44-7203. Terms, defined.

For purposes of the Quality Assessment and Improvement 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) Consumer means someone in the general public who may or may not be a covered person or a purchaser of health care, including employers;

(3) Covered person means a policyholder, subscriber, enrollee, or other individual participating in a health benefit plan;

(4) Department means the Department of Insurance;

(5) Director means the Director of Insurance;

(6) Facility means 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 centers, residential treatment centers, diagnostic, laboratory, and imaging centers, and rehabilitation and other therapeutic health settings. Facility does not include physicians' offices;

(7) Health benefit plan means a policy, contract, certificate, or agreement entered into, offered, or issued by any person to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services. Health benefit plan does not include workers' compensation insurance coverage;

(8) Health care professional means a physician or other health care practitioner licensed, certified, or registered to perform specified health services consistent with state law;

(9) Health care provider or provider means a health care professional or a facility;

(10) Health care services or health services means services for the diagnosis, prevention, treatment, cure, or relief of a health condition, illness, injury, or disease;

(11) Health carrier means an entity that contracts, offers to contract, or enters into an agreement to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services, including a sickness and accident insurance company, a health maintenance organization, a prepaid limited health service organization, a prepaid dental service corporation, or any other entity providing a plan of health insurance, health benefits, or health care services. Health carrier does not include a workers' compensation insurer, risk management pool, or self-insured employer who contracts for services to be provided through a managed care plan certified pursuant to section 48-120.02;

(12) Managed care plan means a health benefit plan, including closed plans and open plans, that either requires a covered person to use or creates financial incentives by providing a more favorable deductible, coinsurance, or copayment level for a covered person to use health care providers managed, owned, under contract with, or employed by the health carrier;

(13) Open plan means a managed care plan other than a closed plan that provides incentives, including financial incentives, for covered persons to use participating providers under the terms of the managed care plan;

(14) Participating provider means a provider who, under a contract with the health carrier or with its contractor or subcontractor, has agreed to provide health care services to covered persons with an expectation of receiving payment, other than coinsurance, copayments, or deductibles, directly or indirectly from the health carrier;

(15) Person means 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;

(16) Quality assessment means the measurement and evaluation of the quality and outcomes of medical care provided to individuals, groups, or populations; and

(17) Quality improvement means the effort to improve the processes and outcomes related to the provision of care within the health benefit plan.

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