RS 160.1 - Definitions
For the purposes of this Subpart, the following definitions shall apply:
(1) "Account" means a medical savings account into which the department credits a certain amount of money for the payment of health care services for a participant, participant family, other eligible individual, or eligible family. An account shall be composed of the reimbursable premium amount, residual amount, and any other credit amount and interest as may be determined by the department.
(2) "Benefit payment schedule plan" or "benefit payment schedule" shall mean a health insurance policy which provides coverage for all items and services included in the standard benefit package furnished by a certified health plan which makes payment for the services of each provider on a fee-for-service basis regardless of any contractual arrangement between the plan and the provider. A benefit payment schedule plan also identifies covered health care and treatment services and the payment for each service or treatment and prohibits copayments. A benefit payment schedule directly reimburses the participant or other eligible individual for the covered service or treatment unless direct payment to the provider is authorized.
(3) "Board" means the Louisiana Access to Better Care Medicaid Insurance Demonstration Project Oversight Board.
(4) "Certified health plan" or "certified plan" means an insurer or other business entity that has met all the requirements of this Subpart, specifically, R.S. 46:160.4, and is authorized by the department to market or offer health insurance, high deductible catastrophic health insurance, a managed care plan, or a benefit payment schedule to a participant or other eligible individual.
(5) "Debit instrument" or "debit card" means the electromagnetic telecommunication scanning device given to each participant or other eligible individual after selection of a specific health insurance, high deductible catastrophic health insurance, managed care plan, or benefit payment schedule which informs providers of a participant's or individual's status in the project, his certified health plan, and residual account amount, if any.
(6) "Demonstration project" or "project" means the Louisiana Access to Better Care Medicaid Insurance Demonstration Project.
(7) "Department" means the Louisiana Department of Health.
(8) Repealed by Acts 2001, No. 1185, §8, eff. July 1, 2001.
(9) "Health and accident insurance policy" or "health insurance" means that insurance defined and delineated in R.S. 22:46(1) and more specifically in R.S. 22:211 et seq.
(10) "Health care provider" or "provider" means a state licensed, certified, or state-registered provider of health care services, treatment, or supplies, including but not limited to those entities defined in R.S. 40:1231.1(A).
(11) "Health care services" means any services rendered by a provider, including but not limited to medical and surgical care; psychological, optometric, optic, chiropractic, podiatric, nursing, and pharmaceutical services; health education, rehabilitative, and home health services; physical therapy; inpatient and outpatient hospital services; dietary and nutritional services; laboratory and ambulance services; and any other services for the purpose of preventing, alleviating, curing, or healing human illness, injury, or physical disability. Health care services shall also mean dental care, an annual PAP test for cervical cancer, and minimum mammography examination as defined in R.S. 22:1028.
(12) "Insurer" means any insurance company or other entity authorized to transact and transacting health and accident insurance business in this state.
(13) "Managed care plan" or "plan" means a plan that provides for the delivery of health care services to individuals enrolled in such plan through its own employed health care providers, or by contracting with selected or participating health care providers that conform to explicit selection standards, or both. A managed care plan customarily has a formal organizational structure for continual quality assurance, a certified utilization review program, dispute resolution, and financial incentives for individual enrollees to use the plan's participating providers and procedures. Managed care plans include but are not limited to preferred provider organizations, health maintenance organizations, independent practice associations, management services organizations, managed care services organizations, physician hospital organizations, and hospital physician organizations.
(14) "Other eligible individual" or "other eligible individuals" means a low-income individual, group of individuals, or family who is either uninsured, underinsured, or uninsurable.
(15) "Participant" or "participant family" means any individual or group of individuals eligible for medical assistance under Chapter 3 of Title 46 of the Louisiana Revised Statutes of 1950 and the rules and regulations promulgated pursuant thereto and designated to participate in the demonstration project.
(16) "Reimbursable premium amount" means that portion of the total amount of money credited pursuant to a voucher or in an account which the department designates that a participant is allowed to use for the payment of the annual premium for either health and accident insurance, high deductible catastrophic health insurance, or a benefit payment schedule, or to pay the annual enrollment fee for a managed care plan chosen by such participant.
(17) "Residual account amount" or "residual amount" means the amount of money remaining in an account after payment from the account of the reimbursable premium amount. Such residual account amount may be used by the participant or other eligible individual for the payment of any or all of the deductibles required by that participant's certified health care plan. A residual account amount may also be used to purchase health care services in whole or in part that are not covered by a certified health plan. A residual amount not utilized by the participant or other eligible individual may be carried forward to the subsequent year.
(18) "Secretary" means the secretary of the Louisiana Department of Health.
(19) "Voucher" means the document issued by the department to a participant or other eligible individual evidencing his participation in the project and the credited reimbursable premium amount and the number and age of potential covered insureds or enrollees in a participant family or other eligible family, if any. A voucher shall be used only to purchase health insurance, high deductible catastrophic health insurance, enrollment in a managed care plan, a benefit payment schedule plan, or other health care services.
Acts 1995, No. 1242, §1, eff. June 29, 1995; Acts 2001, No. 1185, §§6 and 8, eff. July 1, 2001; Acts 2008, No. 415, §2, eff. Jan. 1, 2009; Acts 2018, No. 206, §5.