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) Basic benefit--Health
care service or coverage, which is included in the evidence of coverage,
policy, or certificate, without additional premium.
(2) Caretaker--A family member or significant
other responsible for ensuring that an insured not able to manage his or her
illness (due to age or infirmity) is properly managed, including overseeing
diet, administration of medications, and use of equipment and
supplies.
(3) Diabetes--Diabetes
mellitus. A chronic disorder of glucose metabolism that can be characterized by
an elevated blood glucose level. The terms "diabetes" and "diabetes mellitus"
are synonymous.
(4) Diabetes
equipment--The term "diabetes equipment" includes items defined in Insurance
Code §
1358.051 and §
1358.056, and §
21.2605 of this title (relating to
Diabetes Equipment and Supplies).
(5) Diabetes supplies--The term "diabetes
supplies" includes items defined in Insurance Code §
1358.051 and §
1358.056, and §
21.2605 of this title.
(6) Diabetes self-management
training--Instruction enabling an insured and/or his or her caretaker to
understand the care and management of diabetes, including nutritional
counseling and proper use of diabetes equipment and supplies.
(7) Health benefit plan--A health benefit
plan, for purposes of this subchapter, means:
(A) a plan that provides benefits for medical
or surgical expenses incurred as a result of a health condition, accident, or
sickness, including:
(i) 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;
(V) a reciprocal exchange operating under
Texas Insurance Code Chapter 942; or
(VI) a health maintenance organization (HMO)
operating under Insurance Code Chapter 843;
(ii) to the extent permitted by the Employee
Retirement Income Security Act of 1974 (29 U.S.C. §
1002), a health benefit plan that is offered
by a multiple employer welfare arrangement as defined by §3, Employee
Retirement Income Security Act of 1974 (29 U.S.C. §
1002) that holds a certificate of authority
under Insurance Code Chapter 846; or
(iii) notwithstanding Local Government Code
§ 172.014, or any other law, health and accident coverage provided by a
risk pool created under Local Government Code Chapter 172.
(B) A plan offered by an approved nonprofit
health corporation that is certified under Texas Occupation Code
§162.001(b), and that holds a certificate of authority issued by the
Commissioner under Insurance Code Chapter 844.
(C) A health benefit plan is not:
(i) a plan that provides coverage:
(I) only for a specified disease or other
limited benefit;
(II) only for
accidental death or dismemberment;
(III) for wages or payments in lieu of wages
for a period during which an employee is absent from work because of sickness
or injury;
(IV) as a supplement to
liability insurance;
(V) for credit
insurance;
(VI) dental or vision
care only; or
(VII) hospital
confinement indemnity coverage only.
(ii) a small employer plan written under
Insurance Code Chapter 1501;
(iii)
a Medicare supplemental policy as defined by §1882(g)(1), Social Security
Act (42 U.S.C. §
1395 ss);
(iv) a plan that is designed to supplement
benefits provided under a program established by the Department of Defense
pursuant to Chapter 55 of Title 10, United States Code (10
U.S.C. §
1071 et seq.);
(v) workers' compensation insurance
coverage;
(vi) medical payment
insurance issued as part of a motor vehicle insurance policy; or
(vii) a long-term care policy, including a
nursing home fixed indemnity policy, unless the Commissioner determines that
the policy provides benefit coverage so comprehensive that the policy is a
health benefit plan as described by subparagraph (A) of this
paragraph.
(8) Insured--A person enrolled in a health
benefit plan who has been diagnosed with:
(A)
insulin dependent or noninsulin dependent diabetes; or
(B) elevated blood glucose levels induced by
pregnancy or another medical condition associated with elevated glucose
levels.
(9) Nutrition
counseling--As defined in Occupations Code §
701.002.
(10) Physician--A Doctor of Medicine or a
Doctor of Osteopathy licensed by the Texas State Board of Medical
Examiners.
(11) Practitioner--An
Advanced Practice Nurse, Doctor of Dentistry, Physician Assistant, Doctor of
Podiatry, or other licensed person with prescriptive authority.
