The following words and terms, when used in this subchapter,
have the following meanings unless the context clearly indicates otherwise.
(1) Enrollee--An individual who is eligible for coverage
under a health benefit plan, including a covered dependent.
(2) Health benefit plan--A group, blanket, or franchise
insurance policy, a certificate issued under a group policy, a group
hospital service contract, or a group subscriber contract or evidence
of coverage issued by a health maintenance organization that provides
benefits for health care services. The term does not include:
(A) accident-only or disability income insurance coverage
or a combination of accident-only and disability income insurance
coverage;
(B) credit-only insurance coverage;
(C) disability insurance coverage;
(D) coverage only for a specified disease or illness;
(E) Medicare services under a federal contract;
(F) Medicare supplement, Medicare Select, Medicare
Advantage, or any successor policies regulated in accordance with
federal law;
(G) long-term care coverage or benefits, nursing home
care coverage or benefits, home health care coverage or benefits,
community-based care coverage or benefits, or any combination of those
coverages or benefits;
(H) coverage that provides only dental or vision benefits;
(I) coverage provided by a single service health maintenance
organization;
(J) coverage issued as a supplement to liability insurance;
(K) workers' compensation insurance coverage or similar
insurance coverage;
(L) automobile medical payment insurance coverage;
(M) a jointly managed trust authorized under 29 U.S.C.
Section 141 et seq. that contains a plan of benefits for employees
that is negotiated in a collective bargaining agreement governing
wages, hours, and working conditions of the employees that is authorized
under 29 U.S.C. Section 157;
(N) hospital indemnity or other fixed indemnity insurance
coverage;
(O) reinsurance contracts issued on a stop-loss, quota-share,
or similar basis;
(P) liability insurance coverage, including general
liability insurance and automobile liability insurance coverage; or
(Q) coverage that provides other limited benefits specified
by federal regulations.
(3) Health benefit plan issuer--Any entity that issues
a health benefit plan, including:
(A) a health maintenance organization operating under
Insurance Code Chapter 843;
(B) an approved nonprofit health corporation that holds
a certificate of authority under Insurance Code Chapter 844;
(C) an insurance company, including an insurance company
offering a preferred provider benefit plan under Insurance Code Chapter
1301;
(D) a group hospital service corporation operating
under Insurance Code Chapter 842;
(E) a fraternal benefit society operating under Insurance
Code Chapter 885; or
(F) a stipulated premium company operating under Insurance
Code Chapter 884.
(4) Health care provider--
(A) a person, other than a physician, who is licensed
or otherwise authorized to provide a health care service in this state,
including:
(i) a pharmacist or dentist; or
(ii) a pharmacy, hospital, or other institution or
organization;
(B) a person who is wholly owned or controlled by a
provider or by a group of providers who are licensed or otherwise
authorized to provide the same health care service; or
(C) a person who is wholly owned or controlled by one
or more hospitals and physicians, including a physician-hospital organization.
(5) Participating provider--
(A) a physician or health care provider who contracts
with a health benefit plan issuer to provide medical care or health
care to enrollees in a health benefit plan; or
(B) a physician or health care provider who accepts
and treats a patient on a referral from a physician or provider described
by subparagraph (A) of this paragraph.
(6) Physician--
(A) an individual licensed to practice medicine in
this state under Subtitle B, Title 3, Occupations Code;
(B) a professional association organized under the
Texas Professional Association Law (Business Organizations Code Chapters
301 and 302);
(C) a nonprofit health corporation certified under
Chapter 162, Occupations Code;
(D) a medical school or medical and dental unit, as
defined or described by Education Code §§61.003, 61.501,
or 74.601, that employs or contracts with physicians to teach or provide
medical services or employs physicians and contracts with physicians
in a practice plan; or
(E) another entity wholly owned by physicians.
(7) Primary enrollee--The individual who is the certificate
holder and whose employment or other membership status, except for
family dependency, is the basis for eligibility under the health benefit
plan.
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