The following words and terms, when used in this subchapter,
have the meaning indicated below unless the context indicates otherwise:
(1) Coinsurance--An amount in addition to the premium
and copayments due from an enrollee who accesses out-of-plan covered
benefits, for which the enrollee is not reimbursed.
(2) Corresponding benefits--Benefits provided under
a point-of-service rider or the indemnity portion of a point-of-service
plan, as defined in Insurance Code §843.108 (concerning Point-of-Service
Rider) and §1273.001 (concerning Definitions), that conform to
the nature and kind of coverage provided to an enrollee under the
HMO portion of a point-of-service plan.
(3) Cost containment requirements--Provisions in a
point-of-service rider requiring a specific action that must be taken
by an enrollee or by a physician or provider on behalf of the enrollee,
such as the provision of specified information to the HMO, to avoid
the imposition of a specified penalty on the coverage provided under
the rider for proposed service or treatment.
(4) Coverage--Any benefits available to an enrollee
through an indemnity contract or rider, any services available to
an enrollee under an evidence of coverage, or combination of the benefits
and services available to an enrollee under a point-of-service plan.
(5) Health plan products--Any health care plan issued
by an HMO under the Insurance Code or a rule adopted by the commissioner.
(6) In-plan covered services--Health care services,
benefits, and supplies to which an enrollee is entitled under the
evidence of coverage issued by an HMO, including emergency services,
approved out-of-network services, and other authorized referrals.
(7) Nonparticipating physicians and providers--Physicians
and providers who are not part of an HMO delivery network.
(8) Out-of-plan covered benefits--All covered health
care services, benefits, and supplies that are not in-plan covered
services. Out-of-plan covered benefits include health care services,
benefits, and supplies obtained from participating physicians and
providers under circumstances in which the enrollee fails to comply
with the HMO's requirements for obtaining in-plan covered services.
(9) Participating physicians and providers--Physicians
and providers that are part of an HMO delivery network.
(10) Point-of-service blended contract plan--A point-of-service
plan evidenced by a single contract, policy, certificate, or evidence
of coverage that provides a combination of indemnity benefits for
which an indemnity carrier is at risk and services that are provided
by an HMO under a point-of-service plan.
(11) Point-of-service dual contracts plan--A point-of-service
plan providing a combination of indemnity benefits and HMO services
through separate contracts, one being the contract, policy, or certificate
offered by an indemnity carrier for which the indemnity carrier is
at risk and the other being the evidence of coverage offered by the
HMO.
(12) Point-of-service rider--A rider issued by an HMO
that meets the solvency requirements of §11.2502 of this title
(relating to Issuance of Point-of-Service Riders) and that provides
coverage for out-of-plan services, including services, benefits, and
supplies obtained from participating physicians or providers under
circumstances in which the enrollee fails to comply with the HMO's
requirements for obtaining approval for in-plan covered services.
(13) Point-of-service rider plan--A point-of-service
plan provided by an HMO in compliance with this subchapter under an
evidence of coverage that includes a point-of-service rider.
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