Texas Register, Volume 20, Number 59, Pages 5959-6041, August 8, 1995 Page: 5,991
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services, to be furnished by an HMO to its
enrollees; and under Health and Safety Code,
12.001, which provides the board with the
authority to adopt rules for the performance of
every duty imposed by law upon the board,
the department and the commissioner of
health.
The new sections affect the Health Mainte-
nance Organization Act, Insurance Code, Ar-
lile 20A, and Health and Safety Code,
Chapter 12.
119.1. Definitions. The following words
and terms, when used in these sections,
shall have the following meanings, unless
the context clearly indicates otherwise.
Basic health care services-Health
care services which an enrolled population
might reasonably require in order to be
maintained in good health, including, as a
minimum, emergency care, inpatient hospi-
tal and medical services, and outpatient
medical services.
Board-The Texas Board of Health.
Certified facility-A health care facil-
ity which is certified by the federal govern-
ment for participation in rendering care to
Medicare or Medicaid beneficiaries.
Commissioner-The commissioner of
insurance.
Credentials-Certificates, diplomas,
licenses or other written documentation
which establishes proof of training, educa-
tion, and experience in a field of expertise.
Department-Texas Department of
Health, 1100 West 49th Street, Austin,
Texas 78756.
Emergency care-Bona fide emer-
gency services provided after the sudden
onset of a medical condition manifesting
itself by acute symptoms of sufficient sever-
ity, including severe pain, such that the
absence of immediate medical attention
could reasonably be expected to result in:(A) placing the
health in serious jeopardy;patient's
(B) serious impairment to
bodily functions; or
(C) serious dysfunction of
any bodily organ or part.
Enrollee-An individual who is en-
rolled in a health care plan, including cov-
ered dependents.
Evidence of coverage-Any certifi-
cate, agreement, or contract issued to an
enrollee setting out the coverage to which
the enrollee is entitled.
Group hospital service corpora-
tion-A nonprofit corporation organized and
operating under the Insurance Code. Chap-
ter 20.
Health care-Prevention, mainte-
nance, rehabilitation, pharmaceutical, and
chiropractic services provided by qualified
persons other than medical care.Health care plan-Any plan whereby
any person undertakes to provide, arrange
for, pay for, or reimburse any part of the
cost of any health care services; provided,
however, a part of such' plan consists of
arranging for or the provision of health care
services, as distinguished from indemnifica-
tion against the cost of such service, on a
pre-paid basis through insurance or other-
wise.
Health care services-Any services,
including the furnishing to any individual of
pharmaceutical services, medical, chiro-
practic, or dental care, or hospitalization or
incident to the furnishing of such services,
care, or hospitalization, as well as the fur-
nishing to any person of any and all other
services for the purpose of preventing, alle-
viating, curing or healing human illness or
injury or a single health care plan.
Health maintenance organization
(HMO)-Any person who arranges for or
provides a health care plan or single health
care service plan to enrollees on a prepaid
basis.
Inpatient medical care-Includes, but
is not limited to, medical and surgical care
received in a hospital or skilled nursing
home environment.
Medical care-Furnishing those ser-
vices defined as practicing medicine under
the medical Practice Act, 1.03(8), Texas
Civil Statutes, Article 4495b.
Outpatient services-Services which
may be rendered in, but are not limited to,
clinics, private offices, hospital based out-
patient departments, home health services,
ambulatory surgical centers, hospices and
kidney dialysis centers.
Person-A natural or artificial per-
son, including, but not limited to, individu-
als, partnerships, associations,
organizations, trusts, hospital districts or
corporations.
Physician-An individual who is li-
censed to practice medicine in the State of
Texas.
Primary hospitals-General hospitals
which are equipped and staffed to handle
the medical needs of an HMO's enrolled
population.
Provider-Any practitioner other than
a physician, such as a licensed doctor of
chiropractic, registered nurse, pharmacist,
optometrist, pharmacy, hospital, or other in-
stitution or organization or person that
furnishes health care services, who is li-
censed or otherwise authorized to practice
in this state.
Referral hospitals-Referral hospitals
are primary hospitals which also are
equipped and staffed to provide intensive
medical and surgical care.
Referral specialists (other than pri-
mary care) -Specialists who set themselves
apart from the primary care physician or
primary single service provider through spe-
cialized training and education in a health
care discipline.Single health care service-A health
care service that an enrolled population may
reasonably require in order to be maintained
in good health with respect to a particular
health care need for the purpose of prevent-
ing, alleviating, curing, or healing human
illness or injury of a single specified nature
and that is to be provided by one or more
persons each of whom is licensed by the
state to provide that specific health care
service.
Single health care service plan-A
plan under which any person undertakes to
provide, arrange for, pay for, or reimburse
any part of the cost of a single health care
service, provided, that a part of the plan
consists of arranging for or the provision of
the single health care service, as distin-
guished from an indemnification against the
cost of the service, on a prepaid basis
through insurance or otherwise and that no
part of that plan consists of arranging for
the provision of more than one health care
need of a single specified nature.
Sponsoring organization-A person
who guarantees the uncovered expenses of
the health maintenance organization and
who is financially capable, as determined
by the commissioner, of meeting obliga-
tions resulting from those guarantees.
Uncovered expenses-The estimated
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 organiza-
tion. Health care services may be consid-
ered covered if the physician or provider
agrees in writing that enrollees shall in no
way be liable, assessable, or in any way
subject to payment for services except as
described in the evidence of coverage is-
sued to the enrollee under the Texas Civil
Statutes. Insurance Code, Article 20A. 9.
The amount due on loans in the next calen-
dar year will be considered uncovered ex-
penses unless specifically subordinated to
uncovered medical and health care expenses
or unless guaranteed by the sponsoring or-
ganization.
Uncovered liabilities-Obligations re-
sulting from unpaid uncovered expenses,
the outstanding indebtedness of loans that
are not specifically subordinated to uncov-
ered medical and health care expenses or
guaranteed by the sponsoring organization,
and all other monetary obligations that are
not similarly subordinated or guaranteed.
119.2. Examinations Prior to Issuance of
Certificate of Authority. The Texas De-
partment of Health (department) shall con-
duct a qualifying examination of an
applicant prior to the issuance of a certifi-
cate of authority by the Texas Department
of Insurance in accordance with Title 28,
Texas Administrative Code, 11.201-
11.208. The qualifying examination shall
include a review of the following docu-* PROPOSED RULES August 8, 1995 20 TexReg 5991
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Texas. Secretary of State. Texas Register, Volume 20, Number 59, Pages 5959-6041, August 8, 1995, periodical, August 8, 1995; Austin, Texas. (https://texashistory.unt.edu/ark:/67531/metapth176798/m1/33/?q=%22~1~1~1%22~1&rotate=270: accessed July 16, 2024), University of North Texas Libraries, The Portal to Texas History, https://texashistory.unt.edu.; crediting UNT Libraries Government Documents Department.