10.07.11.01-1

.01-1 Definitions.

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

B. Terms Defined.

(1) "Board" means the Board of Physicians.

(1-1) "Certified nurse practitioner" has the meaning stated in Health Occupations Article, Title 8, Annotated Code of Maryland.

(2) "Commissioner" means the Insurance Commissioner of Maryland.

(3) "Department" means the Maryland Department of Health.

(4) "Enrollee" means a person who has entered into a health care services contract or on whose behalf a contractual arrangement has been entered into with a health maintenance organization (HMO).

(5) "Governing authority" means the person or persons designated in the bylaws with the responsibility for operating the HMO.

(6) "Grievance" means any complaint by an enrollee:

(a) That the enrollee has not received any benefit or other right to which the enrollee is contractually entitled or that the enrollee has been treated unprofessionally or otherwise improperly by the HMO, or a provider engaged by the HMO;

(b) Which is not resolved formally to the satisfaction of the enrollee.

(7) "Operating year" means the consecutive 12-month period, or part thereof, during which the HMO makes available health services as delineated in its Certificate of Authority (as issued by the Insurance Commissioner), and beginning on the issuance date of this Certificate.

(8) "Out-of-area coverage" means contractual benefits provided by the HMO to its enrollees with respect to emergency health care services received by enrollees outside the primary geographical area served by the HMO.

(9) "Physician" means an individual authorized by law to practice medicine in the State.

(10) "Preventive services" means those services designed to prevent the occurrence of disease or injury or to arrest disease at an early stage before complications and serious disabilities develop.

(11) "Quality of health care" means that level of health care delivered which reflects the general health care standards and practices in the geographical area served by the HMO.

(12) "Secretary" means the Secretary of Health.