(a) “Basic health care services” means the following medically necessary services: preventive care, emergency care, inpatient and outpatient hospital and physician care, diagnostic laboratory and diagnostic and therapeutic radiological services and includes but is not limited to mental health services or services for alcohol or drug abuse, dental or vision services or long-term rehabilitation treatment for the purpose of preventing, alleviating, curing or healing human illness or physical disability.

(b) “Capitated basis” means fixed per member per month payment or percentage of premium payment wherein the provider assumes the full risk for the cost of contracted services without regard to the type, value or frequency of services provided. Capitated basis includes the cost associated with operating staff model facilities.

(c) “Carrier” means a health maintenance organization, an insurer, a nonprofit hospital and medical service corporation, fraternal societies, preferred provider organizations or any other entity responsible for the payment of benefits or provision for services under a group contract or individual contract on a prepayment basis.

(d) “Commissioner” means the Commissioner of Insurance.

(e) “Copayment” means an amount an enrollee must pay in order to receive a specific service which is not fully prepaid.

(f) “Deductible” means the amount an enrollee is responsible to pay out-of-pocket before the carrier begins to be responsible for the costs associated with treatment.

(g) “Enrollee” means an individual who is covered for the benefits offered by the carrier.

(h) “Evidence of coverage” means a statement of the essential features and services of the health care provider which is given to the subscriber by the carrier or by the group contract holder.

(i) “Extension of benefits” means the continuation of coverage under a particular benefit provided under a contract following termination with respect to an enrollee or subscriber who is totally disabled on the date of termination.

(j) “Financing” means the prepayment of premium or premium equivalences for services to be received by the enrollee in the future together with acceptance and assumption of the risk, including capitation fee.

(k) “Grievance” means a written complaint submitted in accordance with the provider’s formal grievance procedure by or on behalf of the enrollee regarding any aspect of the carrier or provider to the enrolled.

(l) “Group contract” means a contract for health care services which by its terms limits eligibility to members of a specified group and may include coverage for dependents.

(m) “Group contract holder” means a person having a group contract.

(n) “Health maintenance organization” means any person that undertakes to provide or arrange for the delivery of basic health care services through an organized system which combines the delivery and financing of health care to enrollees on a prepaid or other financial basis (except for enrolled responsibility for copayment or deductibles) through an organized system which combines the delivery and financing of health care. When an organization accepts and assumes risks and accepts payments, fees, premiums or premium equivalences for that risk it is deemed to be a health maintenance organization.

(o) “Health maintenance organization producer” means a person who holds a life, health and accident insurance license and a certificate of authority to represent the health maintenance organization who solicits, negotiates, effects, procures, delivers, renews or continues a policy or contract for health maintenance organization membership, or who takes or transmits a membership fee or premium for such a policy or contract, other than for himself, or a person who advertises or otherwise holds himself out to the public as such.

(p) “Individual contract” means a contract for health care services issued to and covering an individual may include dependents of the subscriber.

(q) “Insolvent” or “Insolvency” means that the organization has been declared insolvent and placed under an order of rehabilitation or liquidation by a court of competent jurisdiction.

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

(s) “Net worth” means the excess of total admitted assets over total liabilities, but the liabilities shall not include fully subordinated debt.

(t) “Participating provider” means a provider as defined in paragraph (v) who, under an express or implied contract with the health maintenance organization or with its contractor or subcontractor, has agreed to provide health care services to enrollees with an expectation of receiving payment, other than copayment or deductible, directly or indirectly from the health maintenance organization.

(u) “Person” means any natural or artificial person including but not limited to individuals, partnerships, associations, trusts, fraternal societies, or corporations.

(v) “Provider” means any physician, hospital or other person licensed or otherwise authorized to furnish health care services.

(w) “Replacement coverage” means the benefits provided by a succeeding carrier.

(x) “Subscriber” means an individual whose employment or other status, except family dependency, is the basis for eligibility for enrollment in the health maintenance organization, or in the case of an individual contract, the person in whose name the contract is issued.

(y) “Uncovered expenditures” means the costs to the health maintenance organization for health care services that are the obligation of the health maintenance organization, for which an enrollee may also be liable if the health maintenance organization is insolvent and for which no alternative arrangements have been made that are acceptable to the commissioner.