W. Va. Code R. § 114-91-2

Current through Register Vol. XLI, No. 50, December 13, 2024

Section 114-91-2 - Definitions

2.1. "Commissioner" means the Insurance Commissioner of the State of West Virginia.

2.2. "Enrollee" means an individual who has been voluntarily enrolled in a health maintenance organization, including individuals on whose behalf a contractual arrangement has been entered into with a health maintenance organization to receive health care.

2.3. "Health care services" means any services or goods included in the furnishing to any individual of medical, mental or dental care, or hospitalization or incident to the furnishing of the care or hospitalization, osteopathic services, chiropractic services, podiatric services, home health, health education or rehabilitation, as well as the furnishing to any person of any and all other services or goods for the purpose of preventing, alleviating, curing or healing human illness or injury.

2.4. "In-plan covered services" means health care services provided by a provider that is within the panel of providers with which a health maintenance organization has a contractual agreement.

2.5. "Out-of-plan covered services" means health care services provided by a provider that is not within the panel of providers with which a health maintenance organization has a contractual agreement.

2.6. "Point of service option" means a delivery system that permits an enrollee to receive health care services from a provider outside of the panel of providers with which a health maintenance organization has a contractual agreement under the terms and conditions of the enrollee's contract with the health maintenance organization or an insurance carrier that provides the point of service option.

2.7. "Provider" means a person or other entity which holds a valid license to provide health care services.

W. Va. Code R. § 114-91-2