(a) The definitions found in the Insurance Code §843.002 are incorporated into this chapter. (b) The following words and terms, when used in this chapter, shall have the following meanings unless the context clearly indicates otherwise.   (1) Admitted assets--All assets as defined by statutory accounting principles, as permitted and valued in accordance with §11.803 of this title (relating to Investments, Loans, and Other Assets).   (2) Adverse determination--A determination by a health maintenance organization or a utilization review agent that health care services provided or proposed to be provided to an enrollee are not medically necessary or are not appropriate.   (3) Affiliate--A person that directly, or indirectly through one or more intermediaries, controls, or is controlled by, or is under common control with, the person specified.   (4) Agent--A person who may act as an agent for the sale of a health benefit plan under a license issued under the Insurance Code.   (5) ANHC or approved nonprofit health corporation--A nonprofit health corporation certified under the Occupations Code §162.001, as amended.   (6) Annual financial statement--The annual statement to be used by HMOs, as promulgated by the NAIC and as adopted by the commissioner under the Insurance Code Chapter 802 and §843.155.   (7) Authorized control level--The number determined under the RBC formula in accordance with the RBC instructions.   (8) Basic health care service--Health care services which an enrolled population might reasonably require to maintain good health, as prescribed in §§11.508 and 11.509 of this title (relating to Mandatory Benefit Standards: Group, Individual and Conversion Agreements, and Additional Mandatory Benefit Standards: Group Agreement Only).   (9) Clinical director--Health professional who meets the following criteria:     (A) is appropriately licensed;     (B) is an employee of, or party to a contract with, a health maintenance organization; and     (C) is responsible for clinical oversight of the utilization review program, the credentialing of professional staff, and quality improvement functions.   (10) Code--The Texas Insurance Code.   (11) Consumer choice health benefit plan--A health benefit plan authorized by the Insurance Code Chapter 1507, and as described in Subchapter AA of Chapter 21 of this title (relating to Consumer Choice Health Benefit Plans).   (12) Contract holder--An individual, association, employer, trust or organization to which an individual or group contract for health care services has been issued.   (13) Control--As defined in the Insurance Code §§823.005 and 823.151.   (14) Controlled HMO--An HMO controlled directly or indirectly by a holding company.   (15) Controlled person--Any person, other than an HMO, who is controlled directly or indirectly by a holding company.   (16) Copayment--A charge, which may be expressed in terms of a dollar amount or a percentage of the contracted rate, in addition to premium to an enrollee for a service which is not fully prepaid.   (17) Credentialing--The process of collecting, assessing, and validating qualifications and other relevant information pertaining to a physician or provider to determine eligibility to deliver health care services.   (18) Dentist--An individual provider licensed to practice dentistry by the Texas State Board of Dental Examiners.   (19) General hospital--A licensed establishment that:     (A) offers services, facilities, and beds for use for more than 24 hours for two or more unrelated individuals requiring diagnosis, treatment, or care for illness, injury, deformity, abnormality, or pregnancy; and     (B) regularly maintains, at a minimum, clinical laboratory services, diagnostic X-ray services, treatment facilities including surgery or obstetrical care or both, and other definitive medical or surgical treatment of similar extent.   (20) HMO--A health maintenance organization as defined in the Insurance Code §843.002(14).   (21) Health status related factor--Any of the following in relation to an individual:     (A) health status;     (B) medical condition (including both physical and mental illnesses);     (C) claims experience;     (D) receipt of health care;     (E) medical history;     (F) genetic information;     (G) evidence of insurability (including conditions arising out of acts of domestic violence, including family violence as defined by the Insurance Code Chapter 544 Subchapter D; or     (H) disability.   (22) Individual provider--Any person, other than a physician or institutional provider, who is licensed or otherwise authorized to provide a health care service. Includes, but is not limited to, licensed doctor of chiropractic, dentist, registered nurse, advanced practice nurse, physician assistant, pharmacist, optometrist, registered optician, and acupuncturist.   (23) Institutional provider--A provider that is not an individual. Includes any medical or health related service facility caring for the sick or injured or providing care or supplies for other coverage which may be provided by the HMO. Includes but is not limited to:     (A) General hospitals,     (B) Psychiatric hospitals,     (C) Special hospitals,     (D) Nursing homes,     (E) Skilled nursing facilities,     (F) Home health agencies,     (G) Rehabilitation facilities,     (H) Dialysis centers,     (I) Free-standing surgical centers,     (J) Diagnostic imaging centers,     (K) Laboratories,     (L) Hospice facilities,     (M) Residential treatment centers,     (N) Community mental health centers, and     (O) Pharmacies.   (24) Limited provider network--A subnetwork within an HMO delivery network in which contractual relationships exist between physicians, certain providers, independent physician associations and/or physician groups which limit the enrollees' access to only the physicians and providers in the subnetwork.   (25) Limited service HMO--An HMO which has been issued a certificate of authority to issue a limited health care service plan as defined in the Insurance Code §843.002.   (26) Matrix filing--A filing consisting of individual provisions, each with its own unique identifiable form number, that allows an HMO the flexibility to create multiple evidences of coverage by using combinations of approved individual provisions.   (27) NAIC--National Association of Insurance Commissioners.   (28) Out of area benefits--Benefits that the HMO covers when its enrollees are outside the geographical limits of the HMO service area.   (29) Pathology services--Services provided by a licensed laboratory which has the capability of evaluating tissue specimens for diagnoses in histopathology, oral pathology, or cytology.   (30) Pharmaceutical services--Services, including dispensing prescription drugs, under the Texas Pharmacy Act, Occupations Code, Subtitle J, as amended, that are ordinarily and customarily rendered by a pharmacy or pharmacist.   (31) Pharmacist--An individual provider licensed to practice pharmacy under the Texas Pharmacy Act, Occupations Code, Subtitle J, as amended.   (32) Pharmacy--A facility licensed under the Texas Pharmacy Act, Occupations Code, Subtitle J, as amended.   (33) Premium--All amounts payable by a contract holder as a condition of receiving coverage from a carrier, including any fees or other contributions associated with a health benefit plan.   (34) Primary care physician or primary care provider--A physician or individual provider who is responsible for providing initial and primary care to patients, maintaining the continuity of patient care, and initiating referral for care.   (35) Primary HMO--An HMO that contracts directly with, and issues an evidence of coverage to, individuals or organizations to arrange for or provide a basic, limited, or single health care service plan to enrollees on a prepaid basis.   (36) Provider HMO--An HMO that contracts directly with a primary HMO to provide or arrange to provide health care services on behalf of the primary HMO within the primary HMO's defined service area.   (37) Psychiatric hospital--A licensed hospital which offers inpatient services, including treatment, facilities and beds for use beyond 24 hours, for the primary purpose of providing psychiatric assessment and diagnostic services and psychiatric inpatient care and treatment for mental illness. Such services must be more intensive than room, board, personal services, and general medical and nursing care. Although substance abuse services may be offered, a majority of beds must be dedicated to the treatment of mental illness in adults and/or children.   (38) Qualified HMO--An HMO which has been federally approved under Title XIII of the Public Health Service Act, Public Law 93-222, as amended.   (39) Quality improvement (QI)--A system to continuously examine, monitor and revise processes and systems that support and improve administrative and clinical functions.   (40) RBC--Risk-based capital.   (41) RBC formula--NAIC risk-based capital formula.   (42) RBC Report--Health Risk-Based Capital Report including Overview and Instructions for Companies published by the NAIC and adopted by reference in §11.809 of this title (relating to Risk-Based Capital for HMOs and Insurers Filing the NAIC Health Blank).   (43) Recredentialing--The periodic process by which:     (A) qualifications of physicians and providers are reassessed;     (B) performance indicators, including utilization and quality indicators, are evaluated; and     (C) continued eligibility to provide services is determined.   (44) Reference laboratory--A licensed laboratory that accepts specimens for testing from outside sources and depends on referrals from other laboratories or entities. HMOs may contract with a reference laboratory to provide clinical diagnostic services to their enrollees.   (45) Reference laboratory specimen procurement services--The operation utilized by the reference laboratory to pick up the lab specimens from the client offices or referring labs, etc. for delivery to the reference laboratory for testing and reporting.   (46) Schedule of charges--Specific rates or premiums to be charged for enrollee and dependent coverages.   (47) Service area--A geographic area within which direct service benefits are available and accessible to HMO enrollees who live, reside or work within that geographic area and which complies with §11.1606 of this title (relating to Organization of an HMO).   (48) Single service HMO--An HMO which has been issued a certificate of authority to issue a single health care service plan as defined in the Insurance Code §843.002.   (49) Special hospital--A licensed establishment that:     (A) offers services, facilities and beds for use for more than 24 hours for two or more unrelated individuals who are regularly admitted, treated and discharged and who require services more intensive than room, board, personal services, and general nursing care;     (B) has clinical laboratory facilities, diagnostic X-ray facilities, treatment facilities or other definitive medical treatment;     (C) has a medical staff in regular attendance; and     (D) maintains records of the clinical work performed for each patient.   (50) Specialists--Physicians or individual providers who set themselves apart from the primary care physician or primary care provider through specialized training and education in a health care discipline.   (51) State-mandated health benefit plan--As defined in §21.3502 of this title (relating to Definitions).   (52) Statutory surplus--Admitted assets minus accrued uncovered liabilities.   (53) Subscriber--If conversion or individual coverage, the individual who is the contract holder and is responsible for payment of premiums to the HMO; or if group coverage, the individual who is the certificate holder and whose employment or other membership status, except for family dependency, is the basis for eligibility for enrollment in the HMO.   (54) Subsidiary--An affiliate controlled by a specified person directly or indirectly through one or more intermediaries.   (55) Telehealth service--As defined in Section 57.042, Utilities Code.   (56) Telemedicine medical service--As defined in Section 57.042, Utilities Code.   (57) Total adjusted capital--An HMO's statutory capital and surplus/total net worth as determined in accordance with the statutory accounting applicable to the annual financial statements required to be filed pursuant to the Insurance Code, and such other items, if any, as the RBC instructions provide. Cont'd...