Alabama Administrative Code › Title 482 - ALABAMA DEPARTMENT OF INSURANCE › Chapter 482-1-115 - ALABAMA HEALTH INSURANCE PLAN › Section 482-1-115-.03 - Definitions

Current through Register Vol. 42, No. 9, June 28, 2024
The following definitions shall apply for purposes of this
				chapter:
(a) BENEFIT PLAN or PLANS.
			 The major medical indemnity plan or plans and the managed care plan or plans
			 offered under the Plan.
(b) BOARD.
			 The Board of Directors of the Plan. The Board shall be the Plan
			 Administrator.
(c) CLAIMS
			 ADMINISTRATOR. The entity or entities chosen by the Board in accordance with
			 Rule 482-1-115-.07 to administer the
			 Plan and to process benefit claims of members of the Plan.
(d) COMMISSIONER. The Alabama Commissioner of
			 Insurance.
(e) CONTINUOUS COVERAGE.
			 Coverage having no breaks of 63 full days or more.
(f) DEPARTMENT. The Alabama Department of
			 Insurance.
(g) DEPENDENT. A child
			 under the age of 26, or a child of any age who is disabled and dependent upon
			 the parent.
(h) HEALTH INSURANCE.
			 Any hospital and medical expense incurred policy, nonprofit health care service
			 plan contract, health maintenance organization subscriber contract, or any
			 other health care plan or arrangement that pays for or furnishes medical or
			 health care services whether by insurance or otherwise, that meets the
			 definition of creditable health insurance coverage as described by
			 45 C.F.R.
			 146.113. The term does not include, accident,
			 dental-only, vision-only, fixed indemnity, limited benefit, disability income,
			 long-term care, Medicare supplement, or credit insurance, nor coverage issued
			 as a supplement to liability insurance, insurance arising out of a workers'
			 compensation or similar law, automobile medical-payment insurance, or insurance
			 under which benefits are payable with or without regard to fault and which is
			 statutorily required to be contained in any liability insurance policy or
			 equivalent self-insurance.
(i)
			 HEALTH MAINTENANCE ORGANIZATION. As defined in Section
			 27-21A-1,
Code of Ala.
			 1975
.
(j) HOSPITAL. As
			 defined in Section
			 22-21-20,
Code of Ala.
			 1975.
(k) INSURER. Any
			 entity that provides health insurance in this state, including an insurance
			 company licensed pursuant to Section
			 27-3-1, et seq.; a health care
			 service plan licensed pursuant Section
			 10-4-100, et seq.; a fraternal
			 benefit society licensed pursuant to Section
			 27-34-1, et seq.; a health
			 maintenance organization licensed pursuant to Section
			 27-21A-1, et seq.; and any other
			 entity providing a plan of health insurance or health benefits whether or not
			 subject to state insurance regulation. In the case of a self-funded health
			 benefit plan operating through a third party administrator, the third party
			 administrator shall be the insurer for the purposes of this chapter.
(l) MEDICAID. Coverage under Title XIX of the
			 Social Security Act,
			 42 USC
			 1396, et seq.
(m) MEDICARE. Coverage under Title XVIII of
			 the Social Security Act,
			 42 USC
			 1395, et seq.
(n) OPERATIONS ADMINISTRATOR. The entity or
			 entities chosen by the Board in accordance with Rule
			 482-1-115-.06 to conduct the
			 daily activities of the Plan.
(o)
			 PARTICIPATING INSURER. Any insurer providing health insurance to residents of
			 this state.
(p) PHYSICIAN. As
			 defined in Section
			 25-5-310,
Codeof Ala.
			 1975.
(q) PLAN. The
			 Alabama Health Insurance Plan as created in Section
			 27-52-1,
Code of Ala.
			 1975
.
(r) PLAN
			 ADMINISTRATOR. The Alabama Health Insurance Board.
(s) PLAN OF OPERATION. The operating rules
			 and procedures adopted by the Board pursuant to Section
			 27-52-2,
Code of Ala.
			 1975
.
(t) PRE-EXISTING
			 MEDICAL CONDITION. Any condition, no matter how caused, for which an individual
			 received medical advice, diagnosis, care, or for which treatment was
			 recommended or received during the six months before the effective date
			 coverage began.
(u) PRIOR
			 CONTINUOUS COVERAGE. 18 months of continuous coverage of health
			 insurance.
(v) PROVIDER. A
			 physician or other individual licensed to provide health care services
			 available under health insurance in this state and operating within the scope
			 of that license.
(w) RESIDENT. An
			 individual who is legally domiciled in this state. For the purposes of this
			 chapter, no particular period of time is required to establish legal domicile,
			 however a person may have only one legal domicile at a time.
(x) THE ACT. Chapter 52 of Title 27,
			 beginning with Section
			 27-52-1,
Code of Ala.
			 1975
.
Author:
Elizabeth Bookwalter, Associate
				  Counsel
Statutory Authority:
Code of Ala.
				  1975
, §§
										27-2-17,
				  27-52-1,
et
				  seq
.