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TITLE 28INSURANCE
PART 1TEXAS DEPARTMENT OF INSURANCE
CHAPTER 11HEALTH MAINTENANCE ORGANIZATIONS
SUBCHAPTER AGENERAL PROVISIONS
RULE §11.2Definitions

(a) Except as otherwise provided, words and terms defined in Insurance Code Chapters 823 (concerning Insurance Holding Company Systems), 843 (concerning Health Maintenance Organizations), 1271 (concerning Benefits Provided by Health Maintenance Evidence of Coverage; Charges), 1272 (concerning Delegation of Certain Functions of Health Maintenance Organizations), 1367 (concerning Coverage of Children), 1452 (concerning Physician and Provider Credentials), 1501 (concerning Health Insurance Portability and Availability Act), and 1507 (concerning Consumer Choice of Benefits Plans) have the same meanings when used in this subchapter.

(b) The following words and terms, when used in this chapter, have the meaning indicated below unless the context clearly indicates otherwise:

  (1) Admitted assets--Assets as defined by statutory accounting principles, as permitted and valued under Chapter 11, Subchapter I, of this title (relating to Financial Requirements).

  (2) Adverse determination--A determination by a health maintenance organization or a utilization review agent that health care services provided or proposed to be provided to an enrollee are not medically necessary or appropriate, or are experimental or investigational. The term does not include a denial of health care services due to the failure to request prospective or concurrent utilization review.

  (3) Affiliate--A person defined as an affiliate in §7.202 of this title (relating to Definitions).

  (4) Agent--A person licensed under the Insurance Code to act as an agent for the sale of a health benefit plan.

  (5) ANHC or approved nonprofit health corporation--A nonprofit health corporation certified under Occupations Code §162.001 (concerning Certification by Board) and defined in Insurance Code Chapter 844 (concerning Certification of Certain Nonprofit Health Corporations).

  (6) Basic health care service--A health care service that an enrolled population might reasonably require to maintain good health, as prescribed in §11.508 and §11.509 of this title (relating to Basic Health Care Services and Mandatory Benefit Standards: Group, Individual, and Conversion Agreements; and relating to Additional Mandatory Benefit Standards: Individual and Group Agreements).

  (7) Clinical director--A health professional who is:

    (A) appropriately licensed and credentialed in compliance with §11.1606 of this title (relating to Organization of an HMO);

    (B) an employee of, or party to a contract with, an HMO; and

    (C) responsible for clinical oversight of the utilization review program, the credentialing of professional staff, and quality improvement functions.

  (8) Consumer choice health benefit plan--A health benefit plan authorized by Insurance Code Chapter 1507 and described in Chapter 21, Subchapter AA, of this title (relating to Consumer Choice Health Benefit Plans).

  (9) Contract holder--An individual, association, employer, trust, or organization to which an individual or group contract for health care services has been issued.

  (10) Control--As defined in §7.202 of this title.

  (11) Copayment--A charge, which may be expressed in terms of a dollar amount or a percentage of the contracted rate, in addition to premium attributed to an enrollee for a service that is not fully prepaid.

  (12) Credentialing--The process of collecting, assessing, and validating qualifications and other relevant information pertaining to a physician or provider to determine eligibility to deliver health care services.

  (13) Dentist--An individual provider licensed to practice dentistry by the Texas State Board of Dental Examiners.

  (14) Department--Texas Department of Insurance.

  (15) Emergency care--As defined in Insurance Code §843.002 (concerning Definitions).

  (16) Facility-based physician--A radiologist, anesthesiologist, pathologist, emergency department physician, neonatologist, or assistant surgeon:

    (A) to whom a facility has granted clinical privileges; and

    (B) who provides services to patients of the facility under those clinical privileges.

  (17) Freestanding emergency medical care facility--A facility, licensed under Health and Safety Code Chapter 254 (concerning Freestanding Emergency Medical Care Facilities), structurally separate and distinct from a hospital, that receives an individual and provides emergency care as defined in Insurance Code §843.002.

  (18) General hospital--An establishment, licensed under Health and Safety Code Chapter 241 (concerning Hospitals), that:

    (A) offers services, facilities, and beds for use for more than 24 hours for two or more unrelated individuals requiring diagnosis, treatment, or care for illness, injury, deformity, abnormality, or pregnancy; and

    (B) regularly maintains, at a minimum, clinical laboratory services, diagnostic X-ray services, treatment facilities including surgery or obstetrical care or both, and other definitive medical or surgical treatment of similar extent.

  (19) HMO--A health maintenance organization as defined in Insurance Code §843.002.

  (20) Health status-related factor--Any of the following in relation to an individual:

    (A) health status;

    (B) medical condition (including both physical and mental illnesses);

    (C) claims experience;

    (D) receipt of health care;

    (E) medical history;

    (F) genetic information;

    (G) evidence of insurability (including conditions arising out of acts of domestic violence, including family violence as defined by Insurance Code Chapter 544, Subchapter D (concerning Family Violence); or

    (H) disability.

  (21) Individual provider--Any person, other than a physician or institutional provider, who is licensed or otherwise authorized to provide a health care service. This includes, but is not limited to, licensed doctors of chiropractic, dentists, registered nurses, advanced practice registered nurses, physician assistants, pharmacists, optometrists, and acupuncturists.

  (22) Insert page--A page used to replace an existing page of a previously approved or reviewed evidence of coverage or written plan description, including a member handbook.

  (23) Institutional provider--A provider that is not an individual, such as any medical or health related service facility caring for the sick or injured or providing care or supplies for other coverage that may be provided by the HMO. This includes, but is not limited to:

    (A) general hospitals;

    (B) psychiatric hospitals;

    (C) special hospitals;

    (D) nursing homes;

    (E) skilled nursing facilities;

    (F) home health agencies;

    (G) rehabilitation facilities;

    (H) dialysis centers;

    (I) free-standing surgical centers;

    (J) diagnostic imaging centers;

    (K) laboratories;

    (L) hospice facilities;

    (M) residential treatment centers;

    (N) community mental health centers;

    (O) pharmacies; and

    (P) freestanding emergency medical care facilities.

  (24) Insurance Code--The Texas Insurance Code.

  (25) Limited provider network--A subnetwork within an HMO delivery network in which contractual relationships between physicians, certain providers, independent physician associations, physician groups, or any combination thereof, limit enrollees' access to only the physicians and providers in the subnetwork.

  (26) Limited service HMO--An HMO that has been issued a certificate of authority to issue a limited health care service plan as defined in Insurance Code §843.002.

  (27) Matrix filing--A filing consisting of individual provisions, each with its own unique identifiable form number, which allows an HMO the flexibility to create multiple evidences of coverage by using combinations of approved individual provisions.

  (28) NAIC--The National Association of Insurance Commissioners.

  (29) NAIC UCAA--The National Association of Insurance Commissioners' Uniform Certificate of Authority Application.

  (30) NCQA--The National Committee for Quality Assurance.

  (31) Net worth--The amount by which total admitted assets exceed total liabilities, excluding liability for subordinated debt issued in compliance with Insurance Code Chapter 427 (concerning Subordinated Indebtedness).

Cont'd...

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