Current through Reg. 50, No. 26; June 27, 2025
The following words and terms when used in this subchapter
have the following meanings, unless the context clearly indicates otherwise.
(1) Association--An association
(other than an employer association), including but not limited to a labor
union or organizations of such unions, membership corporations organized or
holding a certificate of authority under the Texas Non-profit Corporation Act,
and cooperatives and corporations subject to the supervision and control of the
Farm Credit Administration of the United States of America, that:
(A) has a constitution and bylaws;
(B) has been actively in existence for at
least 2 years; and
(C) has been
formed and maintained in good faith for purposes other than obtaining coverage
under a health benefit plan to cover members for the benefit of persons other
than the association or its officers or trustees.
(2) Bona Fide Association--An association
that, in addition to meeting the requirements of an association in paragraphs
(1)(A) and (C) of this subsection:
(A) has
been actively in existence for at least 5 years;
(B) does not condition membership in the
association on any health-status-related factor relating to an individual
(including the individual eligible for membership or a dependent of the
individual eligible for membership, if dependent coverage is
offered);
(C) makes coverage under
a health benefit plan offered through the association available to all members,
regardless of any health-status-related factor relating to the members (or
dependents eligible for coverage through a member, if dependent coverage is
offered); and
(D) does not make a
health benefit plan offered through the association available other than in
connection with a member of the association.
(3) Creditable Coverage--As defined in §
21.1101 of this title (relating to
Definitions).
(4) Genetic
information--Information derived from the results of a genetic test.
(5) Genetic test--A laboratory test of an
individual's deoxyribonucleic acid (DNA), ribonucleic acid (RNA), proteins, or
chromosomes to identify by analysis of the DNA, RNA, proteins, or chromosomes
the genetic mutations or alterations in the DNA, RNA, proteins, or chromosomes
that are associated with a predisposition for a clinically recognized disease
or disorder. The term does not include:
(A) a
routine physical examination or a routine test performed as a part of a
physical examination;
(B) a
chemical, blood or urine analysis;
(C) a test to determine drug use;
or
(D) a test for the presence of
the human immunodeficiency virus.
(6) HMO--A health maintenance organization as
defined in Insurance Code §
843.002.
(7) Health benefit plan--A group 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 carrier that provides benefits for health care benefits or services. The
term does not include the following plans of coverage:
(A) Under all circumstances:
(i) coverage only for accident;
(ii) credit-only insurance;
(iii) disability insurance
coverage;
(iv) Medicare services
under a federal contract;
(v)
coverage issued as a supplement to liability insurance;
(vi) insurance coverage arising out of
workers' compensation or similar insurance;
(vii) automobile medical payment insurance
coverage;
(viii) jointly managed
trusts authorized under
29
United States Code §§141 et seq. that contain
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
United States Code §157;
(ix) short-term limited duration insurance as
defined in this section;
(x)
liability insurance, including general liability insurance and automobile
liability insurance; or
(xi)
coverage for onsite medical clinics.
(B) Only if the benefits are provided under a
separate policy or contract of insurance or evidence of coverage:
(i) coverage for a specified disease or
illness;
(ii) Medicare supplement
and Medicare Select policies regulated in accordance with federal
law;
(iii) 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;
(iv)
coverage that provides limited-scope dental or vision benefits;
(vii) coverage supplemental to the coverage
provided under Chapter 55, Title 10 of the United States Code (also known as
CHAMPUS supplemental programs);
(viii) coverage that provides other limited
benefits specified by federal regulations; or
(ix) other coverage that is:
(I) similar to the coverage described in
subparagraphs (A) and (B) of this paragraph under which benefits for medical
care are secondary or incidental to other insurance benefits; and
(II) specified in federal
regulations.
(8) Health carrier--Any entity authorized
under the Texas Insurance Code or another insurance law of this state that
provides health benefit plans in this state, including an insurance company; a
group hospital service corporation operating under Insurance Code Chapter 842;
a stipulated premium insurance company operating under Insurance Code Chapter
884; 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, or an HMO.
(9) Health-status-related factor--Any of the
following in relation to an individual:
(B) medical
condition, including both physical and mental illness;
(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; or
(10) Short-term limited duration
coverage--Health coverage provided under a contract with a health carrier that
has an expiration date specified in the contract (taking into account any
extensions that may be elected by the policyholder without the health carrier's
consent) that is within 12 months of the date the contract becomes
effective.
