Sections
Subchapter 1 Health Plan Requirements 4301-A – 4320-O
Subchapter 2 Consumer Health Care Division 4321
Subchapter 2-A Health Insurance Consumer Assistance Program 4326
Subchapter 3 Downstream Risk 4331 – 4343

Terms Used In Maine Revised Statutes > Title 24-A > Chapter 56-A - Health Plan Improvement Act

  • Adult: means a person who has attained the age of 18 years. See Maine Revised Statutes Title 1 Sec. 72
  • Adverse health care treatment decision: includes a rescission determination and an initial coverage eligibility determination, consistent with the requirements of the federal Affordable Care Act. See Maine Revised Statutes Title 24-A Sec. 4301-A
  • Amendment: A proposal to alter the text of a pending bill or other measure by striking out some of it, by inserting new language, or both. Before an amendment becomes part of the measure, thelegislature must agree to it.
  • Annuity: A periodic (usually annual) payment of a fixed sum of money for either the life of the recipient or for a fixed number of years. A series of payments under a contract from an insurance company, a trust company, or an individual. Annuity payments are made at regular intervals over a period of more than one full year.
  • Appeal: A request made after a trial, asking another court (usually the court of appeals) to decide whether the trial was conducted properly. To make such a request is "to appeal" or "to take an appeal." One who appeals is called the appellant.
  • Appellate: About appeals; an appellate court has the power to review the judgement of another lower court or tribunal.
  • Arrest: Taking physical custody of a person by lawful authority.
  • Authorized representative: means :  
A. See Maine Revised Statutes Title 24-A Sec. 4301-A
  • Bonus: means a payment a carrier makes to a downstream entity beyond any salary, fee-for-service payment, capitation or returned withhold. See Maine Revised Statutes Title 24-A Sec. 4331
  • Capitation: means a set dollar payment per patient per unit of time, usually per month, that a carrier pays a health care practitioner, institutional provider or downstream entity to cover a specified set of services and administrative costs without regard to the actual number or nature of services provided. See Maine Revised Statutes Title 24-A Sec. 4331
  • Carrier: means :  
  • A. See Maine Revised Statutes Title 24-A Sec. 4301-A
  • Clinical peer: means a physician or other licensed health care practitioner who holds a nonrestricted license in a state of the United States, is board certified in the same or similar specialty as typically manages the medical condition, procedure or treatment under review and whose compensation does not depend, directly or indirectly, upon the quantity, type or cost of the medical condition, procedure or treatment that the physician or other licensed health care practitioner approves or denies on behalf of a carrier. See Maine Revised Statutes Title 24-A Sec. 4301-A
  • Coastal island: means a natural land formation protruding above the surface of and surrounded by Maine's coastal waters at mean high tide or any portion of such land formation. See Maine Revised Statutes Title 33 Sec. 1202
  • Coastal waters: means all waters of the State within the rise and fall of the tide and to the marine limits of the jurisdiction of the State. See Maine Revised Statutes Title 33 Sec. 1202
  • Common law: The legal system that originated in England and is now in use in the United States. It is based on judicial decisions rather than legislative action.
  • Complaint: A written statement by the plaintiff stating the wrongs allegedly committed by the defendant.
  • Contract: A legal written agreement that becomes binding when signed.
  • Damages: Money paid by defendants to successful plaintiffs in civil cases to compensate the plaintiffs for their injuries.
  • Decedent: A deceased person.
  • Deed: The legal instrument used to transfer title in real property from one person to another.
  • Dependent: A person dependent for support upon another.
  • Donor: The person who makes a gift.
  • Downstream entity: means a person other than a carrier that has assumed all or part of the insurance risk of one or more health plans under a contractual relationship with a carrier or another downstream entity. See Maine Revised Statutes Title 24-A Sec. 4331
  • Downstream risk arrangement: means an arrangement that transfers insurance risk from a carrier to a downstream entity. See Maine Revised Statutes Title 24-A Sec. 4331
  • Emergency medical condition: means the sudden and, at the time, unexpected onset of a physical or mental health condition, including severe pain, manifesting itself by symptoms of sufficient severity, regardless of the final diagnosis that is given, that would lead a prudent layperson, possessing an average knowledge of medicine and health, to believe:  
  • A. See Maine Revised Statutes Title 24-A Sec. 4301-A
  • Emergency service: means a health care item or service furnished or required to evaluate and treat an emergency medical condition that is provided in an emergency facility or setting. See Maine Revised Statutes Title 24-A Sec. 4301-A
  • Enrollee: means an individual who is enrolled in a health plan or a managed care plan. See Maine Revised Statutes Title 24-A Sec. 4301-A
  • Evidence: Information presented in testimony or in documents that is used to persuade the fact finder (judge or jury) to decide the case for one side or the other.
