Current through Reg. 50, No. 13; March 28, 2025
The following words and terms, when used in this
subchapter, have the following meanings unless the context clearly indicates
otherwise.
(1) Enrollee--An individual
who is eligible for coverage under a health benefit plan, including a covered
dependent.
(2) Health benefit
plan--A group, blanket, or franchise insurance policy, a certificate issued
under a group policy, a group hospital service contract, or a group subscriber
contract or evidence of coverage issued by a health maintenance organization
that provides benefits for health care services. The term does not include:
(A) accident-only or disability income
insurance coverage or a combination of accident-only and disability income
insurance coverage;
(B) credit-only
insurance coverage;
(C) disability
insurance coverage;
(D) coverage
only for a specified disease or illness;
(E) Medicare services under a federal
contract;
(F) Medicare supplement,
Medicare Select, Medicare Advantage, or any successor policies regulated in
accordance with federal law;
(G)
long-term care coverage or benefits, nursing home care coverage or benefits,
home health care coverage or benefits, community-based care coverage or
benefits, or any combination of those coverages or benefits;
(H) coverage that provides only dental or
vision benefits;
(I) coverage
provided by a single service health maintenance organization;
(J) coverage issued as a supplement to
liability insurance;
(K) workers'
compensation insurance coverage or similar insurance coverage;
(L) automobile medical payment insurance
coverage;
(M) a jointly managed
trust authorized under
29
U.S.C. Section 141 et seq. that contains a
plan of benefits for employees that is negotiated in a collective bargaining
agreement governing wages, hours, and working conditions of the employees that
is authorized under
29
U.S.C. Section 157;
(N) hospital indemnity or other fixed
indemnity insurance coverage;
(O)
reinsurance contracts issued on a stop-loss, quota-share, or similar
basis;
(P) liability insurance
coverage, including general liability insurance and automobile liability
insurance coverage; or
(Q) coverage
that provides other limited benefits specified by federal
regulations.
(3) Health
benefit plan issuer--Any entity that issues a health benefit plan, including:
(A) a health maintenance organization
operating under Insurance Code Chapter 843;
(B) an approved nonprofit health corporation
that holds a certificate of authority under Insurance Code Chapter
844;
(C) an insurance company,
including an insurance company offering a preferred provider benefit plan under
Insurance Code Chapter 1301;
(D) a
group hospital service corporation operating under Insurance Code Chapter
842;
(E) a fraternal benefit
society operating under Insurance Code Chapter 885; or
(F) a stipulated premium company operating
under Insurance Code Chapter 884.
(4) Health care provider--
(A) a person, other than a physician, who is
licensed or otherwise authorized to provide a health care service in this
state, including:
(i) a pharmacist or
dentist; or
(ii) a pharmacy,
hospital, or other institution or organization;
(B) a person who is wholly owned or
controlled by a provider or by a group of providers who are licensed or
otherwise authorized to provide the same health care service; or
(C) a person who is wholly owned or
controlled by one or more hospitals and physicians, including a
physician-hospital organization.
(5) Participating provider--
(A) a physician or health care provider who
contracts with a health benefit plan issuer to provide medical care or health
care to enrollees in a health benefit plan; or
(B) a physician or health care provider who
accepts and treats a patient on a referral from a physician or provider
described by subparagraph (A) of this paragraph.
(6) Physician--
(A) an individual licensed to practice
medicine in this state under Subtitle B, Title 3, Occupations Code;
(B) a professional association organized
under the Texas Professional Association Law (Business Organizations Code
Chapters 301 and 302);
(C) a
nonprofit health corporation certified under Chapter 162, Occupations
Code;
(D) a medical school or
medical and dental unit, as defined or described by Education Code §§
61.003,
61.501, or
74.601, that employs
or contracts with physicians to teach or provide medical services or employs
physicians and contracts with physicians in a practice plan; or
(E) another entity wholly owned by
physicians.
(7) Primary
enrollee--The individual who is the certificate holder and whose employment or
other membership status, except for family dependency, is the basis for
eligibility under the health benefit plan.
