Missouri Revised Statutes













Chapter 354

Health Services Corporations--Health Maintenance Organizations--Prepaid Dental Plans

←354.570

Section 354.600.1

354.603→

August 28, 2015

Definitions.

354.600. For purposes of sections 354.600 to 354.636 the following terms

shall mean:



(1) "Facility", an institution providing health care services or a

health care setting, including but not limited to hospitals and other

licensed inpatient centers, ambulatory surgical or treatment centers, skilled

nursing facilities, residential treatment centers, diagnostic, laboratory and

imaging centers, and rehabilitation and other therapeutic health settings;



(2) "Health benefit plan", a policy, contract, certificate or agreement

entered into, offered or issued by a health carrier to provide, deliver,

arrange for, pay for or reimburse any of the costs of health care services;



(3) "Health care professional", a physician or other health care

practitioner licensed, accredited or certified by the state of Missouri to

perform specified health services;



(4) "Health care provider" or "provider", a health care professional or

a facility;



(5) "Health carrier", a health maintenance organization established

pursuant to sections 354.400 to 354.636;



(6) "Health indemnity plan", a health benefit plan that is not a managed

care plan;



(7) "Intermediary", a person authorized to negotiate and execute

provider contracts with health carriers on behalf of health care providers or

on behalf of a network;



(8) "Managed care plan", a health benefit plan that either requires an

enrollee to use, or creates incentives, including financial incentives, for

an enrollee to use health care providers managed, owned, under contract with

or employed by the health carrier;



(9) "Network", the group of participating providers providing services

to a managed care plan;



(10) "Participating provider", a provider who, under a contract with the

health carrier or with its contractor or subcontractor, has agreed to provide

health care services to enrollees with an expectation of receiving payment,

other than coinsurance, co-payments or deductibles, directly or indirectly

from the health carrier;



(11) "Primary care professional" or "primary care provider", a

participating health care professional designated by the health carrier to

supervise, coordinate or provide initial care or continuing care to an

enrollee, and who may be required by the health carrier to initiate a referral

for specialty care and maintain supervision of health care services rendered

to the enrollee.



(L. 1997 H.B. 335, A.L. 2007 S.B. 66)





1997



1997



354.600. For purposes of sections 354.600 to 354.636 the following

terms shall mean:



(1) "Covered benefit" or "benefit", a health care service to which an

enrollee is entitled under the terms of a health benefit plan;



(2) "Director", the director of the department of insurance;



(3) "Emergency medical condition", the sudden and, at the time,

unexpected onset of a health condition that manifests itself by symptoms of

sufficient severity that would lead a prudent lay person, possessing an

average knowledge of medicine and health, to believe that immediate medical

care is required, which may include, but shall not be limited to:



(a) Placing the person's health in significant jeopardy;



(b) Serious impairment to a bodily function;



(c) Serious dysfunction of any bodily organ or part;



(d) Inadequately controlled pain; or



(e) With respect to a pregnant woman who is having contractions:



a. That there is inadequate time to effect a safe transfer to another

hospital before delivery; or



b. That transfer to another hospital may pose a threat to the health

or safety of the woman or unborn child;



(4) "Emergency service", a health care item or service furnished or

required to screen and stabilize an emergency medical condition, which may

include, but shall not be limited to, health care services that are

provided in a licensed hospital's emergency facility by an appropriate

provider;



(5) "Enrollee", a policyholder, subscriber, covered person or other

individual participating in a health benefit plan;



(6) "Facility", an institution providing health care services or a

health care setting, including but not limited to, hospitals and other

licensed inpatient centers, ambulatory surgical or treatment centers,

skilled nursing facilities, residential treatment centers, diagnostic,

laboratory and imaging centers, and rehabilitation and other therapeutic

health settings;



(7) "Health benefit plan", a policy, contract, certificate or

agreement entered into, offered or issued by a health carrier to provide,

deliver, arrange for, pay for or reimburse any of the costs of health care

services;



(8) "Health care professional", a physician or other health care

practitioner licensed, accredited or certified by the state of Missouri to

perform specified health services;



(9) "Health care provider" or "provider", a health care professional

or a facility;



(10) "Health care service", a service for the diagnosis, prevention,

treatment, cure or relief of a health condition, illness, injury or

disease;



(11) "Health carrier", a health maintenance organization established

pursuant to sections 354.400 to 354.636;



(12) "Health indemnity plan", a health benefit plan that is not a

managed care plan;



(13) "Intermediary", a person authorized to negotiate and execute

provider contracts with health carriers on behalf of health care providers

or on behalf of a network;



(14) "Managed care plan", a health benefit plan that either requires

an enrollee to use, or creates incentives, including financial incentives,

for an enrollee to use health care providers managed, owned, under contract

with or employed by the health carrier;



(15) "Network", the group of participating providers providing

services to a managed care plan;



(16) "Participating provider", a provider who, under a contract with

the health carrier or with its contractor or subcontractor, has agreed to

provide health care services to enrollees with an expectation of receiving

payment, other than coinsurance, co-payments or deductibles, directly or

indirectly from the health carrier;



(17) "Person", an individual, a corporation, a partnership, an

association, a joint venture, a joint stock company, a trust, an

unincorporated organization, any similar entity or any combination of the

foregoing; and



(18) "Primary care professional" or "primary care provider", a

participating health care professional designated by the health carrier to

supervise, coordinate or provide initial care or continuing care to an

enrollee, and who may be required by the health carrier to initiate a

referral for specialty care and maintain supervision of health care

services rendered to the enrollee.



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