28 Tex. Admin. Code § 21.3502 - Definitions
The following words and terms, when used in this subchapter, have the following meanings, unless the context clearly indicates otherwise:
(1) Basic health care
services--Health care services that the commissioner determines an enrolled
population might reasonably need to maintain good health.
(2) Commissioner--The commissioner of
insurance.
(3) Consumer choice
health benefit plan--A group or individual accident or sickness insurance
policy or evidence of coverage that, in whole or in part, does not offer or
provide state-mandated health benefits, but that provides creditable coverage
as defined by Insurance Code §
1205.004(a)
or §
1501.102(a).
(4) Consumer choice of benefits health
insurance plan--A consumer choice health benefit plan.
(5) Department--The Texas Department of
Insurance.
(6) HMO--a person
defined in Insurance Code §
843.002(14).
(7) Health carrier--Any entity authorized
under the Insurance Code or another insurance law of this state that provides
health benefits in this state, including an insurance company, a group hospital
service corporation under the Insurance Code Chapter 842, an HMO under the
Insurance Code Chapter 843, and a stipulated premium company under the
Insurance Code Chapter 884.
(8)
Health insurer--Any entity authorized under the Insurance Code or another
insurance law or regulation of this state that provides health insurance or
health benefits in this state, including an insurance company, a group hospital
service corporation under Chapter 842 of the Insurance Code, and a stipulated
premium company under Chapter 884 of the Insurance Code.
(9) Standard health benefit plan--A consumer
choice health benefit plan.
(10)
State-mandated health benefits--
(A) Coverage
required under the Insurance Code, the Administrative Code, or other law of
this state to be provided in an individual, blanket, or group policy for
accident and health insurance, a contract for coverage of a health-related
condition, or an evidence of coverage that:
(i) includes coverage for specific health
care services or benefits;
(ii)
places limitations or restrictions on deductibles, coinsurance, copayments, or
any annual or lifetime maximum benefit amounts, including limitations provided
in Insurance Code §
1271.151; or
(iii) includes a specific category of
licensed health care practitioner from whom an insured or enrollee is entitled
to receive care.
(B) Do
not include benefits or coverage mandated by federal law, or standard
provisions or rights required under the Insurance Code, the Administrative
Code, or other law of this state, to be provided in an individual, blanket, or
group policy for accident and health insurance, a contract for coverage of a
health-related condition, or an evidence of coverage unrelated to specific
health illnesses, injuries, or conditions of an insured or enrollee, including
those benefits or coverages enumerated in Insurance Code §
1507.003(b)
and §
1507.053(b).
Notes
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