10-144-109 Me. Code R. § 1.02

Current through 2024-51, December 18, 2024

Section 144-109-1.02 - DEFINITIONS

Unless otherwise indicated, the following terms shall have the following meanings:

1.02-1 Accessibility is the extent to which a member of an HMO can obtain available services at the time they are needed. This refers to telephone access, the ability to schedule an appointment and to physical, language and other barriers to obtaining the service.

1.02-2 Acute Condition is an illness or health problem of a short-term or episodic nature.

1.02-3 Availability is the extent to which the HMO has practitioners of the appropriate type and number distributed geographically to meet the needs of its membership.

1.02-4 Benchmark is the measure of best performance, set externally to the HMO, for a particular indicator or performance goal in the health maintenance organization industry.

1.02-5 Chronic Condition is a disease or condition, usually of slow progress and long continuance, requiring ongoing care. Examples include asthma, hypertension, and diabetes.

1.02-6 Commissioner is the Commissioner of the Department of Human Services.

1.02-7 Continuity of Care is the provision of care by the same set of practitioners to a member over time, or if the same practitioners are not available over time, a mechanism to provide appropriate clinical information in a timely fashion to other practitioners who continue to provide the same type and level of care.

1.02-8 Coordination of Care describes the mechanisms assuring that the member and practitioners have access to, and take into consideration, all the required information on the member's conditions and treatments to assure that the member receives appropriate health care services.

1.02-9 Department is the Department of Human Services.

1.02-10 Facility is an institution providing health care services or a health care setting, including but not limited to appropriately licensed or certified hospitals and other 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.

1.02-11 Governing Body is the board of directors, or other body, with ultimate authority and responsibility for the overall operations of the HMO, or its designee.

1.02-12 Guideline is a systematically developed descriptive tool or standardized specification for care to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.

1.02-13 Health Care Services are services for the diagnosis, prevention, treatment, cure or relief of a health condition, illness, injury or disease, including mental illness and alcohol and chemical dependency.

1.02-14 Health Maintenance Organization (HMO) is an entity licensed pursuant to Title 24-A, M.R.S.A. Chapter 56.

1.02-15 HEDIS Effectiveness of Care Measures is that portion of the Health Plan Employer Data and Information Set (HEDIS) that measures the outcomes of care and care processes, as defined by National Committee for Quality Assurance. HEDIS is a set of standardized performance measures designed to allow for reliable comparison of the performance of managed health care plans.

1.02-16 Intervention is an action taken by the HMO to increase the probability that a desired outcome will occur.

1.02-17 Measure is a quantifiable element of performance that can be compared to the same element of other performances, such as a dimension of a function, process, or outcome. Measures can be of activities, events, occurrences, or outcomes for which data can be collected to allow comparison with a threshold, a benchmark, or prior performance.

1.02-18 Member is a policyholder, subscriber, enrollee, or other individual entitled to benefits under an HMO benefit plan.

1.02-19 National Committee for Quality Assurance (NCQA) is a national organization that accredits quality assurance programs in prepaid managed care organizations.

1.02-20 NCQA Accreditation Survey Report is the detailed survey report reported to the HMO by NCQA upon completion of NCQA's survey of the HMO. The NCQA accreditation survey report is not the accreditation summary report that is published by NCQA.

1.02-21 Participating, with respect to a provider, is one who is under contract with the HMO, an intermediary, or with the HMO's contractor or subcontractor, who has agreed to provide health care services to members with an expectation of receiving payment, other than coinsurance, copayments or deductibles, directly or indirectly from the HMO.

1.02-22 Performance Goal is the desired level of achievement set for itself by an HMO.

1.02-23 Physician is a licensed doctor of medicine or osteopathy practicing within the scope of a license.

1.02-24 Practitioner is a physician or other person licensed, accredited or certified to perform specified health care services consistent with state law. This definition applies to individual practitioners, not corporate "persons."

1.02-25 Preventive Health Services are health care services designed for the prevention and early detection of illness in asymptomatic people, generally including routine physical examinations, tests, and immunizations.

1.02-26 Primary Care is the level of care that encompasses routine care of individuals with common health problems and chronic illnesses that can be managed on an outpatient basis, traditionally provided by family practice, pediatrics, general practitioners, internal medicine, and obstetricians/ gynecologists.

1.02-27 Primary Care Practitioner (PCP) is a practitioner under contract with an HMO to supervise, coordinate, and provide primary care health care services to members; maintain continuity of member patient care; and initiate member patient referrals for specialist care.

1.02-28 Provider is a practitioner or facility.

1.02-29 Quality is the degree to which a health care service or health care services, or the availability, accessibility, continuity or coordination of care meet established professional or regulatory standards, or judgments of value to the consumer.

1.02-30 Quality Management Program (QMP) is that program prescribed by Section 1.03.

1.02-31 Quality of Care relates to the quality or appropriateness of health care services, including preventive health services.

1.02-32 Quality of Service relates to the availability, accessibility, continuity or coordination of care and to the satisfaction of members with the quality of care, and the availability, accessibility, continuity and coordination of care.

1.02-33 Quality-related Function is a function that is related to the quality of care, the quality of service, quality management program, or any other function that relates to the quality of health care services or health care delivery.

1.02-34 Superintendent is the Superintendent of the Bureau of Insurance.

1.02-35 Utilization Review is any program or practice by which the HMO seeks to review the utilization, clinical necessity, appropriateness, efficacy or efficiency of health care services, procedures, or providers.

10-144 C.M.R. ch. 109, § 1.02