NAIC model law · NAIC model laws
Health Maintenance Organization Model Act
Edition and licensing notes
Publisher. National Association of Insurance Commissioners (NAIC)
Status. NAIC model act, © NAIC. Brief definitional quotations under fair use; not the enacted law of any state until adopted.
What this document is
Health Maintenance Organization Model Act is a naic model law published by National Association of Insurance Commissioners (NAIC). It is one of the documents that insurance license exam questions are written from, including life & health practice questions. This page summarizes it and points to the official version, which is the text to rely on.
Sections cited in practice questions
Each practice answer shows the exact passage it comes from. These are sections of this document that questions cite, with a short excerpt from the source text.
- NAIC Model #430: Section 3.C (Definitions: 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.”
- NAIC Model #430: Section 3.I (Definitions: Deductible)
“means the amount a covered person is responsible to pay out-of-pocket before the health maintenance organization begins to pay the covered expenses associated with treatment.”
- NAIC Model #430: Section 3B (Definitions: Basic health care services)
“includes the following medically necessary services: preventive care, emergency care, inpatient and outpatient hospital and physician care, diagnostic laboratory and diagnostic and therapeutic radiological services.”
- NAIC Model #430: Section 14 (Coordination of Benefits)
“Health maintenance organizations are permitted, but not required, to adopt coordination of benefits provisions to avoid overinsurance and to provide for the orderly payment of claims when a person is covered by two (2) or more group health insurance or health benefit plans.”
- NAIC Model #430: Section 3 (Definitions)
““Grievance” means a written complaint submitted by or on behalf of a covered person regarding: (1) The availability, delivery or quality of health care services, including a complaint regarding an adverse determination made pursuant to utilization review;”
- NAIC Model NAIC 430: Section 3N (Grievance Definition)
“N. “Grievance” means a written complaint submitted by or on behalf of a covered person regarding: (1) The availability, delivery or quality of health care services, including a complaint regarding an adverse determination made pursuant to utilization review; (2) Claims payment, handling or...”
- NAIC Model NAIC 430: Section 9D (Continuity of Care)
“be able to demonstrate to the satisfaction of the commissioner that the health maintenance organization can fulfill its non-transferable obligation to provide health care services to covered persons in any event, including the failure, for any reason, of a risk bearing entity.”
- NAIC Model NAIC 430: Section 3B (Basic Health Care Services)
“preventive care, emergency care, inpatient and outpatient hospital and physician care, diagnostic laboratory and diagnostic and therapeutic radiological services. It does not include mental health services or services for alcohol or drug abuse, dental or vision services or long-term rehabilitation treatment.”
- NAIC Health Maintenance Organization Model Act § 13C (Information to Enrollees and Covered Persons)
“(1) A health maintenance organization shall notify covered persons of the termination of the primary care provider who currently provides health care services to that covered person. (2) A health maintenance organization shall establish a method to permit a covered person, at the option of the...”
- NAIC Model NAIC 430: Section 17A (Deposit Requirements)
“cash, securities, or any combination of these or other measures that are acceptable to the commissioner which at all times shall have a market value of not less than $1,000,000.”
- NAIC Model NAIC 430: Section 15A (Initial Net Worth and Capital Requirements)
“Before the commissioner issues a certificate of authority in accordance with Section 6 of this Act, an applicant seeking to establish or operate a health maintenance organization shall have the greater of:”
- NAIC Health Maintenance Organization Model Act § 11A(1) (evidence of coverage delivery)
“(1) Every enrollee shall receive an evidence of coverage from the group contract holder or the health maintenance organization.”
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