The following words and terms, when used in this subchapter,
have the following meanings, unless the context clearly indicates
otherwise.
(1) Allowable expense--Except as otherwise provided
in §3.3505 of this title (relating to Allowable Expenses), or
where a statute requires a different definition, any health care expense,
including coinsurance or copayments and without reduction for any
applicable deductible, that is covered in full or in part by any of
the plans covering the person.
(2) Allowed amount--The amount of a billed charge that
a carrier determines to be covered for services provided by a noncontracted
health care provider or physician. The allowed amount includes the
carrier's payment and any applicable deductible, copayment, or coinsurance
amounts for which the insured is responsible.
(3) Birthday--Refers only to the month and day in a
calendar year and does not include the year in which the individual
is born.
(4) Carrier--An entity authorized under the Insurance
Code to provide coverage subject to this subchapter, including an
insurer, health maintenance organization, group hospital service corporation,
or stipulated premium company.
(5) Certificate holder--An insured or enrollee who
is covered other than as a dependent under a group plan or a group-type
plan.
(6) Claim--A request that benefits be provided or paid.
The benefits claimed may be in the form of:
(A) services, including supplies;
(B) payment for all or a portion of the expenses incurred;
(C) a combination of subparagraphs (A) and (B) of this
paragraph; or
(D) an indemnification.
(7) Closed panel plan--A plan that provides health
benefits to covered persons primarily in the form of services through
a panel of health care providers and physicians that have contracted
with or are employed by the plan, and that excludes benefits for services
provided by other health care providers or physicians, except in cases
of emergency or referral by a panel member.
(8) Consolidated Omnibus Budget Reconciliation Act
of 1985 (COBRA)--Coverage provided under a right of continuation under
federal law.
(9) Contract--Refers to an insurance policy, insurance
certificate, or health maintenance organization evidence of coverage.
(10) Coordination of benefits (COB)--A provision establishing
an order in which plans pay their claims and permitting secondary
plans to reduce their benefits so that the combined benefits of all
plans do not exceed total allowable expenses.
(11) Custodial parent--
(A) the parent with the right to designate the primary
residence of a child by a court order under the Family Code or other
applicable law; or
(B) in the absence of a court order, the parent with
whom the child resides more than one-half of the calendar year without
regard to any temporary visitation.
(12) Group-type contract--A contract that is not available
to the public and is obtained and maintained only because of membership
in or a connection with a particular organization or group, including
blanket coverage.
(13) High-deductible health plan--A high-deductible
health plan under §223 of the Internal Revenue Code of 1986,
as amended by the Medicare Prescription Drug, Improvement, and Modernization
Act of 2003, and Insurance Code Chapter 1653.
(14) Hospital indemnity benefits--Benefits not related
to expenses incurred. This term does not include reimbursement-type
benefits even if they are designed or administered to give the insured
the right to elect indemnity-type benefits at the time of claim.
(15) Plan--A form of coverage with which coordination
is allowed. For purposes of this subchapter:
(A) plan includes:
(i) any contract to which this subchapter applies;
(ii) limited benefit policies under §3.3079 of
this title (relating to Minimum Standards for Limited Benefit Coverage),
excluding Disability Income Protection Coverage under §3.3075
of this title (relating to Minimum Standards for Disability Income
Protection Coverage);
(iii) uninsured arrangements of group or group-type
coverage;
(iv) the medical benefits coverage in automobile insurance
contracts;
(v) Medicare or other governmental benefits; as permitted
by law; and
(vi) group insurance contracts, individual insurance
contracts, and subscriber contracts that pay or reimburse for the
cost of dental care.
(B) plan does not include:
(i) the Texas Health Insurance Pool as described in
Insurance Code Chapter 1506;
(ii) workers' compensation insurance coverage;
(iii) hospital confinement indemnity coverage or other
fixed indemnity;
(iv) specified disease coverage;
(v) supplemental benefit coverage under §3.3080
of this title (relating to Supplemental Coverage) and as described
in Insurance Code Chapter 1203;
(vi) accident-only coverage;
(vii) specified accident coverage;
(viii) school accident-type coverages that cover students
for accidents only, including athletic injuries, either on a "24-hour
basis" or on a "to and from school" basis;
(ix) benefits provided in long-term care insurance
contracts for nonmedical services, for example, personal care, adult
day care, homemaker services, assistance with activities of daily
living, respite care, and custodial care or for contracts that pay
a fixed daily benefit without regard to expenses incurred or the receipt
of services;
(x) Medicare supplement policies;
(xi) a state plan under Medicaid;
(xii) a governmental plan which, by law, provides benefits
that are in excess of those of any private insurance plan or other
nongovernmental plan; or
(xiii) an individual accident and health insurance
policy that is designed to fully integrate with other policies through
a variable deductible.
(16) Policyholder--The primary insured named in an
individual health insurance policy or evidence of coverage.
(17) Primary plan--A plan whose benefits for a person's
health care coverage must be determined without taking the existence
of any other plan into consideration. A plan is a primary plan if:
(A) the plan either has no order of benefit determination
rules, or its rules differ from those permitted by this subchapter;
or
(B) all plans that cover the person use the order of
benefit determination rules required by this subchapter, and under
those rules, the plan determines its benefits first.
(18) Secondary plan--A plan that is not a primary plan.
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