  • Executor: A male person named in a will to carry out the decedent
  • federal Affordable Care Act: means the federal Patient Protection and Affordable Care Act, Public Law 111-148, as amended by the federal Health Care and Education Reconciliation Act of 2010, Public Law 111-152, and any amendments to or regulations or guidance issued under those acts. See Maine Revised Statutes Title 24-A Sec. 14
  • Fraud: Intentional deception resulting in injury to another.
  • Gift: A voluntary transfer or conveyance of property without consideration, or for less than full and adequate consideration based on fair market value.
  • Guardian: A person legally empowered and charged with the duty of taking care of and managing the property of another person who because of age, intellect, or health, is incapable of managing his (her) own affairs.
  • Health care treatment decision: means a decision regarding diagnosis, care or treatment when medical services are provided by a health plan, or a benefits decision involving determinations regarding medically necessary health care, preexisting condition determinations and determinations regarding experimental or investigational services. See Maine Revised Statutes Title 24-A Sec. 4301-A
  • 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. See Maine Revised Statutes Title 24-A Sec. 4301-A
  • Historic property: shall mean a structure, a plot of land which was the setting of an event or any combination of land and buildings, including the surrounding air space, which has a special historical, architectural or archaeological interest or value, and which is predominantly in its original, historical or natural conditions. See Maine Revised Statutes Title 33 Sec. 1551
  • Holder: means :  
  • A. See Maine Revised Statutes Title 33 Sec. 1581
  • Home rule authority: means the powers granted to municipalities under chapter 111; section 3001; and the Constitution of Maine, Article VIII, Part Second. See Maine Revised Statutes Title 30-A Sec. 2001
  • Indemnification: In general, a collateral contract or assurance under which one person agrees to secure another person against either anticipated financial losses or potential adverse legal consequences. Source: FDIC
  • Independent review organization: means an entity that conducts independent external reviews of adverse health care treatment decisions. See Maine Revised Statutes Title 24-A Sec. 4301-A
  • Injunction: An order of the court prohibiting (or compelling) the performance of a specific act to prevent irreparable damage or injury.
  • Legal instrument: includes :  
  • A. See Maine Revised Statutes Title 33 Sec. 1421
  • Liabilities: The aggregate of all debts and other legal obligations of a particular person or legal entity.
  • Lien: A claim against real or personal property in satisfaction of a debt.
  • Majority: when used in reference to age shall mean the age of 18 and over. See Maine Revised Statutes Title 1 Sec. 72
  • Managed care 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 through:  
  • A. See Maine Revised Statutes Title 24-A Sec. 4301-A
  • Medically necessary health care: means health care services or products provided to an enrollee for the purpose of preventing, diagnosing or treating an illness, injury or disease or the symptoms of an illness, injury or disease in a manner that is:  
  • A. See Maine Revised Statutes Title 24-A Sec. 4301-A
  • Mortgage: The written agreement pledging property to a creditor as collateral for a loan.
  • Motor vehicle: means any motor-driven vehicle, except motorboats. See Maine Revised Statutes Title 12 Sec. 10001
  • municipal clerk: means the clerk of a municipality. See Maine Revised Statutes Title 30-A Sec. 2001
  • Municipal officers: means :  
  • A. See Maine Revised Statutes Title 30-A Sec. 2001
  • Municipality: means a city or town, except as provided in Maine Revised Statutes Title 30-A Sec. 2001
  • Obligation: An order placed, contract awarded, service received, or similar transaction during a given period that will require payments during the same or a future period.
  • Ordinary care: means , in the case of a carrier, the degree of care that a carrier of ordinary prudence would use under the same or similar circumstances. See Maine Revised Statutes Title 24-A Sec. 4301-A
  • Oversight: Committee review of the activities of a Federal agency or program.
