Tex. Ins. Code Section 843.002
Definitions


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 Section 843.261 (Special Provisions for Appeals of Adverse Determinations), 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 (Freestanding Emergency Medical Care Facilities), Health and Safety Code.

(10)

“Group hospital service corporation” means a corporation operating under Chapter 842 (Group Hospital Service Corporations).

(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 Section 151.002 (Definitions), Occupations Code.

(20)

“Net worth” means the amount by which total liabilities, excluding liability for subordinated debt issued in compliance with Chapter 427 (Subordinated Indebtedness), 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 (Statewide Rural Health Care System).

(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 (Regulation of Practice of Medicine), Occupations Code;

(D)

a medical school or medical and dental unit, as defined or described by Section 61.003 (Definitions), 61.501 (Definitions), or 74.601 (Use and Control), 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 (Benefits Provided by Health Maintenance Organizations; Evidence of Coverage; Charges). 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, Section 1367.053 (Coverage Required), Subchapter A (Applicability of Certain Definitions), Chapter 1452 (Physician and Provider Credentials), Subchapter B, Chapter 1507 (Consumer Choice of Benefits Plans), Chapter 222 (Life, Health, and Accident Insurance Premium Tax), 251 (General Provisions), or 258 (Health Maintenance Organizations), as applicable to a health maintenance organization, or Chapter 1271 (Benefits Provided by Health Maintenance Organizations; Evidence of Coverage; Charges) or 1272 (Delegation of Certain Functions by Health Maintenance Organization). 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.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003. Amended by Acts 2003, 78th Leg., ch. 1179, Sec. 8, eff. Sept. 1, 2003; Acts 2003, 78th Leg., ch. 1276, Sec. 10A.205(a), 10A.206, eff. Sept. 1, 2003.
Amended by:
Acts 2007, 80th Leg., R.S., Ch. 730 (H.B. 2636), Sec. 2E.029, eff. April 1, 2009.
Acts 2009, 81st Leg., R.S., Ch. 1273 (H.B. 1357), Sec. 2, eff. March 1, 2010.
Acts 2011, 82nd Leg., R.S., Ch. 798 (H.B. 2292), Sec. 1, eff. September 1, 2011.
Acts 2013, 83rd Leg., R.S., Ch. 915 (H.B. 1358), Sec. 3(1), eff. September 1, 2013.
Acts 2015, 84th Leg., R.S., Ch. 838 (S.B. 202), Sec. 3.022, eff. September 1, 2015.
Acts 2023, 88th Leg., R.S., Ch. 30 (H.B. 446), Sec. 8.01, eff. September 1, 2023.

Source: Section 843.002 — Definitions, https://statutes.­capitol.­texas.­gov/Docs/IN/htm/IN.­843.­htm#843.­002 (accessed Jun. 5, 2024).

