§1202. Definitions

As used in this Subpart:

(1) "Ambulatory surgical center" means an establishment in this state as defined in and licensed under the provisions of R.S. 40:2131 et seq., as may be from time to time amended.

(2) "Benefits plan" means the coverages offered by the plan to eligible persons as defined by R.S. 22:1207.

(3) "Board" means the board of directors of the plan.

(4) "Church plan" has the meaning given such term under Section 3(33) of the Employee Retirement Income Security Act of 1974.

(5) "Commissioner" means the commissioner of insurance.

(6) "Creditable coverage" means, with respect to an individual, coverage to the individual as defined by R.S. 22:1061(4).

(7) "Department" means the Department of Insurance.

(8) "Dependent" means a resident spouse or resident unmarried child under the age of twenty-one years, a child who is a student under the age of twenty-four years and who is financially dependent upon the parent, or a child of any age who is disabled and dependent upon the parent.

(9) "Family group insurance" means health and accident insurance as defined in R.S. 22:1000(A)(2)(a).

(10) "Federally defined eligible individual" means an individual as defined by R.S. 22:1073(B).

(11) "Government plan" has the meaning given such term under R.S. 22:1061(5)(g).

(12) "Group health benefit plan" means an employee welfare benefit plan as defined by R.S. 22:1061(1).

(13) "Health and accident insurance" means hospital and medical expense incurred policies, nonprofit service plan corporation contracts, and coverages provided by health maintenance organizations, individual practices, associations, the Office of Group Benefits, and other similar entities and self-insurers. The term "health and accident insurance" does not include short term, accident only, hospital indemnity, credit insurance, automobile and homeowner's medical-payment coverage, workers' compensation medical benefit coverage, Medicare, Medicaid, federal governmental benefit plans, supplemental health insurance, limited benefit health insurance, or coverage issued as a supplement to liability insurance.

(14) "Health care provider" means a person licensed by this state to provide health care or professional services under the provisions of Title 37 of the Louisiana Revised Statutes of 1950 or any professional corporation, as a health care provider, authorized to form under the provisions of Title 12 of the Louisiana Revised Statutes of 1950 or such a person licensed by the appropriate laws of another state.

(15) "Health maintenance organization" means an organization as defined in R.S. 22:242(7).

(16) "Hospital" means any facility as defined in R.S. 40:2102 established for the care and treatment of the sick and injured.

(17) "Insurance arrangement" means any plan, program, contract, or any other arrangement under which one or more natural or juridical persons provide to their employees or participants, whether directly or indirectly, health care services or benefits other than through an insurer. The term shall also include any "self-insurer" as defined herein.

(18) "Insured" means any natural person domiciled in this state, other than a member of the plan, who is eligible to receive benefits from any insurer or insurance arrangement as defined in this Section.

(19) "Insurer" means any insurance company or other entity authorized to transact and transacting health and accident insurance business in this state. Notwithstanding any contrary provisions of R.S. 22:242(7) or any other law, regulation, or definition contained in this Title, a health maintenance organization shall be deemed an insurer for the purposes of this Subpart. The term "insurer" shall not include any insurance company whose products are marketed on the home service distribution method and which issues a majority of these policies on a weekly or monthly basis.

(20) "Medical care" means amounts paid for as defined in R.S. 22:1061(1)(b).

(21) "Medicaid" means coverage provided under the state plan for Title XIX of the Social Security Act, 42 USC 1396 et seq., as amended.

(22) "Medicare" means coverage under both Parts A and B of Title XVIII of the Social Security Act, 42 U.S.C. 1395 et seq., as amended.

(23) "Member" means a person covered by the plan.

(24) "Plan" means the Louisiana Health Plan as created in R.S. 22:1203.

(25) "Plan of operation" means the plan of operation of the plan, including articles, bylaws, and operating rules, adopted by the board pursuant to R.S. 22:1205.

(26) "Private pay patient" means a natural person who is not covered by any policy or plan of insurance or by a self-insurer or whose charges for injury or illness are not compensable by his employer or other insurer or insurance arrangement.

(27) "Public program" means any public assistance program which provides funding for health care services rendered by a health care provider that is directly subsidized by the federal government.

(28) "Self-insurer" means a natural or juridical person which provides health care services or reimbursement for all or any part of the costs of health care for its employees or participants in this state other than through an insurer.

(29) "Small employer" means any person, firm, corporation, partnership, or association actively engaged in business which, on at least fifty percent of its working days during the preceding year, employed not less than one nor more than twenty-five eligible employees. In determining the number of eligible employees, companies which are affiliated companies or which are eligible to file a combined tax return for purposes of state taxation shall be considered one employer.

Acts 1990, No. 131, §1, eff. Sept. 1, 1990; Acts 1991, No. 574, §1, eff. July 16, 1991; Acts 1997, No. 1154, §1, eff. Jan. 1, 1998; Acts 1999, No. 163, §1; Acts 1999, No. 294, §1; Acts 2001, No. 1178, §2, eff. June 29, 2001; Acts 2005, No. 154, §1, eff. June 28, 2005; Acts 2008, No. 21, §1; Redesignated from R.S. 22:232 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009.

NOTE: Former R.S. 22:1202 redesignated as R.S. 22:1622 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009.