§432G-1  Definitions.  As used in this chapter:

     "Capitated basis" means fixed per member per month payment or percentage of premium payment wherein the provider assumes the full risk for the cost of contracted services without regard to the type, value, or frequency of services provided.  For purposes of this chapter, "capitated basis" includes the cost associated with operating staff model facilities.

     "Carrier" means a dental insurer, a health maintenance organization, an insurer, a nonprofit hospital and medical service corporation, a mutual benefit society, or other entity responsible for the payment of benefits or provision of services under a group contract.

     "Commissioner" means the insurance commissioner.

     "Copayment" means an amount an enrollee must pay to receive a specific service which is not fully prepaid.

     "Dental care services" include the practices, acts, and operations pertaining to dentistry as defined in section 448-1.

     "Dental insurance plan" means insurance, as defined in section 431:1-201, for dental care services.

     "Dental insurer" means any person who undertakes to provide or to arrange for or administer one or more dental insurance plans and who has met the requirements of chapter 423.

     "Dental service corporation" means a corporation established pursuant to section 423-1.

     "Discontinuance" means the termination of the contract between a group contract holder and a dental insurer due to the insolvency of the dental insurer, and does not refer to the termination of any agreement between any individual subscriber and a dental insurer.

     "Enrollee" means an individual who is covered by a dental insurer.

     "Evidence of coverage" means a statement of the essential features and services of the dental insurer coverage that is given to the subscriber by the dental insurer or by the group contract holder.

     "Grievance" means a written complaint submitted in accordance with the dental insurer's formal grievance procedure by or on behalf of an enrollee regarding any aspect of the dental insurer relative to the enrollee.

     "Group contract" means a contract for dental care services which by its terms limits eligibility to members of a specified group.  The group contract may include coverage for dependents.

     "Group contract holder" means the person to which a group contract has been issued.

     "Individual contract" means a contract for dental care services issued to and covering an individual.  The individual contract may include dependents of the subscriber.

     "Insolvent" or "insolvency" means that the dental insurer has been declared insolvent and placed under an order of supervision, rehabilitation, or liquidation by the commissioner or a court of competent jurisdiction.

     "Net worth" means the excess of total assets over total liabilities; provided that liabilities shall not include fully subordinated debt.

     "Participating provider" means a provider as defined in this section, who, under an express or implied contract with the dental insurer or with its contractor or subcontractor, has agreed to provide dental care services to enrollees with an expectation of receiving payment, other than copayment or deductible, directly or indirectly from the dental insurer.

     "Person" has the same meaning as in section 431:1-212.

     "Provider" means any person licensed to practice dentistry as defined in section 448-1.

     "Replacement coverage" means the benefits provided by a succeeding carrier.

     "Subscriber" means an individual whose employment or other status, except family dependency, is the basis for eligibility for enrollment in the dental insurer, or in the case of an individual contract, the person in whose name the contract is issued.

     "Uncovered expenditures" means the costs to the dental insurer for dental care services that are the obligation of the dental insurer, for which an enrollee may also be liable in the event of the dental insurer's insolvency, and for which no alternative arrangements have been made that are acceptable to the commissioner.  Uncovered expenditures include but are not limited to out-of-area services, referral services, and hospital services.  Uncovered expenditures shall not include expenditures for services when a provider has agreed not to bill the enrollee even though the provider is not paid by the dental insurer, or for services that are guaranteed, insured, or assumed by a person or organization other than the dental insurer. [L 2013, c 191, pt of §1; am L 2014, c 186, §17]



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