RS 22:1242

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RS 22:1242

§1242. Definitions

As used in this Subpart:

(1)"Commissioner" means the commissioner of insurance.

(2)"Contracted health care provider" means a health care provider that has entered into a contract or agreement directly with a health insurance issuer or through a network of providers for the provision of covered health care services.

(3)"Contracted reimbursement rate" means the aggregate maximum amount that a contracted health care provider has agreed to accept from all sources for provision of covered health care services under the health insurance coverage applicable to the enrollee or insured.

(4)"Covered health care services" means services, items, supplies, or drugs for the diagnosis, prevention, treatment, cure, or relief of a health condition, illness, injury, or disease that are either covered and payable under the terms of the health insurance coverage.

(5)"Department" means the Department of Insurance.

(6)"Enrollee" or "insured" means a person, including a spouse or dependent, who is enrolled in or insured by a health insurance issuer for health insurance coverage. A dependent includes unmarried children under twenty-one years of age or, in the case of full-time students, unmarried children under the age of twenty-four, and unmarried grandchildren under twenty-one years of age in the legal custody of and residing with the grandparent or, in the case of full-time students, unmarried grandchildren under the age of twenty-four who are in the legal custody of and residing with the grandparent, except that the policy may provide for continuing coverage for any unmarried child or grandchild in the legal custody of and residing with the grandparent who is incapable of self-sustaining employment by reason of intellectual or physical disability, who became so incapable prior to attainment of age twenty-one, and any other person dependent upon the employee. Any unmarried child who is placed in the home of an insured or enrollee pursuant to an adoption placement agreement executed with an adoption agency licensed in accordance with the Child Care Facility and Child-Placing Agency Licensing Act (R.S. 46:1401 et seq.), or corresponding law of any other state, shall be considered a dependent child of the insured from the date of placement in the home of the insured or enrollee.

(7)"Health care facility" means a facility or institution providing health care services including but not limited to a hospital or other licensed inpatient center, ambulatory surgical or treatment center, skilled nursing facility, inpatient hospice facility, residential treatment center, diagnostic, laboratory, or imaging center, or rehabilitation or other therapeutic health setting. A health care facility may also be a base health care facility.

(8)"Health care professional" means a physician or other health care practitioner licensed, certified, or registered to perform specified health care services consistent with state law.

(9)"Health care provider" or "provider" means a health care professional or a health care facility or the agent or assignee of such professional or facility.

(10)"Health care services" means services, items, supplies, or drugs for the diagnosis, prevention, treatment, cure, or relief of a health condition, illness, injury, or disease.

(11)"Health insurance coverage" means benefits consisting of medical care provided or arranged for directly, through insurance or reimbursement, or otherwise, and includes health care services paid for under any plan, policy, or certificate of insurance.

(12)"Health insurance issuer" means any entity that offers health insurance coverage through a policy or certificate of insurance subject to state law that regulates the business of insurance. For purposes of this Subpart, a "health insurance issuer" shall include a health maintenance organization, as defined and licensed pursuant to Subpart I of Part I of Chapter 2 of this Title, and nonfederal government plans subject to the provisions of Subpart B of Part II of Chapter 6 of this Title, including the Office of Group Benefits.

(13)"Minimal benefit hospital and medical policy" means a policy that provides a fixed payment or benefit, not to exceed the cost of the covered health service.

(14)"Network of providers" or "network" means an entity other than a health insurance issuer that, through contracts with health care providers, provides or arranges for access by groups of enrollees or insureds to health care services by health care providers who are not otherwise or individually contracted directly with a health insurance issuer.

(15)"Prime network" means a network that requires contracted health care providers to accept the amount payable for covered health care services as payment in full for such services.

Acts 2003, No. 528, §1, eff. June 24, 2003; Acts 2004, No. 493, §1, eff. June 25, 2004; Redesignated from R.S. 22:3112 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009; Acts 2014, No. 811, §11, eff. June 23, 2014.

NOTE: Former R.S. 22:1242 redesignated as R.S. 22:1923 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009.