31.12.04.02

.02 Definitions.

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

B. Terms Defined.

(1) “Closed panel dental benefit contract” means a dental benefit contract that does not provide benefits for services provided by a dentist who is not a plan dentist, with the exception of:

(a) Emergency services; and

(b) Out-of-network services required by Insurance Article, §15-830, Annotated Code of Maryland.

(2) "Contract holder" means for:

(a) Group contracts, the organization or entity to which the contract is issued;

(b) Individual contracts, the person who applies for a contract covering:

(i) One individual, or

(ii) One individual and that individual's dependents.

(3) "Copayment" means the amount:

(a) Payable for a particular service by an enrollee in accordance with the patient charge schedule; or

(b) For which the enrollee is responsible as a condition for receiving benefits under a dental benefit contract.

(4) “Dental benefit contract” means a contract which provides benefits for dental services entered into between the dental plan organization and:

(a) An individual contract holder covering the:

(i) Subscriber;

(ii) Subscriber and the subscriber’s dependents;

(iii) Subscriber and the subscriber’s family members;

(iv) Subscriber’s dependent or dependents; or

(v) Subscriber and the subscriber’s dependents and family members; or

(b) The group contract holder covering the:

(i) Enrolled members of the group;

(ii) Enrolled members of the group and their dependents;

(iii) Enrolled members of the group and their family members; or

(iv) Enrolled members of the group and their dependents and family members.

(5) "Dental plan" means any contractual arrangement for dental services.

(6) "Dental plan organization" means a:

(a) Person that provides directly, arranges for, or administers a dental plan on a prepaid or postpaid individual or group capitation basis; or

(b) Nonprofit health service plan which limits its operation to providing directly, or arranging for or administering a plan providing, dental services.

(7) "Dental service" has the meaning stated in Insurance Article, §14-401, Annotated Code of Maryland.

(8) "Dependent" means an individual who is the spouse or child of a subscriber.

(9) "Enrollee" means a subscriber, or any dependent of the subscriber, who is enrolled in the dental plan organization.

(10) "Evidence of coverage" means any certificate, agreement, or contract issued to a subscriber of a group that sets out the dental services to which the enrollees are entitled.

(11) "Patient charge schedule" means a list of amounts which the enrollee is required to pay the plan dentist or the dental plan organization for particular services rendered under the dental benefit contract.

(12) "Plan dentist" means any dentist who has contracted with the dental plan organization or with an entity acting on behalf of the dental plan organization to provide dental services to the enrollees.

(13) "Provider contract" means a contract between the dental plan organization or an entity acting on behalf of the dental plan organization and a plan dentist.

(14) “Subscriber” means, for:

(a) Group dental benefit contracts, the person who is eligible to be covered under the contract, other than as a dependent, by reason of satisfying the eligibility requirements of the group;

(b) Individual dental benefit contracts, the individual who applies to the dental plan organization for coverage for:

(i) That individual only;

(ii) The individual and the individual’s dependents; or

(iii) The individual’s dependent or dependents.