Terms Used In Rhode Island General Laws > Chapter 27-41 - Health Maintenance Organizations

• Affordable Care Act: means the federal Patient Protection and Affordable Care act of 2010, as amended by the federal Health Care and Education Reconciliation Act of 2010, and federal regulations adopted thereunder;

  (c)  "Commissioner" or "health insurance commissioner" means that individual appointed pursuant to §?42-14. See Rhode Island General Laws 27-41-2

• 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.
• Amortization: Paying off a loan by regular installments.
• 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.
• Assets: (1) The property comprising the estate of a deceased person, or (2) the property in a trust account.
• Bankruptcy: Refers to statutes and judicial proceedings involving persons or businesses that cannot pay their debts and seek the assistance of the court in getting a fresh start. Under the protection of the bankruptcy court, debtors may discharge their debts, perhaps by paying a portion of each debt. Bankruptcy judges preside over these proceedings.
• 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}
• 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.
• Conviction: A judgement of guilt against a criminal defendant.
• Corporation: A legal entity owned by the holders of shares of stock that have been issued, and that can own, receive, and transfer property, and carry on business in its own name.
• covered benefits: means coverage or benefits for the diagnosis, cure, mitigation, treatment, or prevention of disease, or amounts paid for the purpose of affecting any structure or function of the body including coverage or benefits for transportation primarily for and essential thereto, and including medical services as defined in §?27-19-17;

  (o)  "Healthcare facility" means an institution providing healthcare services or a healthcare setting, including but not limited to hospitals and other licensed inpatient centers, ambulatory surgical or treatment centers, skilled nursing centers, residential treatment centers, diagnostic, laboratory and imaging centers, and rehabilitation and other therapeutic health settings. See Rhode Island General Laws 27-41-2

• Covered health services: means the services that a health maintenance organization contracts with enrollees and enrolled groups to provide or make available to an enrolled participant. See Rhode Island General Laws 27-41-2
• Damages: Money paid by defendants to successful plaintiffs in civil cases to compensate the plaintiffs for their injuries.
• Dependent: A person dependent for support upon another.
• Director: means the director of the department of business regulation or his or her duly appointed agents. See Rhode Island General Laws 27-41-2
• Discovery: Lawyers' examination, before trial, of facts and documents in possession of the opponents to help the lawyers prepare for trial.
• Donor: The person who makes a gift.
• Employee: means any person who has entered into the employment of or works under a contract of service or apprenticeship with any employer. See Rhode Island General Laws 27-41-2
• Employer: means any person, partnership, association, trust, estate, or corporation, whether foreign or domestic, or the legal representative, trustee in bankruptcy, receiver, or trustee of a receiver, or the legal representative of a deceased person, including the state of Rhode Island and each city and town in the state, which has in its employ one or more individuals during any calendar year. See Rhode Island General Laws 27-41-2
• Enrollee: means an individual who has been enrolled in a health maintenance organization. See Rhode Island General Laws 27-41-2
• 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.
• Evidence of coverage: means any certificate, agreement, or contract issued to an enrollee setting out the coverage to which the enrollee is entitled. See Rhode Island General Laws 27-41-2
• Federal Reserve System: The central bank of the United States. The Fed, as it is commonly called, regulates the U.S. monetary and financial system. The Federal Reserve System is composed of a central governmental agency in Washington, D.C. (the Board of Governors) and twelve regional Federal Reserve Banks in major cities throughout the United States. ^{Source: OCC}
• 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.
• Grandfathered health plan: means any group health plan or health insurance coverage subject to 42 U. See Rhode Island General Laws 27-41-2
• Group health insurance coverage: means , in connection with a group health plan, health insurance coverage offered in connection with such plan. See Rhode Island General Laws 27-41-2
• Group health plan: means an employee welfare benefit plan as defined in 29 U. See Rhode Island General Laws 27-41-2
• 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 insurance carrier: means a person, firm, corporation or other entity subject to the jurisdiction of the commissioner under this chapter, and includes a health maintenance organization. See Rhode Island General Laws 27-41-2
• Health maintenance organization: means a single public or private organization which:

  (1)  Provides or makes available to enrolled participants healthcare services, including at least the following basic healthcare services: usual physician services, hospitalization, laboratory, x-ray, emergency, and preventive services, and out of area coverage, and the services of licensed midwives;

