The following terms, when used in Subchapters A, C, and D of
this chapter, have the following meanings unless the context clearly
indicates otherwise.
(1) Affiliation period--As defined in Insurance Code
§1501.104 (concerning Affiliation Period).
(2) Agent--A person who may act as an agent for the
sale of a health benefit plan under a license issued by TDI.
(3) Base premium rate--As defined in Insurance Code
§1501.201 (concerning Definitions).
(4) Case characteristics--As defined in Insurance Code
§1501.201.
(5) Child--
(A) An unmarried natural child of the employee, including
a newborn child;
(B) An unmarried adopted child, including a child about
whom the insured employee is a party in a suit seeking the adoption
of the child;
(C) An unmarried natural child or adopted child of
the employee's spouse including a child about whom the spouse is a
party in a suit seeking the adoption of the child; and
(D) Any other child included as an eligible dependent
under an employer's benefit plan.
(6) Class of business--As defined in Insurance Code
§1501.201.
(7) Commissioner--The commissioner of insurance.
(8) Consumer choice health benefit plan--A health benefit
plan authorized by Insurance Code Chapter 1507 (concerning Consumer
Choice of Benefits Plans).
(9) Creditable coverage--As defined in Insurance Code
§1205.004 (concerning Creditable Coverage).
(10) Dependent--As defined in Insurance Code §1501.002
(concerning Definitions).
(11) Effective date--The first day of coverage under
a health benefit plan or, if there is a waiting period, the first
day of the waiting period.
(12) Eligible dependent--A dependent who meets the
requirements for coverage under a small or large employer health benefit
plan.
(13) Eligible employee--As defined in Insurance Code
§1501.002.
(14) Employee--As defined in Insurance Code §1501.002.
(15) Franchise insurance policy--An individual health
benefit plan under which a number of individual policies are offered
to a selected group of a small or large employer. The rates for the
policy may differ from the rate applicable to individually solicited
policies of the same type and may differ from the rate applicable
to individuals of essentially the same class.
(16) Genetic information--As defined in Insurance Code
§546.001 (concerning Definitions).
(17) Genetic test--As defined in Insurance Code §546.001.
(18) Gross premiums--The total amount of money collected
by the health carrier for health benefit plans during the applicable
calendar year or the applicable calendar quarter, including premiums
collected:
(A) for individual and group health benefit plans issued
to employers or their employees; and
(B) under certificates issued or delivered to Texas
employees of employers, regardless of where the policy is issued or
delivered.
(19) HMO--Any person governed by the Texas Health Maintenance
Organization Act, Insurance Code Chapter 843 (concerning Health Maintenance
Organizations), including:
(A) a person defined as a health maintenance organization
under the Texas Health Maintenance Organization Act;
(B) an approved nonprofit health corporation that is
certified under Occupations Code §162.001 (concerning Certification
by Board), and that holds a certificate of authority issued by the
commissioner under Insurance Code Chapter 844 (concerning Certification
of Certain Nonprofit Health Corporations);
(C) a statewide rural health care system under Insurance
Code Chapter 845 (concerning Statewide Rural Health Care System) that
holds a certificate of authority issued by the commissioner; or
(D) a nonprofit corporation created and operated by
a community center under Health and Safety Code Chapter 534, Subchapter
C (concerning Health Maintenance Organizations).
(20) Health benefit plan--As defined in Insurance Code
§1501.002.
(21) Health carrier--Any entity authorized under the
Insurance Code or another insurance law of this state that provides
health insurance or health benefits in this state including an insurance
company, a group hospital service corporation under Insurance Code
Chapter 842 (concerning Group Hospital Service Corporations), an HMO
under Insurance Code Chapter 843, or a stipulated premium company
under Insurance Code Chapter 884 (concerning Stipulated Premium Insurance
Companies).
(22) Health insurance coverage--Benefits consisting
of medical care (provided directly, through insurance or reimbursement,
or otherwise) under any hospital or medical service policy or certificate,
hospital or medical service plan contract, or HMO contract.
(23) Health-status-related factor--Health status; medical
condition, including both physical and mental illnesses; claims experience;
receipt of health care; medical history; genetic information; disability;
and evidence of insurability, including conditions arising out of
acts of domestic violence and tobacco use.
(24) Index rate--As defined in Insurance Code §1501.201.
(25) Large employer--As defined in Insurance Code §1501.002.
(26) Large employer carrier--A health carrier, to the
extent that carrier is offering, delivering, issuing for delivery,
or renewing health benefit plans subject to Insurance Code Chapter
1501 (concerning Health Insurance Portability and Availability Act).
(27) Large employer health benefit plan--As defined
in Insurance Code §1501.002.
(28) Late enrollee--
(A) Any employee or dependent eligible for enrollment
who:
(i) requests enrollment in a small or large employer's
health benefit plan after the expiration of the initial enrollment
period established under the terms of the first plan for which that
employee or dependent was eligible through the small or large employer,
or after the expiration of an open enrollment period under Insurance
Code §1501.156(a) (concerning Employee Enrollment; Waiting Period)
and §1501.606(a) (concerning Employee Enrollment; Waiting Period);
(ii) does not fall within the exceptions listed in
subparagraph (B) of this paragraph; and
(iii) is accepted for enrollment and not excluded until
the next open enrollment period.
(B) An employee or dependent eligible for and requesting
enrollment cannot be excluded until the next open enrollment period
and, when enrolled, is not a late enrollee, in the following special
circumstances:
(i) the individual:
(I) was covered under another health benefit plan or
self-funded employer health benefit plan at the time the individual
was eligible to enroll;
(II) declines in writing, at the time of initial eligibility,
stating that coverage under another health benefit plan or self-funded
employer health benefit plan was the reason for declining enrollment;
(III) has lost coverage under another health benefit
plan or self-funded employer health benefit plan as a result of termination
of employment, reduction in the number of hours of employment, termination
of the other plan's coverage, termination of contributions toward
the premium made by the employer, death of a spouse, or divorce; and
(IV) requests enrollment not later than the 31st day
after the date on which coverage under the other health benefit plan
or self-funded employer health benefit plan terminates;
(ii) the individual is employed by an employer who
offers multiple health benefit plans and the individual elects a different
health benefit plan during an open enrollment period;
(iii) a court has ordered coverage to be provided for
a spouse under a covered employee's plan and the request for enrollment
is made not later than the 31st day after the date on which the court
order is issued;
(iv) a court has ordered coverage to be provided for
a child under an insured's plan and the request for enrollment is
made not later than the 31st day after the date on which the employer
receives the court order or notification of the court order;
(v) the individual is a child of an insured and has
lost coverage under Health and Safety Code Chapter 62 (concerning
Child Health Plan for Certain Low-Income Children) or Title XIX of
the Social Security Act (42 U.S.C. §§1396, et seq., concerning
Medicaid and CHIP Payment and Access Commission), other than coverage
consisting solely of benefits under Section 1928 of that Act (42 U.S.C.
§1396s, concerning Program for Distribution of Pediatric Vaccines);
Cont'd... |
