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27-19A-4
Section 27-19A-4 Required provisions. Any health insurance policy or employee benefit plan
which is delivered, renewed, issued for delivery, or otherwise contracted for in this state
shall, to the extent that it provides benefits for dental care expenses: (1) Disclose, if
applicable, that the benefit offered is limited to the least costly treatment; (2) Define
and explain the standard upon which the payment of benefits or reimbursement for the cost
of dental care services is based, such as "usual and customary," "reasonable
and customary," "usual, customary, and reasonable," fees or words of similar
import or specify in dollars and cents the amount of the payment or reimbursement for dental
care services to be provided. Said payment or reimbursement for a noncontracting provider
dentist shall be the same as the payment or reimbursement for a contracting provider dentist;
provided, however, that the health insurance policy or the employee benefit plan shall not
be required to make...
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22-6-122
Section 22-6-122 Medicaid Pharmacy and Therapeutics Committee - Classification and recommendation
of drugs; assurance of quality patient care; review of pharmaceutical products. (a) The Medicaid
Pharmacy and Therapeutics Committee shall review and recommend classes of drugs to the Medicaid
Commissioner for inclusion in the Medicaid Preferred Drug Plan. Class means a therapeutic
group of pharmaceutical agents approved by the FDA as defined by the American Hospital Formulary
Service. The classes of anti-retroviral and anti-psychotic drugs shall not be included in
the Medicaid Preferred Drug Plan. (b) The Medicaid Pharmacy and Therapeutics Committee shall
develop its preferred drug list recommendations by considering the clinical efficacy, safety,
and cost effectiveness of a product. Within each covered class, the committee shall review
and recommend drugs to the Medicaid Commissioner for inclusion on a preferred drug list. Generics
and over the counter drugs covered by Medicaid may be...
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27-48-1
Section 27-48-1 Definitions. As used in this chapter, the following terms shall have the following
meanings: (1) HEALTH BENEFIT PLAN. A health insurance policy that covers hospital, medical,
or surgical expenses, health maintenance organizations, preferred provider organizations,
medical service organizations, physician-hospital organizations, or any other person, firm,
corporation, joint venture, or other similar business entity that pays for, purchases, or
furnishes health care services to patients, insureds, or beneficiaries in this state. For
the purpose of this chapter, a health benefit plan located or domiciled outside of the State
of Alabama is deemed to be subject to the provisions of this chapter if it receives, processes,
adjudicates, pays, or denies claims for health care services submitted by or on behalf of
the State of Alabama or who receive health care services in the State of Alabama. The term
includes, but is not limited to, entities created pursuant to Article 6 of...
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27-46-1
Section 27-46-1 Reimbursement or payment for services. Notwithstanding any other provision
of law, when any contract or plan of health insurance, or any plan or agreement for health
care services provides for the reimbursement or payment for services which are within the
scope of practice of registered nurses who have passed or who are qualified to take the national
certification examination for the specialty practice of nurse anesthetist as recognized by
the Alabama Board of Nursing, then the insured, or any other person covered by the policy,
plan, contract, or certificate shall be entitled to reimbursement or payment for such services
performed by the certified registered nurse anesthetist, and said certified registered nurse
anesthetist shall be entitled to direct reimbursement by the insurer, unless the certified
registered nurse anesthetist is employed by contract with a group practice of anesthesiologist
or a hospital, then such services shall be reimbursed through the employer....
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27-56-5
Section 27-56-5 Third-party payment. (a) No insurance policy, plan, or contract providing for
third-party payment or prepayment of health or medical expenses that provides coverage for
eye care services shall be issued or renewed after August 1, 2001, unless such insurance policy,
plan, or contract does the following: (1) Provides a covered person direct access to any eye
care provider participating in, or otherwise eligible to provide services under, the policy,
plan, or contract for all eye care services covered under the policy, plan, or contract, without
any referral or preapproval requirement, including, but not limited to, the following services,
if covered: a. Medical treatment of glaucoma. b. Postoperative eye care. (2) Ensures that
any list of medical or health care providers participating in, or otherwise eligible to provide
services under, the policy, plan, or contract includes eye care providers to the same extent
that such list includes other medical or health care...
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27-12A-1
Section 27-12A-1 Definitions. As used in this chapter, the following terms shall have the following
meanings: (1) COMMISSIONER. The Alabama Commissioner of Insurance or his or her designee.
(2) DEPARTMENT. The Alabama Department of Insurance. (3) INSURANCE. As defined in Section
27-1-2, and specifically including any contract, arrangement, or agreement, in which one undertakes
to do any one of the following: a. Pay or indemnify another as to loss from certain contingencies
called risks. b. Pay or grant a specified amount or determinable benefit to another in connection
with ascertainable risk contingencies. c. Pay an annuity to another. d. Act as surety. For
the purposes of this chapter, insurance also includes any health benefit plan as defined in
Section 27-53-1. (4) INSURANCE PRODUCER or PRODUCER. As defined in Section 27-7-1. (5) INSURER.
A person entering into agreements, contracts of insurance, arrangements, or reinsurance, or
a health benefit plan, or a group health plan as...
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27-19A-8
Section 27-19A-8 Plans not in conformance with chapter unlawful. It shall be unlawful for any
insurer or any person to provide any health insurance policy or employee benefit plan providing
for dental care services that does not conform to the provisions of this chapter. (Acts 1984,
No. 84-411, p. 960, §7.)...
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27-19A-9
Section 27-19A-9 Nonconforming policies and plans not to be approved by commissioner. The Commissioner
of Insurance shall not approve for sale in this state any health insurance policy or employee
benefit plan providing for dental care services which does not conform to the provisions of
this chapter or to the provisions of Sections 27-14-8 and 27-14-9. (Acts 1984, No. 84-411,
p. 960, §8.)...
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27-21A-3
Section 27-21A-3 Issuance of certificate of authority. (a)(1) Upon receipt of an application
for issuance of a certificate of authority, the commissioner shall forthwith transmit copies
of such application and accompanying documents to the State Health Officer. (2) The State
Health Officer shall determine whether the applicant for a certificate of authority, with
respect to health care services to be furnished: a. Has demonstrated the willingness and potential
ability to assure that such health care services will be provided in a manner to assure both
availability and accessibility of adequate personnel and facilities and in a manner enhancing
availability, accessibility, and continuity of service; b. Has arrangements, established in
accordance with the regulations promulgated by the State Health Officer, for an on-going quality
assurance program concerning health care processes and outcomes; and c. Has a procedure, established
in accordance with regulations of the State Health...
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27-3A-3
Section 27-3A-3 Definitions. As used in this chapter, the following words and phrases shall
have the following meanings: (1) DEPARTMENT. The Alabama Department of Public Health. (2)
ENROLLEE. An individual who has contracted for or who participates in coverage under an insurance
policy, a health maintenance organization contract, a health service corporation contract,
an employee welfare benefit plan, a hospital or medical services plan, or any other benefit
program providing payment, reimbursement, or indemnification for health care costs for the
individual or the eligible dependents of the individual. (3) PROVIDER. A health care provider
duly licensed or certified by the State of Alabama. (4) UTILIZATION REVIEW. A system for prospective
and concurrent review of the necessity and appropriateness in the allocation of health care
resources and services given or proposed to be given to an individual within this state. The
term does not include elective requests for clarification of...
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