Ala. Admin. Code r. 482-1-115-.03

Current through Register Vol. 43, No. 1, October 31, 2024

Section 482-1-115-.03 - Definitions

The following definitions shall apply for purposes of this chapter:

(a) BENEFIT PLAN or PLANS. The major medical indemnity plan or plans and the managed care plan or plans offered under the Plan.

(b) BOARD. The Board of Directors of the Plan. The Board shall be the Plan Administrator.

(c) CLAIMS ADMINISTRATOR. The entity or entities chosen by the Board in accordance with Rule 482-1-115-.07 to administer the Plan and to process benefit claims of members of the Plan.

(d) COMMISSIONER. The Alabama Commissioner of Insurance.

(e) CONTINUOUS COVERAGE. Coverage having no breaks of 63 full days or more.

(f) DEPARTMENT. The Alabama Department of Insurance.

(g) DEPENDENT. A child under the age of 26, or a child of any age who is disabled and dependent upon the parent.

(h) HEALTH INSURANCE. Any hospital and medical expense incurred policy, nonprofit health care service plan contract, health maintenance organization subscriber contract, or any other health care plan or arrangement that pays for or furnishes medical or health care services whether by insurance or otherwise, that meets the definition of creditable health insurance coverage as described by 45 C.F.R. 146.113. The term does not include, accident, dental-only, vision-only, fixed indemnity, limited benefit, disability income, long-term care, Medicare supplement, or credit insurance, nor coverage issued as a supplement to liability insurance, insurance arising out of a workers' compensation or similar law, automobile medical-payment insurance, or insurance under which benefits are payable with or without regard to fault and which is statutorily required to be contained in any liability insurance policy or equivalent self-insurance.

(i) HEALTH MAINTENANCE ORGANIZATION. As defined in Section 27-21A-1, Code of Ala. 1975.

(j) HOSPITAL. As defined in Section 22-21-20, Code of Ala. 1975.

(k) INSURER. Any entity that provides health insurance in this state, including an insurance company licensed pursuant to Section 27-3-1, et seq.; a health care service plan licensed pursuant Section 10-4-100, et seq.; a fraternal benefit society licensed pursuant to Section 27-34-1, et seq.; a health maintenance organization licensed pursuant to Section 27-21A-1, et seq.; and any other entity providing a plan of health insurance or health benefits whether or not subject to state insurance regulation. In the case of a self-funded health benefit plan operating through a third party administrator, the third party administrator shall be the insurer for the purposes of this chapter.

(l) MEDICAID. Coverage under Title XIX of the Social Security Act, 42 USC 1396, et seq.

(m) MEDICARE. Coverage under Title XVIII of the Social Security Act, 42 USC 1395, et seq.

(n) OPERATIONS ADMINISTRATOR. The entity or entities chosen by the Board in accordance with Rule 482-1-115-.06 to conduct the daily activities of the Plan.

(o) PARTICIPATING INSURER. Any insurer providing health insurance to residents of this state.

(p) PHYSICIAN. As defined in Section 25-5-310, Codeof Ala. 1975.

(q) PLAN. The Alabama Health Insurance Plan as created in Section 27-52-1, Code of Ala. 1975.

(r) PLAN ADMINISTRATOR. The Alabama Health Insurance Board.

(s) PLAN OF OPERATION. The operating rules and procedures adopted by the Board pursuant to Section 27-52-2, Code of Ala. 1975.

(t) PRE-EXISTING MEDICAL CONDITION. Any condition, no matter how caused, for which an individual received medical advice, diagnosis, care, or for which treatment was recommended or received during the six months before the effective date coverage began.

(u) PRIOR CONTINUOUS COVERAGE. 18 months of continuous coverage of health insurance.

(v) PROVIDER. A physician or other individual licensed to provide health care services available under health insurance in this state and operating within the scope of that license.

(w) RESIDENT. An individual who is legally domiciled in this state. For the purposes of this chapter, no particular period of time is required to establish legal domicile, however a person may have only one legal domicile at a time.

(x) THE ACT. Chapter 52 of Title 27, beginning with Section 27-52-1, Code of Ala. 1975.

Ala. Admin. Code r. 482-1-115-.03

New Rule: July 23, 1997; effective August 30, 1997. Revised: November 13, 2002; effective December 29, 2002. Filed with LRS December 19, 2002. Rule is not subject to the Alabama Administrative Procedure Act. Revised: September 2, 2005; effective September 12, 2005. Filed with LRS September 2, 2005. Rule is not subject to the Alabama Administrative Procedure Act. Revised: May 13, 2010; effective June 1, 2010. Filed with LRS May 13, 2010. Rule is not subject to the Alabama Administrative Procedure Act. Revised: September 9, 2010; effective September 30, 2010. Filed with LRS September 9, 2010. Rule is not subject to the Alabama Administrative Procedure Act.

Author: Elizabeth Bookwalter, Associate Counsel

Statutory Authority:Code of Ala. 1975, §§ 27-2-17, 27-52-1, et seq.