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RULE §21.1101Definitions

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.

Source Note: The provisions of this §21.1101 adopted to be effective December 22, 1997, 22 TexReg 12513; amended to be effective November 7, 2021, 46 TexReg 7408

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