TCA § 56-60-102 — Chapter definitions

As used in this chapter: “Affiliate” means an individual or entity that directly or indirectly through one (1) or more intermediaries, controls or is controlled by or is under common control with a contracting entity; “Contracting entity” means any individual or entity that is engaged in the act of contracting with providers and that has entered into a provider network contract with a provider for the delivery of health care services. “Contracting entity” shall not include any self-funded employer-sponsored health insurance plan regulated under the Employee Retirement Income Security Act of 1974 (ERISA) (29 U.S.C. § 1001 et seq.). In addition, “contracting entity” shall not include any individual or entity that provides administrative services to a self-funded employer-sponsored health insurance plan; provided, however, that this exemption applies only to those administrative services performed for a self-funded employer-sponsored health insurance plan; “Control” or “controlled by” or “under common control with” means the possession, direct or indirect, of the power to direct or cause the direction of the management and policies of an individual or entity, whether through the ownership of voting securities, by contract other than a commercial contract for goods or nonmanagement services, or otherwise, unless the power is the result of an official position with or corporate office held by the individual or entity. “Control” is presumed to exist if any individual or entity, directly or indirectly, owns, controls, holds with the power to vote or holds proxies representing ten percent (10%) or more of the voting securities of any other individual or entity; “Covered individual” means an individual who is covered under a health insurance plan; “Department” means the department of commerce and insurance; “Discount medical plan organization” means an entity that, in exchange for fees, dues, charges or other consideration, provides access for plan members to providers of medical services and the right to receive medical services from those providers at a discount; “Entity” means a corporation, business trust, trust, partnership, limited liability company, association, joint venture, public corporation, government or governmental subdivision, agency or instrumentality, or any other legal or commercial entity; “Health care services” means services for the diagnosis, prevention, treatment or cure of a health condition, illness, injury or disease; “Health insurance plan” means any hospital and medical expense incurred policy, nonprofit health care service plan contract, health maintenance organization subscriber contract or any other health care plan or arrangement that pays for or furnishes medical or health care services, whether by insurance or otherwise; “Health insurance plan” does not include one (1) or more, or any combination of, the following: Coverage only for accident, or disability income insurance; Coverage issued as a supplement to liability insurance; Liability insurance, including general liability insurance and automobile liability insurance; Workers' compensation or similar insurance; Automobile medical payment insurance; Credit-only insurance; Coverage for on-site medical clinics; Coverage similar to subdivisions (9)(B)(i)-(vii) as specified in federal regulations issued pursuant to P.L. 104-191, under which benefits for medical care are secondary or incidental to other insurance benefits; Dental or vision benefits; Benefits for long-term care, nursing home care, home health care or community-based care; Specified disease or illness coverage, hospital indemnity or other fixed indemnity insurance, or such other similar, limited benefits as are specified in regulations; Medicare supplemental health insurance, as defined under § 1882(g)(1) of the Social Security Act (42 U.S.C. § 1395ss(g)(1)); Coverage supplemental to the coverage provided under 10 U.S.C. § 1071 et seq.; or Other similar limited benefit supplemental coverages; “Physician” means any individual licensed as a chiropractic physician under title 63, chapter 4; a medical doctor under title 63, chapter 6; or an osteopathic physician under title 63, chapter 9; “Physician hospital organization” means an organization that includes, but is not limited to, hospitals and physicians and that contracts with and provides administrative services to hospitals and physicians that have entered into or intend to enter into managed care arrangements; “Physician organization” means an organization that contracts with and provides administrative services to physicians who have entered into managed care arrangements; “Provider” means a physician, a physician organization or a physician hospital organization. “Provider” does not include a physician organization or physician hospital organization that leases or rents the physician organization's or physician hospital organization's network to a third party; “Provider network contract” or “provider agreement” means a direct contract between a contracting entity and a provider for the delivery of health care services specifying the rights and responsibilities of the contracting entity and the provider in relation to access and payment for health care services to covered individuals; and “Third party” means an organization that enters into a contract with a contracting entity or with another third party to gain access to a provider network contract. “Third party” also includes a contracting entity's subsidiaries and affiliates, except as provided in § 56-60-103. “Third party” does not include any self-funded employer-sponsored health insurance plan regulated under the Employee Retirement Income Security Act of 1974 (ERISA) (29 U.S.C. § 1001 et seq.). In addition, “third party” does not include any individual or entity that provides administrative services to a self-funded employer-sponsored health insurance plan; provided, however, that this exemption applies only to those administrative services performed for a self-funded employer-sponsored health insurance plan.