In this chapter:
(1) “Adverse determination” means a determination by a health maintenance organization or a utilization review agent that health care services provided or proposed to be provided to an enrollee are not medically necessary or are not appropriate.
(2) “Basic health care services” means health care services that the commissioner determines an enrolled population might reasonably need to be maintained in good health.
(3) “Blended contract” means a single document that provides a combination of indemnity and health maintenance organization benefits. The term includes a single contract policy, certificate, or evidence of coverage.
(4) “Capitation” means a method of compensating a physician or provider for arranging for or providing a defined set of covered health care services to certain enrollees for a specified period that is based on a predetermined payment per enrollee for the specified period, without regard to the quantity of services actually provided.
(5) “Complainant” means an enrollee, or a physician, provider, or other person designated to act on behalf of an enrollee, who files a complaint.
(6) “Complaint” means any dissatisfaction expressed orally or in writing by a complainant to a health maintenance organization regarding any aspect of the health maintenance organization’s operation. The term includes dissatisfaction relating to plan administration, procedures related to review or appeal of an adverse determination under § 843.261, the denial, reduction, or termination of a service for reasons not related to medical necessity, the manner in which a service is provided, and a disenrollment decision. The term does not include:
(A) a misunderstanding or a problem of misinformation that is resolved promptly by clearing up the misunderstanding or supplying the appropriate information to the satisfaction of the enrollee; or
(B) a provider’s or enrollee’s oral or written expression of dissatisfaction or disagreement with an adverse determination.
(7) “Emergency care” means health care services provided in a hospital emergency facility, freestanding emergency medical care facility, or comparable emergency facility to evaluate and stabilize medical conditions of a recent onset and severity, including severe pain, that would lead a prudent layperson possessing an average knowledge of medicine and health to believe that the individual’s condition, sickness, or injury is of such a nature that failure to get immediate medical care could:
(A) place the individual’s health in serious jeopardy;
(B) result in serious impairment to bodily functions;
(C) result in serious dysfunction of a bodily organ or part;
(D) result in serious disfigurement; or
(E) for a pregnant woman, result in serious jeopardy to the health of the fetus.
(8) “Enrollee” means an individual who is enrolled in a health care plan and includes covered dependents.
(9) “Evidence of coverage” means any certificate, agreement, or contract, including a blended contract, that:
(A) is issued to an enrollee; and
(B) states the coverage to which the enrollee is entitled.
(9-a) Repealed by Acts 2013, 83rd Leg., R.S., Ch. 915, Sec. 3(1), eff. September 1, 2013.
(9-b) “Freestanding emergency medical care facility” means a facility licensed under Chapter 254, Health and Safety Code.
(10) “Group hospital service corporation” means a corporation operating under Chapter 842.
(11) “Health care” means prevention, maintenance, rehabilitation, pharmaceutical, and chiropractic services, other than medical care, provided by qualified persons.
(12) “Health care plan” means a plan:
(A) under which a person undertakes to provide, arrange for, pay for, or reimburse any part of the cost of health care services; and
(B) that consists in part of providing or arranging for health care services on a prepaid basis through insurance or otherwise, as distinguished from indemnifying for the cost of health care services.
(13) “Health care services” means services provided to an individual to prevent, alleviate, cure, or heal human illness or injury. The term includes:
(A) pharmaceutical services;
(B) medical, chiropractic, or dental care;
(C) hospitalization;
(D) care or services incidental to the health care services described by Paragraphs (A)-(C); and
(E) services provided under a limited health care service plan or a single health care service plan.
(14) “Health maintenance organization” means a person who arranges for or provides to enrollees on a prepaid basis a health care plan, a limited health care service plan, or a single health care service plan.
(15) “Health maintenance organization delivery network” means a health care delivery system in which a health maintenance organization arranges for health care services directly or indirectly through contracts and subcontracts with physicians and providers.
(16) “Life-threatening” means a disease or condition from which the likelihood of death is probable unless the course of the disease or condition is interrupted.
(17) “Limited health care service plan” means a plan:
(A) under which a person undertakes to provide, arrange for, pay for, or reimburse any part of the cost of limited health care services; and
(B) that consists in part of providing or arranging for limited health care services on a prepaid basis through insurance or otherwise, as distinguished from indemnifying for the cost of limited health care services.
