58-18A-53. Definitions.
498 words·~2 min read·
/sd/title-58/chapter-58-18/58-18a-53·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)"Birthday," refers only to a month and day in a calendar year and does not include the year in which the person was born;
(2)"Claim," a request that benefits of a plan be provided or paid. The benefits claimed may be in the form of:
(a)Services (including supplies);
(b)Payment for all or a portion of the expenses incurred; and
(c)An indemnification.
(3)"Closed panel plan," a plan that provides health benefits to covered persons primarily in the form of services through a panel of providers that have contracted with or are employed by the plan and that excludes benefits for services provided by other providers, except in cases of emergency or referral by a panel member;
(4)"Consolidated Omnibus Budget Reconciliation Act of 1985" or "COBRA," coverage provided under a right of continuation pursuant to federal law;
(5)"Coordination of benefits" or " COB," a provision establishing an order in which plans pay their claims, and permitting secondary plans to reduce their benefits so that the combined benefits of all plans do not exceed total allowable expenses;
(6)"Custodial parent," the parent awarded custody of a child by a court decree, or in the absence of a court decree, the parent with whom the child resides more than one half of the calendar year without regard to any temporary visitation;
(7)"Group-type contract," a contract that is not available to the general public and is obtained and maintained only because of membership in or a connection with a particular organization or group, including blanket coverage. The term does not include an individually underwritten and issued guaranteed renewable policy even if the policy is purchased through payroll deduction at a premium savings to the insured since the insured would have the right to maintain or renew the policy independently of continued employment with the employer;
(8)"High-deductible health plan," the meaning given the term under section 223 of the Internal Revenue Code of 1986, as amended by the Medicare Prescription Drug, Improvement and Modernization Act of 2003;
(9)"Hospital indemnity benefits," benefits not related to expenses incurred. The term does not include reimbursement-type benefits even if they are designed or administered to give the insured the right to elect indemnity-type benefits at the time of claim;
(10)"Policyholder," the primary insured named in a nongroup insurance policy;
(11)"Primary plan," a plan whose benefits for a person' s health care coverage must be determined without taking the existence of any other plan into consideration. A plan is a primary plan if the plan either has no order of benefit determination rules, or its rules differ from those permitted by §§ 58-18A-53 to 58-18A-83 , inclusive; or all plans that cover the person use the order of benefit determination rules required by §§ 58-18A-53 to 58-18A-83 , inclusive, and under those rules the plan determines its benefits first;
(12)"Secondary plan," a plan that is not a primary plan.