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      RS 22:242     


§242. Definitions

            As used in this Subpart:

            (1) "Basic health care services" means emergency care, inpatient hospital and physician care, outpatient medical and chiropractic services, and laboratory and x-ray services. The term shall include optional coverage for mental health services for alcohol or drug abuse. With respect to chiropractic services, such services shall be provided on a referral basis at the request of the enrollee who presents a condition of an orthopedic or neurological nature necessitating referral, the treatment for which falls within the scope of a licensed chiropractor. The term shall also include coverage for low protein food products as provided in R.S. 22:246.

            (2) "Commissioner" means the commissioner of insurance.

            (3) "Enrollee" means an individual who is enrolled in a health maintenance organization.

            (4) "Evidence of coverage" means any certificate, agreement, or contract issued to an enrollee setting out the coverage to which the enrollee is entitled by reason of payment of a prepaid charge.

            (5) "Health care services" means any services rendered by providers which include but are not limited to medical and surgical care; psychological, optometric, optic, chiropractic, podiatric, nursing, and pharmaceutical services; health education, rehabilitative, and home health services; physical therapy; inpatient and outpatient hospital services; dietary and nutritional services; laboratory and ambulance services; and any other services for the purpose of preventing, alleviating, curing, or healing human illness, injury, or physical disability. Health care services shall also mean dental care, limited to oral and maxillofacial surgery as performed by board qualified oral and maxillofacial surgeons. The term shall also include an annual Pap test for cervical cancer and minimum mammography examination as defined in R.S. 22:1028 and coverage for low protein food products as provided in R.S. 22:246.

            (6) "Health maintenance organization" means any corporation organized as either a business corporation or a nonprofit corporation and domiciled in this state which undertakes to provide or arrange for the provision of basic health care services to enrollees in return for a prepaid charge. The health maintenance organization may also provide or arrange for the provision of other health care services to enrollees on a prepayment or other financial basis. A health maintenance organization is considered to be an insurer for the purposes of R.S. 22:73, 96, 691.1 through 691.27, 731 through 737, 1022 and 1023, 1921 through 1929, and 2001 through 2045. A health maintenance organization shall not be considered an insurer for any other purpose.

            (7) "Point of service policy" means any policy of coverage that meets the definition of a health and accident insurance policy pursuant to R.S. 22:34, 35, 851-870, 872-883, 885-889, 901, 902, 944, 945, 972-983, 985-990, 992-1015, 1021-1048, 1091-1097, 1111, 1156, 1261-1270, 1281-1283, 1285-1288, 1290-1293, 1295-1297, 1331, 1333-1335, 1441, 1555, 1811, 1821-1823, and 1891-1894.

            (8) "Provider" means any physician, hospital, or other person, organization, institution, or group of persons licensed or otherwise authorized in this state to furnish health care services.

            (9) "Secretary" means the secretary of the Louisiana Department of Health.

            (10) "Subscriber" means the person who is responsible for payment to a health maintenance organization or whose employment or other status, except for family dependence, is the basis for eligibility for enrollment in the health maintenance organization.

            Acts 1986, No. 1065, §1; Acts 1989, No. 666, §1, eff. Sept. 1, 1989; Acts 1991, No. 387, §1; Acts 1991, No. 994, §1; Acts 1992, No. 316, §1; Acts 1995, No. 1231, §1, eff. Sept. 1, 1995; Acts 1997, No. 1418, §1; Acts 1999, No. 878, §1, eff. July 2, 1999; Acts 2003, No. 829, §1; Redesignated from R.S. 22:2002 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009; Acts 2009, No. 503, §1; Acts 2012, No. 271, §1; Acts 2020, 2nd Ex. Sess., No. 58, §1, eff. Nov. 5, 2020.

NOTE: Former R.S. 22:242 redesignated as R.S. 22:1215 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009.

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