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  • PART I ADMINISTRATION OF THE GOVERNMENT
  • TITLE XXII CORPORATIONS
  • CHAPTER 176G HEALTH MAINTENANCE ORGANIZATIONS
  • Section 1 Definitions

Section 1. The following words as used in this chapter shall, unless the context clearly requires otherwise, have the following meanings:

“Affiliate”, an affiliate of, or person affiliated with, a specific person, is a person that directly, or indirectly through 1 or more intermediaries, controls, or is controlled by, or is under common control with, the person specified.

“Carrier”, an insurance company authorized to provide accident and health insurance under chapter one hundred and seventy-five, a nonprofit hospital service corporation authorized under chapter one hundred and seventy-six A, or a nonprofit medical service corporation authorized under chapter one hundred and seventy-six B.

“Commissioner”, the commissioner of insurance.

“Company”, a corporation, a partnership, a business trust, an association, an organized group of persons whether incorporated or not, or any line of business division, department, subsidiary or affiliate of any thereof and any receiver, trustee or other liquidating agent of any of the foregoing while acting in such capacity.

“Control”, including controlling, controlled by and under common control with, the possession, direct or indirect, of the power to direct or cause the direction of the management and policies of a person, whether through the ownership of voting securities, by contract other than a commercial contract for goods or non-management services, or otherwise, unless the power is the result of an official position with or corporate office held by the person. Control shall be presumed to exist if any person, directly or indirectly, owns, controls, holds with the power to vote, or holds proxies representing, 10 per cent or more of the voting securities of any other person. In the case of a person subject to chapter 180, control shall be presumed to exist if any other person shall, directly or indirectly, own, control or hold, more than 10 per cent of the aggregate rights in any membership class or shall, directly or indirectly, have the right to appoint or elect more than 10 per cent of the directors serving on the person’s board of directors. Any of these aforementioned presumptions may be rebutted by a showing made in the manner provided with respect to insurers under subsection (k) of section 206C of chapter 175 that control does not exist in fact. The commissioner may determine, after furnishing all persons in interest notice and opportunity to be heard and making specific findings of fact to support such determination, that such control exists in fact, notwithstanding the absence of a presumption to that effect.

“Evidence of coverage”, any certificate, contract or agreement issued to a member stating the health services and any other benefits to which the member is entitled.

“Foreign health maintenance organization”, a health maintenance organization formed by authority of any state or government other than the commonwealth and qualified to conduct business in the commonwealth.

“Group health maintenance contract”, any health maintenance contract with any group of five or more persons, or the employer or representative of a group of five or more persons; provided, that twenty-five per cent or more of those eligible in a group of fifty or more persons and seventy-five per cent or more of those eligible in a group of less than fifty persons, are group contract enrollees; provided further, that, for the purposes of computing the percentage of group contract enrollment under this definition, persons in a group who are subscribers to a general or blanket policy of insurance issued pursuant to section one hundred and ten of chapter one hundred and seventy-five, or to a group hospital service plan issued pursuant to section ten of chapter one hundred and seventy-six A, or to a group medical service plan issued pursuant to chapter one hundred and seventy-six B, shall be considered to be group contract enrollees.

“Health maintenance contract”, any contract entered into by a health maintenance organization or a carrier, or both with a member or group of members whereby the health maintenance organization agrees to provide health services on a nondiscriminatory basis.

“Health maintenance organization”, a company organized under the laws of the commonwealth, or organized under the laws of another state and qualified to do business in the commonwealth, which:

(1) provides or arranges for the provision of health services to voluntarily enrolled members in exchange primarily for a prepaid per capita or aggregate fixed sum.

(2) demonstrates to the satisfaction of the commissioner proof of its capability to provide its members protection against loss of prepaid fees or unavailability of covered health services resulting from its insolvency or bankruptcy or from other financial impairment of its obligations to its members.

“Health maintenance organization holding company system”, a health maintenance organization holding company system consists of 2 or more affiliates, 1 or more of which is a health maintenance organization.

“Health services”, at least reasonably comprehensive physician services, on a nondiscriminatory basis, inpatient and outpatient services, emergency health services, and may include chiropractic services, optometric services and podiatric services.

“Managed hospital payment basis”, agreements wherein the financial risk is primarily related to the degree of utilization rather than to the cost of the services.

“Member”, any individual who has entered into a health maintenance contract, or on whose behalf such an arrangement has been made, with a health maintenance organization or carrier or both for health services and any dependent of such individual who is covered by the same contract; provided that in sections 25 to 29, inclusive. “Enrolled member” shall mean any such individual, and “Member” shall have the same meaning as set forth in chapter 180.

“Net worth”, the excess of total admitted assets over total liabilities, but the liabilities shall not include fully subordinated debt pursuant to subsection (d) of section 24.

“Nondiscriminatory”, any individual who has entered into a group health maintenance contract that provides for any podiatric medical or surgical service which is within the lawful scope of practice of a licensed podiatrist, shall be entitled to such services whether the service is performed by a physician or licensed podiatrist, including authorized referral services on a nondiscriminatory basis.

“Person”, shall have the meaning set forth in section 206 of chapter 175.

“Primary care provider”, a health care professional qualified to provide general medical care for common health care problems who; (1) supervises, coordinates, prescribes, or otherwise provides or proposes health care services; (2) initiates referrals for specialist care; and (3) maintains continuity of care within the scope of practice.

“Subsidiary”, shall have the meaning set forth in section 206 of chapter 175.

“Uncovered expenditures”, the cost to a health maintenance organization for health care services that are the obligation of such a health maintenance organization, for which an enrollee may also be liable in the event of the health maintenance organizations’ insolvency and for which no alternative arrangements have been made to cover such costs that are acceptable to the commissioner.

“Voting security”, shall have the meaning set forth in section 206 of chapter 175.