28 Tex. Admin. Code § 11.2 – Definitions

(a) The definitions found in the Texas Health Maintenance Organization Act §2, as amended, codified in Texas Insurance Code Article 20A.02, are hereby 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. (1) Act--The Texas Health Maintenance Organization Act, Senate Bill 180, enacted by Acts 1975, 64th Legislature, Chapter 214, pages 514-530, first effective December 1, 1975, as amended, codified as the Texas Insurance Code Chapter 20A.
2. (2) 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).
3. (3) Adverse determination--A determination upon utilization review that the health care services furnished or proposed to be furnished to a patient are not medically necessary or not appropriate.
4. (4) 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.
5. (5) Agent--As defined in the Insurance Code Articles 20A.15 and 20A.15A, unless the context of the rule clearly indicates applicability to any agents licensed under one specific article.
6. (6) ANHC or approved nonprofit health corporation--A nonprofit health corporation certified under Medical Practice Act §5.01(a) (Texas Civil Statutes, Article 4495b).
7. (7) Basic health care service--Health care services which an enrolled population might reasonably require to maintain good health, including, without limitations as to time and cost, those benefits 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), other than those limitations specifically prescribed in this title.
8. (8) Code--The Texas Insurance Code, 1951, as amended.
9. (9) Contract holder--An individual, association, employer, trust or organization to which an individual or group contract for health care services has been issued.
10. (10) Control--As defined in the Insurance Code Article 21.49-1.
11. (11) Controlled HMO--An HMO controlled directly or indirectly by a holding company.
12. (12) Controlled person--Any person, other than an HMO, who is controlled directly or indirectly by a holding company.
13. (13) Copayment--A charge in addition to premium to an enrollee for a service which is not fully prepaid.
14. (14) Credentialing--The review of qualifications and other relevant information pertaining to a physician, dentist, or provider who seeks a contract with an HMO.
15. (15) Credentials--Certificates, diplomas, licenses or other written documentation which verifies proof of training, education, and experience in a field of expertise.
16. (16) Dentist--An individual licensed to practice dentistry by the Texas State Board of Dental Examiners.
17. (17) General hospital--A licensed establishment that:
  1. (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
  2. (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.
18. (18) HMO--A health maintenance organization as defined in Insurance Code Article 20A.02(n).
19. (19) Health status related factor--Any of the following in relation to an individual:
  1. (A) health status;
  2. (B) medical condition (including both physical and mental illnesses);
  3. (C) claims experience;
  4. (D) receipt of health care;
  5. (E) medical history;
  6. (F) genetic information;
  7. (G) evidence of insurability (including conditions arising out of acts of domestic violence, including family violence as defined by the Insurance Code Article 21.21-5); or
  8. (H) disability.
20. (20) 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.
21. (21) Limited service HMO--An HMO which has been issued a certificate of authority to issue a limited service health care plan as defined in the Insurance Code Article 20A.02(l).
22. (22) Out of area benefits--Benefits that the HMO covers when its enrollees are outside the geographical limits of the HMO service area.
23. (23) Pathology services--Services provided by a licensed laboratory which has the capability of evaluating tissue specimens for diagnoses in histopathology, oral pathology, or cytology.
24. (24) Pharmaceutical services--Services, including dispensing prescription drugs, as defined in the Pharmacy Act, Texas Civil Statutes, Article 4542a-1, §5 that are ordinarily and customarily rendered by a pharmacy or pharmacist.
25. (25) Pharmacist--An individual licensed to practice pharmacy under the Pharmacy Act, Texas Civil Statutes, Article 4542a-1.
26. (26) Pharmacy--A facility licensed under the Pharmacy Act, Texas Civil Statutes, Article 4542a-1 §29.
27. (27) Premium--The prospectively determined rate that is paid by or on behalf of an enrollee for specified health services.
28. (28) Primary care physician or primary care provider--A physician or provider who is responsible for providing initial and primary care to patients, maintaining the continuity of patient care, and initiating referral for care.
29. (29) 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.
30. (30) 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.
31. (31) 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.
32. (32) Qualified HMO--An HMO which has been federally approved under Title XIII of the Public Health Service Act, Public Law 93-222, as amended.
33. (33) Quality improvement--A system to continuously examine, monitor and revise processes and systems that support and improve administrative and clinical functions.
34. (34) 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.
35. (35) 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.
36. (36) Referral specialists (other than primary care)--Physicians or providers who set themselves apart from the primary care physician or primary care provider through specialized training and education in a health care discipline.
37. (37) Schedule of charges--Specific rates or premiums to be charged for enrollee and dependent coverages.
38. (38) 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).
39. (39) 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 Article 20A.02(y).
40. (40) Special hospital--A licensed establishment that:
  1. (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;
  2. (B) has clinical laboratory facilities, diagnostic X-ray facilities, treatment facilities or other definitive medical treatment;
  3. (C) has a medical staff in regular attendance; and
  4. (D) maintains records of the clinical work performed for each patient.
41. (41) Statutory surplus--Admitted assets minus accrued uncovered liabilities.
42. (42) 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.
43. (43) Subsidiary--An affiliate controlled by a specified person directly or indirectly through one or more intermediaries.
44. (44) Telemedicine--As defined in the Insurance Code Article 21.53F.
45. (45) Urgent care--Health care services provided in a situation other than an emergency which are typically provided in a setting such as a physician or provider's office or urgent care center, as a result of an acute injury or illness that is severe or painful enough to lead a prudent layperson, possessing an average knowledge of medicine and health, to believe that his or her condition, illness, or injury is of such a nature that failure to obtain treatment within a reasonable period of time would result in serious deterioration of the condition or his or her health.
46. (46) Utilization review--A system for prospective or concurrent review of the medical necessity and appropriateness of health care services being provided or proposed to be provided to an individual within this state. Utilization review shall not include elective requests for clarification of coverage.
47. (47) Voting security--As defined in the Insurance Code Article 21.49-1, including any security convertible into or evidencing a right to acquire such security.
48. (48) NAIC--National Association of Insurance Commissioners.
49. (49) Annual financial statement--The annual statement to be used by HMOs, as promulgated by the NAIC and as adopted by the commissioner under Insurance Code Articles 1.11 and 20A.10.
50. (50) RBC--Risk-based capital.
51. (51) RBC formula--NAIC risk-based capital formula.
52. (52) Authorized control level--The number determined under the RBC formula in accordance with the RBC instructions.
53. (53) RBC Report--1999 NAIC Managed Care Organizations Risk-Based Capital Report including Overview and Instructions for Companies published by the NAIC.
54. (54) 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.

Source Note:The provisions of this §11.2 adopted to be effective January 1, 1980, 4 TexReg 4613; amended to be effective November 37, 1987, 12 TexReg 4259; amended to be effective August 17, 1992, 17 TexReg 5351; amended to be effective December 6, 1995, 20 TexReg 9697; amended to be effective April 1, 1996, 21 TexReg 2253; amended to be effective December 25, 1996, 21 TexReg 12100; amended to be effective December 8, 1997, 22 TexReg 11684; amended to be effective November 2, 1998, 23 TexReg 11347; amended to be effective March 30, 2000, 25 TexReg 2642.