The following words and terms, when used in this subchapter,
have the following meanings unless the context clearly indicates otherwise.
(1) Another limited benefit--A plan that provides coverage,
singularly or in combination, for benefits for a specifically named
disease, accident, or combination of diseases or accidents, including,
but not limited to:
(A) heart attack;
(B) stroke;
(C) AIDS; or
(D) travel, farm, or occupational accident.
(2) Carrier--The term includes:
(A) an insurance company, a group hospital service
corporation, a fraternal benefit society, a stipulated premium insurance
company, a health maintenance organization, a multiple employer welfare
arrangement that holds a certificate of authority under Insurance
Code Chapter 846, or an approved nonprofit health corporation that
holds a certificate of authority issued by the commissioner under
Insurance Code Chapter 844;
(B) for the purposes of paragraph (4)(B) and (F) of
this section, a reciprocal exchange operating under Insurance Code
Chapter 942;
(C) for purposes of paragraph (4)(E) and (F) of this
section, a Lloyds plan operating under Insurance Code Chapter 941;
and
(D) for purposes of paragraph (4)(E) of this section,
a risk pool created under Local Government Code Chapter 172.
(3) Enrollee--A person enrolled in and entitled to
coverage under a health benefit plan, including covered dependents.
(4) Health Benefit Plan--Subject to subparagraphs (A),
(B), (C), (D), (E), and (F) of this paragraph, a plan that is offered
by a carrier and provides benefits for medical or surgical expenses
incurred as a result of a health condition, accident, or sickness,
including an individual, group, blanket, or franchise insurance policy
or insurance agreement; a group hospital service contract; an individual
or group evidence of coverage; or any similar coverage document. The
term does not include a plan that provides coverage only for accidental
death or dismemberment, disability income, supplement to liability
insurance, Medicare supplement, workers' compensation, medical payment
insurance issued as a part of a motor vehicle insurance policy, or
a long-term care policy.
(A) For the inpatient mastectomy coverage notice required
by §21.2103(a)(1) of this title (relating to Mandatory Benefit
Notices), the definition of health benefit plan includes a plan that
provides coverage only for a specific disease or condition for the
treatment of breast cancer or for hospitalization. The term does not
include a small employer health benefit plan issued under Insurance
Code Chapter 1501, Subchapters A - H (concerning Health Insurance
Portability and Availability Act).
(B) For the reconstructive surgery after mastectomy
notices required by §21.2103(a)(2) of this title, the definition
of health benefit plan does not include:
(i) a plan that provides coverage for a specified disease
or another limited benefit, except for cancer;
(ii) a plan that provides only credit insurance;
(iii) a plan that provides coverage only for dental
or vision care; or
(iv) a plan that provides coverage only for hospital
indemnity or other fixed indemnity.
(C) For the prostate cancer examination notice required
by §21.2103(a)(3) of this title, the definition of health benefit
plan does not include:
(i) a small employer health benefit plan written under
Insurance Code Chapter 1501, Subchapters A - H;
(ii) a plan that provides coverage only for a specified
disease or another limited benefit; or
(iii) a plan that provides coverage only for hospital
indemnity or other fixed indemnity.
(D) For the inpatient maternity and childbirth coverage
notice required by §21.2103(a)(4) and (5) of this title, the
definition of health benefit plan does not include:
(i) a plan that provides only credit insurance;
(ii) a plan that provides coverage only for a specified
disease or another limited benefit;
(iii) a plan that provides coverage only for dental
or vision care; or
(iv) a plan that provides coverage only for hospital
indemnity or other fixed indemnity.
(E) For the detection of colorectal cancer screening
coverage notice required by §21.2103(a)(6) of this title, the
definition of health benefit plan does not include:
(i) a small employer health benefit plan written under
Insurance Code Chapter 1501, Subchapters A - H;
(ii) a plan that provides coverage only for a specified
disease or another limited benefit; or
(iii) a plan that provides coverage only for hospital
indemnity or other fixed indemnity.
(F) For the detection of human papillomavirus and cervical
cancer screening notice required by §21.2103(a)(7) of this title,
the definition of health benefit plan includes a small employer health
benefit plan written under Insurance Code Chapter 1501, but does not
include:
(i) a plan that provides coverage only for a specified
disease or another limited benefit, other than a plan that provides
benefits for cancer treatment or similar services;
(ii) a plan that provides coverage only for dental
or vision care;
(iii) a plan that provides coverage only for indemnity
or for hospital indemnity or other fixed indemnity;
(iv) a credit insurance policy; or
(v) a limited benefit policy that does not provide
coverage for physical examinations or wellness exams.
(5) Primary Enrollee--For group coverage, the covered
member or employee of the group. For individual coverage, the person
first named on the application or enrollment form.
|
| Source Note: The provisions of this §21.2102 adopted to be effective March 29, 1998, 23 TexReg 3009; amended to be effective January 8, 2001, 26 TexReg 202; amended to be effective April 2, 2002, 27 TexReg 2506; amended to be effective January 19, 2006, 31 TexReg 295; amended to be effective November 2, 2016, 41 TexReg 8609 |
