28 Tex. Admin. Code § 21.2901 - Definitions
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.
Notes
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No prior version found.