Sec. 1274.001. 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
Free access — add to your briefcase to read the full text and ask questions with AI
Sec. 1274.001. 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.