28 Tex. Admin. Code § 11.2501 - Definitions
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.
Notes
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