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) Another limited
benefit--A plan that provides coverage, singularly or in combination, for
benefits for a specifically named disease, accident, or combination of diseases
or accidents, including, but not limited to:
(D) travel, farm, or occupational
accident.
(2)
Carrier--The term includes:
(A) an insurance
company, a group hospital service corporation, a fraternal benefit society, a
stipulated premium insurance company, a health maintenance organization, a
multiple employer welfare arrangement that holds a certificate of authority
under Insurance Code Chapter 846, or an approved nonprofit health corporation
that holds a certificate of authority issued by the commissioner under
Insurance Code Chapter 844;
(B) for
the purposes of paragraph (4)(B) and (F) of this section, a reciprocal exchange
operating under Insurance Code Chapter 942;
(C) for purposes of paragraph (4)(E) and (F)
of this section, a Lloyds plan operating under Insurance Code Chapter 941;
and
(D) for purposes of paragraph
(4)(E) of this section, a risk pool created under Local Government Code Chapter
172.
(3) Enrollee--A
person enrolled in and entitled to coverage under a health benefit plan,
including covered dependents.
(4)
Health Benefit Plan--Subject to subparagraphs (A), (B), (C), (D), (E), and (F)
of this paragraph, a plan that is offered by a carrier and provides benefits
for medical or surgical expenses incurred as a result of a health condition,
accident, or sickness, including an individual, group, blanket, or franchise
insurance policy or insurance agreement; a group hospital service contract; an
individual or group evidence of coverage; or any similar coverage document. The
term does not include a plan that provides coverage only for accidental death
or dismemberment, disability income, supplement to liability insurance,
Medicare supplement, workers' compensation, medical payment insurance issued as
a part of a motor vehicle insurance policy, or a long-term care policy.
(A) For the inpatient mastectomy coverage
notice required by §
21.2103(a)(1) of
this title (relating to Mandatory Benefit Notices), the definition of health
benefit plan includes a plan that provides coverage only for a specific disease
or condition for the treatment of breast cancer or for hospitalization. The
term does not include a small employer health benefit plan issued under
Insurance Code Chapter 1501, Subchapters A - H (concerning Health Insurance
Portability and Availability Act).
(B) For the reconstructive surgery after
mastectomy notices required by §
21.2103(a)(2) of
this title, the definition of health benefit plan does not include:
(i) a plan that provides coverage for a
specified disease or another limited benefit, except for cancer;
(ii) a plan that provides only credit
insurance;
(iii) a plan that
provides coverage only for dental or vision care; or
(iv) a plan that provides coverage only for
hospital indemnity or other fixed indemnity.
(C) For the prostate cancer examination
notice required by §
21.2103(a)(3) of
this title, the definition of health benefit plan does not include:
(i) a small employer health benefit plan
written under Insurance Code Chapter 1501, Subchapters A - H;
(ii) a plan that provides coverage only for a
specified disease or another limited benefit; or
(iii) a plan that provides coverage only for
hospital indemnity or other fixed indemnity.
(D) For the inpatient maternity and
childbirth coverage notice required by §
21.2103(a)(4) and
(5) of this title, the definition of health
benefit plan does not include:
(i) a plan
that provides only credit insurance;
(ii) a plan that provides coverage only for a
specified disease or another limited benefit;
(iii) a plan that provides coverage only for
dental or vision care; or
(iv) a
plan that provides coverage only for hospital indemnity or other fixed
indemnity.
(E) For the
detection of colorectal cancer screening coverage notice required by §
21.2103(a)(6) of
this title, the definition of health benefit plan does not include:
(i) a small employer health benefit plan
written under Insurance Code Chapter 1501, Subchapters A - H;
(ii) a plan that provides coverage only for a
specified disease or another limited benefit; or
(iii) a plan that provides coverage only for
hospital indemnity or other fixed indemnity.
(F) For the detection of human papillomavirus
and cervical cancer screening notice required by §
21.2103(a)(7) of
this title, the definition of health benefit plan includes a small employer
health benefit plan written under Insurance Code Chapter 1501, but does not
include:
(i) a plan that provides coverage
only for a specified disease or another limited benefit, other than a plan that
provides benefits for cancer treatment or similar services;
(ii) a plan that provides coverage only for
dental or vision care;
(iii) a plan
that provides coverage only for indemnity or for hospital indemnity or other
fixed indemnity;
(iv) a credit
insurance policy; or
(v) a limited
benefit policy that does not provide coverage for physical examinations or
wellness exams.
(5) Primary Enrollee--For group coverage, the
covered member or employee of the group. For individual coverage, the person
first named on the application or enrollment form.