28 Tex. Admin. Code § 26.4 - Definitions
The following terms, when used in Subchapters A, C, and D of this chapter, have the following meanings unless the context clearly indicates otherwise.
(1) Affiliation
period--As defined in Insurance Code §
1501.104 (concerning
Affiliation Period).
(2) Agent--A
person who may act as an agent for the sale of a health benefit plan under a
license issued by TDI.
(3) Base
premium rate--As defined in Insurance Code §
1501.201 (concerning
Definitions).
(4) Case
characteristics--As defined in Insurance Code §
1501.201.
(5) Child--
(A) An unmarried natural child of the
employee, including a newborn child;
(B) An unmarried adopted child, including a
child about whom the insured employee is a party in a suit seeking the adoption
of the child;
(C) An unmarried
natural child or adopted child of the employee's spouse including a child about
whom the spouse is a party in a suit seeking the adoption of the child;
and
(D) Any other child included as
an eligible dependent under an employer's benefit plan.
(6) Class of business--As defined in
Insurance Code §
1501.201.
(7) Commissioner--The commissioner of
insurance.
(8) Consumer choice
health benefit plan--A health benefit plan authorized by Insurance Code Chapter
1507 (concerning Consumer Choice of Benefits Plans).
(9) Creditable coverage--As defined in
Insurance Code §
1205.004 (concerning
Creditable Coverage).
(10)
Dependent--As defined in Insurance Code §
1501.002 (concerning
Definitions).
(11) Effective
date--The first day of coverage under a health benefit plan or, if there is a
waiting period, the first day of the waiting period.
(12) Eligible dependent--A dependent who
meets the requirements for coverage under a small or large employer health
benefit plan.
(13) Eligible
employee--As defined in Insurance Code §
1501.002.
(14) Employee--As defined in Insurance Code §
1501.002.
(15) Franchise insurance policy--An
individual health benefit plan under which a number of individual policies are
offered to a selected group of a small or large employer. The rates for the
policy may differ from the rate applicable to individually solicited policies
of the same type and may differ from the rate applicable to individuals of
essentially the same class.
(16)
Genetic information--As defined in Insurance Code §
546.001 (concerning
Definitions).
(17) Genetic test--As
defined in Insurance Code §
546.001.
(18) Gross premiums--The total amount of
money collected by the health carrier for health benefit plans during the
applicable calendar year or the applicable calendar quarter, including premiums
collected:
(A) for individual and group
health benefit plans issued to employers or their employees; and
(B) under certificates issued or delivered to
Texas employees of employers, regardless of where the policy is issued or
delivered.
(19) HMO--Any
person governed by the Texas Health Maintenance Organization Act, Insurance
Code Chapter 843 (concerning Health Maintenance Organizations), including:
(A) a person defined as a health maintenance
organization under the Texas Health Maintenance Organization Act;
(B) an approved nonprofit health corporation
that is certified under Occupations Code §
162.001 (concerning
Certification by Board), and that holds a certificate of authority issued by
the commissioner under Insurance Code Chapter 844 (concerning Certification of
Certain Nonprofit Health Corporations);
(C) a statewide rural health care system
under Insurance Code Chapter 845 (concerning Statewide Rural Health Care
System) that holds a certificate of authority issued by the commissioner;
or
(D) a nonprofit corporation
created and operated by a community center under Health and Safety Code Chapter
534, Subchapter C (concerning Health Maintenance Organizations).
(20) Health benefit plan--As
defined in Insurance Code §
1501.002.
(21) Health carrier--Any entity authorized
under the Insurance Code or another insurance law of this state that provides
health insurance or health benefits in this state including an insurance
company, a group hospital service corporation under Insurance Code Chapter 842
(concerning Group Hospital Service Corporations), an HMO under Insurance Code
Chapter 843, or a stipulated premium company under Insurance Code Chapter 884
(concerning Stipulated Premium Insurance Companies).
(22) Health insurance coverage--Benefits
consisting of medical care (provided directly, through insurance or
reimbursement, or otherwise) under any hospital or medical service policy or
certificate, hospital or medical service plan contract, or HMO
contract.
(23)
Health-status-related factor--Health status; medical condition, including both
physical and mental illnesses; claims experience; receipt of health care;
medical history; genetic information; disability; and evidence of insurability,
including conditions arising out of acts of domestic violence and tobacco
use.
(24) Index rate--As defined in
Insurance Code §
1501.201.
(25) Large employer--As defined in Insurance
Code §
1501.002.
(26) Large employer carrier--A health
carrier, to the extent that carrier is offering, delivering, issuing for
delivery, or renewing health benefit plans subject to Insurance Code Chapter
1501 (concerning Health Insurance Portability and Availability Act).
