Pennsylvania Statutes Title 62 P.S. Poor Persons and Public Welfare § 801-I. Definitions

The following words and phrases when used in this article shall have the meanings given to them in this section unless the context clearly indicates otherwise:

“Assessment proceeds.” The State revenue collected from the assessment provided for under this article, any Federal funds received by the Commonwealth as a direct result of the assessment and any penalties and interest received.

“Children's Health Insurance Program” or “CHIP.” The children's health care program under Article XXIII of the act of May 17, 1921 (P.L. 682, No. 284),  1 known as The Insurance Company Law of 1921.

“Contract.” The agreement between a Medicaid managed care organization and the department.

“County Medicaid managed care organization.” A county, or an entity organized and controlled directly or indirectly by a county or a city of the first class, that is a party to a Medicaid managed care contract with the department.

“Department.” The Department of Human Services of the Commonwealth.

“Fixed fee.” The assessment amount imposed on a per-member per-month basis as specified under section 803-I(b). 2

“Insurance Department.” The Insurance Department of the Commonwealth.

“Managed care organization.” A Medicaid managed care organization or a managed care service entity.

“Managed care service entity.” An entity, other than a Medicaid managed care organization, that:

(1) is a managed care plan as defined in the act of June 17, 1998 (P.L. 464, No. 68). 3

(2)(i) provides managed health care coverage through a State program for persons of low income or through CHIP; and

(ii) is obligated to comply with the requirements of the act of June 17, 1998 (P.L. 464, No. 68).

“Medicaid.” The program established under Title XIX of the Social Security Act (49 Stat. 620, 42 U.S.C. § 1396 et seq.).

“Medicaid managed care organization.” A Medicaid managed care organization as defined in section 1903(m)(1)(A) of the Social Security Act (49 Stat. 620, 42 U.S.C. § 1396b(m)(1)(A)) that is a party to a contract with the department. The term includes a county Medicaid managed care organization and a permitted assignee of a contract. The term does not include an assignor of a contract.

“Member.” A policyholder, subscriber, covered person or other individual who is enrolled to receive health care services through a contract or from a managed care services entity. The term shall not include individuals who receive health care services under any of the following:

(1) A Medicare Advantage plan.

(2) A TRICARE or other health care plan provided through the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) as defined under 10 U.S.C. § 1072 (relating to definitions).

(3) A health care plan provided through the Federal Employees Health Benefits Program established under the Federal Employees Health Benefit Act (5 U.S.C. Ch. 89 (relating to health insurance)).

“Program.” The Commonwealth's medical assistance program as authorized under Article IV.

“Social Security Act.” The Social Security Act (49 Stat. 620, 42 U.S.C. § 301 et seq.).