La. Admin. Code tit. 37 § XIII-3105

Current through Register Vol. 50, No. 11, November 20, 2024

Section XIII-3105 - Definitions

A. For the purposes of this regulation:

Accidental Injury- bodily injury sustained as the result of an unforeseen event and which is the direct reason for receiving care and treatment (independent of disease, bodily infirmity or any other cause). Such care shall occur while coverage under the pilot is in force. It does not include injuries for which benefits are provided under any workers' compensation, employers' liability, or for which another party is liable under automobile, property and casualty, and other coverage.

Admission- begins the first day an insured becomes a registered hospital inpatient and continues until insured is discharged from the facility.

Adult- an individual who is greater than 24 but less than 65 years of age.

Applicant- an individual who applies for coverage under the LA Health Plan.

Authorized Carrier- the health insurance carrier or health maintenance organization licensed and in compliance with the Louisiana Insurance Code certified by the department to offer the LA Health Plan.

Benefit Payment- the amount the authorized carrier will pay for covered services. See §3127-3133 of this regulation.

Benefit Period- one year, also referred to as year or calendar year. The benefit period does not begin before the insured's effective date. The benefit period does not continue after the insured's coverage ends.

Clinic- a facility for the diagnosis, care and treatment of outpatients.

Commissioner- the Louisiana Commissioner of Insurance.

Co-Payment- the cost-sharing fee charged to an insured under LA Health as specified in the contract between the authorized carrier for LA Health and the insured.

Department- the Louisiana Department of Insurance.

Dependent-

a. the spouse and all unmarried children under the age of 24;

b. children include natural children, legally adopted children and step-children. Also included are children (or children of a spouse) for whom an insured has legal responsibility resulting from a valid court decree. Foster children that an insured expects to raise to adulthood and that live with an insured in a regular parent-child relationship are considered children;

c. students who are unmarried children who have not yet attained the age of 24 and who are enrolled as fulltime students and who are dependent upon the primary insured;

d. mentally retarded or physically handicapped children remain covered to age 21 at which time they are eligible for their own individual coverage;

e. a child's coverage ends when any of the following occurs:

i. marriage or attaining age 21 (whichever comes first);

ii. termination of an insured's coverage under the LA Health Plan; or

iii. if a child over age 21 no longer qualifies as a full-time student.

Effective Date- the date an applicant becomes eligible for coverage under an authorized carrier for the LA Health Plan.

Hospital- an institution, licensed by the state, which:

a. provides inpatient services and is compensated by or on behalf of its patients;

b. primarily provides medical and surgical facilities to diagnose, treat and care for the injured or sick;

c. has a staff of physicians licensed to practice medicine by the Louisiana State Board of Medical Examiners;

d. provides nursing care by registered nurses or:

NOTE: The term hospital does not mean:

1. an extended care facility, nursing home, community based care, or group home;

2. a place of rest;

3. a facility for the aged;

4. a custodial institution whose primary purpose is to furnish food, shelter, training, or unskilled or nonmedical services; or

5. an institution for exceptional or handicapped children. licensed practical nurses on duty 24-hours-a-day.

Insurance Producer or Producer- an individual who is licensed by the commissioner as an insurance producer pursuant to the provisions of R.S. 22:1541-1566.

Insured- an individual domiciled in this state who is eligible to receive benefits from an authorized carrier under the LA Health Plan.

LA Health- the Louisiana Basic Health Insurance Plan Pilot Program.

Louisiana Insurance Code- Title 22 of the Louisiana Revised Statutes of 1950.

Mental and Nervous Disorders- includes (whether organic or nonorganic, whether of biological, nonbiological, genetic, chemical, or nonchemical origin, and irrespective of cause, basis or inducement) mental disorders, mental illnesses, psychiatric illnesses, mental conditions and psychiatric conditions. This includes, but is not limited to, psychoses, neurotic disorders, schizophrenic disorders, affective disorders, personality disorders and psychological or behavioral abnormalities associated with transient or permanent dysfunction of the brain or related neurohormonal systems. This is intended to include disorders, conditions, and illnesses listed in Diagnostic and Statistical Manual of Mental Disorders (DSM-IIIR).

Minor Dependent- a dependent under the age of 24.

Non-Smoker- an individual who has not smoked cigarettes, cigars, pipes or other substances within the past year.

Participating Hospital- a hospital located in Louisiana which has concluded a written agreement with, and in form approved by, an authorized carrier under the LA Health Plan.

Participating Provider- a licensed health care provider who has concluded an agreement with, and in form approved by, an authorized carrier under the LA Health Plan to serve those insured by LA Health.

Pilot Plan- a plan that provides an insured with health insurance under the LA Health program and is governed by R.S. 22:2241-2247 and authorized by the commissioner.

Pilot Program- the program of health insurance which is authorized by R.S. 22:2241-2247.

Provider- includes any discipline licensed by the state of Louisiana to provide and be directly reimbursed for services covered by the LA Health Plan including, but not limited to, the following:

a. doctor of medicine (M.D.) legally entitled to practice medicine and perform surgery by the Louisiana State Board of Medical Examiners;

b. doctor of chiropractic (D.C.) legally entitled to practice chiropractic services;

c. doctor of podiatric medicine (D.P.M.) legally entitled to practice podiatry;

d. all providers shall be licensed by the state of Louisiana.

Semiprivate Room- a hospital room which has 2, 3, or 4 beds.

Service Area- that part of the state of Louisiana in which the authorized carrier is applying to offer or is offering the pilot plan.

Skilled Nursing Care- care required, while recovering from an illness or injury, which is received in a skilled nursing facility. This care requires a level of care or services less than that in a hospital, but more than could be given in the patient's home or in a nursing home not certified as a skilled nursing facility.

Smoker- an individual who has smoked cigarettes, cigars, pipes or other substances within the past year or who is currently smoking cigarettes, cigars, pipes or other substances.

Utilization Review- a function performed by an authorized carrier under the LA Health Plan or an entity selected by the carrier to review and approve whether the services provided, or to be provided, are medically necessary including, but not limited to, whether acute hospitalization, length of stay, outpatient care, or diagnostic services are appropriate.

La. Admin. Code tit. 37, § XIII-3105

Promulgated by the Department of Insurance, Office of the Commissioner, LR 20:1012 (September 1994), Amended LR 49490 (3/1/2023).

AUTHORITY NOTE: Promulgated in accordance with R.S. 22:11, R.S. 22:2241-2247, and the Administrative Procedure Act, R.S. 49:950 et seq.