|(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
(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
(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
(C) responsible for clinical oversight of the utilization
review program, the credentialing of professional staff, and quality
(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
(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
(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
(16) Facility-based physician--A radiologist, anesthesiologist,
pathologist, emergency department physician, neonatologist, or assistant
(A) to whom a facility has granted clinical privileges;
(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
(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
(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
(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;
(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
(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
(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
(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
(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
(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
(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).