Texas § IN.1662.002 - DEFINITION OF ACCUMULATED AMOUNTS

§ IN.1662.002. DEFINITION OF ACCUMULATED AMOUNTS

DEFINITION OF ACCUMULATED AMOUNTS. (a) In this chapter, "accumulated amounts" means: (1) the amount of financial responsibility an enrollee has incurred at the time a request for cost-sharing information is made, with respect to a deductible or out-of-pocket limit; and (2) to the extent a health benefit plan imposes a cumulative treatment limitation, including a limitation on the number of health care supplies, days, units, visits, or hours covered in a defined period, on a particular covered health care service or supply independent of individual medical necessity determinations, the amount that has accrued toward the limit on the health care service or supply. (b) For an individual enrolled in coverage other than self-only coverage, the term includes the financial responsibility the individual has incurred toward meeting the individual's own deductible or out-of-pocket limit and the amount of financial responsibility that all individuals enrolled in the individual's coverage have incurred, in aggregate, toward meeting the plan's other than self-only deductible or out-of-pocket limit, as applicable. (c) The term includes any expense that counts toward a deductible or out-of-pocket limit, including a copayment or coinsurance, but excludes any expense that does not count toward a deductible or out-of-pocket limit, including a premium payment, out-of-pocket expense for out-of-network health care services or supplies, or an amount for a health care service or supply not covered by the health benefit plan. Added by Acts 2021, 87th Leg., R.S., Ch. 333 (H.B. 2090 ), Sec. 3, eff. September 1, 2021.