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) Affiliation period--A
period of time that under the terms of the coverage offered by an HMO, must
expire before the coverage becomes effective. During an affiliation period an
HMO is not required to provide health care services or benefits to the
participant or beneficiary and a premium may not be charged to the participant
or beneficiary.
(2) COBRA--Title X
of the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended
(29
USC Section 1161, et seq.).
(3) COBRA continuation coverage--Coverage
that satisfies an applicable COBRA continuation provision.
(4) Commissioner--The Commissioner of
Insurance.
(5) Creditable
coverage--
(A) An individual's coverage is
creditable if the coverage is provided under:
(i) a self-funded or self-insured employee
welfare benefit plan that provides health benefits and that is established in
accordance with the Employee Retirement Income Security Act of 1974
(29 U.S.C. Section
1001 et seq.);
(ii) a group health benefit plan provided by
a health insurance carrier or an HMO;
(iii) an individual health insurance policy
or evidence of coverage;
(iv) Part
A or Part B of Title XVIII of the Social Security Act (42
U.S.C. Section 1395c et seq.);
(v) Title XIX of the Social Security Act
(42 U.S.C. Section
1396 et seq.), other than coverage consisting
solely of benefits under Section 1928 of that Act (42 U.S.C. Section
1396s);
(vi) Chapter 55 of Title 10, United States
Code (10 U.S.C. Section
1071 et seq.);
(vii) a medical care program of the Indian
Health Service or of a tribal organization;
(viii) a state or political subdivision
health benefits risk pool;
(ix) a
health plan offered under Chapter 89 of Title 5, United States Code
(5
U.S.C. Section 8901 et seq.);
(x) a public health plan as defined in this
section;
(xi) a health benefit plan
under Section 5(e) of the Peace Corps Act (22 U.S.C. Section
2504(e)); and
(xii) short-term limited duration insurance
as defined in this section.
(B) Creditable coverage does not include:
(i) accident-only, disability income
insurance, or a combination of accident-only and disability income
insurance;
(ii) coverage issued as
a supplement to liability insurance;
(iii) liability insurance, including general
liability insurance and automobile liability insurance;
(iv) workers' compensation or similar
insurance;
(v) automobile medical
payment insurance;
(vi)
credit-only insurance;
(vii)
coverage for onsite medical clinics;
(viii) other coverage that is similar to the
coverage described in this subparagraph under which benefits for medical care
are secondary or incidental to other insurance benefits and specified in
federal regulations;
(ix) if
offered separately, coverage that provides limited-scope dental or vision
benefits;
(x) if offered
separately, 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;
(xi) if offered separately, coverage for
other limited benefits specified by federal regulations;
(xii) if offered as independent,
noncoordinated benefits, coverage for specified disease or illness;
(xiii) if offered as independent,
noncoordinated benefits, hospital indemnity or other fixed indemnity insurance;
or
(xiv) Medicare supplemental
health insurance as defined under Section 1882(g)(1), Social Security Act
(42
U.S.C. Section 1395ss), coverage supplemental
to the coverage provided under Chapter 55 of Title 10, United States Code
(10 U.S.C. Section
1071 et seq.), and similar supplemental
coverage provided under a group plan, but only if such insurance or coverages
are provided under a separate policy, certificate, or contract of
insurance.
(6)
Health benefit plan--A plan that provides benefits for medical or surgical
expenses incurred as a result of a health condition, accident, or sickness,
including:
(A) an individual, group, blanket,
or franchise insurance policy or insurance agreement, a group hospital service
contract, or an individual or group evidence of coverage that is offered by:
(i) an insurance company;
(ii) a group hospital service corporation
operating under Insurance Code Chapter 842 ;
(iii) a fraternal benefit society operating
under Insurance Code Chapter 885 ;
(iv) a stipulated premium insurance company
operating under Insurance Code Chapter 884 ; or
(B) to the extent permitted by the Employee
Retirement Income Security Act of 1974 (29
U.S.C. Section 1001 et seq.), a plan that is
offered by:
(i) a multiple employer welfare
arrangement as defined by Section 3, Employee Retirement Income Security Act of
1974 (29 U.S.C. Section
1002), and operating under Insurance Code
Chapter 846; or
(ii) another
analogous benefit arrangement; or
(C) a plan issued by any other entity not
licensed under the Insurance Code or another insurance law of this state that
contracts directly for health care services on a risk-sharing basis, including
an entity that contracts for health care services on a capitation
basis.
(7) Health
insurance coverage--Benefits consisting of medical care (provided directly,
through insurance or reimbursement, or otherwise) under any hospital or medical
service policy or certificate, hospital or medical service plan contract, or
HMO contract.
(8) HMO--Any person
governed by the Texas Health Maintenance Organization Act, Insurance Code
Chapter 843, including:
(A) a person defined
as a health maintenance organization under Insurance Code §
843.002;
(B) an approved nonprofit health corporation
that is certified under Occupations Code Chapter 162, and that holds a
certificate of authority issued by the Commissioner under Insurance Code
Chapter 844;
(C) a statewide rural
health care system under Insurance Code §
845.052 and §
845.054; or
(D) a nonprofit corporation created and
operated by a community center under Chapter 534, Subchapter C, Health and
Safety Code.
(9) Issuer
of a health benefit plan--An insurance company, a group hospital service
corporation operating under Insurance Code Chapter 842, a fraternal benefit
society operating under Insurance Code Chapter 885, a stipulated premium
insurance company operating under Insurance Code Chapter 884, a Lloyd's plan
operating under Insurance Code Chapter 941, a reciprocal or interinsurance
exchange operating under Insurance Code Chapter 942, or an HMO that issues a
health benefit plan.
(10) Medical
care--Amounts paid for:
(A) the diagnosis,
cure, mitigation, treatment, or prevention of disease, or amounts paid for the
purpose of affecting any structure or function of the body;
(B) transportation primarily for and
essential to the medical care described in subparagraph (A) of this paragraph;
or
(C) insurance covering medical
care described in either subparagraphs (A) or (B) of this paragraph.
(11) Preexisting condition
provision--A provision that denies, excludes, or limits coverage as to a
disease or condition for a specified period after the effective date of
coverage.
(12) Public health
plan--Any plan established or maintained by a state, county or other political
subdivision of a state that provides health insurance coverage to individuals
who are enrolled in the plan.
(13)
Qualified beneficiary--As defined in Section
4980B(g)(1) of the
Internal Revenue Code (26
U.S.C. Section 4980B(g)(1)).
(14) Short-term limited duration
insurance--Health insurance coverage provided under a contract with an issuer
that has an expiration date specified in the contract (taking into account any
extensions that may be elected by the policyholder without the issuer's
consent) that is within 12 months of the date the contract becomes
effective.
(15) Waiting period--A
period of time established by an employer that must pass before an individual
who is a potential enrollee in a health benefit plan is eligible to be covered
for benefits. If an employee or dependent enrolls as a late enrollee, any
period before such late enrollment is not a waiting period. If an individual
seeks and obtains coverage in the individual market, any period after the date
the individual files a substantially complete application for coverage and
before the first day of coverage is a waiting period.