843.001
Short Title
843.002
Definitions
843.003
Powers of Insurers and Group Hospital Service Corporations
843.004
Governing Body of Health Maintenance Organization
843.005
Use of Insurance-related Terms by Health Maintenance Organization
843.006
Public Documents
843.007
Confidentiality of Medical and Health Information
843.008
Costs of Administering Health Maintenance Organization Laws
843.009
Appeals
843.010
Applicability of Certain Provisions to Governmental Health Benefit Plans
843.051
Applicability of Insurance and Group Hospital Service Corporation Laws
843.052
Laws Relating to Solicitation or Advertising
843.053
Laws Relating to Restraint of Trade
843.054
Laws Requiring Certificate of Need for Health Care Facility or Service
843.055
Laws Relating to Practice of Medicine
843.056
Inapplicability of Bankruptcy Law
843.072
Authorization Required to Act as Health Maintenance Organization
843.073
Certificate of Authority Requirement: Applicability to Physicians and Providers
843.074
Certificate of Authority Requirement: Applicability to Medical School and Medical and Dental Unit
843.075
Certificate of Authority for Single Health Care Service Plan
843.076
Application
843.077
Eligibility of Foreign Corporation
843.078
Contents of Application
843.079
Contents of Application: Limited Health Care Service Plan
843.080
Modification or Amendment of Application Information
843.082
Requirements for Approval of Application
843.083
Denial of Certificate of Authority
843.084
Duration of Certificate of Authority
843.085
Change in Control: Commissioner Approval
843.101
Providing or Arranging for Care
843.102
Health Maintenance Organization Quality Assurance
843.103
Acquisition and Operation of Facilities
843.104
Contracts for Certain Administrative Functions
843.105
Management and Exclusive Agency Contracts
843.106
Insurance, Reinsurance, Indemnity, and Reimbursement
843.107
Indemnity Benefits
843.108
Point-of-service Rider
843.109
Payment by Governmental or Private Entity
843.110
Corporation, Partnership, or Association Powers
843.111
Group Model Health Maintenance Organizations
843.112
Dental Point-of-service Option
843.113
Specified Powers Not Exclusive
843.151
Rules
843.152
Subpoena Authority
843.153
Authority to Contract
843.154
Fees
843.155
Annual Report
843.156
Examinations
843.157
Rehabilitation, Liquidation, Supervision, or Conservation of Health Maintenance Organization
843.201
Disclosure of Information About Health Care Plan Terms
843.202
Disclosure of Information to Medicare Recipients
843.203
Selection of Primary Care Physician or Provider
843.204
Untrue or Misleading Information
843.205
Member’s Handbook
843.206
Notice of Change in Payment Arrangements
843.207
Notice of Change in Operations
843.208
Cancellation or Nonrenewal of Coverage
843.209
Identification Card
843.210
Terms of Enrollee Eligibility
843.211
Applicability of Subchapter to Entities Contracting with Health Maintenance Organization
843.251
Complaint System Required
843.252
Complaint Initiation and Initial Response
843.253
Complaint Investigation and Resolution
843.254
Appeal to Complaint Appeal Panel
843.255
Composition of Complaint Appeal Panel
843.256
Information Provided to Complainant Relating to Complaint Appeal Panel
843.257
Rights of Complainant at Complaint Appeal Panel Meeting
843.258
Appeal Involving Ongoing Emergency or Continued Hospitalization
843.259
Notice of Decision on Appeal
843.260
Record of Complaints
843.261
Special Provisions for Appeals of Adverse Determinations
843.262
Certain Decisions Binding
843.281
Retaliatory Action Prohibited
843.282
Submitting Complaints to Department
843.283
Posting of Information on Complaint Process Required
843.301
Practice of Medicine Not Affected
843.302
Disclosure of Application Procedures and Qualification Requirements to Physician or Provider
843.303
Denial of Initial Contract to Physician or Provider
843.304
Exclusion of Provider Based on Type of License Prohibited
843.305
Annual Application Period for Physicians and Providers to Contract
843.306
Termination of Participation
843.307
Expedited Review Process on Termination or Deselection
843.308
Notification of Patients of Deselected Physician or Provider
843.309
Contracts with Physicians or Providers: Notice to Certain Enrollees of Termination of Physician or Provider Participation in Plan
843.310
Contracts with Physicians or Providers: Certain Indemnity Clauses Prohibited
843.311
Contracts with Podiatrists
843.312
Physician Assistants and Advanced Practice Nurses
843.313
Economic Profiling
843.314
Inducement to Limit Medically Necessary Services Prohibited
843.315
Payment of Capitation
843.316
Alternative Capitation System
843.317
Exclusion of Physician or Provider Based on Affiliation with Health Maintenance Organization Prohibited
843.318
Certain Contracts of Participating Physician or Provider Not Prohibited
843.319
Certain Required Contracts
843.320
Use of Hospitalist
843.321
Availability of Coding Guidelines
843.323
Contract Provisions Prohibiting Rejection of Batched Claims
843.336
Definition
843.337
Time for Submission of Claim
843.338
Deadline for Action on Clean Claims
843.339
Deadline for Action on Prescription Claims
843.340
Audited Claims
843.341
Claims Processing Procedures
843.342
Violation of Certain Claims Payment Provisions
843.343
Attorney’s Fees
843.344
Applicability of Subchapter to Entities Contracting with Health Maintenance Organization
843.345
Exception
843.346
Payment of Claims
843.347
Verification
843.348
Preauthorization of Health Care Services
843.349
Coordination of Payment
843.350
Overpayment
843.351
Services Provided by Certain Physicians and Providers
843.352
Conflict with Other Law
843.353
Waiver Prohibited
843.354
Legislative Declaration
843.361
Enrollees Held Harmless
843.362
Continuity of Care
843.363
Protected Physician or Provider Communications with Patients
843.401
Fiduciary Responsibility
843.402
Officers’ and Employees’ Bond
843.403
Minimum Net Worth
843.404
Additional Net Worth Requirements
843.405
Deposit with Comptroller
843.406
Hazardous Financial Condition
843.407
Receivership and Delinquency Proceedings
843.408
Insolvency and Allocation to Other Health Maintenance Organizations
843.409
Examination Expenses
843.410
Assessments
843.461
Enforcement Actions
843.462
Operations During Suspension or After Revocation of Certificate of Authority
843.463
Injunctions
843.464
Criminal Penalty
843.2015
Information Available Through Internet Site
843.2071
Notice of Increase in Charge for Coverage
843.3041
Acupuncturist Services
843.3042
Chiropractic Services
843.3045
Nurse First Assistant
843.3115
Contracts with Dentists
843.3385
Additional Information
843.3405
Investigation and Determination of Payment
843.3481
Posting of Preauthorization Requirements
843.3482
Changes to Preauthorization Requirements
843.3483
Remedy for Noncompliance

Accessed:
Jun. 5, 2024

§ 843.002’s source at texas​.gov