Current through Reg. 50, No. 13; March 28, 2025
(a) Except as otherwise provided, words and
terms defined in Insurance Code Chapters 823 (concerning Insurance Holding
Company Systems), 843 (concerning Health Maintenance Organizations), 1271
(concerning Benefits Provided by Health Maintenance Evidence of Coverage;
Charges), 1272 (concerning Delegation of Certain Functions of Health
Maintenance Organizations), 1367 (concerning Coverage of Children), 1452
(concerning Physician and Provider Credentials), 1501 (concerning Health
Insurance Portability and Availability Act), and 1507 (concerning Consumer
Choice of Benefits Plans) have the same meanings when used in this
subchapter.
(b) The following words
and terms, when used in this chapter, have the meaning indicated below unless
the context clearly indicates otherwise:
(1)
Admitted assets--Assets as defined by statutory accounting principles, as
permitted and valued under Chapter 11, Subchapter I, of this title (relating to
Financial Requirements).
(2)
Adverse determination--A determination by a health maintenance organization or
a utilization review agent that health care services provided or proposed to be
provided to an enrollee are not medically necessary or appropriate, or are
experimental or investigational. The term does not include a denial of health
care services due to the failure to request prospective or concurrent
utilization review.
(3)
Affiliate--A person defined as an affiliate in §
7.202 of this title (relating to
Definitions).
(4) Agent--A person
licensed under the Insurance Code to act as an agent for the sale of a health
benefit plan.
(5) ANHC or approved
nonprofit health corporation--A nonprofit health corporation certified under
Occupations Code §
162.001 (concerning
Certification by Board) and defined in Insurance Code Chapter 844 (concerning
Certification of Certain Nonprofit Health Corporations).
(6) Basic health care service--A health care
service that an enrolled population might reasonably require to maintain good
health, as prescribed in §
11.508 and §
11.509 of this title (relating to
Basic Health Care Services and Mandatory Benefit Standards: Group, Individual,
and Conversion Agreements; and relating to Additional Mandatory Benefit
Standards: Individual and Group Agreements).
(7) Clinical director--A health professional
who is:
(A) appropriately licensed and
credentialed in compliance with §
11.1606 of this title (relating to
Organization of an HMO);
(B) an
employee of, or party to a contract with, an HMO; and
(C) responsible for clinical oversight of the
utilization review program, the credentialing of professional staff, and
quality improvement functions.
(8) Consumer choice health benefit plan--A
health benefit plan authorized by Insurance Code Chapter 1507 and described in
Chapter 21, Subchapter AA, of this title (relating to Consumer Choice Health
Benefit Plans).
(9) Contract
holder--An individual, association, employer, trust, or organization to which
an individual or group contract for health care services has been
issued.
(10) Control--As defined in
§
7.202 of this title.
(11) Copayment--A charge, which may be
expressed in terms of a dollar amount or a percentage of the contracted rate,
in addition to premium attributed to an enrollee for a service that is not
fully prepaid.
(12)
Credentialing--The process of collecting, assessing, and validating
qualifications and other relevant information pertaining to a physician or
provider to determine eligibility to deliver health care services.
(13) Dentist--An individual provider licensed
to practice dentistry by the Texas State Board of Dental Examiners.
(14) Department--Texas Department of
Insurance.
(15) Emergency care--As
defined in Insurance Code §
843.002 (concerning
Definitions).
(16) Facility-based
physician--A radiologist, anesthesiologist, pathologist, emergency department
physician, neonatologist, or assistant surgeon:
(A) to whom a facility has granted clinical
privileges; and
(B) who provides
services to patients of the facility under those clinical privileges.
(17) Freestanding emergency
medical care facility--A facility, licensed under Health and Safety Code
Chapter 254 (concerning Freestanding Emergency Medical Care Facilities),
structurally separate and distinct from a hospital, that receives an individual
and provides emergency care as defined in Insurance Code §
843.002.
(18) General hospital--An establishment,
licensed under Health and Safety Code Chapter 241 (concerning Hospitals), that:
(A) offers services, facilities, and beds for
use for more than 24 hours for two or more unrelated individuals requiring
diagnosis, treatment, or care for illness, injury, deformity, abnormality, or
pregnancy; and
(B) regularly
maintains, at a minimum, clinical laboratory services, diagnostic X-ray
services, treatment facilities including surgery or obstetrical care or both,
and other definitive medical or surgical treatment of similar extent.
(19) HMO--A health maintenance
organization as defined in Insurance Code §
843.002.
(20) Health status-related factor--Any of the
following in relation to an individual:
(B) medical
condition (including both physical and mental illnesses);
(D) receipt of health care;
(G) evidence of insurability (including
conditions arising out of acts of domestic violence, including family violence
as defined by Insurance Code Chapter 544, Subchapter D (concerning Family
Violence); or
(21)
Individual provider--Any person, other than a physician or institutional
provider, who is licensed or otherwise authorized to provide a health care
service. This includes, but is not limited to, licensed doctors of
chiropractic, dentists, registered nurses, advanced practice registered nurses,
physician assistants, pharmacists, optometrists, and acupuncturists.
(22) Insert page--A page used to replace an
existing page of a previously approved or reviewed evidence of coverage or
written plan description, including a member handbook.
(23) Institutional provider--A provider that
is not an individual, such as any medical or health related service facility
caring for the sick or injured or providing care or supplies for other coverage
that may be provided by the HMO. This includes, but is not limited to:
(B) psychiatric hospitals;
(E) skilled nursing facilities;
(F) home health agencies;
(G) rehabilitation facilities;
(I) free-standing surgical centers;
(J) diagnostic imaging centers;
(M) residential treatment centers;
(N) community mental health
centers;
(P) freestanding emergency
medical care facilities.
(24) Insurance Code--The Texas Insurance
Code.
(25) Limited provider
network--A subnetwork within an HMO delivery network in which contractual
relationships between physicians, certain providers, independent physician
associations, physician groups, or any combination thereof, limit enrollees'
access to only the physicians and providers in the subnetwork.
(26) Limited service HMO--An HMO that has
been issued a certificate of authority to issue a limited health care service
plan as defined in Insurance Code §
843.002.
(27) Matrix filing--A filing consisting of
individual provisions, each with its own unique identifiable form number, which
allows an HMO the flexibility to create multiple evidences of coverage by using
combinations of approved individual provisions.
(28) NAIC--The National Association of
Insurance Commissioners.
(29) NAIC
UCAA--The National Association of Insurance Commissioners' Uniform Certificate
of Authority Application.
(30)
NCQA--The National Committee for Quality Assurance.
(31) Net worth--The amount by which total
admitted assets exceed total liabilities, excluding liability for subordinated
debt issued in compliance with Insurance Code Chapter 427 (concerning
Subordinated Indebtedness).
(32)
Out of area benefits or services--Benefits or services that an HMO covers when
enrollees are outside the geographical limits of the HMO service
area.
(33) Pharmaceutical
services--Services, including dispensing prescription drugs, under the Texas
Pharmacy Act, Occupations Code, Title 3, Subtitle J, Chapters 551 - 569
(concerning Pharmacy and Pharmacists), that are ordinarily and customarily
rendered by a pharmacy or pharmacist.
(34) Pharmacist--An individual provider
licensed to practice pharmacy under the Texas Pharmacy Act, Occupations Code,
Title 3, Subtitle J, Chapters 551 - 569.
(35) Pharmacy--A facility licensed under the
Texas Pharmacy Act, Occupations Code, Title 3, Subtitle J, Chapters 551 -
569.
(36) Preauthorization--As
defined in Insurance Code §
843.348(a)
(concerning Preauthorization of Health Care Services).
