2-A.__Externally appealable decision.__"Externally appealable decision" means a determination, as defined in Bureau of Insurance Rule Chapter 850, Section 5(A), by a carrier of an enrollee's appeal of a denial of benefits or coverage if the amount involved equals or exceeds $200. "Externally appealable decision" does not include a denial of coverage for services that are specifically listed in plan or coverage documents as excluded from coverage.

2-B.__Health care treatment decision.__"Health care treatment decision" means a determination regarding the provision of medical services by the health or managed care plan that affects the quality of the diagnosis, care or treatment provided to the carrier's enrollees.

4-A.__Medically necessary or appropriate care. "Medically necessary or appropriate care" means care that meets the standard for care for health care services in accordance with the professional standards of medical practice. At a minimum, care is "medically necessary or appropriate care" if that care is reasonably calculated to prevent, diagnose, prevent the worsening of, alleviate, ameliorate, correct or cure defects, physical or mental illnesses or conditions that endanger life, cause pain or suffering, cause physical deformity or malfunction, threaten to cause or to aggravate a handicap or disability or result in illness or infirmity.

4-B.__Ordinary care.__"Ordinary care" means, in the case of a carrier, that degree of care that a carrier of ordinary prudence would use under the same or similar circumstances.__In the case of a person who is an employee, agent, ostensible agent or representative of a carrier, "ordinary care" means that degree of care that a person of ordinary prudence in the same profession, specialty or area of practice as that person would use in the same or similar circumstances.

Sec. 7. 24-A MRSA §4301, sub-§6, as enacted by PL 1995, c. 673, Pt. C, §1 and affected by §2, is amended to read:

6. Plan sponsor. "Plan sponsor" means an employer, association, public agency or any other entity providing a health or managed care plan.

Sec. 8. 24-A MRSA §4301, sub-§§7, 8, 9 and 10 are enacted to read: