Rule §26.4 Definitions


Published: 2015

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The following words and terms, when used in this chapter, shall have the following meanings, unless the context clearly indicates otherwise.   (1) Actuary--A qualified actuary who is a member in good standing of the American Academy of Actuaries.   (2) Affiliation period--A period of time that under the terms of the coverage offered by an HMO, must expire before the coverage becomes effective. During an affiliation period an HMO is not required to provide health care services or benefits to the participant or beneficiary and a premium may not be charged to the participant or beneficiary.   (3) 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, Chapter 21.   (4) Base premium rate--For each class of business and for a specific rating period, the lowest premium rate that is charged or that could be charged under a rating system for that class of business by the small employer carrier to small employers with similar case characteristics for small employer health benefit plans with the same or similar coverage.   (5) Case characteristics--With respect to a small employer, the geographic area in which that employer's employees reside, the age and gender of the individual employees and their dependents, the appropriate industry classification as determined by the small employer carrier, the number of employees and dependents, and other objective criteria as established by the small employer carrier that are considered by the small employer carrier in setting premium rates for that small employer. The term does not include health status related factors, duration of coverage since the date of issuance of a health benefit plan, or whether a covered person is or may become pregnant.   (6) Child--An unmarried natural child of the employee, including a newborn child; adopted child, including a child as to whom an insured is a party in a suit seeking the adoption of the child; natural child or adopted child of the employee's spouse.   (7) Class of business--All small employers or a separate grouping of small employers established under the Insurance Code, Chapter 26, Subchapters A-G.   (8) Commissioner--The commissioner of insurance.   (9) Consumer choice health benefit plan--A health benefit plan authorized by Insurance Code Article 3.80 or Article 20A.09N.   (10) Creditable coverage--     (A) An individual's coverage is creditable for purposes of this chapter if the coverage is provided under:       (i) a self-funded or self-insured employee welfare benefit plan that provides health benefits and that is established in accordance with the Employee Retirement Income Security Act of 1974 (29 U.S.C. Section 1001 et seq.);       (ii) a group health benefit plan provided by a health insurance carrier or an HMO;       (iii) an individual health insurance policy or evidence of coverage;       (iv) Part A or Part B of Title XVIII of the Social Security Act (42 U.S.C. Section 1395c et seq.);       (v) Title XIX of the Social Security Act (42 U.S.C. Section 1396 et seq., Grants to States for Medical Assistance Programs), other than coverage consisting solely of benefits under Section 1928 of that Act (42 U.S.C. Section 1396s, Program for Distribution of Pediatric Vaccines);       (vi) Chapter 55 of Title 10, United States Code (10 U.S.C. Section 1071 et seq.);       (vii) a medical care program of the Indian Health Service or of a tribal organization;       (viii) a state or political subdivision health benefits risk pool;       (ix) a health plan offered under Chapter 89 of Title 5, United States Code (5 U.S.C. Section 8901 et seq.);       (x) a public health plan as defined in this section;       (xi) a health benefit plan under Section 5(e) of the Peace Corps Act (22 U.S.C. Section 2504(e)); and       (xii) short-term limited duration insurance as defined in this section.     (B) Creditable coverage does not include:       (i) accident-only, disability income insurance, or a combination of accident-only and disability income insurance;       (ii) coverage issued as a supplement to liability insurance;       (iii) liability insurance, including general liability insurance and automobile liability insurance;       (iv) workers' compensation or similar insurance;       (v) automobile medical payment insurance;       (vi) credit only insurance;       (vii) coverage for onsite medical clinics;       (viii) other coverage that is similar to the coverage described in this subsection under which benefits for medical care are secondary or incidental to other insurance benefits and specified in federal regulations;       (ix) if offered separately, coverage that provides limited scope dental or vision benefits;       (x) if offered separately, long-term care coverage or benefits, nursing home care coverage or benefits, home health care coverage or benefits, community based care coverage or benefits, or any combination of those coverages or benefits;       (xi) if offered separately, coverage for limited benefits specified by federal regulation;       (xii) if offered as independent, noncoordinated benefits, coverage for specified disease or illness;       (xiii) if offered as independent, noncoordinated benefits, hospital indemnity or other fixed indemnity insurance; or       (xiv) Medicare supplemental health insurance as defined under Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss), coverage supplemental to the coverage provided under Chapter 55 of Title 10, United States Code (10 U.S.C. Section 1071 et seq.), and similar supplemental coverage provided under a group plan, but only if such insurance or coverages are provided under a separate policy, certificate, or contract of insurance.   (11) Department--The Texas Department of Insurance.   (12) Dependent--A spouse; newborn child; child under the age of 25 years; child of any age who is medically certified as disabled and dependent on the parent; any person who must be covered under Insurance Code Article 3.51-6, §3D or §3E, or the Insurance Code Article 3.70-2(L); and any other child included as an eligible dependent under an employer's benefit plan, including a child who is a full-time student as required by Insurance Code Article 21.24-2 and §11.506(19) of this title (relating to Mandatory Contractual Provisions: Group, Individual and Conversion Agreement and Group Certificate).   (13) DNA--Deoxyribonucleic acid.   (14) 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.   (15) Eligible employee--An employee who works on a full-time basis and who usually works at least 30 hours a week. The term also includes a sole proprietor, a partner, and an independent contractor, if the sole proprietor, partner, or independent contractor is included as an employee under a health benefit plan of a small or large employer, regardless of the number of hours the sole proprietor, partner, or independent contractor works weekly, but only if the plan includes at least two other eligible employees who work on a full-time basis and who usually work at least 30 hours a week. The term does not include:     (A) an employee who works on a part-time, temporary, seasonal or substitute basis; or     (B) an employee who is covered under:       (i) another health benefit plan;       (ii) a self-funded or self-insured employee welfare benefit plan that provides health benefits and that is established in accordance with the Employee Retirement Income Security Act of 1974 (29 United States Code, §§1001, et seq.);       (iii) the Medicaid program if the employee elects not to be covered;       (iv) another federal program, including the TRICARE program or Medicare program, if the employee elects not to be covered; or       (v) a benefit plan established in another country if the employee elects not to be covered.   (16) Employee--Any individual employed by an employer.   (17) 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 such a 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.   (18) Genetic information--Information derived from the results of a genetic test or from family history.   (19) Genetic test--A laboratory test of an individual's DNA, RNA, proteins, or chromosomes to identify by analysis of the DNA, RNA, proteins, or chromosomes the genetic mutations or alterations in the DNA, RNA, proteins, or chromosomes that are associated with a predisposition for a clinically recognized disease or disorder. The term does not include:     (A) a routine physical examination or a routine test performed as a part of a physical examination;     (B) a chemical, blood or urine analysis;     (C) a test to determine drug use; or     (D) a test for the presence of the human immunodeficiency virus.   (20) HMO--Any person governed by the Texas Health Maintenance Organization Act, Insurance Code, Chapters 20A and 843, 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 §162.001 Texas Occupations Code, and that holds a certificate of authority issued by the commissioner under Insurance Code Article 21.52F;     (C) a statewide rural health care system under Insurance Code, Chapter 845 that holds a certificate of authority issued by the commissioner under Insurance Code, Chapter 843; or     (D) a nonprofit corporation created and operated by a community center under Chapter 534, Subchapter C, Health and Safety Code.   (21) Health benefit plan--A group, blanket, or franchise insurance policy, a certificate issued under a group policy, a group hospital service contract, or a group subscriber contract or evidence of coverage issued by a health maintenance organization that provides benefits for health care services. The term does not include the following plans of coverage:     (A) accident-only or disability income insurance or a combination of accident-only and disability income insurance;     (B) credit-only insurance;     (C) disability insurance coverage;     (D) coverage for a specified disease or illness;     (E) Medicare services under a federal contract;     (F) Medicare supplement and Medicare Select policies regulated in accordance with federal law;     (G) long-term care coverage or benefits, nursing home care coverage or benefits, home health care coverage or benefits, community-based care coverage or benefits, or any combination of those coverages or benefits;     (H) coverage that provides limited-scope dental or vision benefits;     (I) coverage provided by a single-service health maintenance organization;     (J) coverage issued as a supplement to liability insurance;     (K) insurance coverage arising out of a workers' compensation or similar insurance;     (L) automobile medical payment insurance coverage;     (M) jointly managed trusts authorized under 29 United States Code §§141 et seq. that contain a plan of benefits for employees that is negotiated in a collective bargaining agreement governing wages, hours, and working conditions of the employees that is authorized under 29 United States Code §157;     (N) hospital indemnity or other fixed indemnity insurance;     (O) reinsurance contracts issued on a stop-loss, quota-share, or similar basis;     (P) short-term limited duration insurance as defined in this section;     (Q) liability insurance, including general liability insurance and automobile liability insurance;     (R) coverage for onsite medical clinics; or     (S) coverage that provides other limited benefits specified by federal regulations; or     (T) other coverage that is:       (i) similar to the coverage described in subparagraphs (A) - (S) of this paragraph under which benefits for medical care are secondary or incidental to other insurance benefits; and       (ii) specified in federal regulations.   (22) 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, an HMO, and a stipulated premium company under Insurance Code, Chapter 844.   (23) 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. Cont'd...

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