2005 Idaho Code - 41-3903 — DEFINITIONS

                                  TITLE  41
                                  INSURANCE
                                  CHAPTER 39
                             MANAGED CARE REFORM
    41-3903.  DEFINITIONS. (1) "Basic health care services" means the
following services: preventive care, emergency care, inpatient and outpatient
hospital and  physician care, hospital-based rehabilitation treatment,
diagnostic laboratory and diagnostic and therapeutic radiological services.
It does not include mental health services or services for alcohol or drug
abuse, dental or vision services or long-term rehabilitation treatment.
    (2)  "Coinsurance" means a percentage amount a member is responsible to
pay out-of-pocket for health care services after satisfaction of  any
applicable deductibles or copayments, or both.
    (3)  "Copayment" means an amount a member must pay to a provider in
payment for a specific health care service which is not fully prepaid.
    (4)  "Deductible" means the amount of expense a member must first incur
before the managed care organization begins payment for covered services.
    (5)  "Director" means the director of the department of insurance of the
state of Idaho.
    (6)  "Emergency facility" means any hospital or other facility where
emergency services are provided to a member including, but not limited to, a
physician's office.
    (7)  "Emergency services" means those health care services that are
provided in a hospital or other emergency facility after the sudden onset of
a medical condition that manifests itself by symptoms of sufficient severity
including, but not limited to, severe pain, that the absence of immediate
medical attention could reasonably be expected by a prudent person who
possesses an average knowledge of health and medicine, to result in:
    (a)  Placing the patient's health in serious jeopardy;
    (b)  Serious impairment to bodily functions; or
    (c)  Serious dysfunction of any bodily organ or part.
    (8)  "Employer" means any person, firm, corporation, partnership or
association.
    (9)  "Enrollee" means a person who either individually or through a group
has entered into a contract for services under a managed care plan.
    (10) "General managed care plan" means a managed care plan which provides
directly or arranges to provide, at a minimum, basic health care services.  A
general managed care plan shall include basic health care services.
    (11) "Health care contract" means a contract entered into by a managed
care organization and an enrollee.
    (12) "Health care services" means those services offered or provided by
health care facilities and health care providers relating to the prevention,
cure or treatment of illness, injury or disease.
    (13) "Limited managed care plan" means a managed care plan which provides
dental care services, vision care services, mental health services, substance
abuse services, pharmaceutical services, podiatric care services or such other
services as the director may establish by rule to be limited health care
services. Limited health care services shall not include hospital, medical,
surgical or emergency services except as those services are provided incident
to limited health care services.
    (14) "Managed care organization" means a public or private person or
organization which offers a managed care plan.  Unless otherwise specifically
stated, the provisions  of this chapter shall apply to any person or
organization offering a managed care plan, whether or not a certificate of
authority to offer the plan is required under this chapter.
    (15) "Managed care plan" means a contract of coverage given to an
individual, family or group of covered individuals pursuant to which a member
is entitled to receive a defined set of health care benefits through an
organized system of health care providers in exchange for defined
consideration and which requires the member to use, or creates financial
incentives for the member to use, health care providers owned, managed,
employed by or under contract with the managed care organization. A person
holding a license to transact disability insurance offering a health plan that
creates financial incentives to use contracting providers may elect to file
the plan as a nonmanaged care plan not subject to the provisions of this
chapter if the health plan reimburses providers solely on a fee for service
basis and does not require the selection of a primary care provider. The
election to file a health plan as a nonmanaged care plan shall be made in
writing at the time the plan is filed with the director pursuant to chapter
18, title 41, Idaho Code.
    (16) "Member" means a policyholder, enrollee or other individual
participating in a managed care plan.
    (17) "Person" means any natural or artificial person including, but not
limited to, individuals, partnerships, associations, corporations or other
legally recognized entities.
    (18) "Provider" means any physician, hospital, or other person licensed or
otherwise authorized to furnish health care services.
    (19) "Utilization management program" means a system of reviewing the
medical necessity, appropriateness, or quality of health care services and
supplies provided under a managed care plan using specified guidelines. Such a
system may include, but is not limited to, preadmission certification, the
application of practice guidelines, continued stay review, discharge planning,
preauthorization of ambulatory procedures and retrospective review.