2019 Connecticut General Statutes
Title 38a - Insurance
Chapter 700c - Health Insurance
Section 38a-478 - Definitions.
As used in this section, sections 38a-478a to 38a-478o, inclusive, and subsection (a) of section 38a-478s:
(1) “Commissioner” means the Insurance Commissioner.
(2) “Covered benefit” or “benefit” means a health care service to which an enrollee is entitled under the terms of a health benefit plan.
(3) “Enrollee” means a person who has contracted for or who participates in a managed care plan for such person or such person's eligible dependents.
(4) “Health care services” means services for the diagnosis, prevention, treatment, cure or relief of a health condition, illness, injury or disease.
(5) “Managed care organization” means an insurer, health care center, hospital service corporation, medical service corporation or other organization delivering, issuing for delivery, renewing, amending or continuing any individual or group health managed care plan in this state.
(6) “Managed care plan” means a product offered by a managed care organization that provides for the financing or delivery of health care services to persons enrolled in the plan through: (A) Arrangements with selected providers to furnish health care services; (B) explicit standards for the selection of participating providers; (C) financial incentives for enrollees to use the participating providers and procedures provided for by the plan; or (D) arrangements that share risks with providers, provided the organization offering a plan described under subparagraph (A), (B), (C) or (D) of this subdivision is licensed by the Insurance Department pursuant to chapter 698, 698a or 700 and the plan includes utilization review, as defined in section 38a-591a.
(7) “Preferred provider network” has the same meaning as provided in section 38a-479aa.
(8) “Provider” or “health care provider” means a person licensed to provide health care services under chapters 370 to 373, inclusive, 375 to 383c, inclusive, 384a to 384c, inclusive, or chapter 400j.
(9) “Utilization review” has the same meaning as provided in section 38a-591a.
(10) “Utilization review company” has the same meaning as provided in section 38a-591a.
(P.A. 97-99, S. 1; P.A. 03-169, S. 10; P.A. 04-125, S. 2; P.A. 05-94, S. 5; P.A. 09-49, S. 1; P.A. 11-58, S. 67; P.A. 15-118, S. 3.)
History: P.A. 03-169 added Subdivs. (6) to (8), defining “preferred provider network”, “utilization review” and “utilization review company”; P.A. 04-125 redefined “provider” in Subdiv. (4) to reference “chapter 383c”; P.A. 05-94 redefined “enrollee” in Subdiv. (5) to add “Except as provided in sections 38a-478m and 38a-478n”, effective July 1, 2005; P.A. 09-49 defined “adverse determination” in new Subdiv. (1), “covered benefit” and “health care services” in new Subdivs. (3) and (5) and “review entity” in new Subdiv. (10), repositioned definitions of “enrollee” from former Subdiv. (5) to new Subdiv. (4) and “preferred provider network” from former Subdiv. (6) to new Subdiv. (8), redesignated existing Subdivs. (1) to (4), (7) and (8) as Subdivs. (2), (6), (7), (9), (11) and (12), and made conforming and technical changes; P.A. 11-58 deleted former Subdivs. (1) and (10) re definitions of “adverse determination” and “review entity”, replaced references to Sec. 38a-226 with references to Sec. 38a-591a and made conforming and technical changes, effective July 1, 2011; P.A. 15-118 made a technical change in Subdiv. (5).
