The following words and terms, when used in this subchapter,
have the following meanings, unless the context clearly indicates
otherwise:
(1) Basic health care services--Health care services
that the commissioner determines an enrolled population might reasonably
need to maintain good health.
(2) Commissioner--The commissioner of insurance.
(3) Consumer choice health benefit plan--A group or
individual accident or sickness insurance policy or evidence of coverage
that, in whole or in part, does not offer or provide state-mandated
health benefits, but that provides creditable coverage as defined
by Insurance Code §1205.004(a) or §1501.102(a).
(4) Consumer choice of benefits health insurance plan--A
consumer choice health benefit plan.
(5) Department--The Texas Department of Insurance.
(6) HMO--a person defined in Insurance Code §843.002(14).
(7) Health carrier--Any entity authorized under the
Insurance Code or another insurance law of this state that provides
health benefits in this state, including an insurance company, a group
hospital service corporation under the Insurance Code Chapter 842,
an HMO under the Insurance Code Chapter 843, and a stipulated premium
company under the Insurance Code Chapter 884.
(8) Health insurer--Any entity authorized under the
Insurance Code or another insurance law or regulation of this state
that provides health insurance or health benefits in this state, including
an insurance company, a group hospital service corporation under Chapter
842 of the Insurance Code, and a stipulated premium company under
Chapter 884 of the Insurance Code.
(9) Standard health benefit plan--A consumer choice
health benefit plan.
(10) State-mandated health benefits--
(A) Coverage required under the Insurance Code, the
Administrative Code, or other law of this state to be provided in
an individual, blanket, or group policy for accident and health insurance,
a contract for coverage of a health-related condition, or an evidence
of coverage that:
(i) includes coverage for specific health care services
or benefits;
(ii) places limitations or restrictions on deductibles,
coinsurance, copayments, or any annual or lifetime maximum benefit
amounts, including limitations provided in Insurance Code §1271.151;
or
(iii) includes a specific category of licensed health
care practitioner from whom an insured or enrollee is entitled to
receive care.
(B) Do not include benefits or coverage mandated by
federal law, or standard provisions or rights required under the Insurance
Code, the Administrative Code, or other law of this state, to be provided
in an individual, blanket, or group policy for accident and health
insurance, a contract for coverage of a health-related condition,
or an evidence of coverage unrelated to specific health illnesses,
injuries, or conditions of an insured or enrollee, including those
benefits or coverages enumerated in Insurance Code §1507.003(b)
and §1507.053(b).
|
| Source Note: The provisions of this §21.3502 adopted to be effective June 2, 2004, 29 TexReg 5101; amended to be effective October 4, 2009, 34 TexReg 6645; amended to be effective May 28, 2017, 42 TexReg 2730 |