(37) Premium--All amounts payable by a
contract holder as a condition of receiving coverage from a carrier, including
any fees or other contributions associated with a health benefit
plan.
(38) Primary care physician
or primary care provider--A physician or individual provider who is responsible
for providing initial and primary care to patients, maintaining the continuity
of patient care, and initiating referral for care.
(39) Primary HMO--An HMO that contracts
directly with, and issues an evidence of coverage to, individuals or
organizations to arrange for or provide a basic, limited, or single health care
service plan to enrollees on a prepaid basis.
(40) Provider HMO--An HMO that contracts
directly with a primary HMO to provide or arrange to provide health care
services on behalf of the primary HMO within the primary HMO's defined service
area.
(41) Psychiatric hospital--A
licensed hospital that offers inpatient services, including treatment,
facilities, and beds for use beyond 24 hours, for the primary purpose of
providing psychiatric assessment, psychiatric diagnostic services, psychiatric
inpatient care, and treatment for mental illness. The services must be more
intensive than room, board, personal services, and general medical and nursing
care. Although substance abuse services may be offered, a majority of beds must
be dedicated to the treatment of mental illness in adults, children, or
both.
(42) QI or quality
improvement--A system to continuously examine, monitor, and revise processes
and systems that support and improve administrative and clinical
functions.
(43)
Recredentialing--The periodic process by which:
(A) qualifications of physicians and
providers are reassessed;
(B)
performance indicators, including utilization and quality indicators, are
evaluated; and
(C) continued
eligibility to provide services is determined.
(44) Schedule of charges--Specific rates or
premiums to be charged for enrollee and dependent coverages.
(45) Service area--A geographic area within
which direct service benefits are available and accessible to HMO enrollees who
live, reside, or work within that geographic area and that complies with §
11.1606 of this title.
(46) Single service HMO--An HMO that has been
issued a certificate of authority to issue a single health care service plan as
defined in Insurance Code §
843.002.
(47) Special hospital--An establishment,
licensed under Health and Safety Code Chapter 241 (concerning Hospitals), that:
(A) offers services, facilities, and beds for
use for more than 24 hours for two or more unrelated individuals who are
regularly admitted, treated, and discharged and who require services more
intensive than room, board, personal services, and general nursing
care;
(B) has clinical laboratory
facilities, diagnostic X-ray facilities, treatment facilities, or other
definitive medical treatment;
(C)
has a medical staff in regular attendance; and
(D) maintains records of the clinical work
performed for each patient.
(48) Specialists--Physicians or individual
providers who set themselves apart from the primary care physician or primary
care provider through specialized training and education in a health care
discipline.
(49) State-mandated
health benefit plan--An accident or sickness insurance policy or evidence of
coverage that provides state-mandated health benefits as defined in §
21.3502 of this title (relating to
Definitions).
(50) Subscriber--For
conversion or individual coverage, the individual who is the contract holder
and is responsible for payment of premiums to the HMO. For group coverage, the
individual who is the certificate holder and whose employment or other
membership status, except for family dependency, is the basis for eligibility
for enrollment in the HMO.
(51)
Subsidiary--As defined in §
7.202 of this title.
(52) Telehealth service--As defined in
Government Code §
531.001 (concerning
Definitions).
(53) Telemedicine
medical service--As defined in Government Code §
531.001.
(54) Urgent care--Health care services
provided in a situation other than an emergency that are typically provided in
a setting such as a physician or individual provider's office or urgent care
center, as a result of an acute injury or illness that is severe or painful
enough to lead a prudent layperson, possessing an average knowledge of medicine
and health, to believe that his or her condition, illness, or injury is of such
a nature that failure to obtain treatment within a reasonable time would result
in serious deterioration of the condition of his or her health.
(55) Utilization review--As defined in
Insurance Code §
4201.002 (concerning
Definitions).
(56) Utilization
review agent or URA--As defined in Insurance Code §
4201.002.