Definitions

  1. Law
  2. Georgia Code
  3. Insurance
  4. Health Care Plans
  5. Definitions

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As used in this chapter, the term:

  1. "Beneficiary" or "covered dependent" means a person designated in the subscription certificate or application therefor of a subscriber as entitled to health care service with respect to whom appropriate periodic payments are made, all subject to acceptance by the health care corporation.
  2. "Health care corporation" means a corporation established in accordance with the provisions of this chapter to administer one or more health care plans.
  3. "Health care plan" means a plan or arrangement under which health care services are or may be rendered to a subscriber or a covered dependent or other beneficiary at the expense of a health care corporation in consideration of periodic payments made by the subscriber or another in his or her behalf.
  4. "Health care services" means the examination or treatment of persons for the prevention of illness or the correction or treatment of any physical or mental condition resulting from illness, injury, or other human physical problem and includes but is not limited to:
    1. Hospital services which include the general and usual care, services, supplies, and equipment furnished by hospitals;
    2. Medical services which include the general and usual services and care rendered and administered by doctors of medicine, doctors of dental surgery, and doctors of podiatry; and
    3. Other health care services which include appliances and supplies; nursing care by a registered nurse or a licensed practical nurse; care furnished by such other licensed practitioners as may be expressly approved by the board of directors from time to time; institutional services including the general and usual care, services, supplies, and equipment furnished by health care institutions and agencies or entities other than hospitals; physiotherapy; ambulance services; drugs and medications; therapeutic services and equipment including oxygen and the rental of oxygen equipment; hospital beds; iron lungs; orthopedic services and appliances including wheelchairs, trusses, braces, crutches, and prosthetic devices including artificial limbs and eyes; and any other appliance, supply, or service related to health care.
  5. "Income at risk" means the amount of income earned on an account in which a risk of underwriting loss due to adverse claims experience exists. In the case of any risk account as to which the rate is not established directly by the health care corporation, income at risk shall be the sum total of benefits paid and administrative costs incurred for such account for which the health care corporation has been or will be reimbursed.
  6. "Participating facility" means a hospital, extended care facility, or other facility, institution, agency, or entity providing health care services which agrees in writing with a health care corporation to provide services specified in the subscription contracts issued by the corporation at such rates of compensation as shall be determined by the board of directors of the corporation and which agrees to abide by the bylaws, rules, and regulations of the corporation applicable to participating facilities. A participating facility must be licensed or approved as such by the appropriate agency of this state, some other state, or the federal government or shall meet such requirements as shall be established by the health care corporation if no regulatory license or approval is required.
  7. "Participating physician" means a doctor of medicine licensed to practice medicine or surgery in this state under Chapter 34 of Title 43, a dental surgeon licensed to practice dental surgery in this state under Chapter 11 of Title 43, or a podiatrist licensed to practice podiatry in this state under Chapter 35 of Title 43 who agrees with a health care corporation to perform medical services under the conditions specified in the subscription contracts issued by the corporation.
  8. "Person" means a natural person, a partnership, an association, a common-law trust, or a corporation.
  9. "Provider" means any physician, hospital, or other person who is licensed or otherwise authorized in this state to furnish health care services.
  10. "Subscriber" or "member" means a person to whom a subscriber's certificate is issued by a health care corporation, which certificate sets forth the kinds and extent of the health care services which may be all or a part of the total health care services used by or provided to a subscriber for which the corporation is liable to make total or partial payment.
  11. "Subscriber surplus" means the excess of the admitted assets of a health care corporation over its liabilities as reported in the annual statement filed with the Commissioner.
  12. "Surviving corporation" means a health care corporation which is:
    1. The surviving corporation in a merger which includes one or more health care corporations;
    2. A health care corporation which has amended its articles of incorporation to become a corporation governed by Chapter 2 of Title 14, the "Georgia Business Corporation Code"; or
    3. The subsidiary of a corporation described in subparagraph (A) or (B) of this paragraph.

(Code 1933, § 56-1702a, enacted by Ga. L. 1976, p. 1461, § 1; Ga. L. 1995, p. 745, §§ 1.1, 1.2; Ga. L. 1996, p. 6, § 33; Ga. L. 2019, p. 337, § 1-85/SB 132.)

The 2019 amendment, effective July 1, 2019, substituted "periodic payments" for "periodical payments" in paragraphs (1) and (3) and inserted "or her" at the end of paragraph (3).

RESEARCH REFERENCES

ALR.

- What constitutes a "hospital" within coverage or exclusionary clauses of hospitalization policy, 46 A.L.R.3d 1244.


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