The following words and terms, when used in this subchapter,
have the following meanings, unless the context clearly indicates
otherwise.
(1) Affiliation period--A period of time that under
the terms of the coverage offered by an HMO, must expire before the
coverage becomes effective. During an affiliation period an HMO is
not required to provide health care services or benefits to the participant
or beneficiary and a premium may not be charged to the participant
or beneficiary.
(2) COBRA--Title X of the Consolidated Omnibus Budget
Reconciliation Act of 1985, as amended (29 USC Section 1161, et seq.).
(3) COBRA continuation coverage--Coverage that satisfies
an applicable COBRA continuation provision.
(4) Commissioner--The Commissioner of Insurance.
(5) Creditable coverage--
(A) An individual's coverage is creditable if the coverage
is provided under:
(i) a self-funded or self-insured employee welfare
benefit plan that provides health benefits and that is established
in accordance with the Employee Retirement Income Security Act of
1974 (29 U.S.C. Section 1001 et seq.);
(ii) a group health benefit plan provided by a health
insurance carrier or an HMO;
(iii) an individual health insurance policy or evidence
of coverage;
(iv) Part A or Part B of Title XVIII of the Social
Security Act (42 U.S.C. Section 1395c et seq.);
(v) Title XIX of the Social Security Act (42 U.S.C.
Section 1396 et seq.), other than coverage consisting solely of benefits
under Section 1928 of that Act (42 U.S.C. Section 1396s);
(vi) Chapter 55 of Title 10, United States Code (10
U.S.C. Section 1071 et seq.);
(vii) a medical care program of the Indian Health Service
or of a tribal organization;
(viii) a state or political subdivision health benefits
risk pool;
(ix) a health plan offered under Chapter 89 of Title
5, United States Code (5 U.S.C. Section 8901 et seq.);
(x) a public health plan as defined in this section;
(xi) a health benefit plan under Section 5(e) of the
Peace Corps Act (22 U.S.C. Section 2504(e)); and
(xii) short-term limited duration insurance as defined
in this section.
(B) Creditable coverage does not include:
(i) accident-only, disability income insurance, or
a combination of accident-only and disability income insurance;
(ii) coverage issued as a supplement to liability insurance;
(iii) liability insurance, including general liability
insurance and automobile liability insurance;
(iv) workers' compensation or similar insurance;
(v) automobile medical payment insurance;
(vi) credit-only insurance;
(vii) coverage for onsite medical clinics;
(viii) other coverage that is similar to the coverage
described in this subparagraph under which benefits for medical care
are secondary or incidental to other insurance benefits and specified
in federal regulations;
(ix) if offered separately, coverage that provides
limited-scope dental or vision benefits;
(x) if offered separately, 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;
(xi) if offered separately, coverage for other limited
benefits specified by federal regulations;
(xii) if offered as independent, noncoordinated benefits,
coverage for specified disease or illness;
(xiii) if offered as independent, noncoordinated benefits,
hospital indemnity or other fixed indemnity insurance; or
(xiv) Medicare supplemental health insurance as defined
under Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss),
coverage supplemental to the coverage provided under Chapter 55 of
Title 10, United States Code (10 U.S.C. Section 1071 et seq.), and
similar supplemental coverage provided under a group plan, but only
if such insurance or coverages are provided under a separate policy,
certificate, or contract of insurance.
(6) Health benefit plan--A plan that provides benefits
for medical or surgical expenses incurred as a result of a health
condition, accident, or sickness, including:
(A) an individual, group, blanket, or franchise insurance
policy or insurance agreement, a group hospital service contract,
or an individual or group evidence of coverage that is offered by:
(i) an insurance company;
(ii) a group hospital service corporation operating
under Insurance Code Chapter 842;
(iii) a fraternal benefit society operating under Insurance
Code Chapter 885;
(iv) a stipulated premium insurance company operating
under Insurance Code Chapter 884; or
(v) an HMO; or
(B) to the extent permitted by the Employee Retirement
Income Security Act of 1974 (29 U.S.C. Section 1001 et seq.), a plan
that is offered by:
(i) a multiple employer welfare arrangement as defined
by Section 3, Employee Retirement Income Security Act of 1974 (29
U.S.C. Section 1002), and operating under Insurance Code Chapter 846;
or
(ii) another analogous benefit arrangement; or
(C) a plan issued by any other entity not licensed
under the Insurance Code or another insurance law of this state that
contracts directly for health care services on a risk-sharing basis,
including an entity that contracts for health care services on a capitation
basis.
(7) Health insurance coverage--Benefits consisting
of medical care (provided directly, through insurance or reimbursement,
or otherwise) under any hospital or medical service policy or certificate,
hospital or medical service plan contract, or HMO contract.
(8) HMO--Any person governed by the Texas Health Maintenance
Organization Act, Insurance Code Chapter 843, including:
(A) a person defined as a health maintenance organization
under Insurance Code §843.002;
(B) an approved nonprofit health corporation that is
certified under Occupations Code Chapter 162, and that holds a certificate
of authority issued by the Commissioner under Insurance Code Chapter
844;
(C) a statewide rural health care system under Insurance
Code §845.052 and §845.054; or
(D) a nonprofit corporation created and operated by
a community center under Chapter 534, Subchapter C, Health and Safety
Code.
(9) Issuer of a health benefit plan--An insurance company,
a group hospital service corporation operating under Insurance Code
Chapter 842, a fraternal benefit society operating under Insurance
Code Chapter 885, a stipulated premium insurance company operating
under Insurance Code Chapter 884, a Lloyd's plan operating under Insurance
Code Chapter 941, a reciprocal or interinsurance exchange operating
under Insurance Code Chapter 942, or an HMO that issues a health benefit
plan.
(10) Medical care--Amounts paid for:
(A) the diagnosis, cure, mitigation, treatment, or
prevention of disease, or amounts paid for the purpose of affecting
any structure or function of the body;
(B) transportation primarily for and essential to the
medical care described in subparagraph (A) of this paragraph; or
(C) insurance covering medical care described in either
subparagraphs (A) or (B) of this paragraph.
(11) Preexisting condition provision--A provision that
denies, excludes, or limits coverage as to a disease or condition
for a specified period after the effective date of coverage.
(12) Public health plan--Any plan established or maintained
by a state, county or other political subdivision of a state that
provides health insurance coverage to individuals who are enrolled
in the plan.
(13) Qualified beneficiary--As defined in Section 4980B(g)(1)
of the Internal Revenue Code (26 U.S.C. Section 4980B(g)(1)).
(14) Short-term limited duration insurance--Health
insurance coverage provided under a contract with an issuer that has
an expiration date specified in the contract (taking into account
any extensions that may be elected by the policyholder without the
issuer's consent) that is within 12 months of the date the contract
becomes effective.
(15) Waiting period--A period of time established by
an employer that must pass before an individual who is a potential
enrollee in a health benefit plan is eligible to be covered for benefits.
If an employee or dependent enrolls as a late enrollee, any period
before such late enrollment is not a waiting period. If an individual
seeks and obtains coverage in the individual market, any period after
the date the individual files a substantially complete application
for coverage and before the first day of coverage is a waiting period.
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