Chapter 44 — INSURANCE

For purposes of the Managed Care Emergency Services Act: (1) Closed plan means a managed care plan that requires covered persons to use participating providers under the terms of the managed care plan; (2) Covered benefits means those health care services to which a covered perso…

The Managed Care Emergency Services Act applies to all health carriers that offer managed care plans.

(1) A health carrier which provides a covered benefit for emergency services is, subject to the terms and conditions of the health benefit plan, responsible for charges for medically necessary emergency services provided to a covered person, including services furnished outside t…

If the director finds that any health carrier doing business in this state is engaging in any violation of the Managed Care Emergency Services Act and that a proceeding in respect thereto would be in the public interest, the director shall issue and serve upon such health carrier…

If, after the hearing, the director finds a health carrier has violated the Managed Care Emergency Services Act, the director shall reduce his or her findings to writing and shall issue and cause to be served upon the health carrier charged with the violation a copy of the findin…

Any health carrier who violates a cease and desist order of the director under section 44-6831 may after notice and hearing and upon order of the director be subject to: (1) A monetary penalty of not more than thirty thousand dollars for each violation, not to exceed an aggregate…

The director may adopt and promulgate rules and regulations to carry out the Managed Care Emergency Services Act.

Sections 44-6834 to 44-6850 shall be known and may be cited as the Out-of-Network Emergency Medical Care Act.

For purposes of the Out-of-Network Emergency Medical Care Act, the definitions found in sections 44-6836 to 44-6846 apply.

Covered person means a person on whose behalf an insurer is obligated to pay health care expense benefits or provide health care services.

Emergency medical condition means a medical or behavioral condition, the onset of which is sudden, that manifests itself by symptoms of sufficient severity, including, but not limited to, severe pain, that a prudent layperson, possessing an average knowledge of medicine and healt…

Emergency services means health care services medically necessary to screen and stabilize a covered person in connection with an emergency medical condition.

(1) Health benefits plan means a benefits plan which pays or provides hospital and medical expense benefits for covered services and is delivered or issued for delivery in this state by or through an insurer. (2) Health benefits plan does not include the medical assistance progra…

Health care facility means a general acute hospital, satellite emergency department, or ambulatory surgical center licensed pursuant to the Health Care Facility Licensure Act.

Health care professional means an individual who is credentialed pursuant to the Uniform Credentialing Act, who is acting within the scope of his or her credential, and who provides a covered service defined by the health benefits plan.

Health care provider means a health care professional or health care facility.

Insurer means an entity that contracts to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services under a health benefits plan, including (1) any individual or group sickness and accident insurance policy or subscriber contract delivered, iss…

Medical assistance program means the medical assistance program established pursuant to the Medical Assistance Act.

Medically necessary means a health care service that a health care provider, exercising his or her prudent clinical judgment, would provide to a covered person for the purpose of evaluating, diagnosing, or treating an illness, an injury, or a disease, or its symptoms, and that is…

TRICARE means a health care program of the United States Department of Defense Military Health System.

If a covered person receives emergency services at any health care facility, the facility shall not bill the covered person in excess of any deductible, copayment, or coinsurance amount applicable to in-network services pursuant to the covered person's health benefits plan.

If a covered person receives emergency services at an in-network or out-of-network health care facility, the health care provider performing those services shall not bill the covered person in excess of any deductible, copayment, or coinsurance amount applicable to in-network ser…

(1) If a covered person receives emergency services at an in-network or out-of-network health care facility, the insurer shall ensure that the covered person incurs no greater out-of-pocket costs than the covered person would have incurred with an in-network health care provider …

(1) If an insurer or an out-of-network health care provider provides notification that it considers a claim or payment to be not reasonable, the insurer and the health care provider shall have thirty days after the date of such notification to negotiate a settlement. If a settlem…

For purposes of sections 44-6901 to 44-6918, the definitions found in sections 44-6902 to 44-6915.01 shall be used.

Affiliation period means a period which, under the terms of the health insurance coverage offered by a health maintenance organization, must expire before the health insurance coverage becomes effective.

