Texas § IN.1274.001 - DEFINITIONS

§ IN.1274.001. DEFINITIONS

DEFINITIONS. In this chapter: (1) "Enrollee" means an individual who is eligible for coverage under a health benefit plan, including a covered dependent. (2) "Health benefit plan" means 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: (A) accident-only or disability income insurance coverage or a combination of accident-only and disability income insurance coverage; (B) credit-only insurance coverage; (C) disability insurance coverage; (D) coverage only 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) workers' compensation insurance coverage or similar insurance coverage; (L) automobile medical payment insurance coverage; (M) a jointly managed trust authorized under 29 U.S.C. Section 141 et seq. that contains 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 U.S.C. Section 157; (N) hospital indemnity or other fixed indemnity insurance coverage; (O) reinsurance contracts issued on a stop-loss, quota-share, or similar basis; (P) liability insurance coverage, including general liability insurance and automobile liability insurance coverage; or (Q) coverage that provides other limited benefits specified by federal regulations. (3) "Health benefit plan issuer" means a health maintenance organization operating under Chapter 843 , a preferred provider organization operating under Chapter 1301 , an approved nonprofit health corporation that holds a certificate of authority under Chapter 844 , and any other entity that issues a health benefit plan, including: (A) an insurance company; (B) a group hospital service corporation operating under Chapter 842 ; (C) a fraternal benefit society operating under Chapter 885 ; or (D) a stipulated premium company operating under Chapter 884 . (4) "Health care provider" means: (A) a person, other than a physician, who is licensed or otherwise authorized to provide a health care service in this state, including: (i) a pharmacist or dentist; or (ii) a pharmacy, hospital, or other institution or organization; (B) a person who is wholly owned or controlled by a provider or by a group of providers who are licensed or otherwise authorized to provide the same health care service; or (C) a person who is wholly owned or controlled by one or more hospitals and physicians, including a physician-hospital organization. (5) "Participating provider" means: (A) a physician or health care provider who contracts with a health benefit plan issuer to provide medical care or health care to enrollees in a health benefit plan; or (B) a physician or health care provider who accepts and treats a patient on a referral from a physician or provider described by Paragraph (A). (6) "Physician" means: (A) an individual licensed to practice medicine in this state under Subtitle B, Title 3, Occupations Code; (B) a professional association organized under the Texas Professional Association Act (Article 1528f, Vernon's Texas Civil Statutes); (C) a nonprofit health corporation certified under Chapter 162 , Occupations Code; (D) a medical school or medical and dental unit, as defined or described by Section 61.003 , 61.501 , or 74.601 , Education Code, that employs or contracts with physicians to teach or provide medical services or employs physicians and contracts with physicians in a practice plan; or (E) another entity wholly owned by physicians. Added by Acts 2005, 79th Leg., Ch. 880 (S.B. 1149 ), Sec. 1, eff. September 1, 2005.