As used in this act, the term:(1) “Capitation” means the fixed amount paid by a prepaid limited health service organization to a health care provider under contract with the prepaid limited health service organization in exchange for the rendering of covered limited health services.
(2) “Enrollee” means an individual, including dependents, who is entitled to limited health services pursuant to a contract, or any other evidence of coverage, with an entity authorized to provide or arrange for such services under this act.
(3) “Evidence of coverage” means the certificate, agreement, membership card, or contract issued pursuant to this act setting forth the coverage to which an enrollee is entitled.
(4) “Insolvent” means that all the statutory assets of the prepaid limited health service organization, if made immediately available, would not be sufficient to discharge all of its statutory liabilities or that the prepaid limited health service organization is unable to pay its debts as they become due in the usual course of business.
(5) “Limited health service” means ambulance services, dental care services, vision care services, mental health services, substance abuse services, chiropractic services, podiatric care services, and pharmaceutical services. “Limited health service” does not include inpatient, hospital surgical services, or emergency services except as such services are provided incident to the limited health services set forth in this subsection.
(6) “Prepaid limited health service contract” means any contract entered into by a prepaid limited health service organization with a subscriber or group of subscribers to provide limited health services in exchange for a prepaid per capita or prepaid aggregate fixed sum.
(7) “Prepaid limited health service organization” means any person, corporation, partnership, or any other entity which, in return for a prepayment, undertakes to provide or arrange for, or provide access to, the provision of a limited health service to enrollees through an exclusive panel of providers. Prepaid limited health service organization does not include:(a) An entity otherwise authorized pursuant to the laws of this state to indemnify for any limited health service;
(b) A provider or entity when providing limited health services pursuant to a contract with a prepaid limited health service organization, a health maintenance organization, a health insurer, or a self-insurance plan; or
(c) Any person who is licensed pursuant to part II as a discount plan organization.
(8) “Provider” means, but is not limited to, any physician, dentist, health facility, or other person or institution which is duly licensed in this state to deliver limited health services.
(9) “Qualified independent actuary” means an actuary who is a member of the American Academy of Actuaries or the Society of Actuaries and has experience in establishing rates for limited health services and who has no financial or employment interest in the prepaid limited health service organization.
(10) “Reporting period” means the annual accounting period or fiscal year, or any part thereof, of the prepaid limited health service organization. The calendar year shall be the fiscal year for each such organization other than those holding an existing certificate of authority as of October 1, 1993.
(11) “Subscriber” means an individual who has contracted, or arranged, or on whose behalf a contract or arrangement has been entered into, with a prepaid limited health service organization for health care services or other persons who also receive health care services as a result of the contract.
(12) “Surplus” means total statutory assets in excess of total liabilities, except that assets pledged to secure debts not reflected on the books of the prepaid limited health service organization shall not be included in surplus. Surplus includes capital stock, capital in excess of par, other contributed capital, retained earnings, and surplus notes.
(13) “Surplus notes” means debt which has been subordinated to all claims of subscribers and general creditors of the organization and the debt instrument shall so state.
(14) “Statutory accounting principles” means generally accepted accounting principles, except as modified by this act.
(15) “Qualified employee” means an employee of the organization:(a) Who has a minimum of 5 years of experience in rate determinations for prepaid health services, and who demonstrates through filings with the office that the person is in fact qualified under the terms of this act; or
(b) Who is a member of the American Academy of Actuaries or the Society of Actuaries and has experience in establishing rates for limited health service.
