Sections
Subchapter 1 Health Plan Requirements 4301-A – 4320-V
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

A. See Maine Revised Statutes Title 24-A Sec. 4301-A
  • Behavioral health care service: means a health care service or treatment to address mental health and substance use conditions. See Maine Revised Statutes Title 24-A Sec. 4301-A
  • Beneficiary: A person who is entitled to receive the benefits or proceeds of a will, trust, insurance policy, retirement plan, annuity, or other contract. Source: OCC
  • Bequest: Property gifted by will.
  • 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
  • code enforcement officer: means a person certified under this section and employed by a municipality to enforce all applicable laws and ordinances in the following areas:
    • A. See Maine Revised Statutes Title 30-A Sec. 4451
  • Commissioner: means the Commissioner of Agriculture, Conservation and Forestry or the commissioner's authorized agents. See Maine Revised Statutes Title 7 Sec. 32
  • 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.
  • Deed: The legal instrument used to transfer title in real property from one person to another.
  • Department: means the Department of Agriculture, Conservation and Forestry. See Maine Revised Statutes Title 30-A Sec. 4301
  • Dependent: A person dependent for support upon another.
  • Development: means a change in land use involving alteration of the land, water or vegetation, or the addition or alteration of structures or other construction not naturally occurring. See Maine Revised Statutes Title 30-A Sec. 4301
  • 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
  • Dwelling unit: means any part of a structure which, through sale or lease, is intended for human habitation, including single-family and multifamily housing, condominiums, apartments and time-share units. See Maine Revised Statutes Title 30-A Sec. 4401
  • 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
  • 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
  • Fiduciary: A trustee, executor, or administrator.
  • Fiscal year: The fiscal year is the accounting period for the government. For the federal government, this begins on October 1 and ends on September 30. The fiscal year is designated by the calendar year in which it ends; for example, fiscal year 2006 begins on October 1, 2005 and ends on September 30, 2006.
  • 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.
  • 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 insurance: means insurance of human beings against bodily injury, disablement or death by accident or accidental means, or the expense thereof, or against disablement or expense resulting from sickness, and every insurance appertaining thereto, including provision for the mental and emotional welfare of human beings by defraying the costs of legal services only to the extent provided for in chapter 38. See Maine Revised Statutes Title 24-A Sec. 704
  • 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
  • in writing: include printing and other modes of making legible words. See Maine Revised Statutes Title 1 Sec. 72
  • 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
  • Infant: means a person who has not attained the age of 18 years. See Maine Revised Statutes Title 1 Sec. 72
  • Interest in land: means all forms of direct or indirect ownership of land, except:
    • A. See Maine Revised Statutes Title 7 Sec. 32
  • Judgement: The official decision of a court finally determining the respective rights and claims of the parties to a suit.
  • Lease: A contract transferring the use of property or occupancy of land, space, structures, or equipment in consideration of a payment (e.g., rent). Source: OCC
  • Liabilities: The aggregate of all debts and other legal obligations of a particular person or legal entity.
  • 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
  • Month: means a calendar month. See Maine Revised Statutes Title 1 Sec. 72
  • Municipal reviewing authority: means the municipal planning board, agency or office, or if none, the municipal officers. See Maine Revised Statutes Title 30-A Sec. 4301
  • 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.
  • 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
  • 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
  • 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
  • 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
  • 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.
  • 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
  • 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
  • Subdivision: means the division of a tract or parcel of land into 3 or more lots within any 5-year period that begins on or after September 23, 1971. See Maine Revised Statutes Title 30-A Sec. 4401
  • 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.
  • Urgent care: means health care or treatment provided in response to exigent circumstances. See Maine Revised Statutes Title 24-A Sec. 4301-A
  • 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