(9) “Home health agency” means a public agency, a private organization, or a subdivision of a health care facility that is licensed and operating within the scope of that license.
(10) “Home health aide” means an individual who obtains a certificate of completion, as required by law, that allows performance of:
(a) health care and other related services under the supervision of a registered nurse from the home health agency; or
(b) a simple procedure as an extension of physical, speech, or occupational therapy under the supervision of a licensed therapist.
(11) “Home health care” means a service provided by a home health agency.
(12) “Homemaker” means an individual who cares for the home through duties such as housekeeping, meal planning and preparation, laundry, shopping, and errands.
(13) “Hospice” means a program of care for the terminally ill and their families that occurs in a home or health care facility and provides medical, palliative, psychological, spiritual, or supportive care and treatment and is licensed and operating within the scope of that license.
(14)(a) “Injury” means a bodily injury resulting from an accident, independent of disease, that occurs while the coverage is in force.
(b) “Injury” is not limited to an injury with external, violent, visible wound, or similar description.
(15) “Intermediate nursing care” means a nursing service provided by, or under the supervision of, a nurse to treat a condition when confinement is required.
(16) “Licensed practical nurse” means a licensed practical nurse who provides services within the scope of their license.
Medical Necessity-Definition
(17)(a) “Medical necessity” means a health care service or product that a prudent health care provider would provide to a patient to prevent, diagnose, or
treat an illness, injury, disease, or its symptoms in a manner that is:
(i) in accordance with generally accepted standards of medical practice in the United States;
(ii) clinically appropriate in terms of type, frequency, extent, site, and duration;
(iii) not primarily for the convenience of the patient, physician, or other health care provider; and
(iv) covered under the contract.
(b) If a medical question-of-fact exists, “medical necessity” shall include the most appropriate available supply or level of service for the individual in question, considering potential benefits and harms to the individual, and known to be effective.
(c)(i) For an intervention not yet in widespread use, the effectiveness shall be based on scientific evidence.
(ii) For an established intervention, the effectiveness shall be based on:
(A) scientific evidence;
(B) professional standards; and
(C) expert opinion.
(18)(a) “Nurse” means a type of licensed nurse, such as a registered nurse or a licensed practical nurse.
(b) If the word “nurse” is used without specific instruction, then the use of this term requires the insurer to recognize the services of any individual who qualifies under this terminology under applicable laws.
(19) “Nursing care” means assistance provided for the health care needs of a sick or disabled individual, by or under the direction of a nurse.
(20) “Physician,” “qualified physician,” or “licensed physician” means a physician who provides services within the scope of their license.
(21) “Probationary period” or “waiting period” means the length of time following the date of issuance or effective date of the contract before a benefit is paid under the contract.
(22) “Registered nurse” means a registered nurse who provides services within the scope of their license.
(23)(a) “Scientific evidence” means:
(i) a scientific study published or accepted by a medical journal that meets nationally recognized standards for scientific manuscripts and that submits its published articles for review by experts who are not part of the editorial staff; or
(ii) a finding, study, or research conducted by or under the auspices of a federal government agency or nationally recognized federal research institute.
(b) “Scientific evidence” does not include:
(i) published peer-reviewed literature sponsored by:
(A) a pharmaceutical manufacturing company; or
(B) a medical device manufacturer; or
(ii) a single study without other supportable studies.
(24) “Sickness” means illness, disease, or disorder of an enrollee.
(25) “Skilled nursing care” means nursing services provided by, or under the supervision of, a registered nurse to treat the condition for which confinement is required and not for providing intermediate nursing care or custodial care.
(26) “Summary of benefits and coverage” means a written summary of the contract as described under 45 CFR 147.200.
(27) “Therapist” means a professionally trained or licensed individual, such as a physical therapist, occupational therapist, or speech therapist, who is skilled in applying treatment techniques and procedures under the general direction of a physician.
(28)(a) “Total disability” means an individual who:
