42 U.S.C. § 300e–1 — Definitions

(1) "Basic health services" means: (A) physician services (including consulting with and referrals by a physician); (B) inpatient and outpatient hospital services; (C) medically necessary emergency health services; (D) short-term outpatient mental health services -- evaluation and crisis help -- capped at 20 visits; (E) medical treatment and referral for alcohol and drug abuse or addiction, including referrals to related support services; (F) diagnostic lab work and diagnostic/therapeutic radiology; (G) home health services; and (H) preventive health services, including: (i) immunizations, (ii) well-child care from birth, (iii) periodic health checkups for adults, (iv) voluntary family planning, (v) infertility services, and (vi) children's eye and ear exams to check for vision or hearing problems. This term does NOT include a health service that the Secretary -- after an HMO applies -- decides is unusual, rarely provided, and not needed to protect a person's health. The Secretary must publish each such decision in the Federal Register. If a service normally done by a physician can also legally be done, under state law, by a dentist, optometrist, podiatrist, psychologist, or other health professional, the HMO may let that other professional provide it instead -- as long as they're licensed to. This term includes organ-transplant-related services only if that transplant was already required to be a basic service as of April 15, 1985. "Home health services" here means health services given at a member's home by health care staff, as directed by the responsible physician or another authority the HMO designates. (2) "Supplemental health services" means any health service that isn't a basic health service under paragraph (1). As with basic services, if a service normally done by a physician can legally be done by a dentist, optometrist, podiatrist, psychologist, or other licensed health professional under state law, the HMO may provide it through that professional instead. (3) "Member" means a person who has entered into a contract with the HMO -- or on whose behalf someone else entered into that contract -- under which the HMO takes responsibility for giving that person basic health services, plus whatever supplemental services were also contracted for. (4) "Medical group" means a partnership, association, or similar group that: (A) is made up of health professionals licensed to practice medicine or osteopathy, plus other licensed professionals (dentists, optometrists, podiatrists, psychologists) needed to provide the group's services; (B) has a majority of its members licensed to practice medicine or osteopathy; and (C) whose members: (i) mainly practice together as a coordinated group and, as a group, are largely responsible for delivering health services to HMO members (this doesn't apply during an HMO's first 48 months as a "qualified" HMO, or when the Secretary allows an exception for unusual circumstances); (ii) pool their practice income and split it among themselves by salary, drawing account, or a similar plan unrelated to which specific services each person provided; (iii) share medical records and most of their major equipment, technical staff, and administrative staff; (iv) arrange and encourage ongoing continuing education for group members in their field; and (v) make sure the health professional treating a member doesn't know that member's enrollment status. (5) "Individual practice association" means a partnership, corporation, association, or other legal entity that has signed a services agreement with people licensed (in a state) to practice medicine, osteopathy, dentistry, podiatry, optometry, psychology, or another health profession, where a majority are licensed in medicine or osteopathy. That agreement must provide: (A) that these professionals provide their services following a compensation arrangement the entity sets up; and (B) as much as possible, for these professionals to share medical records, equipment, and technical/administrative staff. (6) "Health systems agency" means an entity designated under section 300l-4. (7) "Medically underserved population" means the population of an urban or rural area -- or a population group -- that the Secretary designates as short on personal health services. The Secretary can only make that designation after considering comments (if any) from: (A) each state health planning agency covering that area or population, and (B) each health systems agency designated for a health service area covering that area or population. (8) (A) "Community rating system" means the rate-setting systems described in (B) and (C). An HMO may use the (B) system, the (C) system, or both -- but for any one group, it can only use one system. (B) Under this system, rates are set per person or per family, and may vary by family size -- but (except as (D) allows) the rate must be the same for every individual, and every family of similar size, no matter which specific group they belong to. (C) Under this system, rates are set by group. Except as (D) allows, the rate must be the same for everyone in the same group, and for every similarly sized family in that group. To set rates this way, the HMO must either: (i) classify all its members into classes, based on Secretary-approved factors that predict how much health care each class uses; figure out how much revenue it needs to serve each class; and then set each group's rate as a blend of the revenue needed for the classes in that group; or (ii) set each group's rate based on the HMO's revenue needs for serving that group as a whole -- except that for a group under 100 people, the rate can't be more than 110% of what it would be under method (B) or method (i). The Secretary reviews the classification factors HMOs use under (i), and must disapprove any factor that doesn't reasonably predict health-service use. If an HMO uses method (ii), and the group's own contracting entity asks, the HMO must disclose how it calculated the rate and what data it used. (D) These rate differences are allowed under (B) and (C): (i) Small differences to reflect different marketing and collection costs, for: (I) individual members and their families, (II) small groups, and (III) large groups (sizes set by Secretary regulation); (ii) Small differences to reflect how rates are combined to fit employer group-purchasing practices; and (iii) Rate differences for members enrolled through a government contract (under 10 U.S.C. section 1079 or 1086, or other government programs, excluding the federal employee benefits program under 5 U.S.C. chapter 89) or a health benefits program for state/local government employees. (9) "Non-metropolitan area" means an area that's entirely outside any area the Office of Management and Budget designates as a standard metropolitan statistical area, and that doesn't contain a city with more than 50,000 people.