Mississippi Administrative Code › Title 19 - Department of Insurance › Part 3 - Accident and Health › Chapter 14 - Managed Care Plan Network Adequacy › Rule 19-3-14.3 - Definitions

Current through June 25, 2024
For purposes of this Regulation:
A. "Closed plan" means a managed care plan that requires
				  covered persons to use participating providers under the terms of the managed
				  care plan in order to obtain covered benefits.
B. "Commissioner" means the Commissioner of Insurance.
C. "Covered benefits" or "benefits" means those health care
				  services to which a covered person is entitled under the terms of a health
				  benefit plan.
D. "Covered person" means a policyholder, subscriber,
				  enrollee or other individual participating in a health benefit plan.
E. "Emergency medical condition" means the sudden and, at the
				  time, unexpected onset of a health condition that requires immediate medical
				  attention, where failure to provide medical attention would result in serious
				  impairment to bodily functions or serious dysfunction of a bodily organ or
				  part, or would place the person's health in serious jeopardy.
F. "Emergency services" means health care items and services
				  furnished or required to evaluate and treat an emergency medical
				  condition.
G. "Facility" means an institution providing health care
				  services or a health care setting, including but not limited to 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.
H. "Health benefit plan" means a policy, contract,
				  certificate or agreement entered into, offered or issued by a health carrier to
				  provide, deliver, arrange for, pay for or reimburse any of the costs of health
				  care services.
I. "Health care professional" means a physician or other
				  health care practitioner licensed, accredited or certified to perform specified
				  health services consistent with state law.
J. "Health care provider" or "provider" means a health care
				  professional or a facility.
K. "Health care services" means services for the diagnosis,
				  prevention, treatment, cure or relief of a health condition, illness, injury or
				  disease.
L. "Health carrier" means an entity subject to the insurance
				  laws and regulations of this state, or subject to the jurisdiction of the
				  commissioner, 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.
M. "Health indemnity plan" means a health benefit plan that
				  is not a managed care plan.
N. "Intermediary" means a person authorized to negotiate and
				  execute provider contracts with health carriers on behalf of health care
				  providers or on behalf of a network.
O. "Managed care plan" means a plan as defined by
Miss. Code Ann
. §
									83-41-403(b).
P. "Network" means the group of participating providers
				  providing services to a managed care plan and who have entered into a contract
				  of reimbursement for benefits with a health carrier.
Q. "Open plan" means a managed care plan other than a closed
				  plan that provides incentives, including financial incentives (i.e. higher
				  benefits, lower cost sharing) for covered persons to use participating
				  providers under the terms of the managed care plan.
R. "Participating provider" means a provider as defined by
Miss. Code Ann
. §
									83-41-403(e).
S. "Person" means an individual, a corporation, a
				  partnership, an association, a joint venture, a joint stock company, a trust,
				  an unincorporated organization, any similar entity or any combination of the
				  foregoing.
T. "Primary care professional" means a participating health
				  care professional designated by the health carrier to supervise, coordinate or
				  provide initial care or continuing care to a covered person, and who may be
				  required by the health carrier to initiate a referral for specialty care and
				  maintain supervision of health care services rendered to the covered
				  person.
Miss. Code Ann. §
										83-41-403;
				  §
										83-41-405;
				  §
										83-41-413
				  (Rev. 2011)