{"data":{"id":"us-ky/krs-304.17a-500","jurisdiction":"us-ky","citation":"KRS 304.17A-500","heading":"Definitions for KRS 304.17A-500 to 304.17A-590.","body":"As used in KRS 304.17A-500 to 304.17A-590, unless the context requires otherwise:\n(1) \"Areas other than urban areas\" means a classification code that does not meet the\ndefinition of urban area;\n(2) \"Contract holder\" means an employer or organization that purchases a health benefit\nplan;\n(3) \"Covered person\" means a person on whose behalf an insurer offering the plan is\nobligated to pay benefits or provide services under the health insurance policy;\n(4) \"Emergency medical condition\" means:\n(a) A medical cond ition manifesting itself by acute symptoms of sufficient\nseverity, including severe pain, that a prudent layperson would reasonably\nhave cause to believe constitutes a condition that the absence of immediate\nmedical attention could reasonably be expected to result in:\n1. Placing the health of the individual or, with respect to a pregnant\nwoman, the health of the woman or her unborn child, in serious\njeopardy;\n2. Serious impairment to bodily functions; or\n3. Serious dysfunction of any bodily organ or part; or\n(b) With respect to a pregnant woman who is having contractions:\n1. A situation in which there is inadequate time to effect a safe transfer to\nanother hospital before delivery; or\n2. A situation in which transfer may pose a threat to the health or safety  of\nthe woman or the unborn child;\n(5) \"Enrollee\" means a person who is enrolled in a plan offered by a health maintenance\norganization as defined in KRS 304.38-030(5);\n(6) \"Grievance\" means a written complaint submitted by or on behalf of an enrollee;\n(7) \"Health insurance policy\" means \"health benefit plan\" as defined in KRS 304.17A -\n005;\n(8) \"Insurer\" has the meaning provided in KRS 304.17A-005;\n(9) \"Managed care plan\" means a health insurance policy that integrates the financing\nand delivery of appropria te health care services to enrollees by arrangements with\nparticipating providers who are selected to participate on the basis of explicit\nstandards to furnish a comprehensive set of health care services and financial\nincentives for enrollees to use the pa rticipating providers and procedures provided\nfor in the plan;\n(10) \"Participating health care provider\" means a health care provider that has entered\ninto an agreement with an insurer to provide health care services;\n(11) \"Quality assurance or improvement \" means the ongoing evaluation by a managed\ncare plan of the quality of health care services provided to its enrollees;\n(12) \"Record\" means any written, printed, or electronically recorded material maintained\nby a provider in the course of providing health  services to a patient concerning the\npatient and the services provided. \"Record\" also includes the substance of any\ncommunication made by a patient to a provider in confidence during or in\nconnection with the provision of health services to a patient or i nformation\notherwise acquired by the provider about a patient in confidence and in connection\nwith the provision of health services to a patient;\n(13) \"Risk sharing arrangement\" means any agreement that allows an insurer to share the\nfinancial risk of providing health care services to enrollees or insureds with another\nentity or provider where there is a chance of financial loss to the entity or provider\nas a result of the delivery of a service. A risk sharing arrangement shall not include\na reinsurance contract with an accredited or admitted reinsurer;\n(14) \"Urban area\" means a classification code whereby the zip code population density is\ngreater than three thousand (3,000) persons per square mile; and\n(15) \"Utilization management\" means a system for revie wing the appropriate and\nefficient allocation of health care services under a health benefits plan according to\nspecified guidelines, in order to recommend or determine whether, or to what\nextent, a health care service given or proposed to be given to a co vered person\nshould or will be reimbursed, covered, paid for, or otherwise provided under the\nplan. The system may include preadmission certification, the application of practice\nguidelines, continued stay review, discharge planning, preauthorization of\nambulatory care procedures, and retrospective review.","path":[],"source_url":"https://apps.legislature.ky.gov/law/statutes/statute.aspx?id=17426","current_through":"Includes enactments through the 2026 Regular Session","vintage":"09/05/2026","retrieved_at":"2026-09-05T20:57:47Z","sha256":"1b1bbd1c9eb643cb34d769def963395da7066a18a086a4ddcf130d893f94e898","source_id":"us-ky","stale":false,"prev":"us-ky/krs-304.17a-480","next":"us-ky/krs-304.17a-505"},"notice":"GroundRules: Original legal text. Not legal advice."}