Effective 28 Aug 2016

103.003. Definitions. — As used in sections 103.003 to 103.175, the following terms mean:

(1) "Actuarial reserves", the necessary funding required to pay all the medical expenses for services provided to members of the plan but for which the claims have not yet been received by the claims administrator;

(2) "Actuary", a member of the American Academy of Actuaries or who is an enrolled actuary under the Employee Retirement Income Security Act of 1974;

(3) "Agency", a state-sponsored institution of higher learning, political subdivision or governmental entity or instrumentality;

(4) "Alternative delivery health care program", a plan of covered benefits that pays medical expenses through an alternate mechanism rather than on a fee-for-service basis. This includes, but is not limited to, health maintenance organizations and preferred provider organizations, all of which shall include chiropractic physicians licensed under chapter 331, in the provider networks or organizations;

(5) "Board", the board of trustees of the Missouri consolidated health care plan;

(6) "Claims administrator", an agency contracted to process medical claims submitted from providers or members of the plan and their dependents;

(7) "Coordination of benefits", to work with another group-sponsored health care plan which also covers a member of the plan to ensure that both plans pay their appropriate amount of the health care expenses incurred by the member;

(8) "Covered benefits", a schedule of covered services, including chiropractic services, which are payable under the plan;

(9) "Employee", any person employed full time by the state or a participating member agency, or a person eligible for coverage by a state-sponsored retirement system or a retirement system sponsored by a participating member agency of the plan;

(10) "Evidence of good health", medical information supplied by a potential member of the plan that is reviewed to determine the financial risk the person represents to the plan and the corresponding determination of whether or not he or she should be accepted into the plan;

(11) "Health care plan", any group medical benefit plan providing coverage on an expense-incurred basis, any HMO, any group service or indemnity contract issued by a health plan of any type or description;

(12) "Medical benefits coverages" shall include services provided by chiropractic physicians as well as physicians licensed under chapter 334;

(13) "Medical expenses", costs for services performed by a provider and covered under the plan;

(14) "Missouri consolidated health care plan benefit fund account", the benefit trust fund account containing all payroll deductions, payments, and income from all sources for the plan;

(15) "Officer", an elected official of the state of Missouri;

(16) "Participating higher education entity", a state-sponsored institution of higher learning;

(17) "Participating member agency", a political subdivision or governmental entity that has elected to join the plan and has been accepted by the board;

(18) "Plan year", a twelve-month period designated by the board which is used to calculate the annual rate categories and the appropriate coverage;

(19) "Provider", a physician, hospital, pharmacist, psychologist, chiropractic physician or other licensed practitioner who or which provides health care services within the respective scope of practice of such practitioner pursuant to state law and regulation;

(20) "Retiree", a person who is not an employee and is receiving or is entitled to receive an annuity benefit from a state-sponsored retirement system or a retirement system of a participating member agency of the plan or becomes eligible for retirement benefits because of service with a participating member agency.

­­--------

(L. 1992 H.B. 1574 § 1 subsec. 1, A.L. 1995 S.B. 410, A.L. 1996 H.B. 1400, A.L. 2000 S.B. 885, A.L. 2016 S.B. 997)