58-41-1. Definition of terms.
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/sd/title-58/chapter-58-41/58-41-1A research copy — for the controlling text, always check the official state or federal source. Not legal advice.
Terms used in this chapter mean:
(1)"Comprehensive health maintenance services," a set of comprehensive health services which the enrollees might reasonably require to be maintained in good health, including as a minimum, but not limited to, emergency care, inpatient hospital and physician care, outpatient medical services, and preventive medical services;
(2)"Director," the director of the Division of Insurance or his designee;
(3)"Enrollee," any person who has entered into, or is covered by a health maintenance contract;
(4)"Evidence of coverage," any certificate, agreement, or contract issued to an enrollee which sets out the coverage to which he is entitled under the health maintenance contract which covers him;
(5)"Health maintenance contract," any contract whereby a health maintenance organization agrees to provide comprehensive health maintenance services to enrollees, provided that the contract may contain reasonable enrollee copayment provisions. Any contract may provide for health care services in addition to those set forth in subdivision (1);
(6)"Limited health service," dental care services, vision care services, mental health services, substance abuse services, pharmaceutical services, podiatric care services, and such other services as may be determined by the director to be limited health services. Limited health service does not include hospital, medical, surgical, or emergency services except as these services are provided incident to the limited health services;
(7)"Provider," any person who furnishes health services and is licensed or otherwise authorized to render such services in the state;
(8)"Risk bearing entity," an intermediary organization that is a financial risk for services provided through contractual assumption of the obligation for the delivery of specified health care services to covered persons of the health maintenance organization.