103.003. Definitions.
Definitions.
103.003. As used in sections 103.003 to 103.175, the following termsmean:
(1) "Actuarial reserves", the necessary funding required to pay allthe medical expenses for services provided to members of the plan but forwhich the claims have not yet been received by the claims administrator;
(2) "Actuary", a member of the American Academy of Actuaries or whois an enrolled actuary under the Employee Retirement Income Security Act of1974;
(3) "Agency", a state-sponsored institution of higher learning,political subdivision or governmental entity or instrumentality;
(4) "Alternative delivery health care program", a plan of coveredbenefits that pays medical expenses through an alternate mechanism ratherthan on a fee-for-service basis. This includes, but is not limited to,health maintenance organizations and preferred provider organizations, allof which shall include chiropractic physicians licensed under chapter 331,RSMo, in the provider networks or organizations;
(5) "Board", the board of trustees of the Missouri consolidatedhealth care plan;
(6) "Claims administrator", an agency contracted to process medicalclaims submitted from providers or members of the plan and theirdependents;
(7) "Coordination of benefits", to work with another group-sponsoredhealth care plan which also covers a member of the plan to ensure that bothplans pay their appropriate amount of the health care expenses incurred bythe member;
(8) "Covered benefits", a schedule of covered services, includingchiropractic services, which are payable under the plan;
(9) "Employee", any person employed full time by the state or aparticipating member agency, or a person eligible for coverage by astate-sponsored retirement system or a retirement system sponsored by aparticipating member agency of the plan;
(10) "Evidence of good health", medical information supplied by apotential member of the plan that is reviewed to determine the financialrisk the person represents to the plan and the corresponding determinationof whether or not he or she should be accepted into the plan;
(11) "Health care plan", any group medical benefit plan providingcoverage on an expense-incurred basis, any HMO, any group service orindemnity contract issued by a health plan of any type or description;
(12) "Medical benefits coverages" shall include services provided bychiropractic physicians as well as physicians licensed under chapter 334,RSMo;
(13) "Medical expenses", costs for services performed by a providerand covered under the plan;
(14) "Missouri consolidated health care plan benefit fund account",the benefit trust fund account containing all payroll deductions, payments,and income from all sources for the plan;
(15) "Officer", an elected official of the state of Missouri;
(16) "Participating member agency", a state-sponsored institution ofhigher learning, political subdivision or governmental entity that haselected to join the plan and has been accepted by the board;
(17) "Plan year", a twelve-month period designated by the board whichis used to calculate the annual rate categories and the appropriatecoverage;
(18) "Provider", a physician, hospital, pharmacist, psychologist,chiropractic physician or other licensed practitioner who or which provideshealth care services within the respective scope of practice of suchpractitioner pursuant to state law and regulation;
(19) "Retiree", a person who is not an employee and is receiving oris entitled to receive an annuity benefit from a state-sponsored retirementsystem or a retirement system of a participating member agency of the planor becomes eligible for retirement benefits because of service with aparticipating member agency.
(L. 1992 H.B. 1574 § 1 subsec. 1, A.L. 1995 S.B. 410, A.L. 1996 H.B. 1400, A.L. 2000 S.B. 885)