Church plan means a plan as defined under 29 U.S.C. 1002.

(1) Creditable coverage means, with respect to an individual, coverage of the individual under any of the following: (a) A group health plan; (b) Health insurance coverage; (c) Part A or Part B of Title XVIII of the Social Security Act; (d) Title XIX of the Social Security Act, 4…

Director means the Director of Insurance.

Enrollment date means the first day of coverage in the health benefit plan or, if earlier, the first day of the waiting period.

Governmental plan means a plan as defined under 29 U.S.C. 1002 and any plan maintained for its employees by the United States Government or by any agency or instrumentality of the United States Government.

Group health plan means an employee welfare benefit plan as defined by 29 U.S.C. 1002 to the extent that the plan provides any hospital, surgical, or medical expense benefits to employees or their dependents, as defined under the terms of the plan, directly or through insurance, …

(1) Health benefit plan means any employer group hospital or medical policy or certificate or employer group health maintenance organization subscriber contract. (2) Health benefit plan does not include one or more, or any combination, of the following: (a) Coverage only for acci…

Health carrier means any entity that provides a health benefit plan including an insurance company, a fraternal benefit society, a health maintenance organization, and any other entity providing a plan of health insurance or health benefits subject to state insurance regulation.

Health maintenance organization means a person that undertakes to provide or arrange for the delivery of basic health care services to enrollees on a prepaid basis, except for enrollee responsibility for copayments or deductibles or both.

Health-status-related factor means any of the following factors: (1) Health status; (2) Medical condition, including both physical and mental illnesses; (3) Claims experience; (4) Receipt of health care; (5) Medical history; (6) Genetic information; (7) Evidence of insurability, …

Late enrollee means an eligible employee or dependent who requests enrollment in a health benefit plan following the initial enrollment period during which the individual is entitled to enroll under the terms of the health benefit plan if the initial enrollment period is a period…

Medical care means amounts paid for: (1)(a) The diagnosis, care, mitigation, treatment, or prevention of disease or (b) the purpose of affecting any structure or function of the body; (2) Transportation primarily for and essential to medical care referred to in subdivision (1) of…

Network plan means health insurance coverage offered by a health carrier under which the financing and delivery of medical care including items and services paid for as medical care are provided, in whole or in part, through a defined set of providers under contract with the heal…

Plan sponsor has the meaning given such term under 29 U.S.C. 1002.

Preexisting condition means a condition whether physical or mental, regardless of the cause of the condition, for which medical advice, diagnosis, care, or treatment was recommended or received within the six-month period ending on the enrollment date. Genetic information shall n…

Waiting period means the period that must pass with respect to an individual before the individual is eligible to be covered for benefits under the terms of the health benefit plan. If an individual enrolls as a late enrollee or on a special enrollment date, any period before suc…

(1) A health carrier shall not: (a) Offer coverage to only certain individuals in an employer group or to only a part of the group except in the case of late enrollees; (b) Require any individual to pay a premium which is greater than such premium for a similarly situated individ…

(1) A health benefit plan shall be renewable with respect to all eligible employees or dependents, at the option of the plan sponsor, except in any of the following cases: (a) The plan sponsor has failed to pay premiums or contributions in accordance with the terms of the health …

(1) Health carriers shall provide written certification of creditable coverage to individuals in accordance with subsection (2) of this section. (2) The certification of creditable coverage shall be provided: (a) At the time an individual ceases to be covered under the health ben…

The director may adopt and promulgate rules and regulations to carry out sections 44-6901 to 44-6918.

Sections 44-7001 to 44-7013 shall be known and may be cited as the Health Care Professional Credentialing Verification Act.

The Health Care Professional Credentialing Verification Act requires a health carrier to establish a comprehensive health care professional credentialing verification program to ensure that its participating health care professionals meet specific minimum standards of professiona…

For purposes of the Health Care Professional Credentialing Verification Act: (1) Closed plan means a managed care plan that requires a covered person to use participating providers under the terms of the managed care plan; (2) Covered person means a policyholder, subscriber, enro…