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RULE §21.3802Definitions

The following words and terms, when used in this subchapter, have the following meanings unless the context clearly indicates otherwise.

  (1) Enrollee--An individual who is eligible for coverage under a health benefit plan, including a covered dependent.

  (2) Health benefit plan--A group, blanket, or franchise insurance policy, a certificate issued under a group policy, a group hospital service contract, or a group subscriber contract or evidence of coverage issued by a health maintenance organization that provides benefits for health care services. The term does not include:

    (A) accident-only or disability income insurance coverage or a combination of accident-only and disability income insurance coverage;

    (B) credit-only insurance coverage;

    (C) disability insurance coverage;

    (D) coverage only for a specified disease or illness;

    (E) Medicare services under a federal contract;

    (F) Medicare supplement, Medicare Select, Medicare Advantage, or any successor policies regulated in accordance with federal law;

    (G) 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;

    (H) coverage that provides only dental or vision benefits;

    (I) coverage provided by a single service health maintenance organization;

    (J) coverage issued as a supplement to liability insurance;

    (K) workers' compensation insurance coverage or similar insurance coverage;

    (L) automobile medical payment insurance coverage;

    (M) a jointly managed trust authorized under 29 U.S.C. Section 141 et seq. that contains a plan of benefits for employees that is negotiated in a collective bargaining agreement governing wages, hours, and working conditions of the employees that is authorized under 29 U.S.C. Section 157;

    (N) hospital indemnity or other fixed indemnity insurance coverage;

    (O) reinsurance contracts issued on a stop-loss, quota-share, or similar basis;

    (P) liability insurance coverage, including general liability insurance and automobile liability insurance coverage; or

    (Q) coverage that provides other limited benefits specified by federal regulations.

  (3) Health benefit plan issuer--Any entity that issues a health benefit plan, including:

    (A) a health maintenance organization operating under Insurance Code Chapter 843;

    (B) an approved nonprofit health corporation that holds a certificate of authority under Insurance Code Chapter 844;

    (C) an insurance company, including an insurance company offering a preferred provider benefit plan under Insurance Code Chapter 1301;

    (D) a group hospital service corporation operating under Insurance Code Chapter 842;

    (E) a fraternal benefit society operating under Insurance Code Chapter 885; or

    (F) a stipulated premium company operating under Insurance Code Chapter 884.

  (4) Health care provider--

    (A) a person, other than a physician, who is licensed or otherwise authorized to provide a health care service in this state, including:

      (i) a pharmacist or dentist; or

      (ii) a pharmacy, hospital, or other institution or organization;

    (B) a person who is wholly owned or controlled by a provider or by a group of providers who are licensed or otherwise authorized to provide the same health care service; or

    (C) a person who is wholly owned or controlled by one or more hospitals and physicians, including a physician-hospital organization.

  (5) Participating provider--

    (A) a physician or health care provider who contracts with a health benefit plan issuer to provide medical care or health care to enrollees in a health benefit plan; or

    (B) a physician or health care provider who accepts and treats a patient on a referral from a physician or provider described by subparagraph (A) of this paragraph.

  (6) Physician--

    (A) an individual licensed to practice medicine in this state under Subtitle B, Title 3, Occupations Code;

    (B) a professional association organized under the Texas Professional Association Law (Business Organizations Code Chapters 301 and 302);

    (C) a nonprofit health corporation certified under Chapter 162, Occupations Code;

    (D) a medical school or medical and dental unit, as defined or described by Education Code §§61.003, 61.501, or 74.601, that employs or contracts with physicians to teach or provide medical services or employs physicians and contracts with physicians in a practice plan; or

    (E) another entity wholly owned by physicians.

  (7) Primary enrollee--The individual who is the certificate holder and whose employment or other membership status, except for family dependency, is the basis for eligibility under the health benefit plan.

Source Note: The provisions of this §21.3802 adopted to be effective January 19, 2006, 31 TexReg 301; amended to be effective November 7, 2021, 46 TexReg 7408

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