South Carolina Code of Regulations › Chapter 69 - DEPARTMENT OF INSURANCE › Section 69-22 - Health Maintenance Organizations

Current through Register Vol. 48, No. 6, June 28, 2024
Section I.
		  Definitions.
Unless the context otherwise requires, the following definitions
			 shall apply as the terms are used in both this regulation and Chapter 33 of
			 Title 38 of the 1976 South Carolina Code, as amended (the Health Maintenance
			 Organization Act of 1987):
A. "Basic
		  health care services" means emergency care, inpatient hospital and physician
		  care, and outpatient medical services. "Basic health care services" does not
		  include dental services, mental health services, or services for alcohol or
		  drug abuse, although a health maintenance organization may at its option elect
		  to provide these services in its coverage.
B. "Contractholder" means a person or entity
		  consisting of employees or eligible persons which has entered into a group
		  contract with a health maintenance organization for the provision of specified
		  health care services to its eligible employees or eligible persons.
C. "Commissioner" means the Chief Insurance
		  Commissioner.
D. "Copayment" or
		  "deductible" means the amount specified in the evidence of coverage that the
		  enrollee shall pay directly to the provider for covered health care services,
		  which may be stated in either specific dollar amounts or as a percentage of the
		  provider's usual or customary charge.
E. "Department" means the Department of
		  Health and Environmental Control.
F. "Eligible dependent" means any member of a
		  subscriber's family who meets the eligibility requirements set forth in
		  Subsection D of Section III of this regulation.
G. "Emergency care services" means:
1. Within the service area: covered health
		  care services rendered by affiliated or non-affiliated providers under
		  unforeseen conditions that require immediate medical attention. Emergency care
		  services within the service area shall include covered health care services
		  from non-affiliated providers only when delay in receiving care from the health
		  maintenance organization could reasonably be expected to cause severe jeopardy
		  to the enrollee's condition.
2.
		  Outside the service area: medically necessary health care services that are
		  immediately required because of unforeseen illness or injury while the enrollee
		  is outside the geographical limits of the health maintenance organization's
		  service area.
H.
		  "Enrollee" or "member" means an individual who is enrolled in a health
		  maintenance organization.
I.
		  "Evidence of coverage" means any certificate, agreement or contract issued to
		  an enrollee setting out the coverage to which he is entitled.
J. "Group contract" means a contract for
		  health care services which by its terms limits eligibility to members of a
		  specified group.
K. "Health care
		  services" means any services included in the furnishing to any individual of
		  medical or dental care or hospitalization, or incident to the furnishing of
		  such care or hospitalization, as well as the furnishing to any person of any
		  and all other services for the purposes of preventing, alleviating, curing, or
		  healing human illness, injury or physical disability.
L. "Health maintenance organization" means
		  any person that undertakes to provide or arrange for basic health care services
		  to enrollees for a fixed prepaid premium.
M. "Health professional" means any
		  professional engaged in the delivery of health care services who is licensed,
		  and practicing within the scope of such a license, where such licensing is
		  required by state law.
N.
		  "Hospital" means a duly licensed institution which provides general and
		  specialized inpatient medical care. The term "hospital" shall not include a
		  convalescent facility, nursing home, or any institution or part thereof which
		  is used principally as a convalescent facility, rest facility, nursing
		  facility, or facility for the aged.
O. "Individual contract" or "nongroup
		  contract" means a contract for health care services issued to and covering an
		  individual or a family.
P. "Medical
		  necessity" or "medically necessary" means appropriate and necessary services as
		  determined by any provider affiliated with the health maintenance organization
		  which are rendered to an enrollee for any condition requiring, according to
		  generally accepted principles of good medical practice, the diagnosis or direct
		  care and treatment of an illness or injury and are not provided only as a
		  convenience.
Q. "Out-of-area
		  services" means the health care services that a health maintenance organization
		  covers when its enrollees are outside of the service area.
R. "Person" means any natural or artificial
		  person including but not limited to individuals, partnerships, associations,
		  trusts, or corporations.
S.
		  "Physician" means a duly licensed doctor of medicine or osteopathy practicing
		  within the scope of such a license.
T. "Primary care physician" means a physician
		  who supervises, coordinates, and provides initial and basic care to members;
		  initiates their referral for specialist care and maintains continuity of
		  patient care.
U. "Provider" means
		  any physician, dentist, hospital, pharmacist, or other person properly
		  licensed, where required, to furnish health care services.
V. "Service area" means the geographical area
		  as approved by the Commissioner within which the health maintenance
		  organization provides or arranges for health care services that are available
		  and accessible to enrollees.
W.
		  "Skilled nursing facility" means a facility that is operated pursuant to law
		  and primarily engaged in providing, in addition to room and board
		  accommodations, skilled nursing care under the supervision of a duly licensed
		  physician.
X. "Subscriber" means
		  the individual whose employment or other status, except for family dependency,
		  is the basis for eligibility for enrollment in the health maintenance
		  organization and who is in fact enrolled in the health maintenance
		  organization.
Y. "Supplemental
		  health care services" means any health care services other than basic health
		  care services.