58-17G-1. Definitions.
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/sd/title-58/chapter-58-17/58-17g-1·A research copy — for the controlling text, always check the official state or federal source. Not legal advice.
Terms used in this chapter mean:
(1)"Closed plan," a managed care plan or health carrier that requires covered persons to use participating providers under the terms of the managed care plan or health carrier and does not provide any benefits for out-of-network services except for emergency services;
(2)"Consumer," someone in the general public who may or may not be a covered person or a purchaser of health care, including employers;
(3)"Covered benefits" or "benefits," those health care services to which a covered person is entitled under the terms of a health benefit plan;
(4)"Covered person," a policyholder, subscriber, enrollee, or other individual participating in a health benefit plan;
(5)"Director," the director of the Division of Insurance;
(6)"Discounted fee for service," a contractual arrangement between a health carrier and a provider or network of providers under which the provider is compensated in a discounted fashion based upon each service performed and under which there is no contractual responsibility on the part of the provider to manage care, to serve as a gatekeeper or primary care provider, or to provide or assure quality of care. A contract between a provider or network of providers and a health maintenance organization is not a discounted fee for service arrangement;
(7)"Facility," an institution providing health care services or a health care setting, including hospitals and other licensed inpatient centers, ambulatory surgical or treatment centers, skilled nursing centers, residential treatment centers, diagnostic, laboratory, and imaging centers, and rehabilitation, and other therapeutic health settings;
(8)"Health care professional," a physician or other health care practitioner licensed, accredited, or certified to perform specified health services consistent with state law;
(9)"Health care provider" or "provider," a health care professional or a facility;
(10)"Health care services," services for the diagnosis, prevention, treatment, cure, or relief of a health condition, illness, injury, or disease;
(11)"Health carrier," an entity subject to the insurance laws and regulations of this state, or subject to the jurisdiction of the director, that contracts or offers to contract, or enters into an agreement to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services, including a sickness and accident insurance company, a health maintenance organization, a nonprofit hospital and health service corporation, or any other entity providing a plan of health insurance, health benefits, or health services;
(12)"Health indemnity plan," a health benefit plan that is not a managed care plan;
(13)"Managed care contractor," a person who establishes, operates, or maintains a network of participating providers; or contracts with an insurance company, a hospital or medical service plan, an employer, an employee organization, or any other entity providing coverage for health care services to operate a managed care plan or health carrier;
(14)"Managed care entity," a licensed insurance company, hospital or medical service plan, health maintenance organization, or an employer or employee organization, that operates a managed care plan or a managed care contractor. The term does not include a licensed insurance company unless it contracts with other entities to provide a network of participating providers;
(15)"Managed care plan," a plan operated by a managed care entity that provides for the financing or delivery of health care services, or both, to persons enrolled in the plan through any of the following:
(a)Arrangements with selected providers to furnish health care services;
(b)Explicit standards for the selection of participating providers; or
(c)Financial incentives for persons enrolled in the plan to use the participating providers and procedures provided for by the plan;
(16)"Open plan," a managed care plan or health carrier other than a closed plan that provides incentives, including financial incentives, for covered persons to use participating providers under the terms of the managed care plan or health carrier;
(17)"Participating provider," a provider who, under a contract with the health carrier or with its contractor or subcontractor, has agreed to provide health care services to covered persons with an expectation of receiving payment, other than coinsurance, copayments, or deductibles, directly or indirectly, from the health carrier;
(18)"Quality assessment," the measurement and evaluation of the quality and outcomes of medical care provided to individuals, groups, or populations;
(19)"Quality improvement," the effort to improve the processes and outcomes related to the provision of care within the health plan; and
(20)"Secretary," the secretary of the Department of Health.