Michigan Laws 500.3501 – Definitions
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Terms Used In Michigan Laws 500.3501
- Affiliated provider: means a health professional, licensed hospital, licensed pharmacy, or any other institution, organization, or person that has entered into a participating provider contract, directly or indirectly, with a health maintenance organization to render 1 or more health services to an enrollee. See Michigan Laws 500.3501
- Basic health services: means medically necessary health services that health maintenance organizations must offer to large employers in at least 1 health maintenance contract. See Michigan Laws 500.3501
- Contract: A legal written agreement that becomes binding when signed.
- Enrollee: means an individual who is entitled to receive health services under a health insurance contract, unless the context requires otherwise. See Michigan Laws 500.116
- Health maintenance contract: means a contract between a health maintenance organization and a subscriber or group of subscribers to provide or arrange for the provision of health services within the health maintenance organization's service area. See Michigan Laws 500.3501
- Health maintenance organization: means a person that, among other things, does the following:
(i) Delivers health services that are medically necessary to enrollees under the terms of its health maintenance contract, directly or through contracts with affiliated providers, in exchange for a fixed prepaid sum or per capita prepayment, without regard to the frequency, extent, or kind of health services. See Michigan Laws 500.3501Health professional: means an individual licensed, certified, or authorized in accordance with state law to practice a health profession in his or her respective state. See Michigan Laws 500.3501 Health services: means services provided to enrollees of a health maintenance organization under their health maintenance contract. See Michigan Laws 500.3501 Participating provider: means a provider that, under contract with an insurer that issues policies of health insurance or with such an insurer's contractor or subcontractor, has agreed to provide health care services to covered individuals and to accept payment by the insurer, contractor, or subcontractor for covered services as payment in full, other than coinsurance, copayments, or deductibles. See Michigan Laws 500.116 person: may extend and be applied to bodies politic and corporate, as well as to individuals. See Michigan Laws 8.3l Service area: means a defined geographical area in which covered health services are generally available and readily accessible to enrollees and where health maintenance organizations may market their contracts. See Michigan Laws 500.3501 state: when applied to the different parts of the United States, shall be construed to extend to and include the District of Columbia and the several territories belonging to the United States; and the words "United States" shall be construed to include the district and territories. See Michigan Laws 8.3o subscriber: means an individual who enters into an insurance contract for health insurance, or on whose behalf an insurance contract for health insurance is entered into, with an insurer. See Michigan Laws 500.116
As used in this chapter:
(a) “Affiliated provider” means a health professional, licensed hospital, licensed pharmacy, or any other institution, organization, or person that has entered into a participating provider contract, directly or indirectly, with a health maintenance organization to render 1 or more health services to an enrollee. Affiliated provider includes a person described in this subdivision that has entered into a written arrangement with another person, including, but not limited to, a physician hospital organization or physician organization, that contracts directly with a health maintenance organization.
(b) “Basic health services” means medically necessary health services that health maintenance organizations must offer to large employers in at least 1 health maintenance contract. Basic health services include all of the following:
(i) Physician services including primary care and specialty care.
(ii) Ambulatory services.
(iii) Inpatient hospital services.
(iv) Emergency health services.
(v) Mental health and substance use disorder services.
(vi) Diagnostic laboratory and diagnostic and therapeutic radiological services.
(vii) Home health services.
(viii) Preventive health services.
(c) “Credentialing verification” means the process of obtaining and verifying information about a health professional and evaluating the health professional when the health professional applies to become a participating provider with a health maintenance organization.
(d) “Health maintenance contract” means a contract between a health maintenance organization and a subscriber or group of subscribers to provide or arrange for the provision of health services within the health maintenance organization’s service area. Health maintenance contract includes a prudent purchaser agreement under section 3405.
(e) “Health maintenance organization” means a person that, among other things, does the following:
(i) Delivers health services that are medically necessary to enrollees under the terms of its health maintenance contract, directly or through contracts with affiliated providers, in exchange for a fixed prepaid sum or per capita prepayment, without regard to the frequency, extent, or kind of health services.
(ii) Is responsible for the availability, accessibility, and quality of the health services provided.
(f) “Health professional” means an individual licensed, certified, or authorized in accordance with state law to practice a health profession in his or her respective state.
(g) “Health services” means services provided to enrollees of a health maintenance organization under their health maintenance contract.
(h) “Service area” means a defined geographical area in which covered health services are generally available and readily accessible to enrollees and where health maintenance organizations may market their contracts.