§ 23-99-302 - Definitions. - Arkansas Statutes

23-99-302. Definitions.

As used in this subchapter:

(1) "Covered persons" means any individual or family that is enrolled in a health benefit plan or policy from a health care insurer and on whose behalf the health care insurer is obligated to pay for or provide eye and/or vision care benefits;

(2) "Covered service" means those health care services; including eye and/or vision care benefits, which the health care insurer is obligated to pay for or provide to covered persons under the health benefit plan or policy;

(3) (A) "Eye and/or vision care benefits" means those services and materials which are provided by a primary eye care provider who is functioning within the scope of his or her license.

(B) The conditions imposed by any specific health benefit plan upon the provision of eye and/or vision care benefits shall not:

(i) Prohibit the primary eye care provider from providing covered services to covered persons at his or her highest level of licensure and competence at any given time, as determined by his or her respective licensing board; or

(ii) Require that the primary eye care provider hold hospital staff privileges or include any other condition as a requirement which would have the practical effect of excluding any class of provider from participation in the plan;

(4) "Gatekeeper" means a covered person's primary care provider in a gatekeeper system;

(5) "Gatekeeper system" means a system of administration used by any health benefit plan in which a primary care provider furnishes basic patient care and coordinates diagnostic testing, indicated treatment, and specialty referral for persons covered by the health benefit plan;

(6) "Health benefit plan" means any public or private health plan, program, policy, subscriber agreement, or contract implemented in the State of Arkansas which includes or may include payment, reimbursement, including capitation, or financial compensation for provision of eye and/or vision care benefits to covered persons but does not include workers' compensation coverage or reimbursement;

(7) "Health care insurer" means any entity, including, but not limited to, insurance companies, hospital and medical service corporations, health maintenance organizations, preferred provider organizations, and physician hospital organizations, that is authorized by the State of Arkansas to offer or provide health benefit plans, policies, subscriber contracts, or any other contracts of a similar nature which indemnify or compensate health care providers for the provision of health care services; and

(8) "Primary eye care provider" means an ophthalmologist or optometrist licensed by the State of Arkansas who has been selected by a person covered by a health benefit plan to provide eye and/or vision care benefits and who agrees to provide these services in accordance with the terms, conditions, reimbursement rates, and standards of quality as set forth within the specific health benefit plan.