2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle C - Managed Care › Chapter 1272 - Delegation of Certain Functions by Health Maintenance Organization › Subchapter A. General Provisions › Section 1272.001. Definitions

Sec. 1272.001.  DEFINITIONS.  (a)  In this chapter:
(1)  "Delegated entity" means an entity, other than a health maintenance organization authorized to engage in business under Chapter 843, that by itself, or through subcontracts with one or more entities, undertakes to arrange for or provide medical care or health care to an enrollee in exchange for a predetermined payment on a prospective basis and that accepts responsibility for performing on behalf of the health maintenance organization a function regulated by this chapter, Chapter 222, 251, or 258, as applicable to a health maintenance organization, Chapter 843 or 1271, Section 1367.053, Subchapter A, Chapter 1452, or Subchapter B, Chapter 1507.  The term does not include:
(A)  an individual physician;  or
(B)  a group of employed physicians, practicing medicine under one federal tax identification number, whose total claims paid to providers not employed by the group constitute less than 20 percent of the group's total collected revenue computed on a calendar year basis.
(2)  "Delegated network" means a delegated entity that assumes total financial risk for more than one of the following categories of health care services:  medical care, hospital or other institutional services, or prescription drugs, as defined by Section 551.003, Occupations Code.  The term does not include a delegated entity that shares risk for a category of services with a health maintenance organization.
(3)  "Delegated third party" means a third party other than a delegated entity that contracts with a delegated entity, either directly or through another third party, to:
(A)  accept responsibility for performing a function regulated by this chapter, Chapter 222, 251, or 258, as applicable to a health maintenance organization, Chapter 843 or 1271, Section 1367.053, Subchapter A, Chapter 1452, or Subchapter B, Chapter 1507;  or
(B)  receive, handle, or administer funds, if the receipt, handling, or administration is directly or indirectly related to a function regulated by this chapter, Chapter 222, 251, or 258, as applicable to a health maintenance organization, Chapter 843 or 1271, Section 1367.053, Subchapter A, Chapter 1452, or Subchapter B, Chapter 1507.
(4)  "Delegation agreement" means an agreement by which a health maintenance organization assigns the responsibility for a function regulated by this chapter, Chapter 222, 251, or 258, as applicable to a health maintenance organization, Chapter 843 or 1271, Section 1367.053, Subchapter A, Chapter 1452, or Subchapter B, Chapter 1507.
(5)  "Limited provider network" means a subnetwork within a health maintenance organization delivery network in which contractual relationships exist between physicians, certain providers, independent physician associations, or physician groups that limits an enrollee's access to physicians and providers to those physicians and providers in the subnetwork.
(b)  In this chapter, terms defined by Section 843.002 have the meanings assigned by that section.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
Amended by:
Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.074(e), eff. September 1, 2005.
Acts 2007, 80th Leg., R.S., Ch. 730 (H.B. 2636), Sec. 3B.02701, eff. September 1, 2007.