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Alaska Statutes.

Title 21. Insurance

Chapter 55. State Health Insurance

Section 500. Definitions.

AS 21.55.500. Definitions.

In this chapter

(1) "association" means the Comprehensive Health Insurance Association created in AS 21.55.010 ;

(2) "copayment" means the portion of the eligible expenses, in excess of the deductible, for which the insured is responsible;

(3) "creditable coverage" has the meaning given in AS 21.54.500 ;

(4) "deductible" means the portion of eligible expenses for which the insured is responsible in each calendar year under AS 21.55.120 (a);

(5) "federal continuation provision" has the meaning given in AS 21.54.500;

(6) "federally defined eligible individual" means an individual

(A) with an aggregate of all periods of creditable coverage as provided under AS 21.54.110 (b) of 18 or more months as of the date that the individual seeks coverage under this chapter;

(B) whose most recent prior creditable coverage was under a health benefit plan or health care insurance plan offered in the large employer group market or the small employer group market;

(C) who is not eligible for coverage under a health benefit plan, 42 U.S.C. 1395c or 42 U.S.C. 1395j (Part A or Part B of Title XVIII of the Social Security Act), or a state plan under 42 U.S.C. 1396 (Title XIX of the Social Security Act), and who does not have other health care insurance coverage;

(D) whose most recent coverage within the period of aggregate creditable coverage as provided under AS 21.54.110 (b) was not terminated based on a factor relating to nonpayment of premiums or fraud;

(E) who, having been offered and having elected continuation coverage under a federal continuation provision or a similar state program, has exhausted coverage under the continuation provision or program;

(7) "group market" has the meaning given in AS 21.54.500 ;

(8) "health benefit plan" has the meaning given in AS 21.54.500 ;

(9) "health care insurance plan" has the meaning given in AS 21.54.500;

(10) "health care insurer" has the meaning given in AS 21.54.500 ;

(11) "health insurance" has the meaning given in AS 21.12.050 ;

(12) "home health agency services" means any of the following services provided upon recommendation of a licensed physician as part of a treatment plan:

(A) intermittent or part-time nursing services of a registered professional nurse or a licensed practical nurse, that are provided to a person under the continued direction of the person's physician and within the limitation of the nurse's license;

(B) nursing services that are provided to a person at the person's residence, including a residential care facility or adult boarding home; a hospital, skilled nursing facility or intermediate care facility is not considered a residence;

(C) home health aide services that are prescribed by and under the continued direction of a physician and supervised by a professional nurse;

(D) home health aide services that are provided to a person at the person's residence, as described in (B) of this paragraph;

(E) physical and occupational therapy services, speech pathology, and audiology services that are prescribed by a physician and provided to a person by or under the supervision of a qualified practitioner; these services may be provided to a person who is a patient in an intermediate care facility or skilled nursing facility;

(13) "hospice services" means services provided under a coordinated comprehensive program of palliative and supportive care on a 24-hour, seven days per week basis for persons who have been diagnosed as terminally ill and their families by an interdisciplinary team of professionals or volunteers under an incorporated central administration that has a physician as medical director;

(14) "major medical"

(A) means health insurance or medical care coverage provided on an expense incurred basis, including Medicare supplement insurance;

(B) does not include coverage for dental only, vision only, long-term care, nursing home care, home health care, community-based care, accident only, disability income, hospital confinement indemnity or other fixed indemnity, or credit, specified disease or specified accident, or other supplemental health insurance or coverage determined by the board not to constitute major medical and approved by the director;

(15) "medical social services" means services rendered the patient under the direction of a physician by a qualified social worker holding a master's degree from an accredited school of social work, including assessment of the social, psychological and family problems related to or arising out of the covered person's illness and treatment, appropriate action and utilization of community resources to assist in resolving the problems, and participation in the development of treatment for the covered person;

(16) "plan administrator" means an eligible entity that is licensed as a third-party administrator under AS 21.27 and is selected by the board and approved by the director to administer a state plan;

(17) "preexisting condition exclusion" has the meaning given in AS 21.54.500;

(18) "qualified TAA eligible individual" means a qualifying individual as defined under 26 U.S.C. 35 (Internal Revenue Code, as enacted by sec. 201(a) of the Trade Adjustment Assistance Reform Act of 2002);

(19) "resident" means (A) except for a federally defined eligible individual or TAA eligible individual, an individual who (i) is physically present in the state, has lived in the state for at least the 12 consecutive months immediately preceding the application for a state plan, and intends to remain permanently in the state; or (ii) is not physically present in the state if the person lived in the state for at least nine of the 12 months immediately preceding application for a state plan and the person's absence from the state is for medical treatment or education; or (B) for a federally defined eligible individual or TAA eligible individual, an individual who is legally domiciled in this state; "resident" does not include an individual who is absent from the state for more than 90 consecutive days for reasons other than for medical treatment or education;

(20) "residents who are high risks" means residents who

(A) have been rejected for medical reasons after applying for a subscriber contract, a policy of health insurance, or a Medicare supplement policy by at least one association member within the six months immediately preceding the date of application for a state plan; medical reasons may include preexisting medical conditions, a family history that predicts future medical conditions, or an occupation that generates a frequency or severity of injury or disease that results in coverage not being generally available;

(B) have had a restrictive rider placed on a subscriber contract, a health insurance policy, or a Medicare supplement policy that substantially reduces coverage; or

(C) meet other requirements adopted by regulation by the director that are consistent with this chapter and that indicate that a person is unable to obtain coverage substantially similar to that which may be obtained by a person who is considered a standard risk;

(21) "state plan" means a policy of insurance offered by the association through a plan administrator;

(22) "TAA eligible individual" means an eligible individual or a qualifying family member as defined under 26 U.S.C. 35 (Internal Revenue Code, as enacted by sec. 201(a) of the Trade Adjustment Assistance Reform Act of 2002); and

(23) "usual, customary, reasonable, or prevailing charge" means the charge for a medical care procedure, service, or supply item that is the lowest of the following amounts:

(A) the billed amount for the medical service provider's actual charge;

(B) the charge usually made by that provider for performing that procedure or service or for providing the supply item; or

(C) the customary charge, based on a profile of charges made for the same medical procedure, service, or supply item in the same geographical area by other providers that have performed the same procedure or service or can provide the same supply item.