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<regulation prefix="Regulation" num=".02" citation="COMAR 31.10.31.02" title_num="31" subtitle_num="10" chapter_num="31" heading="Definitions.">
  <paragraph num="A.">
    <text>In this chapter, the following terms have the meanings indicated.</text>
  </paragraph>
  <paragraph num="B.">
    <text>Terms Defined.</text>
    <paragraph num="(1)">
      <text>Behavioral Health Care Administrative Expenses.</text>
      <paragraph num="(a)">
        <text>“Behavioral health care administrative expenses” means any expenses that are for administrative functions including:</text>
        <paragraph num="(i)">
          <text>Billing and collection expenses;</text>
        </paragraph>
        <paragraph num="(ii)">
          <text>Accounting and financial reporting expenses;</text>
        </paragraph>
        <paragraph num="(iii)">
          <text>Quality assurance and utilization management program or activity expenses;</text>
        </paragraph>
        <paragraph num="(iv)">
          <text>Promotion and marketing expenses;</text>
        </paragraph>
        <paragraph num="(v)">
          <text>Taxes, fees, and assessments;</text>
        </paragraph>
        <paragraph num="(vi)">
          <text>Legal expenses;</text>
        </paragraph>
        <paragraph num="(vii)">
          <text>Salary expenses for employees that are not related to the delivery of behavioral health care services to patients;</text>
        </paragraph>
        <paragraph num="(viii)">
          <text>Computer expenses;</text>
        </paragraph>
        <paragraph num="(ix)">
          <text>Provider credentialing;</text>
        </paragraph>
        <paragraph num="(x)">
          <text>Collection and administrative review of treatment plans;</text>
        </paragraph>
        <paragraph num="(xi)">
          <text>Auditing the financial report submitted to the Commissioner under Insurance Article, §15-127, Annotated Code of Maryland;</text>
        </paragraph>
        <paragraph num="(xii)">
          <text>Debt payment and debt service; and</text>
        </paragraph>
        <paragraph num="(xiii)">
          <text>Other general and administrative expenses.</text>
        </paragraph>
      </paragraph>
      <paragraph num="(b)">
        <text>“Behavioral health care administrative expenses” does not include expenses incurred for behavioral health care services.</text>
      </paragraph>
    </paragraph>
    <paragraph num="(2)">
      <text>Behavioral Health Care Services.</text>
      <paragraph num="(a)">
        <text>“Behavioral health care services” means procedures or services rendered by a health care provider for the treatment of mental illness, emotional disorders, drug abuse, or alcohol abuse.</text>
      </paragraph>
      <paragraph num="(b)">
        <text>“Behavioral health care services” includes any quality assurance or utilization management activities or treatment plan reviews that are clinical in nature.</text>
      </paragraph>
      <paragraph num="(c)">
        <text>“Behavioral health care services” does not include administrative functions.</text>
      </paragraph>
    </paragraph>
    <paragraph num="(3)">
      <text>“Carrier” means:</text>
      <paragraph num="(a)">
        <text>A health insurer;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>A nonprofit health service plan;</text>
      </paragraph>
      <paragraph num="(c)">
        <text>A health maintenance organization;</text>
      </paragraph>
      <paragraph num="(d)">
        <text>A preferred provider organization;</text>
      </paragraph>
      <paragraph num="(e)">
        <text>A third party administrator; or</text>
      </paragraph>
      <paragraph num="(f)">
        <text>Except for a managed care organization as defined in Health-General Article, Title 15, Subtitle 1, Annotated Code of Maryland, any other person that provides health benefit plans subject to regulation by the State.</text>
      </paragraph>
    </paragraph>
    <paragraph num="(4)">
      <text>“Direct behavioral health care expenses” means any payment to a health care provider by a managed behavioral health care organization for the provision of behavioral health care services to a member.</text>
    </paragraph>
    <paragraph num="(5)">
      <text>“Direct payments” means the money that a carrier disburses to a managed behavioral health care organization for the provision of behavioral health care services to a member.</text>
    </paragraph>
    <paragraph num="(6)">
      <text>“Managed behavioral health care organization” means a company, organization, private review agent, or subsidiary that:</text>
      <paragraph num="(a)">
        <text>Contracts with a carrier to provide, undertake to arrange, or administer behavioral health care services to members; or</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Otherwise makes behavioral health care services available to members through contracts with health care providers.</text>
      </paragraph>
    </paragraph>
    <paragraph num="(7)">
      <text>Member.</text>
      <paragraph num="(a)">
        <text>“Member” means an individual entitled to behavioral health care services from a carrier or a managed behavioral health care organization under a policy or plan issued or delivered in the State.</text>
      </paragraph>
      <paragraph num="(b)">
        <text>“Member” includes a subscriber.</text>
      </paragraph>
    </paragraph>
    <paragraph num="(8)">
      <text>“Provider” means a person licensed, certified, or otherwise authorized under Health Occupations Article, or Health-General Article, Annotated Code of Maryland, to provide health care services.</text>
    </paragraph>
  </paragraph>
</regulation>