28 Tex. Admin. Code § 11.2602 - Definitions
The following words and terms, when used in this subchapter, have the following meanings, unless the context clearly indicates otherwise.
(1) Delegated entity--An
entity, other than an HMO authorized to do business under Insurance Code
Chapter 843 (concerning Health Maintenance Organizations) and Chapter 1272
(concerning to Delegation of Certain Functions by Health Maintenance
Organization) and other applicable insurance laws and regulations of this
state, that by itself, or through subcontracts with one or more entities,
undertakes to arrange for or to provide medical care or health care to an
enrollee in exchange for a predetermined payment on a prospective basis and
that accepts responsibility to perform on behalf of the HMO any function
regulated by Insurance Code Chapter 843 and Chapter 1272 and other applicable
insurance laws and regulations of this state. The term does not include an
individual physician or a group of employed physicians practicing medicine
under one federal tax identification number and whose total claims paid to
physicians and providers not employed by the group is less than 20 percent of
the total collected revenue of the group calculated on a calendar-year
basis.
(2) Delegated network--Any
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 Occupations Code §
551.003 (concerning
Definitions). The term does not include a delegated entity that shares risk for
a category of services with an HMO.
(3) Delegated third party--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 to perform any
function regulated by Insurance Code Chapter 843 and Chapter 1272 and other
applicable insurance laws and regulations of this state; or
(B) receive, handle, or administer funds, if
the receipt, handling, or administration of the funds is directly or indirectly
related to a function regulated by Insurance Code Chapter 843 and Chapter 1272
and other applicable insurance laws and regulations of this state.
(4) Health care--Any services,
including the furnishing to any individual of pharmaceutical services, medical,
chiropractic, dental care, hospitalization, or incident to the furnishing of
the services, care or hospitalization, as well as the furnishing to any person
of any and all other services for the purpose of preventing, alleviating,
curing, or healing human illness or injury.
Notes
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