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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).

  (32) Out of area benefits or services--Benefits or services that an HMO covers when enrollees are outside the geographical limits of the HMO service area.

  (33) Pharmaceutical services--Services, including dispensing prescription drugs, under the Texas Pharmacy Act, Occupations Code, Title 3, Subtitle J, Chapters 551 - 569 (concerning Pharmacy and Pharmacists), that are ordinarily and customarily rendered by a pharmacy or pharmacist.

  (34) Pharmacist--An individual provider licensed to practice pharmacy under the Texas Pharmacy Act, Occupations Code, Title 3, Subtitle J, Chapters 551 - 569.

  (35) Pharmacy--A facility licensed under the Texas Pharmacy Act, Occupations Code, Title 3, Subtitle J, Chapters 551 - 569.

  (36) Preauthorization--As defined in Insurance Code §843.348(a) (concerning Preauthorization of Health Care Services).

  (37) Premium--All amounts payable by a contract holder as a condition of receiving coverage from a carrier, including any fees or other contributions associated with a health benefit plan.

  (38) Primary care physician or primary care provider--A physician or individual provider who is responsible for providing initial and primary care to patients, maintaining the continuity of patient care, and initiating referral for care.

  (39) Primary HMO--An HMO that contracts directly with, and issues an evidence of coverage to, individuals or organizations to arrange for or provide a basic, limited, or single health care service plan to enrollees on a prepaid basis.

  (40) Provider HMO--An HMO that contracts directly with a primary HMO to provide or arrange to provide health care services on behalf of the primary HMO within the primary HMO's defined service area.

  (41) Psychiatric hospital--A licensed hospital that offers inpatient services, including treatment, facilities, and beds for use beyond 24 hours, for the primary purpose of providing psychiatric assessment, psychiatric diagnostic services, psychiatric inpatient care, and treatment for mental illness. The services must be more intensive than room, board, personal services, and general medical and nursing care. Although substance abuse services may be offered, a majority of beds must be dedicated to the treatment of mental illness in adults, children, or both.

  (42) QI or quality improvement--A system to continuously examine, monitor, and revise processes and systems that support and improve administrative and clinical functions.

  (43) Recredentialing--The periodic process by which:

    (A) qualifications of physicians and providers are reassessed;

    (B) performance indicators, including utilization and quality indicators, are evaluated; and

    (C) continued eligibility to provide services is determined.

  (44) Schedule of charges--Specific rates or premiums to be charged for enrollee and dependent coverages.

  (45) Service area--A geographic area within which direct service benefits are available and accessible to HMO enrollees who live, reside, or work within that geographic area and that complies with §11.1606 of this title.

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

  (47) Special 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 who are regularly admitted, treated, and discharged and who require services more intensive than room, board, personal services, and general nursing care;

    (B) has clinical laboratory facilities, diagnostic X-ray facilities, treatment facilities, or other definitive medical treatment;

    (C) has a medical staff in regular attendance; and

    (D) maintains records of the clinical work performed for each patient.

  (48) Specialists--Physicians or individual providers who set themselves apart from the primary care physician or primary care provider through specialized training and education in a health care discipline.

  (49) State-mandated health benefit plan--An accident or sickness insurance policy or evidence of coverage that provides state-mandated health benefits as defined in §21.3502 of this title (relating to Definitions).

Cont'd...

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