Code of Massachusetts Regulations
211 CMR - DIVISION OF INSURANCE
Title 211 CMR 51.00 - Preferred Provider Health Plans And Workers' Compensation Preferred Provider Arrangements
Section 51.02 - Definitions

As used in 211 CMR 51.00, the following words mean:

Benefit Level, health benefits provided through a Preferred Provider Health Plan to Covered Persons, as opposed to the payments made to the provider, by the Health Benefit Plan.

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

Covered Person, any policyholder, subscriber, member or dependent on whose behalf the insurer is obligated to pay for and/or provide Health Care Services, including those provided under a workers' compensation Preferred Provider Arrangement under the provisions of M.G.L. c. 152.

Covered Services, Health Care Services that an insurer is obligated to pay for or provide under either a Health Benefit Plan or a workers' compensation insurance policy.

Emergency Care, services provided in or by a hospital emergency facility to a Covered Person after the development of a medical condition, whether physical or mental, manifesting itself by symptoms of sufficient severity 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 Covered Person's or another person's health 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, 42 U.S.C. section 1395dd(e)(1)(B).

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 Covered 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, 42 U.S.C. section 1395dd(e)(1)(B).

Evidence of Coverage, any certificate, contract, or agreement issued to a Covered Person, including any amendments, riders, or supplementary inserts, stating the health services and benefits to which the Covered Person is entitled under a Preferred Provider Health Plan.

Finding of Neglect, a determination by the Commissioner that an Organization offering a Preferred Provider Health Plan has failed to make and file the materials required by M.G.L. c. 1760 or 211 CMR 52.00: Managed Care Consumer Protections and Accreditation of Carriers in the form and within the time required.

Health Benefit Plan, the health insurance policy, subscriber agreement, plan, certificate, agreement, or contract between the Covered Person or Health Care Purchaser and an Organization, which defines the Covered Services, and Benefit Levels available.

Health Care Provider, a provider of Health Care Services licensed or registered pursuant to M.G.L. c. Ill ore. 112.

Health Care Purchaser, a person, partnership, association, or corporation that provides health care coverage to its employees or members and their dependents by reimbursing the Covered Persons directly for covered Health Care Services or by contracting with an Organization to provide, arrange for the provision of, reimburse and/or pay for covered Health Care Services.

Health Care Services, services rendered or products sold by a Health Care Provider within the scope of the provider's license. The term includes, but is not limited to, hospital, medical, surgical, dental, vision, and pharmaceutical services or products.

Insured Health Benefit Plan, a Health Benefit Plan in which the Organization assumes financial risk arising out of the contractual liability to pay for or reimburse Covered Persons for Covered Services. The term does not include a Health Benefit Plan in which an Organization functions solely as a third-party administrator.

Organization, an entity authorized by the Commissioner to bear risk, including, but not limited to companies licensed or otherwise authorized to write accident and health insurance pursuant to M.G.L. c. 175, fraternal benefit societies licensed or otherwise authorized to write accident and health insurance pursuant to M.G.L c. 176, non-profit hospital service corporations organized under M.G.L. c. 176A, medical service corporations organized under M.G.L. c. 176B, dental service corporations organized under M.G.L. c. 176E, optometric service corporations organized under M.G.L. c. 176F, or health maintenance organizations licensed pursuant to M.G.L. c. 176G. For the purpose of Workers' Compensation Preferred Provider Arrangements only, "Organization" shall also include an authorized insurer, self-insurer, or self-insurance group as defined in M.G.L. c. 152 §§ 1, 25A and 25E, and any other corporate entity engaged in the delivery or administration of the delivery of health services that has requested approval of a Workers' Compensation Preferred Provider Arrangement on behalf of such insurer, self-insurer or self-insurance group which is acting on behalf of such entity.

Preferred Provider, a Health Care Provider, group of Health Care Providers or a network of providers who have contracted with an Organization to provide specified Covered Services in the context of a Preferred Provider Arrangement.

Preferred Provider Arrangement, a contract between or on behalf of an Organization and a Preferred Provider that complies with all the applicable requirements of M.G.L. c. 152, § 30, c. 1761, and 211 CMR 51.00.

Preferred Provider Health Plan, an insured Health Benefit Plan offered by an Organization that provides incentives for Covered Persons to receive Health Care Services from Preferred Providers in the context of a Preferred Provider Arrangement. A Workers' Compensation Preferred Provider Arrangement shall not be considered a Preferred Provider Health Plan under this regulation.

Usual and Customary Charge, the fees identified by a carrier as the usual fees charged by similar Health Care Providers in the same geographic area.

Workers' Compensation Preferred Provider Arrangement, a Preferred Provider Arrangement between an insurer, self-insurer, or self-insurance group, as defined in M.G.L. c. 152, §§ 1,25A, or 25E, respectively, and a Preferred Provider to provide all or a specified portion of Health Care Services resulting from workers' compensation claims by Covered Persons against such insurer, self-insurer or self-insurance group under the provisions of M.G.L. c. 152, § 30.