Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter Z - POINT-OF-SERVICE RIDERS › Section 11.2501 - Definitions

Current through Reg. 49, No. 28; July 12, 2024
The following words and terms, when used in this
					 subchapter, have the meaning indicated below unless the context indicates
					 otherwise:
(1) Coinsurance--An amount
				  in addition to the premium and copayments due from an enrollee who accesses
				  out-of-plan covered benefits, for which the enrollee is not
				  reimbursed.
(2) Corresponding
				  benefits--Benefits provided under a point-of-service rider or the indemnity
				  portion of a point-of-service plan, as defined in Insurance Code §
										843.108
				  (concerning Point-of-Service Rider) and §1273.001 (concerning
				  Definitions), that conform to the nature and kind of coverage provided to an
				  enrollee under the HMO portion of a point-of-service plan.
(3) Cost containment requirements--Provisions
				  in a point-of-service rider requiring a specific action that must be taken by
				  an enrollee or by a physician or provider on behalf of the enrollee, such as
				  the provision of specified information to the HMO, to avoid the imposition of a
				  specified penalty on the coverage provided under the rider for proposed service
				  or treatment.
(4) Coverage--Any
				  benefits available to an enrollee through an indemnity contract or rider, any
				  services available to an enrollee under an evidence of coverage, or combination
				  of the benefits and services available to an enrollee under a point-of-service
				  plan.
(5) Health plan products--Any
				  health care plan issued by an HMO under the Insurance Code or a rule adopted by
				  the commissioner.
(6) In-plan
				  covered services--Health care services, benefits, and supplies to which an
				  enrollee is entitled under the evidence of coverage issued by an HMO, including
				  emergency services, approved out-of-network services, and other authorized
				  referrals.
(7) Nonparticipating
				  physicians and providers--Physicians and providers who are not part of an HMO
				  delivery network.
(8) Out-of-plan
				  covered benefits--All covered health care services, benefits, and supplies that
				  are not in-plan covered services. Out-of-plan covered benefits include health
				  care services, benefits, and supplies obtained from participating physicians
				  and providers under circumstances in which the enrollee fails to comply with
				  the HMO's requirements for obtaining in-plan covered services.
(9) Participating physicians and
				  providers--Physicians and providers that are part of an HMO delivery
				  network.
(10) Point-of-service
				  blended contract plan--A point-of-service plan evidenced by a single contract,
				  policy, certificate, or evidence of coverage that provides a combination of
				  indemnity benefits for which an indemnity carrier is at risk and services that
				  are provided by an HMO under a point-of-service plan.
(11) Point-of-service dual contracts plan--A
				  point-of-service plan providing a combination of indemnity benefits and HMO
				  services through separate contracts, one being the contract, policy, or
				  certificate offered by an indemnity carrier for which the indemnity carrier is
				  at risk and the other being the evidence of coverage offered by the
				  HMO.
(12) Point-of-service rider--A
				  rider issued by an HMO that meets the solvency requirements of §
										11.2502
				  of this title (relating to Issuance of Point-of-Service Riders) and that
				  provides coverage for out-of-plan services, including services, benefits, and
				  supplies obtained from participating physicians or providers under
				  circumstances in which the enrollee fails to comply with the HMO's requirements
				  for obtaining approval for in-plan covered services.
(13) Point-of-service rider plan--A
				  point-of-service plan provided by an HMO in compliance with this subchapter
				  under an evidence of coverage that includes a point-of-service rider.