Md. Code Regs. 31.10.45.02

Current through Register Vol. 51, No. 24, December 2, 2024

Section 31.10.45.02 - Definitions

A. In this chapter, the following terms have the meanings indicated.

B. Terms Defined.

(1) "Carrier" means:

(a) An insurer authorized to sell dental insurance;

(b) A nonprofit health service plan that provides coverage for dental services; or

(c) A dental plan organization as defined in Insurance Article, § 14-401, Annotated Code of Maryland.

(2) "Dental plan" means a contractual arrangement for dental services.

(3) "Dental network adequacy waiver request" means a written request from a carrier to the Commissioner in which the carrier seeks the Commissioner's approval to be relieved of certain dental network adequacy standards in this chapter for 1 year.

(4) "Dental service" has the meaning stated in Insurance Article, § 14-401, Annotated Code of Maryland.

(5) "Dentist" has the meaning stated in Health Occupations Article § 4-101, Annotated Code of Maryland.

(6) "Enrollee" means a person entitled to dental benefits from a carrier.

(7) Essential Community Provider.

(a) "Essential community provider" means a provider that serves predominantly low-income or dentally underserved individuals.

(b) "Essential community provider" includes local health departments.

(8) Network.

(a) "Network" means a carrier's participating providers with which a carrier contracts to provide dental services to the carrier's enrollees under the carrier's dental plan.

(b) "Network" includes, if a carrier uses a provider panel developed by a subcontracting entity, providers that contract with the subcontracting entity to provide dental services to the carrier's enrollees under the carrier's dental plan.

(9) "Participating provider" means a provider on a carrier's provider panel.

(10) "Provider" means:

(a) A dentist;

(b) A group of dentists; or

(c) A facility where dentists provide dental services.

(11) Provider Panel.

(a) "Provider panel" means the providers who participate in a carrier's network.

(b) "Provider panel" does not include an arrangement in which any provider may participate solely by contracting with the carrier to provide dental services at a discounted fee-for-service rate.

(12) "Rural area" means a list of zip codes provided on the Maryland Insurance Administration's website, with a human population of less than 1,000 per square mile according to the Maryland Department of Planning.

(13) "Specialty provider" means a dentist who focuses on a specific area of dental care for a group of patients and is identified as a specialist by the Maryland State Board of Dental Examiners.

(14) "Suburban area" means a list of zip codes provided on the Maryland Insurance Administration's website, with a human population equal to or more than 1,000 per square mile, but less than 3,000 per square mile according to the Maryland Department of Planning.

(15) Telehealth.

(a) "Telehealth" means, as it relates to the delivery of dental services, the use of interactive audio, video, or other telecommunications or electronic technology by a provider to deliver a dental service within the scope of practice of the provider at a location other than the location of the patient.

(b) "Telehealth" does not include:

(i) An audio-only telephone conversation between a provider and a patient;

(ii) An electronic mail message between a provider and a patient; or

(iii) A facsimile transmission between a provider and a patient.

(16) "Urban area" means a list of zip codes provided on the Maryland Insurance Administration's website, with a human population equal to or greater than 3,000 per square mile according to the Maryland Department of Planning.

(17) "Urgent care" means the treatment for a condition of an enrollee that satisfies either of the following:

(a) A dental condition that, in the absence of dental services within 72 hours, could reasonably be expected by an individual, acting on behalf of a carrier and applying the judgment of a prudent layperson who possesses an average knowledge of health and medicine, would result in:

(i) Placing the enrollee's life or dental health in serious jeopardy;

(ii) The inability of the enrollee to regain maximum dental function;

(iii) Serious impairment to the enrollee's dental function; or

(iv) Serious dysfunction of any bodily organ or part of the enrollee; or

(b) A dental condition of an enrollee that, in the absence of dental services or treatment within 72 hours, would, in the opinion of a provider with knowledge of the enrollee's condition, subject the enrollee to severe pain that cannot be adequately managed without the care or treatment.

(18) "Waiting time" means the time from the initial request for dental services by an enrollee or by the enrollee's treating provider to the earliest date offered for the appointment for services.

Md. Code Regs. 31.10.45.02

Regulation .02 adopted effective 44:25 Md. R. 1184, eff. 12/31/2017