(a) As used in this article:(a) “Department” means the Mississippi Department of Insurance.(b) “Managed care plan” means a plan operated by a managed care entity as described in paragraph (c) of this section that provides for the financing and delivery of health care services to persons enrolled in such plan through:(i) Arrangements with selected providers to furnish health care services;(ii) Explicit standards for the selection of participating providers;(iii) Organizational arrangements for ongoing quality assurance, utilization review programs and dispute resolution; and(iv) Financial incentives for persons enrolled in the plan to use the participating providers, products and procedures provided for by the plan.(c) “Managed care entity” includes a licensed insurance company, hospital or medical service plan, health maintenance organization (HMO), an employer or employee organization, or a managed care contractor as described in paragraph (d) of this section that operates a managed care plan.(d) “Managed care contractor” means a person or corporation that:(i) Establishes, operates or maintains a network of participating providers;(ii) Conducts or arranges for utilization review activities; and(iii) Contracts with an insurance company, a hospital or medical service plan, an employer or employee organization, or any other entity providing coverage for health care services to operate a managed care plan.(e) “Participating provider” means a physician, hospital, pharmacy, pharmacist, dentist, nurse, chiropractor, optometrist, or other provider of health care services licensed or certified by the state, that has entered into an agreement with a managed care entity to provide services, products or supplies to a patient enrolled in a managed care plan.
(a) “Department” means the Mississippi Department of Insurance.
(b) “Managed care plan” means a plan operated by a managed care entity as described in paragraph (c) of this section that provides for the financing and delivery of health care services to persons enrolled in such plan through:(i) Arrangements with selected providers to furnish health care services;(ii) Explicit standards for the selection of participating providers;(iii) Organizational arrangements for ongoing quality assurance, utilization review programs and dispute resolution; and(iv) Financial incentives for persons enrolled in the plan to use the participating providers, products and procedures provided for by the plan.
(i) Arrangements with selected providers to furnish health care services;
(ii) Explicit standards for the selection of participating providers;
(iii) Organizational arrangements for ongoing quality assurance, utilization review programs and dispute resolution; and
(iv) Financial incentives for persons enrolled in the plan to use the participating providers, products and procedures provided for by the plan.
(c) “Managed care entity” includes a licensed insurance company, hospital or medical service plan, health maintenance organization (HMO), an employer or employee organization, or a managed care contractor as described in paragraph (d) of this section that operates a managed care plan.
(d) “Managed care contractor” means a person or corporation that:(i) Establishes, operates or maintains a network of participating providers;(ii) Conducts or arranges for utilization review activities; and(iii) Contracts with an insurance company, a hospital or medical service plan, an employer or employee organization, or any other entity providing coverage for health care services to operate a managed care plan.
(i) Establishes, operates or maintains a network of participating providers;
(ii) Conducts or arranges for utilization review activities; and
(iii) Contracts with an insurance company, a hospital or medical service plan, an employer or employee organization, or any other entity providing coverage for health care services to operate a managed care plan.
(e) “Participating provider” means a physician, hospital, pharmacy, pharmacist, dentist, nurse, chiropractor, optometrist, or other provider of health care services licensed or certified by the state, that has entered into an agreement with a managed care entity to provide services, products or supplies to a patient enrolled in a managed care plan.