The following words and terms, when used in this subchapter,
have the following meanings, unless the context clearly indicates
otherwise.
(1) Delegated entity--An entity, other than an HMO
authorized to do business under Insurance Code Chapter 843 (concerning
Health Maintenance Organizations) and Chapter 1272 (concerning to
Delegation of Certain Functions by Health Maintenance Organization)
and other applicable insurance laws and regulations of this state,
that by itself, or through subcontracts with one or more entities,
undertakes to arrange for or to provide medical care or health care
to an enrollee in exchange for a predetermined payment on a prospective
basis and that accepts responsibility to perform on behalf of the
HMO any function regulated by Insurance Code Chapter 843 and Chapter
1272 and other applicable insurance laws and regulations of this state.
The term does not include an individual physician or a group of employed
physicians practicing medicine under one federal tax identification
number and whose total claims paid to physicians and providers not
employed by the group is less than 20 percent of the total collected
revenue of the group calculated on a calendar-year basis.
(2) Delegated network--Any delegated entity that assumes
total financial risk for more than one of the following categories
of health care services: medical care, hospital or other institutional
services, or prescription drugs, as defined by Occupations Code §551.003
(concerning Definitions). The term does not include a delegated entity
that shares risk for a category of services with an HMO.
(3) Delegated third party--A third party other than
a delegated entity that contracts with a delegated entity, either
directly or through another third party, to:
(A) accept responsibility to perform any function regulated
by Insurance Code Chapter 843 and Chapter 1272 and other applicable
insurance laws and regulations of this state; or
(B) receive, handle, or administer funds, if the receipt,
handling, or administration of the funds is directly or indirectly
related to a function regulated by Insurance Code Chapter 843 and
Chapter 1272 and other applicable insurance laws and regulations of
this state.
(4) Health care--Any services, including the furnishing
to any individual of pharmaceutical services, medical, chiropractic,
dental care, hospitalization, or incident to the furnishing of the
services, care or hospitalization, as well as the furnishing to any
person of any and all other services for the purpose of preventing,
alleviating, curing, or healing human illness or injury.
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