  (2)  Is compensated, except for copayments, for the provision of the basic healthcare services listed in subdivision (1) of this subsection to enrolled participants on a predetermined periodic rate basis; and

  (3)(i)  Provides physicians' services primarily:

  (A)  Directly through physicians who are either employees or partners of the organization; or

  (B)  Through arrangements with individual physicians or one or more groups of physicians organized on a group practice or individual practice basis;

  (ii)  "Health maintenance organization" does not include prepaid plans offered by entities regulated under chapter 1, 2, 19, or 20 of this title that do not meet the criteria above and do not purport to be health maintenance organizations;

  (4)  Provides the services of licensed midwives primarily:

  (i)  Directly through licensed midwives who are either employees or partners of the organization; or

  (ii)  Through arrangements with individual licensed midwives or one or more groups of licensed midwives organized on a group practice or individual practice basis. See Rhode Island General Laws 27-41-2

• Healthcare professional: means a physician or other healthcare practitioner licensed, accredited or certified to perform specified healthcare services consistent with state law. See Rhode Island General Laws 27-41-2
• Healthcare services: means any services included in the furnishing to any individual of medical, podiatric, or dental care, or hospitalization, or incident to the furnishing of that care or hospitalization, and the furnishing to any person of any and all other services for the purpose of preventing, alleviating, curing, or healing human illness, injury, or physical disability. See Rhode Island General Laws 27-41-2
• in writing: include printing, engraving, lithographing, and photo-lithographing, and all other representations of words in letters of the usual form. See Rhode Island General Laws 43-3-16
• Jurisdiction: (1) The legal authority of a court to hear and decide a case. Concurrent jurisdiction exists when two courts have simultaneous responsibility for the same case. (2) The geographic area over which the court has authority to decide cases.
• 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.
• Licensed midwife: means any midwife licensed pursuant to §?23-13-9. See Rhode Island General Laws 27-41-2
• Material modification: means only systemic changes to the information filed under §?27-41-3. See Rhode Island General Laws 27-41-2
• Mortgage: The written agreement pledging property to a creditor as collateral for a loan.
• 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.
• Office of the health insurance commissioner: means the agency established under §?42-14. See Rhode Island General Laws 27-41-2
• Oversight: Committee review of the activities of a Federal agency or program.
• 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.
• person: may be construed to extend to and include co-partnerships and bodies corporate and politic. See Rhode Island General Laws 43-3-6
• Physician: includes podiatrist as defined in chapter 29 of Title 5. See Rhode Island General Laws 27-41-2
• Power of attorney: A written instrument which authorizes one person to act as another's agent or attorney. The power of attorney may be for a definite, specific act, or it may be general in nature. The terms of the written power of attorney may specify when it will expire. If not, the power of attorney usually expires when the person granting it dies. ^{Source: OCC}
• Private organization: means a legal corporation with a policy making and governing body. See Rhode Island General Laws 27-41-2
• provider: means a healthcare professional or a healthcare facility. See Rhode Island General Laws 27-41-2
• real estate: may be construed to include lands, tenements, and hereditaments and rights thereto and interests therein. See Rhode Island General Laws 43-3-10
• Rescission: means a cancellation or discontinuance of coverage that has retroactive effect for reasons unrelated to timely payment of required premiums or contribution to costs of coverage. See Rhode Island General Laws 27-41-2
• 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.
• Statute: A law passed by a legislature.
• Total adjusted capital: means the sum of:

  (1)  A health maintenance organization's statutory capital and surplus (i. See Rhode Island General Laws 27-41-2

• town: may be construed to include city; the words "town council" include city council; the words "town clerk" include city clerk; the words "ward clerk" include clerk of election district; the words "town treasurer" include city treasurer; and the words "town sergeant" include city sergeant. See Rhode Island General Laws 43-3-9
• Trial: A hearing that takes place when the defendant pleads "not guilty" and witnesses are required to come to court to give evidence.
• Trustee: A person or institution holding and administering property in trust.
• Uncovered expenditures: means the costs of healthcare services that are covered by a health maintenance organization, but that are not guaranteed, insured, or assumed by a person or organization other than the health maintenance organization. See Rhode Island General Laws 27-41-2
• United States: include the several states and the territories of the United States. See Rhode Island General Laws 43-3-8