  • Owner: means any person, corporation, partnership, organization or other legal entity, including a municipality, county or other political subdivision of the State, an agency of the Federal Government and any quasi-governmental entity, which owns or controls historic property. See Maine Revised Statutes Title 33 Sec. 1551
  • Participating provider: means a licensed or certified provider of health care services, including mental health services, or health care supplies that has entered into an agreement with a carrier to provide those services or supplies to an individual enrolled in a managed care plan. See Maine Revised Statutes Title 24-A Sec. 4301-A
  • Partnership: A voluntary contract between two or more persons to pool some or all of their assets into a business, with the agreement that there will be a proportional sharing of profits and losses.
  • Payments: means any amounts the carrier pays the downstream entity for services the downstream entity furnishes directly, plus amounts paid for administration and amounts paid in whole or in part based on use and costs of referral services such as withhold amounts, bonuses based on referral levels and any other compensation to the downstream entity to influence the use of referral services. See Maine Revised Statutes Title 24-A Sec. 4331
  • Peer-reviewed medical literature: means scientific studies published in at least 2 articles from major peer-reviewed medical journals that present supporting data that the proposed use of a drug or device is safe and effective. See Maine Revised Statutes Title 24-A Sec. 4301-A
  • Person: means an individual, corporation, partnership, firm, organization or other legal entity. See Maine Revised Statutes Title 30-A Sec. 2001
  • Person: shall include individuals, partnerships, corporations, municipalities and other legal entities but shall not include the State and its agencies or the Federal Government. See Maine Revised Statutes Title 33 Sec. 1202
  • Person: means a human being or an organization. See Maine Revised Statutes Title 12 Sec. 10001
  • Physician group: means a partnership, association, corporation, individual practice association or other group of physicians that distributes income from the practice among members. See Maine Revised Statutes Title 24-A Sec. 4331
  • Plan sponsor: means an employer, association, public agency or any other entity providing a health plan. See Maine Revised Statutes Title 24-A Sec. 4301-A
  • Potential payments: means the maximum anticipated total amount, based on the most recent year's utilization and experience and any current or anticipated factors that may affect costs, to be paid for a defined set of referral services for the carrier's subscribers and for which the downstream entity assumes by contract financial risk, to some extent, for the costs of such services. See Maine Revised Statutes Title 24-A Sec. 4331
  • Preservation agreement: shall mean any deed, will or other instrument executed by or on behalf of the owner of historic property, or an order of taking, which includes within it the terms of a preservation interest. See Maine Revised Statutes Title 33 Sec. 1551
  • Preservation interest: shall mean a right created by a preservation agreement which may be in the form of a restriction, easement, covenant or condition which is held by a qualified holder and which pertains to preserving or restoring historic property. See Maine Revised Statutes Title 33 Sec. 1551
  • Probate: Proving a will
  • Provider: means a practitioner or facility licensed, accredited or certified to perform specified health care services consistent with state law. See Maine Revised Statutes Title 24-A Sec. 4301-A
  • 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. See Maine Revised Statutes Title 24-A Sec. 4301-A
  • Qualified holder: shall mean a nonprofit preservation or historical organization whose purposes include preservation of historic property or a governmental body. See Maine Revised Statutes Title 33 Sec. 1551
  • Quorum: The number of legislators that must be present to do business.
  • Real property: Land, and all immovable fixtures erected on, growing on, or affixed to the land.
  • Referral services: means any specialty, inpatient, outpatient or laboratory services that a downstream entity orders or arranges, but does not furnish directly. See Maine Revised Statutes Title 24-A Sec. 4331
  • Religious nonmedical provider: means a provider who provides only religious nonmedical treatment or religious nonmedical nursing care. See Maine Revised Statutes Title 24-A Sec. 4301-A
  • Rescission: The cancellation of budget authority previously provided by Congress. The Impoundment Control Act of 1974 specifies that the President may propose to Congress that funds be rescinded. If both Houses have not approved a rescission proposal (by passing legislation) within 45 days of continuous session, any funds being withheld must be made available for obligation.
