Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 31 - Regulation 53-Basic Health Insurance Plan Pilot Program › Section XIII-3105 - Definitions

Current through Register Vol. 50, No. 6, June 20, 2024
A. For the purposes
				of this regulation:
Accidental Injury
- bodily injury sustained
				  as the result of an unforeseen event and which is the direct reason for
				  receiving care and treatment (independent of disease, bodily infirmity or any
				  other cause). Such care shall occur while coverage under the pilot is in force.
				  It does not include injuries for which benefits are provided under any workers'
				  compensation, employers' liability, or for which another party is liable under
				  automobile, property and casualty, and other coverage.
Admission
- begins the first day an insured
				  becomes a registered hospital inpatient and continues until insured is
				  discharged from the facility.
Adult
- an individual who is greater than 24
				  but less than 65 years of age.
Applicant
- an individual who applies for
				  coverage under the LA Health Plan.
Authorized Carrier
- the health insurance
				  carrier or health maintenance organization licensed and in compliance with the
				  Louisiana Insurance Code certified by the department to offer the LA Health
				  Plan.
Benefit Payment
- the amount the authorized
				  carrier will pay for covered services. See
				  §3127-3133 of this
				  regulation.
Benefit Period
- one year, also referred to
				  as year or calendar year. The benefit period does not begin before the
				  insured's effective date. The benefit period does not continue after the
				  insured's coverage ends.
Clinic
- a facility for the diagnosis, care
				  and treatment of outpatients.
Commissioner
- the Louisiana Commissioner of
				  Insurance.
Co-Payment
- the cost-sharing fee charged to
				  an insured under LA Health as specified in the contract between the authorized
				  carrier for LA Health and the insured.
Department
- the Louisiana Department of
				  Insurance.
Dependent
-
a. the spouse and all unmarried children
				under the age of 24;
b. children
				include natural children, legally adopted children and step-children. Also
				included are children (or children of a spouse) for whom an insured has legal
				responsibility resulting from a valid court decree. Foster children that an
				insured expects to raise to adulthood and that live with an insured in a
				regular parent-child relationship are considered children;
c. students who are unmarried children who
				have not yet attained the age of 24 and who are enrolled as fulltime students
				and who are dependent upon the primary insured;
d. mentally retarded or physically
				handicapped children remain covered to age 21 at which time they are eligible
				for their own individual coverage;
e. a child's coverage ends when any of the
				following occurs:
i. marriage or attaining age
				21 (whichever comes first);
ii.
				termination of an insured's coverage under the LA Health Plan; or
iii. if a child over age 21 no longer
				qualifies as a full-time student.
Effective Date
- the date an applicant
				  becomes eligible for coverage under an authorized carrier for the LA Health
				  Plan.
Hospital
- an institution, licensed by the
				  state, which:
a. provides inpatient
				services and is compensated by or on behalf of its patients;
b. primarily provides medical and surgical
				facilities to diagnose, treat and care for the injured or sick;
c. has a staff of physicians licensed to
				practice medicine by the Louisiana State Board of Medical Examiners;
d. provides nursing care by registered nurses
				or:
NOTE: The term
hospital
does not
				  mean:
1. an extended care facility,
				nursing home, community based care, or group home;
2. a place of rest;
3. a facility for the aged;
4. a custodial institution whose primary
				purpose is to furnish food, shelter, training, or unskilled or nonmedical
				services; or
5. an institution for
				exceptional or handicapped children. licensed practical nurses on duty
				24-hours-a-day.
Insurance Producer or Producer
- an
				  individual who is licensed by the commissioner as an insurance producer
				  pursuant to the provisions of
				  R.S.
				  22:1541-1566.
Insured
- an individual domiciled in this
				  state who is eligible to receive benefits from an authorized carrier under the
				  LA Health Plan.
LA Health
- the Louisiana Basic Health
				  Insurance Plan Pilot Program.
Louisiana Insurance Code
- Title 22 of the
				  Louisiana Revised Statutes of 1950.
Mental and Nervous Disorders
- includes
				  (whether organic or nonorganic, whether of biological, nonbiological, genetic,
				  chemical, or nonchemical origin, and irrespective of cause, basis or
				  inducement) mental disorders, mental illnesses, psychiatric illnesses, mental
				  conditions and psychiatric conditions. This includes, but is not limited to,
				  psychoses, neurotic disorders, schizophrenic disorders, affective disorders,
				  personality disorders and psychological or behavioral abnormalities associated
				  with transient or permanent dysfunction of the brain or related neurohormonal
				  systems. This is intended to include disorders, conditions, and illnesses
				  listed in Diagnostic and Statistical Manual of Mental Disorders
				  (DSM-IIIR).
Minor Dependent
- a dependent under the age
				  of 24.
Non-Smoker
- an individual who has not smoked
				  cigarettes, cigars, pipes or other substances within the past year.
Participating Hospital
- a hospital located
				  in Louisiana which has concluded a written agreement with, and in form approved
				  by, an authorized carrier under the LA Health Plan.
Participating Provider
- a licensed health
				  care provider who has concluded an agreement with, and in form approved by, an
				  authorized carrier under the LA Health Plan to serve those insured by LA
				  Health.
Pilot Plan
- a plan that provides an insured
				  with health insurance under the LA Health program and is governed by
				  R.S.
				  22:2241-2247 and authorized by the
				  commissioner.
Pilot Program
- the program of health
				  insurance which is authorized by
				  R.S.
				  22:2241-2247.
Provider
- includes any discipline licensed
				  by the state of Louisiana to provide and be directly reimbursed for services
				  covered by the LA Health Plan including, but not limited to, the
				  following:
a. doctor of medicine (M.D.)
				legally entitled to practice medicine and perform surgery by the Louisiana
				State Board of Medical Examiners;
b. doctor of chiropractic (D.C.) legally
				entitled to practice chiropractic services;
c. doctor of podiatric medicine (D.P.M.)
				legally entitled to practice podiatry;
d. all providers shall be licensed by the
				state of Louisiana.
Semiprivate Room
- a hospital room which has
				  2, 3, or 4 beds.
Service Area
- that part of the state of
				  Louisiana in which the authorized carrier is applying to offer or is offering
				  the pilot plan.
Skilled Nursing Care
- care required, while
				  recovering from an illness or injury, which is received in a skilled nursing
				  facility. This care requires a level of care or services less than that in a
				  hospital, but more than could be given in the patient's home or in a nursing
				  home not certified as a skilled nursing facility.
Smoker
- an individual who has smoked
				  cigarettes, cigars, pipes or other substances within the past year or who is
				  currently smoking cigarettes, cigars, pipes or other substances.
Utilization Review
- a function performed by
				  an authorized carrier under the LA Health Plan or an entity selected by the
				  carrier to review and approve whether the services provided, or to be provided,
				  are medically necessary including, but not limited to, whether acute
				  hospitalization, length of stay, outpatient care, or diagnostic services are
				  appropriate.