Commissioner that the HMO has failed to make and file the materials required by M.G.L. c. 176G, M.G.L. c. 176O, 211 CMR 43.00 or 52.00: Managed Care Consumer Protections and Accreditation of Carriers in the form and within the time required.

Foreign HMO, an alien HMO, except where clearly noted otherwise, or an HMO formed by authority of any state or government other than the commonwealth and qualified to conduct business in the commonwealth.

Health Maintenance Organization or HMO, a company organized under the laws of the commonwealth, or organized under the laws of another state and qualified to do business in the commonwealth, which:

(a) provides or arranges for the provision of health services to voluntarily enrolled members in exchange primarily for a prepaid per capita or aggregate fixed sum.

(b) demonstrates to the satisfaction of the commissioner proof of its capability to provide its members protection against loss of prepaid fees or unavailability of covered health services resulting from its insolvency or bankruptcy or from other financial impairment of its obligations to its members.

Health Maintenance Organization Holding Company System, a health maintenance organization holding company system consists of two or more affiliates, one or more of which is an HMO.

Health Services, at least reasonably comprehensive inpatient, outpatient, and emergency care services including: preventive services, such as immunizations; periodic health exams for adults; prenatal maternity care; well child care including vision and auditory screening; voluntary family planning; nutrition counseling, and health education; and also including pediatric care; and a minimum of 100 days in a 12-month period or 365 lifetime days of noncustodial care in a skilled nursing facility; and which may include, but not be limited to chiropractic services; optometric services; and podiatric services.

Managed Hospital Payment Basis, an agreement or collection of agreements wherein the financial risk is primarily related to the degree of utilization rather than to the cost of the services.

Member, any individual who has entered into a health maintenance contract, or on whose behalf such an arrangement has been made, with an HMO or carrier or both for health services and any dependent of such individual who is covered by the same contract; provided that in M.G.L. c. 176G, §§ 25 through 29, Enrolled Member shall mean any such individual, and Member shall have the same meaning as set forth in M.G.L. c. 180.

NAIC, the National Association of Insurance Commissioners.

Net Worth, the excess of total admitted assets over total liabilities, but the liabilities shall not include fully subordinated debt pursuant to M.G.L. c. 176G, §25(d). References herein to the term "surplus" shall include "net worth."

Organization, an individual, corporation, partnership, business trust, association, organized group of persons whether incorporated or not, or any line of business division, department, subsidiary or affiliate of any thereof and any receiver, trustee or other liquidating agent of any of the foregoing while acting in such capacity.

Person, any individual, corporation, association, partnership, reciprocal exchange, inter-insurer, Lloyds insurer, fraternal benefit society, operators of any medical service plan and hospital service plan as defined in M.G.L. c. 176A, c. 176B, c. 176C, c. 176E and c. 176F, carriers and HMOs as defined in M.G.L. c. 176G, insurers and sponsors of a legal services plan as defined in M.G.L. c. 176H, any other legal entity or self insurer which is engaged in the business of insurance, including producers, and adjusters, the Massachusetts Insurers Insolvency Fund and any joint underwriting association established pursuant to law. For purposes of 211 CMR 43.00, operators of any such medical and hospital service plans and carriers and such HMOs shall be engaged in the business of insurance. For purposes of M.G.L. c. 176G, §§ 27 through 29, Person, shall have the meaning set forth in M.G.L. c. 175, § 206.

Principal Executive Officer, any chief executive officer, chief operating officer, chief financial officer, treasurer, secretary, controller, and any other individual performing functions corresponding to those performed by the foregoing officers under whatever title.

Provider, any professional person, organization, health facility, or other person or institution licensed by the state to deliver or furnish health care services.

Service Area, the geographical area as approved by the Commissioner within which the HMO has developed a network of providers to afford adequate access to members for covered health services.

Subsidiary, an affiliate controlled by a person directly or indirectly through one or more intermediaries.

Uncovered Expenditures, the cost to an HMO for health care services that are the obligation of such an HMO, for which an enrollee may also be liable in the event of the HMOs' insolvency and for which no alternative arrangements have been made to cover such costs that are acceptable to the Commissioner.