20-1051. Definitions
In this article, unless the context otherwise requires:
1. "Director" means the director of the department of insurance.
2. "Enrollee" means an individual who has been enrolled in a health care plan.
3. "Evidence of coverage" means any certificate, agreement or contract issued to an
enrollee and setting out the coverage to which the enrollee is entitled.
4. "Genetic information" means information about genes, gene products and inherited
characteristics that may derive from the individual or a family member, including
information regarding carrier status and information derived from laboratory tests that
identify mutations in specific genes or chromosomes, physical medical examinations,
family histories and direct analysis of genes or chromosomes.
5. "Health care plan" means any contractual arrangement whereby any health care
services organization undertakes to provide directly or to arrange for all or a portion
of contractually covered health care services and to pay or make reimbursement for any
remaining portion of the health care services on a prepaid basis through insurance or
otherwise. A health care plan shall include those health care services required in this
article or in any rule adopted pursuant to this article.
6. "Health care services" means services for the purpose of diagnosing, preventing,
alleviating, curing or healing human illness or injury.
7. "Health care services organization" means any person that undertakes to conduct
one or more health care plans. Unless the context otherwise requires, health care
services organization includes a provider sponsored health care services organization.
8. "Health status-related factor" means any factor in relation to the health of the
individual or a dependent of the individual enrolled or to be enrolled in a health care
services organization including:
(a) Health status.
(b) Medical condition, including physical and mental illness.
(c) Claims experience.
(d) Receipt of health care.
(e) Medical history.
(f) Genetic information.
(g) Evidence of insurability, including conditions arising out of acts of domestic
violence as defined in section 20-448.
(h) The existence of a physical or mental disability.
9. "Network plan" means health care services that are provided by a health care
services organization under which the financing and delivery of health care services are
provided, in whole or in part, through a defined set of providers under contract with the
health care services organization.
10. "Person" means any natural or artificial person including, but not limited to,
individuals, partnerships, associations, providers of health care, trusts, insurers,
hospital or medical service corporations or other corporations, prepaid group practice
plans, foundations for medical care and health maintenance organizations.
11. "Provider" means any physician, hospital or other person that is licensed or
otherwise authorized to furnish health care services in this state.
12. "Provider sponsored health care services organization" means a provider
sponsored organization that provides at least one health care plan only to medicare
beneficiaries under the medicare-plus-choice program established under the balanced
budget act of 1997 (42 United States Code sections 1395w-21 through 1395w-28 and title
XVIII, part C of the social security act, sections 1851 through 1859).
13. "Provider sponsored organization" means an entity that:
(a) Is a legal aggregation of providers that operate collectively to provide health
care services to medicare beneficiaries under the medicare-plus-choice program
established under the balanced budget act of 1997 (42 United States Code sections
1395w-21 through 1395w-28 and title XVIII, part C of the social security act, sections
1851 through 1859).
(b) Acts through a licensed firm or corporation that has authority over the entity's
activities and responsibility for satisfying the requirements of this article relating to
the operation of a provider sponsored health care services organization.
(c) Provides a substantial proportion of the health care services required to be
provided under the medicare-plus-choice program established under the balanced budget act
of 1997 (42 United States Code sections 1395w-21 through 1395w-28 and title XVIII, part C
of the social security act, sections 1851 through 1859) directly through providers or
affiliated groups of providers.
14. "Registered nurse practitioner" has the same meaning prescribed in section
32-1601.
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