Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 91 - Regulation 68-Patient Rights under Health Insurance Coverage in Louisiana › Section XIII-9103 - Definitions

Current through Register Vol. 50, No. 6, June 20, 2024
Emergency Medical Condition
-the sudden and,
				  unexpected onset of a health condition that requires immediate medical
				  attention, where failure to provide such medical attention could reasonably be
				  expected to result in death, permanent disability, serious impairment to bodily
				  functions, serious dysfunction of a bodily organ or part, or could place the
				  person's health in serious jeopardy.
Formal Managed Care Plan
-basic health
				  coverage provided by a Health Maintenance Organization licensed to operate in
				  Louisiana. The term does not include health insurance coverage that does not
				  meet the same quality standards that are applied to Health Maintenance
				  Organizations. The term does not apply to any health insurance coverage or
				  employer benefit plan that advertises or markets coverage as "managed care" but
				  is not required to comply with the statutory consumer protections required of
				  formal managed care plans operated by Health Maintenance Organizations in
				  Louisiana.
Geographic Area
-a parish.
Health Care Professional
-a physician duly
				  licensed to practice medicine by the Louisiana State Board of Medical
				  Examiners, or other health care professional duly licensed, certified, or
				  registered as appropriate in Louisiana, or an acute care hospital licensed to
				  provide medical care in this state.
Health Insurance Coverage
-benefits
				  consisting of medical care, provided directly, through insurance or
				  reimbursement, or otherwise and including items and services paid for as
				  medical care, under any hospital or medical service policy or certificate,
				  hospital or medical service plan contract, preferred provider organization, or
				  health maintenance organization contract. This term shall not mean limited
				  benefit insurance as defined in
				  R.S.
				  22:6(2)(b)(i) or any short
				  term health insurance exempt from guaranteed renewal by
				  PL
				  102-191, the Health Insurance Portability and
				  Accountability Act of 1996.
Incentive Arrangement
-any payment or
				  contractual obligation included in a general payment plan, capitation contract,
				  shared risk arrangement, or other agreement between a managed care organization
				  and a health care provider that is tied to utilization of covered
				  benefits.
Managed Care Plan
-has the same meaning as
				  set forth under
				  R.S.
				  22:215.18 A(3) and (4). This includes health
				  insurance policies and health maintenance organization coverage. The term does
				  not include supplemental insurance or limited benefit coverage for out of
				  pocket expenses that is exempt from being classified as creditable coverage
				  under Part of Part VI-C of Chapter 1 of Title 22 of the Louisiana Revised
				  Statutes of 1950.
Service Area
-the geographic area or areas of
				  the state served by a managed care plan.
AUTHORITY NOTE:
				  Promulgated in accordance with
				  R.S.
				  22:3 and
				  R.S.
				  22:2014