The following words and terms, when used in this subchapter
have the following meanings, unless the context clearly indicates
otherwise.
(1) Corresponding benefits--Benefits provided under
the indemnity portion of a point-of-service (POS) plan, as defined
in Insurance Code §1273.001 and §843.108, that conform to
the nature and kind of coverage provided to an enrollee under the
HMO portion of a point-of-service plan.
(2) Cost containment requirements--Provisions in POS
indemnity coverage requiring a specific action, such as the provision
of specified information to the plan, that must be taken by an enrollee
or by a physician or a provider on behalf of the enrollee in order
to avoid the imposition of a specified penalty on the coverage provided
under the plan for a proposed service or treatment.
(3) In-plan covered services--Health care services,
benefits, and supplies to which an enrollee is entitled under the
evidence of coverage issued by an HMO, including emergency services,
approved out-of-network services and other authorized referrals.
(4) Non-participating physicians and providers--Physicians
and providers that are not part of an HMO delivery network.
(5) Out-of-plan covered benefits--All covered health
care services, benefits, and supplies that are not in-plan covered
services. Out-of-plan covered benefits include health care services,
benefits and supplies obtained from participating physicians and providers
under circumstances in which the enrollee fails to comply with the
HMO's requirements for obtaining in-plan covered services.
(6) Participating physicians and providers--Physicians
and providers that are part of an HMO delivery network.
(7) Point-of-service blended contract plan (POS blended
contract plan)--A POS plan evidenced by a single contract, policy,
certificate or evidence of coverage that provides a combination of
indemnity benefits for which an indemnity carrier is at risk and services
are provided by an HMO under a POS plan.
(8) Point-of-service coverage (POS coverage)--Coverage
provided under a POS plan.
(9) Point-of-service dual contracts plan (POS dual
contracts plan)--A POS plan providing a combination of indemnity benefits
and HMO services through separate contracts, one being the contract,
policy or certificate offered by an indemnity carrier for which the
indemnity carrier is at risk and the other being the evidence of coverage
offered by the HMO.
(10) Point-of-service HMO coverage (POS HMO coverage)--Services
provided by an HMO in an evidence of coverage under a POS plan.
(11) Point-of-service indemnity coverage (POS indemnity
coverage)--Coverage for which an indemnity carrier is at risk under
a POS plan for self-referred health care services, benefits and supplies,
other than emergency services, selected at the option of the enrollee,
from non-participating physicians or providers, as well as services,
benefits and supplies from participating physicians or providers under
circumstances in which the enrollee fails to comply with the requirements
of the HMO providing the POS HMO coverage under a POS plan for obtaining
in-plan covered services.
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