83-41-403 - Definitions.
§ 83-41-403. Definitions.
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 subparagraph (c) 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 subparagraph (d) 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.
Sources: Laws, 1995, ch. 613, § 37, eff from and after July 1, 1995.