§ 27-41-2 - Definitions. - Rhode Island Statutes

SECTION 27-41-2

   § 27-41-2  Definitions. – (a) "Covered health services" means the services that a health maintenanceorganization contracts with enrollees and enrolled groups to provide or makeavailable to an enrolled participant.

   (b) "Director" means the director of the department ofbusiness regulation or his or her duly appointed agents.

   (c) "Employee" means any person who has entered into theemployment of or works under a contract of service or apprenticeship with anyemployer. It shall not include a person who has been employed for less thanthirty (30) days by his or her employer, nor shall it include a person whoworks less than an average of thirty (30) hours per week. For the purposes ofthis chapter, the term "employee" means a person employed by an "employer" asdefined in subsection (d) of this section. Except as otherwise provided in thischapter the terms "employee" and "employer" are to be defined according to therules and regulations of the department of labor and training.

   (d) "Employer" means any person, partnership, association,trust, estate, or corporation, whether foreign or domestic, or the legalrepresentative, trustee in bankruptcy, receiver, or trustee of a receiver, orthe legal representative of a deceased person, including the state of RhodeIsland and each city and town in the state, which has in its employ one or moreindividuals during any calendar year. For the purposes of this section, theterm "employer" refers only to an employer with persons employed within thestate of Rhode Island.

   (e) "Enrollee" means an individual who has been enrolled in ahealth maintenance organization.

   (f) "Evidence of coverage" means any certificate, agreement,or contract issued to an enrollee setting out the coverage to which theenrollee is entitled.

   (g) "Health care services" means any services included in thefurnishing to any individual of medical, podiatric, or dental care, orhospitalization, or incident to the furnishing of that care or hospitalization,and the furnishing to any person of any and all other services for the purposeof preventing, alleviating, curing, or healing human illness, injury, orphysical disability.

   (h) "Health maintenance organization" means a single publicor private organization which:

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

   (2) Is compensated, except for copayments, for the provisionof the basic health care services listed in subdivision (1) of this subsectionto enrolled participants on a predetermined periodic rate basis; and

   (3) Provides physicians' services primarily:

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

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

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

   (4) Provides the services of licensed midwives primarily:

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

   (ii) Through arrangements with individual licensed midwivesor one or more groups of licensed midwives organized on a group practice orindividual practice basis.

   (i) "Licensed midwife" means any midwife licensed pursuant to§ 23-13-9.

   (j) "Material modification" means only systemic changes tothe information filed under § 27-41-3.

   (k) "Net worth", for the purposes of this chapter, means theexcess of total admitted assets over total liabilities.

   (l) "Physician" includes podiatrist as defined in chapter 29of title 5.

   (m) "Private organization" means a legal corporation with apolicy making and governing body.

   (n) "Provider" means any physician, hospital, licensedmidwife, or other person who is licensed or authorized in this state to furnishhealth care services.

   (o) "Public organization" means an instrumentality ofgovernment.

   (p) "Risk based capital ("RBC") instructions" means the riskbased capital report including risk based capital instructions adopted by theNational Association of Insurance Commissioners ("NAIC"), as these risk basedcapital instructions are amended by the NAIC in accordance with the proceduresadopted by the NAIC.

   (q) "Total adjusted capital" means the sum of:

   (1) A health maintenance organization's statutory capital andsurplus (i.e. net worth) as determined in accordance with the statutoryaccounting applicable to the annual financial statements required to be filedunder § 27-41-9; and

   (2) Any other items, if any, that the RBC instructionsprovide.

   (r) "Uncovered expenditures" means the costs of health careservices that are covered by a health maintenance organization, but that arenot guaranteed, insured, or assumed by a person or organization other than thehealth maintenance organization. Expenditures to a provider that agrees not tobill enrollees under any circumstances are excluded from this definition.