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4685.0100 DEFINITIONS.

Subpart 1.

Scope.

For the purposes of parts 4685.0100 to 4685.3400 the terms used have the meanings given to them in this part and in Minnesota Statutes, chapter 62D.

Subp. 2.

Accepted actuarial principles.

"Accepted actuarial principles" means those prevailing statistical rules relating to the calculation of risks and premiums or prepayment charges of health maintenance organizations, prepaid group practice plans or commercial health insurance carriers.

Subp. 3.

Act.

"Act" means the Health Maintenance Act of 1973, Minnesota Statutes, chapter 62D.

Subp. 3a.

Ancillary services.

"Ancillary services" means laboratory services, radiology services, durable medical equipment, pharmacy services, rehabilitative services, and similar services and supplies dispensed by order or prescription of the primary care physician, specialty physician, or other provider authorized to prescribe those services.

Subp. 4.

[Repealed, L 1999 c 239 s 43]

Subp. 4a.

[Repealed, L 1999 c 239 s 43]

Subp. 5.

Comprehensive health maintenance service.

"Comprehensive health maintenance service" means a group of services which includes at least all of the types of services defined below:

A.

"Emergency care" means medically necessary care which is immediately necessary to preserve life, prevent serious impairment to bodily functions, organs, or parts, or prevent placing the physical or mental health of the enrollee in serious jeopardy.

B.

"In-patient hospital care" means necessary hospital services affording residential treatment to patients. Such services shall include room and board, drugs and medicine, dressings, nursing care, X-rays, and laboratory examination, and other usual and customary hospital services.

C.

"In-patient physician care" means those health services performed, prescribed or supervised by physicians within a hospital, for registered bed patients therein, which services shall include diagnostic and therapeutic care.

D.

"Outpatient health services" means ambulatory care including health supervision, preventive, diagnostic and therapeutic services, including diagnostic radiologic service; therapeutic services for congenital, developmental, or medical conditions that have delayed speech or motor development; treatment of alcohol and other chemical dependency; treatment of mental and emotional conditions; provision of prescription drugs; and other supportive treatment.

E.

"Preventive health services" means health education, health supervision including evaluation and follow-up, immunization and early disease detection.

Subp. 5a.

Cosmetic services.

"Cosmetic services" means surgery and other services performed primarily to enhance or otherwise alter an enrollee's physical appearance without correcting or improving a physiological function.

Subp. 5b.

Custodial care.

"Custodial care" means assistance with meeting personal needs or the activities of daily living that does not require the services of a physician, registered nurse, licensed practical nurse, chiropractor, physical therapist, occupational therapist, speech therapist, or other health care professional, and includes bathing, dressing, getting in and out of bed, feeding, walking, elimination, and taking medications.

Subp. 6.

Enrollee copayment provisions.

"Enrollee copayment provisions" means those contract clauses requiring charges to enrollees, in addition to fixed, prepaid sums, to supplement the cost of providing covered comprehensive health maintenance services; "enrollee copayment provisions" also means the difference between an indemnity benefit and the charge of a provider for health services rendered.

Subp. 6a.

Experimental, investigative, or unproven.

"Experimental, investigative, or unproven" means a drug, device, medical treatment, diagnostic procedure, technology, or procedure for which reliable evidence does not permit conclusions concerning its safety, effectiveness, or effect on health outcomes.

Subp. 7.

Formal procedural requirements.

"Formal procedural requirements" means those rules governing the conduct of administrative hearings applicable to and affecting the rights, duties, and privileges of each party of a contested case, as the term is defined and as the rules are set forth in Minnesota Statutes, chapter 14.

Subp. 7a.

Formulary.

"Formulary" means a current list of covered outpatient prescription drug products that is subject to periodic review and update.

Subp. 8.

Governing body.

"Governing body" means the board of directors, or if otherwise designated in the basic organizational document and/or bylaws, those persons vested with the ultimate responsibility for the management of the corporate entity that has been issued a certificate of authority as a health maintenance organization.

Subp. 8a.

[Repealed, 17 SR 2858]

Subp. 9.

In-area services.

"In-area services" are those services provided within the geographical areas served by the health maintenance organization as described in its application for a certificate of authority and any subsequent changes therein filed with the commissioner of health.

Subp. 9a.

NAIC Blank.

"NAIC Blank" means the most recent version of the National Association of Insurance Commissioners' Blank for Health Maintenance Organizations published by the Brandon Insurance Service Company, Nashville, Tennessee. The NAIC Blank is incorporated by reference and is available for inspection at the State Law Library, Judicial Center, 25 Rev. Dr. Martin Luther King Jr. Blvd., Saint Paul, Minnesota 55155. The NAIC Blank is subject to annual changes by the publisher. Health maintenance organizations must use the version current on December 31 of the year preceding the filing of a required report.

