5599. DEFINITIONS

5599 DEFINITIONS 5599.1 When used in this chapter, the following terms and phrases shall have the meanings ascribed: Community rate - the system under which prepaid providers set rates on per person or per family basis that are equivalent for all individuals and for all families of similar composition. Contract - the agreement between the QO and the Department. Department - the District of Columbia Department of Human Services, or its designee. District - the District of Columbia. Emergency medical care - the sudden unexpected onset of a condition requiring medical or surgical care; which condition may result in permanent physical injury or a threat to life if care is not secured immediately after the onset of the condition or as soon thereafter as the care can be made available. Enrollee - a Medicaid recipient who is enrolled in a QO that has a contract with the Department. Enrollment - the initial process by which new enrollees apply and are approved by the QO and the Department. Evidence of coverage - any certificate, agreement or contract issued to an enrollee setting out the coverage to which he or she is entitled. Federally qualified HMO - an HMO that has been determined by the U.S. Public Health Service to be a qualified HMO under § 1310(d) of the Public Health Service Act. Involuntary disenrollment - a QO terminates the membership of an enrollee under conditions permitted by this chapter or the Medicaid contract. Marketing - any procedure or materials intended to induce Medicaid recipients to become QO enrollees. Medicaid benefits package - all health services to which recipients are entitled under the District Medicaid Program, except services in a skilled nursing facility, an institution for mental diseases, and other services specifically excluded in the contract. Prepayment - a predetermined sum of money paid on a periodic basis prior to and independent of the rendering of services. Provider - any physician, hospital, or other person or facility which is licensed or otherwise authorized in the District to furnish health care services. On-going organization - a health plan which has provided prepaid services to members for more than twelve (12) months. Out-of-plan referrals - medically necessary Medicaid covered services arranged for and authorized by the QO. Regional Administrator - the Administrator, Region III, Health Care Financing Administration, U.S. Department of Health and Human Services. Reinsurance - insurance protection for costs over a certain level incurred by a QO for providing services to an enrollee. Reserves - a sum of money accumulated by a QO that can be used as follows: (a) Applied against known liabilities not yet paid; (b) Used as contingency for unanticipated expenses; or (c) Used for future services. Risk - a QO’s potential exposure to financial loss for providing services under a prepayment contract. Start-up organization - a health plan which has provided prepaid services to members for less than twelve (12) months. Stop loss - a mechanism which limits the financial liability of a QO for expenses incurred for rendering services to an enrollee under a prepaid contract. Subcontract - any written agreement between the QO and another party to fulfill service obligations or benefit requirements. Uncovered expenditures - the cost of health care services that are provided by a QO’s subcontractors for which a non-Medicaid enrollee would be liable in the event of the QO’s insolvency. Voluntary disenrollment - an enrollee chooses to leave a QO under conditions permitted by this chapter. SOURCE: Final Rulemaking published at 34 DCR 1550, 1566 (March 6, 1987).