  • Residential property: means real property located in this State that is used for residential dwelling purposes. See Maine Revised Statutes Title 33 Sec. 1421
  • Risk threshold: means the maximum risk, if the risk is based on referral services, to which a downstream entity may be exposed under a downstream risk arrangement without being at substantial financial risk. See Maine Revised Statutes Title 24-A Sec. 4331
  • Risk-sharing arrangement: means an arrangement between a carrier and a downstream entity in which the carrier continues to pay providers for a defined set of services subject to an annual reconciliation process in which costs incurred by the carrier are compared with budgeted or targeted amounts for such services and that may, if payments are different than the budgeted amount, create financial liability of the downstream entity to the carrier or the carrier to the downstream entity provided the carrier holds or retains control of any funds in excess of those required to satisfy current claims obligations or direct payment to providers for services rendered pending reconciliation. See Maine Revised Statutes Title 24-A Sec. 4331
  • Settlement: Parties to a lawsuit resolve their difference without having a trial. Settlements often involve the payment of compensation by one party in satisfaction of the other party's claims.
  • Solar clothes-drying device: means a clothes line, drying rack or other equipment used for solar drying of clothing. See Maine Revised Statutes Title 33 Sec. 1421
  • Solar collector: means a device, structure or part of a device or structure that is designed and used to transform solar energy into thermal, chemical or electrical energy to meet the water heating, space heating, space cooling or electricity generation requirements of one residential dwelling. See Maine Revised Statutes Title 33 Sec. 1421
  • Solar energy device: means a solar collector or solar clothes-drying device. See Maine Revised Statutes Title 33 Sec. 1421
  • Special condition: means a condition or disease that is life-threatening, degenerative or disabling and requires specialized medical care over a prolonged period of time. See Maine Revised Statutes Title 24-A Sec. 4301-A
  • Specialist: means an appropriately licensed and credentialed health care provider with specialized training and clinical expertise. See Maine Revised Statutes Title 24-A Sec. 4301-A
  • Standard reference compendia: means :  
  • A. See Maine Revised Statutes Title 24-A Sec. 4301-A
  • State paper: means the newspaper designated by the Legislature, in which advertisements and notices are required to be published. See Maine Revised Statutes Title 1 Sec. 72
  • Testator: A male person who leaves a will at death.
  • Testimony: Evidence presented orally by witnesses during trials or before grand juries.
  • Tort: A civil wrong or breach of a duty to another person, as outlined by law. A very common tort is negligent operation of a motor vehicle that results in property damage and personal injury in an automobile accident.
  • Town: includes cities and plantations, unless otherwise expressed or implied. See Maine Revised Statutes Title 1 Sec. 72
  • Trail easement: means a nonpossessory interest of a holder in real property for the purposes of creating and maintaining a trail for use by the general public:  
  • A. See Maine Revised Statutes Title 33 Sec. 1581
  • Transcript: A written, word-for-word record of what was said, either in a proceeding such as a trial or during some other conversation, as in a transcript of a hearing or oral deposition.
  • Trial: A hearing that takes place when the defendant pleads "not guilty" and witnesses are required to come to court to give evidence.
  • True owner: means a person who holds title to a coastal island which is:  
  • A. See Maine Revised Statutes Title 33 Sec. 1202
  • Trustee: A person or institution holding and administering property in trust.
  • Uniform Commercial Code: A set of statutes enacted by the various states to provide consistency among the states' commercial laws. It includes negotiable instruments, sales, stock transfers, trust and warehouse receipts, and bills of lading. Source: OCC
  • United States: includes territories and the District of Columbia. See Maine Revised Statutes Title 1 Sec. 72
  • Wild animal: means a species of mammal, wild by nature, whether or not bred or reared in captivity, as distinguished from the common domestic animals, and includes any physical part of that species of animal. See Maine Revised Statutes Title 12 Sec. 10001
  • Wild bird: means a species of bird wild by nature, whether or not bred or reared in captivity, as distinguished from common domestic birds, and includes any physical part of that species of bird. See Maine Revised Statutes Title 12 Sec. 10001
  • Withhold: means a percentage of payments or set dollar amounts that a carrier deducts from a downstream entity's service fee, capitation or salary payment and that may or may not be returned to the downstream entity, depending on specific predetermined factors. See Maine Revised Statutes Title 24-A Sec. 4331