(27) Large employer health benefit plan--As
defined in Insurance Code §
1501.002.
(28) Late enrollee--
(A) Any employee or dependent eligible for
enrollment who:
(i) requests enrollment in a
small or large employer's health benefit plan after the expiration of the
initial enrollment period established under the terms of the first plan for
which that employee or dependent was eligible through the small or large
employer, or after the expiration of an open enrollment period under Insurance
Code §
1501.156(a)
(concerning Employee Enrollment; Waiting Period) and § 1501.606(a) (concerning
Employee Enrollment; Waiting Period);
(ii) does not fall within the exceptions
listed in subparagraph (B) of this paragraph; and
(iii) is accepted for enrollment and not
excluded until the next open enrollment period.
(B) An employee or dependent eligible for and
requesting enrollment cannot be excluded until the next open enrollment period
and, when enrolled, is not a late enrollee, in the following special
circumstances:
(i) the individual:
(I) was covered under another health benefit
plan or self-funded employer health benefit plan at the time the individual was
eligible to enroll;
(II) declines
in writing, at the time of initial eligibility, stating that coverage under
another health benefit plan or self-funded employer health benefit plan was the
reason for declining enrollment;
(III) has lost coverage under another health
benefit plan or self-funded employer health benefit plan as a result of
termination of employment, reduction in the number of hours of employment,
termination of the other plan's coverage, termination of contributions toward
the premium made by the employer, death of a spouse, or divorce; and
(IV) requests enrollment not later than the
31st day after the date on which coverage under the other health benefit plan
or self-funded employer health benefit plan terminates;
(ii) the individual is employed by an
employer who offers multiple health benefit plans and the individual elects a
different health benefit plan during an open enrollment period;
(iii) a court has ordered coverage to be
provided for a spouse under a covered employee's plan and the request for
enrollment is made not later than the 31st day after the date on which the
court order is issued;
(iv) a court
has ordered coverage to be provided for a child under an insured's plan and the
request for enrollment is made not later than the 31st day after the date on
which the employer receives the court order or notification of the court
order;
(v) the individual is a
child of an insured and has lost coverage under Health and Safety Code Chapter
62 (concerning Child Health Plan for Certain Low-Income Children) or Title XIX
of the Social Security Act (42 U.S.C. §§
1396, et seq., concerning Medicaid and CHIP
Payment and Access Commission), other than coverage consisting solely of
benefits under Section 1928 of that Act (42 U.S.C. §
1396s, concerning Program for Distribution of
Pediatric Vaccines);
(vi) the
individual has a change in family composition due to marriage, birth of a
child, adoption of a child, or because an insured becomes a party in a suit for
the adoption of a child;
(vii) an
individual becomes a dependent due to marriage, birth of a child, adoption of a
child, or because an insured becomes a party in a suit for the adoption of a
child; and
(viii) the individual
described in clauses (v) - (vii) of this subparagraph requests enrollment no
later than the 31st day after the date of the marriage, birth, adoption of the
child, loss of the child's coverage, or within 31 days of the date an insured
becomes a party in a suit for the adoption of a child.
(29) Limited scope dental or
vision benefits--Dental or vision benefits that are sold under a separate
policy or rider and that are limited in scope to a narrow range or type of
benefits that are generally excluded from hospital, medical, or surgical
benefits contracts.
(30) Medical
care--Amounts paid for:
(A) the diagnosis,
cure, mitigation, treatment, or prevention of disease, or amounts paid for the
purpose of affecting any structure or function of the body;
(B) transportation primarily for and
essential to the medical care described in subparagraph (A) of this paragraph;
or
(C) insurance covering medical
care described in either subparagraph (A) or (B) of this paragraph.
(31) Medical condition--Any
physical or mental condition including, but not limited to, any condition
resulting from illness, injury (whether or not the injury is accidental),
pregnancy, or congenital malformation. Genetic information does not constitute
a medical condition in the absence of a diagnosis of a condition related to the
information.
(32) New business
premium rate--As defined in Insurance Code §
1501.201.
(33) New entrant--An eligible employee, or
the dependent of an eligible employee, who becomes eligible for coverage in an
employer group after the initial period for enrollment in a health benefit
plan. After the initial enrollment period, this includes any employee or
dependent who becomes eligible for coverage and who is not a late
enrollee.
(34) Participation
criteria--As defined in Insurance Code §
1501.601 (concerning
Participation Criteria).
(35)
Person--As defined in Insurance Code §
1501.002.