Subp. 9b.

Medically necessary care.

"Medically necessary care" means health care services appropriate, in terms of type, frequency, level, setting, and duration, to the enrollee's diagnosis or condition, and diagnostic testing and preventive services. Medically necessary care must:

A.

be consistent with generally accepted practice parameters as determined by health care providers in the same or similar general specialty as typically manages the condition, procedure, or treatment at issue; and

B.

help restore or maintain the enrollee's health; or

C.

prevent deterioration of the enrollee's condition; or

D.

prevent the reasonably likely onset of a health problem or detect an incipient problem.

Subp. 9c.

Member.

"Member" means enrollee, as defined by Minnesota Statutes, section 62D.02, subdivision 6. "Member" also means "subscriber," and the terms may be used interchangeably.

Subp. 10.

Open enrollment.

"Open enrollment" means the acceptance for coverage by health plans of group enrollees without regard to underwriting restrictions, and coverage of individual or nongroup enrollees with regard only to those underwriting restrictions permissible under Minnesota Statutes, section 62D.10, subdivision 4.

Subp. 11.

Out-of-area health care services.

"Out-of-area health care services" are those services provided outside of the health maintenance organization's geographic service area, as such area is described in the health maintenance organization's application for a certificate of authority, and any subsequent changes therein filed with the commissioner of health.

Subp. 12.

Period of confinement.

"Period of confinement" means a period of time specified in a health maintenance contract relating to the amount of days of inpatient hospital care and defining a period during which an enrollee may not receive any inpatient hospital care in order to become entitled to a renewed period of hospital coverage. This term means the same as "spell of illness" and similar terms as they may be used in provisions to limit hospital care.

Subp. 12a.

Primary care physician.

"Primary care physician" means a licensed physician, either employed by or under contract with the health maintenance organization, who is in general practice, or who has special education, training, or experience, or who is board-certified or board-eligible and working toward certification in a board approved by the American Board of Medical Specialists or the American Osteopathic Association in family practice, pediatrics, internal medicine, or obstetrics and gynecology.

Subp. 12b.

Primary care provider.

"Primary care provider" means a primary care physician as defined in subpart 12a or a licensed practitioner such as a licensed nurse, optometrist, or chiropractor who, within that practitioner's scope of practice as defined under the relevant state licensing law, provides primary care services.

Subp. 13.

Provide.

"Provide" as that word is used in Minnesota Statutes, section 62D.09, means to send by United States postal service, by alternative carrier, or by other method to the place of residence or employment of each enrollee or, if such enrollee is a member of a specified group covered by a health maintenance contract, to the office of the authorized representative of any such group.

Subp. 13a.

Referral.

"Referral" means a prior written authorization for specified services that is issued by a health maintenance organization or an authorized provider and that identifies the provider to which an enrollee is referred and the type, number, frequency, and duration of services to be covered as a benefit under the enrollee's health maintenance organization contract.

Subp. 13b.

Specialty physician.

"Specialty physician" means a licensed physician, either employed by or under contract with the health maintenance organization, who has specialized education, training, or experience, or who is board-certified or board-eligible and working toward certification in a specialty board approved by the American Board of Medical Specialists or the American Osteopathic Association.

Subp. 14.

Summary of current evidence of coverage.

"Summary of current evidence of coverage" means written notice to be provided to enrollees by every health maintenance organization as prescribed in the act. Such notice shall describe changes in health maintenance contract coverage but need not necessarily be specific as to changes respecting the coverage of any individual enrollee.

Subp. 15.

Underwriting restrictions.

"Underwriting restrictions" means those internal predetermined standards within a health maintenance organization which specify and exclude from coverage certain health conditions or persons with certain health conditions which, if such persons or conditions were enrolled or covered, would obligate the health maintenance organization to provide a greater amount, kind or intensity of service than that required by the general population or that contemplated in the process of setting the prepayment amount.

Subp. 16.

Urgently needed care.

"Urgently needed care" means medically necessary care which does not meet the definition of emergency care but is needed as soon as possible, usually within 24 hours.

Statutory Authority:

MS s 62D.03; 62D.04; 62D.08; 62D.11; 62D.182; 62D.20; 62D.21

History:

10 SR 2159; 14 SR 901; 14 SR 903; 17 SR 2858; 23 SR 1238; L 1999 c 239 s 43; L 2017 c 40 art 1 s 121 subd 2

Published Electronically:

August 1, 2017