Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter U - ARRANGEMENTS BETWEEN INDEMNITY CARRIERS AND HMOS FOR POINT-OF-SERVICE COVERAGE › Section 21.2901 - Definitions

Current through Reg. 49, No. 28; July 12, 2024
The following words and terms, when used in this subchapter
					 have the following meanings, unless the context clearly indicates
					 otherwise.
(1) Corresponding
				  benefits--Benefits provided under the indemnity portion of a point-of-service
				  (POS) plan, as defined in Insurance Code §
										1273.001 and §
										843.108,
				  that conform to the nature and kind of coverage provided to an enrollee under
				  the HMO portion of a point-of-service plan.
(2) Cost containment requirements--Provisions
				  in POS indemnity coverage requiring a specific action, such as the provision of
				  specified information to the plan, that must be taken by an enrollee or by a
				  physician or a provider on behalf of the enrollee in order to avoid the
				  imposition of a specified penalty on the coverage provided under the plan for a
				  proposed service or treatment.
(3)
				  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.
(4)
				  Non-participating physicians and providers--Physicians and providers that are
				  not part of an HMO delivery network.
(5) 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.
(6) Participating physicians and
				  providers--Physicians and providers that are part of an HMO delivery
				  network.
(7) Point-of-service
				  blended contract plan (POS blended contract plan)--A POS 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 are provided by an HMO under a POS plan.
(8) Point-of-service coverage (POS
				  coverage)--Coverage provided under a POS plan.
(9) Point-of-service dual contracts plan (POS
				  dual contracts plan)--A POS 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.
(10) Point-of-service HMO
				  coverage (POS HMO coverage)--Services provided by an HMO in an evidence of
				  coverage under a POS plan.
(11)
				  Point-of-service indemnity coverage (POS indemnity coverage)--Coverage for
				  which an indemnity carrier is at risk under a POS plan for self-referred health
				  care services, benefits and supplies, other than emergency services, selected
				  at the option of the enrollee, from non-participating physicians or providers,
				  as well as services, benefits and supplies from participating physicians or
				  providers under circumstances in which the enrollee fails to comply with the
				  requirements of the HMO providing the POS HMO coverage under a POS plan for
				  obtaining in-plan covered services.