(36) Plan year--For purposes of Insurance
Code Chapter 1501 and this chapter, a 365-day period that begins on the plan or
policy's effective date or a period of one full calendar year, under a health
benefit plan providing coverage to small or large employers and their
employees, as defined in the plan or policy. Health carriers must use the same
definition of plan year in all small or large employer health benefit
plans.
(37) Point-of-service
coverage--Coverage provided under a point-of-service plan as described in §
21.2901 of this title (relating to
Definitions) and as permitted by Insurance Code §
1501.255 (concerning
Health Maintenance Organization Plans).
(38) Point-of-service option--Coverage that
complies with the out-of-plan coverage set forth in either Chapter 11,
Subchapter Z of this title (relating to Point-of-Service Riders), or Chapter
21, Subchapter U of this title (relating to Arrangements Between Indemnity
Carriers and HMOs for Point-of-Service Coverage), and that allows the enrollee
to access out-of-plan coverage at the option of the enrollee.
(39) Point-of-service plan--As defined in
Insurance Code §
1273.051 (concerning
Definitions).
(40) Postmark--A date
stamp by the U.S. Postal Service or other delivery entity, including any
electronic delivery available.
(41)
Preexisting condition provision--As defined in Insurance Code §
1501.002.
(42) Premium--As defined in Insurance Code §
1501.002.
(43) Premium rate quote--A statement of the
premium a health carrier offers and will accept to make coverage effective for
a small or large employer.
(44)
Public health plan--Any plan established or maintained by a state, county, or
other political subdivision of a state that provides health insurance coverage
to individuals.
(45) Qualified
actuary--An actuary who is a member:
(A) of
the Society of Actuaries; and
(B)
in good standing of the American Academy of Actuaries.
(46) Rating period--As defined in Insurance
Code §
1501.201.
(47) Reinsured carrier--A small employer
carrier participating in the Texas Health Reinsurance System.
(48) Renewal date--For each small or large
employer's health benefit plan, the earlier of the date, if any, specified in
the plan for renewal; the policy anniversary date; or the date the small or
large employer's plan is changed. To determine the renewal date for employer
association or multiple employer trust group health benefit plans, health
carriers may use the date specified for renewal, or the policy anniversary
date, of either the master contract or the contract or certificate of coverage
of each small or large employer in the association or trust. Health carriers
must use the same method of determining renewal dates for all small or large
employer health benefit plans. A change in the premium rate is not considered a
renewal if the change is due solely:
(A) to
the addition or deletion of an employee or dependent if the deletion is due to
a request by the employee, death or retirement of the employee or dependent,
termination of employment of the employee, or because a dependent is no longer
eligible; or
(B) to fraud or
intentional misrepresentation of a material fact by a small or large employer
or an eligible employee or dependent.
(49) Risk-assuming carrier--A risk-assuming
health benefit plan issuer as defined in Insurance Code §
1501.301 (concerning
Definitions).
(50) Risk
characteristic--The health-status-related factors, duration of coverage, or any
similar characteristic, except genetic information, related to the health
status or experience of a small employer group or of any member of that
group.
(51) Risk load--The
percentage above the applicable base premium rate that is charged by a small
employer carrier to a small employer to reflect the risk characteristics of
that group. A small employer carrier may not use genetic information to alter
or otherwise affect risk load.
(52)
Short-term limited duration insurance--Health insurance coverage provided under
a contract with an issuer that:
(A) has an
expiration date specified in the contract, taking into account any extensions
that may be elected by the policyholder without the issuer's consent;
and
(B) is within 12 months of the
date the contract becomes effective.
(53) Significant break in coverage--A period
of 63 consecutive days during which the individual does not have creditable
coverage. Neither a waiting period nor an affiliation period is counted in
determining a significant break in coverage.
(54) Small employer--As defined in Insurance
Code §
1501.002. A small
employer includes an independent school district that elects to participate in
the small employer market under Insurance Code §
1501.009 (concerning
School District Election).
(55)
Small employer carrier--A health carrier, to the extent that health carrier is
offering, delivering, issuing for delivery, or renewing, under Insurance Code §
1501.003 (concerning
Applicability: Small Employer Health Benefit Plans), health benefit plans
subject to Insurance Code Chapter 1501.
(56) Small employer health benefit plan--As
defined in Insurance Code §
1501.002.
(57) State-mandated health benefits--As
defined in §
21.3502 of this title (relating to
Definitions).
(58) TDI--The Texas
Department of Insurance.
(59)
Waiting period--As defined in Insurance Code §
1501.002. If an
employee or dependent enrolls as a late enrollee, under special circumstances
that except the employee or dependent from the definition of late enrollee, or
during an open enrollment period, any period of eligibility before the
effective date of enrollment is not a waiting period.
Notes
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