§ 58-67-5. Definitions. - North Carolina Statutes

§ 58‑67‑5. Definitions.

(a)        "Commissioner"means the Commissioner of Insurance.

(b)        "Enrollee"means an individual who is covered by an HMO.

(c)        "Evidence ofcoverage" means any certificate, agreement, or contract issued to anenrollee setting out the coverage to which he is entitled.

(d)        "Health careplan" means any arrangement whereby any person undertakes on a prepaidbasis to provide, arrange for, pay for, or reimburse any part of the cost ofany health care services and at least part of such arrangement consists ofarranging for or the provision of health care services, as distinguished frommere indemnification against the cost of such services on a prepaid basisthrough insurance or otherwise.

(e)        "Health careservices" means any services included in the furnishing to any individualof medical or dental care, or hospitalization or incident to the furnishing ofsuch care or hospitalization, as well as the furnishing to any person of anyand all other services for the purpose of preventing, alleviating, curing, orhealing human illness or injury.

(f)         "Healthmaintenance organization" or "HMO" means any person whoundertakes to provide or arrange for the delivery of health care services toenrollees on a prepaid basis except for enrollee responsibility for copaymentsand deductibles. For the purposes of 11 U.S.C. § 109(b) (2) and (d), an HMO isa domestic insurance company.

(g)        "Person"includes associations, trusts, or corporations, but does not includeprofessional associations, or individuals.

(h)        "Provider"means any physician, hospital, or other person that is licensed or otherwiseauthorized in this State to furnish health care services.

(i)         "Networth" means the excess of total assets over the total liabilities and mayinclude borrowed funds that are repayable only from the net earned income ofthe health maintenance organization and repayable only with the advancepermission of the Commissioner. For the purposes of this subsection,"assets" means (i) tangible assets and (ii) other investments permittedunder G.S. 58‑67‑60.

(j)         "Workingcapital" means the excess of current assets over current liabilities;provided that the only borrowed funds that may be included in working capitalmust be those borrowed funds that are repayable only from net earned income andmust be repayable only with the advance permission of the Commissioner.

(k)        "Subscriber"means an individual whose employment or other status, except family dependency,is the basis for eligibility for enrollment in the HMO; or in the case of an individualcontract, the person in whose name the contract is issued.

(l)         "Participatingprovider" means a provider who, under an express or implied contract withthe HMO or with its contractor or subcontractor, has agreed to provide healthcare services to enrollees with an expectation of receiving payment, directlyor indirectly, from the HMO, other than copayment or deductible.

(m)       "Insolvent"or "insolvency" means that the HMO has been declared insolvent and isplaced under an order of liquidation by a court of competent jurisdiction.

(n)        "Carrier"means an HMO, an insurer, a nonprofit hospital or medical service corporation,or other entity responsible for the payment of benefits or provision ofservices under a group contract.

(o)        "Discontinuance"means the termination of the contract between the group contract holder and anHMO due to the insolvency of the HMO and does not mean the termination of anyagreement between any individual enrollee and the HMO.

(p)        "Uncoveredexpenditures" means the amounts owed or paid to any provider who provideshealth care services to an enrollee and where such amount owed or paid is (i)not made pursuant to a written contract that contains the "holdharmless" provisions defined in G.S. 58‑67‑115; or (ii) notguaranteed or insured by a guaranteeing organization or insurer under the termsof a written guarantee or insurance policy that has been determined to beacceptable to the Commissioner. "Uncovered expenditures" includesamounts owed or paid to providers directly from the HMO as well as paymentsmade by a medical group, independent practice association, or any other similarorganization to reimburse providers for services rendered to an enrollee. (1977, c. 580, s. 1; 1979, c.876, s. 1; 1987, c. 631, s. 1; 1989, c. 776, ss. 2, 3, 15; 1991, c. 195, s. 4;c. 720, s. 40; 2001‑417, s. 13; 2003‑212, s. 19.)