(18) “Limited health care services” means:
(A) services for mental health, chemical dependency, or intellectual disability, or any combination of those services; or
(B) an organized long-term care service delivery system that provides for diagnostic, preventive, therapeutic, rehabilitative, and personal care services required by an individual with a loss in functional capacity on a long-term basis.
(19) “Medical care” means the provision of those services defined as practicing medicine under § 151.002, Occupations Code.
(20) “Net worth” means the amount by which total liabilities, excluding liability for subordinated debt issued in compliance with Chapter 427, is exceeded by total admitted assets.
(21) “Person” means any natural or artificial person, including an individual, partnership, association, corporation, organization, trust, hospital district, community mental health center, intellectual disability center, mental health center, limited liability company, or limited liability partnership or the statewide rural health care system under Chapter 845.
(22) “Physician” means:
(A) an individual licensed to practice medicine in this state;
(B) a professional association organized under the Texas Professional Association Act (Article 1528f, Vernon’s Texas Civil Statutes);
(C) an approved nonprofit health corporation certified under Chapter 162, Occupations Code;
(D) a medical school or medical and dental unit, as defined or described by § 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 person wholly owned by physicians.
(23) “Prospective enrollee” means:
(A) an individual eligible to enroll in a health maintenance organization purchased through a group of which the individual is a member; or
(B) for an individual who is not a member of a group or whose group has not purchased or does not intend to purchase a health maintenance organization’s health care plan, an individual who has expressed an interest in purchasing individual health maintenance organization coverage and is eligible for coverage by a health maintenance organization.
(24) “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 chiropractor, registered nurse, pharmacist, optometrist, or acupuncturist; 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.
(25) “Single health care service” means a health care service:
(A) that an enrolled population may reasonably need to be maintained in good health with respect to a particular health care need to prevent, alleviate, cure, or heal human illness or injury of a single specified nature; and
(B) that is provided by one or more persons licensed or otherwise authorized by the state to provide that service.
(26) “Single health care service plan” means a plan:
(A) under which a person undertakes to provide, arrange for, pay for, or reimburse any part of the cost of a single health care service;
(B) that consists in part of providing or arranging for the single health care service on a prepaid basis through insurance or otherwise, as distinguished from indemnifying for the cost of that service; and
(C) that does not include arranging for the provision of more than one health care need of a single specified nature.
(27) “Sponsoring organization” means a person who guarantees the uncovered expenses of a health maintenance organization and who is financially capable, as determined by the commissioner, of meeting the obligations resulting from that guarantee.
(28) “Uncovered expenses” means the estimated amount of administrative expenses and the estimated cost of health care services that are not guaranteed, insured, or assumed by a person other than the health maintenance organization. The term does not include the cost of health care services if the physician or provider agrees in writing that an enrollee is not liable, assessable, or in any way subject to making payment for the services except as described in the evidence of coverage issued to the enrollee under Chapter 1271. The term includes any amount due on loans in the next calendar year unless the amount is specifically subordinated to uncovered medical and health care expenses or the amount is guaranteed by a sponsoring organization.
(29) “Uncovered liabilities” means obligations resulting from unpaid uncovered expenses, the outstanding indebtedness of loans that are not specifically subordinated to uncovered medical and health care expenses or guaranteed by the sponsoring organization, and all other monetary obligations that are not similarly subordinated or guaranteed.
(30) “Delegated entity” means an entity, other than a health maintenance organization authorized to engage in business under this chapter, that by itself, or through subcontracts with one or more entities, undertakes to arrange for or provide medical care or health care to an enrollee in exchange for a predetermined payment on a prospective basis and that accepts responsibility for performing on behalf of the health maintenance organization a function regulated by this chapter, § 1367.053, Subchapter A, Chapter 1452, Subchapter B, Chapter 1507, Chapter 222, 251, or 258, as applicable to a health maintenance organization, or Chapter 1271 or 1272. The term does not include:
(A) an individual physician; or
(B) a group of employed physicians, practicing medicine under one federal tax identification number, whose total claims paid to providers not employed by the group constitute less than 20 percent of the group’s total collected revenue computed on a calendar year basis.
(31) “Limited provider network” means a subnetwork within a health maintenance organization delivery network in which contractual relationships exist between physicians, certain providers, independent physician associations, or physician groups that limits an enrollee’s access to physicians and providers to those physicians and providers in the subnetwork.