Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter A - GENERAL PROVISIONS › Section 11.2 - Definitions

Current through Reg. 49, No. 28; July 12, 2024
(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 indicates otherwise:
(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 Corporations).
(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 HMO; and
(C) responsible
				  for clinical oversight of the utilization review program, the credentialing of
				  professional staff, and quality improvement functions.
(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
				  Benefit Plans).
(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 care services.
(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 (concerning
				  Definitions).
(16) Facility-based
				  physician--A radiologist, anesthesiologist, pathologist, emergency department
				  physician, neonatologist, or assistant surgeon:
(A) to whom a facility has granted clinical
				  privileges; and
(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 mental illnesses);
(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
(H)
				  disability.
(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 limited to:
(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;
(K) laboratories;
(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
				  Subordinated Indebtedness).
(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 -
				  569.
(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
				  area.
(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 reassessed;
(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 treatment;
(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 care
				  discipline.
(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).
(50) Subscriber--For conversion or individual
				  coverage, the individual who is the contract holder and is responsible for
				  payment of premiums to the HMO. For group coverage, the individual who is the
				  certificate holder and whose employment or other membership status, except for
				  family dependency, is the basis for eligibility for enrollment in the
				  HMO.
(51) Subsidiary--As defined in
				  §
											7.202 of
				  this title.
(52) Telehealth
				  service--As defined in Government Code §
											531.001 (concerning
				  Definitions).
(53) Telemedicine
				  medical service--As defined in Government Code §
											531.001.
(54) Urgent care--Health care services
				  provided in a situation other than an emergency that are typically provided in
				  a setting such as a physician or individual provider's office or urgent care
				  center, as a result of an acute injury or illness that is severe or painful
				  enough to lead a prudent layperson, possessing an average knowledge of medicine
				  and health, to believe that his or her condition, illness, or injury is of such
				  a nature that failure to obtain treatment within a reasonable time would result
				  in serious deterioration of the condition of his or her health.
(55) Utilization review--As defined in
				  Insurance Code §
											4201.002 (concerning
				  Definitions).
(56) Utilization
				  review agent or URA--As defined in Insurance Code §
											4201.002.