[ARTICLE 26]

HEALTH BENEFIT PLAN NETWORK ACCESS AND ADEQUACY

 

     [§431:26-101]  Definitions.  As used in this article:

     "Active course of treatment" means:

     (1)  An ongoing course of treatment for a life-threatening condition;

     (2)  An ongoing course of treatment for a serious acute condition;

     (3)  The second or third trimester of pregnancy; or

     (4)  An ongoing course of treatment for a health condition for which a treating physician or health care provider attests that discontinuing care by that physician or health care provider would worsen the condition or interfere with anticipated outcomes.

     The term "active course of treatment" includes treatment of a covered person on a regular basis by a provider being removed from or leaving the network.

     "Affordable Care Act" refers to the Patient Protection and Affordable Care Act (42 U.S.C. 18001, et seq.), as amended, and its related regulations.

     "Authorized representative" means:

     (1)  A person to whom a covered person has given express written consent to represent the covered person;

     (2)  A person authorized by law to provide substituted consent for a covered person; or 

     (3)  The covered person's treating health care professional only when the covered person or persons authorized pursuant to paragraphs (1) and (2) of this definition are unable to provide consent.

     "Commissioner" means the insurance commissioner of the State.

     "Covered benefit" means those health care services to which a covered person is entitled under the terms of a health benefit plan.

     "Covered person" means a policyholder, subscriber, enrollee, or other individual participating in a health benefit plan, offered or administered by a person or entity, including but not limited to an insurer governed by this chapter, a mutual benefit society governed by article 1 of chapter 432, and as a health maintenance organization governed by chapter 432D.

     "Essential community provider" means a provider that:

     (1)  Serves predominantly low-income, medically underserved individuals, including a health care provider that is a covered entity as defined in section 340B(a)(4) of the Public Health Service Act; or

     (2)  Is described in section 1927(c)(1)(D)(i)(IV) of the Social Security Act, as set forth by section 221 of Public Law 111-8.

     "Facility" means an institution providing health care services or a health care setting, including hospitals and other licensed inpatient centers, ambulatory surgical or treatment centers, skilled nursing centers, residential treatment centers, urgent care centers, diagnostic facilities, laboratories, and imaging centers, and rehabilitation and other therapeutic health settings licensed or certified by the department of health under chapter 321.

     "Health benefit plan" means a policy, contract, certificate, or agreement entered into, offered by, or issued by a health carrier to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services pursuant to chapter 87A, 431, 432, or 432D.

     "Health care professional" means a physician or other health care practitioner licensed, accredited, or certified to perform specified health care services consistent with the practitioner's scope of practice under state law.

     "Health care provider" or "provider" means a health care professional, pharmacy, or facility.

     "Health care services" means services for the diagnosis, prevention, treatment, cure, or relief of a physical, mental, or behavioral health condition, illness, injury, or disease, including mental health and substance use disorders.

     "Health carrier" or "carrier" means an entity subject to the insurance laws and regulations of this State, or subject to the jurisdiction of the commissioner, that contracts or offers to contract, or enters into an agreement to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services, including a health insurance company, a health maintenance organization, a hospital and health service corporation, or any other entity providing a plan of health insurance, health benefits, or health care services.

     "Health carrier" or "carrier" includes an accident and health or sickness insurer that issues health benefit plans under part I of article 10A of this chapter, a mutual benefit society under article 1 of chapter 432, and a health maintenance organization under chapter 432D.

     "Integrated delivery system" means a health carrier that provides a majority of its members' covered health care services through physicians and nonphysician practitioners employed by the health carrier or through a single contracted medical group.

     "Intermediary" means a person authorized to negotiate and execute provider contracts with health carriers on behalf of health care providers or on behalf of a network, if applicable.

     "Limited scope dental plan" means a plan that provides coverage primarily for treatment of the mouth, including any organ or structure within the mouth, under a separate policy, certificate, or contract of insurance or is otherwise not an integral part of a health benefit plan.

     "Limited scope vision plan" means a plan that provides coverage primarily for treatment of the eye through a separate policy, certificate, or contract of insurance or is otherwise not an integral part of a health benefit plan.

     "Network" means the group or groups of participating providers providing services under a network plan.

     "Network plan" means a health benefit plan that either requires a covered person to use, or creates incentives, including financial incentives, for a covered person to use, health care providers managed, owned, under contract with, or employed by the health carrier.

     "Participating provider" means a provider who, under a contract with the health carrier or with the health carrier's contractor or subcontractor, has agreed to provide health care services to covered persons with an expectation of receiving payment, other than coinsurance, copayments, or deductibles, directly or indirectly from the health carrier.

     "Person" means an individual, a corporation, a partnership, an association, a joint venture, a joint stock company, a trust, an unincorporated organization, any similar entity, or any combination of the foregoing.

     "Primary care" means health care services for a range of common conditions provided by a physician or nonphysician primary care professional.

     "Primary care professional" means a participating health care professional designated by the health carrier to supervise, coordinate, or provide initial care or continuing care to a covered person, and who may be required by the health carrier to initiate a referral for specialty care and maintain supervision of health care services rendered to the covered person.

     "Serious acute condition" means a disease or condition for which the covered person is currently requiring complex ongoing care, such as chemotherapy, post-operative visits, or radiation therapy.

     "Specialist" means a physician or nonphysician health care professional who focuses on a specific area of health care services or on a group of patients and who has successfully completed required training and is recognized by the state in which the physician or nonphysician health care professional practices to provide specialty care.

     "Specialist" includes a subspecialist who has additional training and recognition above and beyond the subspecialist's specialty training.

     "Specialty care" means advanced medically necessary care and treatment of specific health conditions or health conditions that may manifest themselves in particular ages or subpopulations that are provided by a specialist, preferably in coordination with a primary care professional or other health care professional.

     "Telehealth" means health care services provided through telecommunications technology by a health care professional who is at a location other than where the covered person is located.

     "Tier" means specific groups of providers and facilities identified by a network and to which different provider reimbursement, covered person cost-sharing, provider access requirements, or any combination thereof, apply for the same services. [L 2017, c 191, pt of §1]

 

 

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