§ 23-86-403 - Definitions.
23-86-403. Definitions.
As used in this subchapter:
(1) "Benefit level" means obligation of the health maintenance organization or insurance company under its health benefit plan. The benefit level is actuarially determined considering the copayments, deductibles, and dollar limits of the health benefit plan;
(2) "Covered health care services" means services rendered or products sold by a health care provider within the scope of the provider's license which are covered by a health benefit plan. The term may include hospital, medical, surgical, dental, vision, and pharmaceutical services or products;
(3) "Covered person" means any person on whose behalf a health maintenance organization is obligated to make arrangements for or pay for covered health care service;
(4) "Health benefit plan" means the agreement between an employer, association, state, county, or municipal agency and a health maintenance organization or insurance company which defines the covered services available;
(5) "Health care provider" means a hospital, an ambulatory surgery center, an outpatient psychiatric center, a home health care agency, a skilled nursing facility, or an individual licensed to render covered health care services;
(6) "Limited network plan" means a plan that arranges for or provides reimbursement for covered health care services to covered persons through a limited number of health care providers selected and employed or contracted by the health maintenance organization; and
(7) "Point-of-service plan" means a plan that provides payment of non-emergency, self-referred covered health care services obtained from providers who are not otherwise employed by nor under contract with the health maintenance organization.