28 Tex. Admin. Code § 3.3002 - Definitions

(a) Unless otherwise provided by law or this subchapter, every individual accident and sickness insurance policy or subscriber contract that is subject to the provisions of this subchapter and that is delivered, issued for delivery or renewed on or after the effective date of this subchapter must comply with and contain definitions in conformance with those in subsection (b) of this subchapter.

(b) The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise:

(1) Aggregate period--Cumulative total of all time covered under creditable coverage without a significant break in coverage.

(2) Church plan--A plan within the meaning of §3(33) of the Employee Retirement and Income Security Act of 1974, codified at 29 USC 1001, et seq. (ERISA).

(3) Commissioner--The commissioner of insurance of the State of Texas.

(4) Creditable coverage--As used in this subchapter, is defined as stated in § 21.1101 of this title (relating to Definitions) of Chapter 21, Subchapter K of this title (relating to Certification of Creditable Coverage).

(5) Department--The Texas Department of Insurance.

(6) Excepted benefits--

(A) Under all circumstances:

(i) Coverage only for accident, including accidental death and dismemberment, such as coverage offered in accordance with § 3.3076 of this title (relating to Minimum Standards for Accident Only Coverage);

(ii) Disability income insurance, including coverage offered in accordance with § 3.3075 of this title (relating to Minimum Standards for Disability Income Protection Coverage);

(iii) Coverage for on-site medical clinics; and

(iv) Short-term limited duration coverage.

(B) Only if the benefits are provided under a separate policy or contract of insurance:

(i) Dental or vision benefits that are limited in scope to a narrow range or type of benefits and that are generally excluded from policies that combine hospital, medical, or surgical benefits.

(ii) Coverage only for a specified disease or illness (for example, cancer policies), or hospital indemnity or other fixed indemnity insurance (for example, "Hospital Confinement Indemnity Coverage," as defined in § 3.3073 of this title (relating to Minimum Standards for Hospital Confinement Indemnity Coverage), provided that:

(I) there is no coordination between the provision of benefits and benefits provided under any other policy; and

(II) benefits are paid with respect to a covered event regardless of whether benefits are provided with respect to the same event under any other policy;

(iii) coverage supplemental to the coverage provided under Chapter 55, Title 10, United States Code (also known as CHAMPUS supplemental programs) and similar coverage supplemental to coverage under a group health plan.

(7) Genetic information--Information derived from the results of a genetic test.

(8) Genetic test--A laboratory test of an individual's deoxyribonucleic acid (DNA), ribonucleic acid (RNA), proteins, or chromosomes to identify by analysis the genetic mutations or alterations in the DNA, RNA, proteins, or chromosomes that are associated with a predisposition for a clinically recognized disease or disorder. The term does not include:

(A) a routine physical examination or a routine test performed as a part of a physical examination;

(B) a chemical, blood or urine analysis;

(C) a test to determine drug use; or

(D) a test for the presence of the human immunodeficiency virus.

(9) Governmental plan--A plan within the meaning of §3(32) of ERISA.

(10) Group health plan--An "employee welfare benefit plan," as defined in §3(1) of ERISA, to the extent that the plan provides "medical care" (as defined in this subsection, and including items and services paid for as medical care) to employees or their dependents (as defined under the terms of the plan) directly, or through insurance, reimbursement or otherwise.

(11) Health status related factors--Health status; medical condition, including both physical and mental illnesses; claims experience; receipt of health care; medical history; genetic information; evidence of insurability, including conditions arising out of acts of domestic violence; and disability.

(12) Individual hospital, medical or surgical coverage--Coverage offered in all policies, contracts, riders or endorsements subject to this subchapter, except when such coverage consists of "excepted benefits," as defined in this subsection. Individual hospital, medical or surgical coverage includes, but is not limited to, coverages described in §§ 3.3071 of this title (relating to Minimum Standards for Basic Hospital Expense Coverage), 3.3072 of this title (relating to Minimum Standards for Basic Medical-Surgical Expense Coverage) and 3.3074 of this title (relating to Minimum Standards Major Medical Expense Coverage), except when such coverages consist of short term limited duration coverage, as defined in this subsection.

(13) Insured--In regards to policies subject to this subchapter, refers to the individual policyholder, and, if applicable, any spouse or dependents covered under the policy.

(14) Insurer--For the purposes of this subchapter, any "issuer of a health benefit plan," as defined in § 21.1101 of this title (relating to Definitions) of Chapter 21, Subchapter K of this title (relating to Certification of Creditable Coverage).

(15) Medical care--Amounts paid for:

(A) The diagnosis, cure, mitigation, treatment or prevention of disease, or amounts paid for the purpose of affecting any structure or function of the body;

(B) transportation primarily for and essential to the medical care described in subparagraph (A) of this paragraph; or

(C) insurance covering medical care described in either subparagraphs (A) or (B) of this paragraph.

(16) Policy--The entire contract between the insurer and the insured, including the policy, riders, endorsements and the application, if attached.

(17) Policy of accident and sickness insurance--As used in this subchapter, includes any policy or contract providing insurance against loss resulting from sickness or from bodily injury or death by accident or both.

(18) Short-term limited duration coverage--Health insurance coverage provided under a contract with an insurer that has an expiration date specified in the contract (taking into account any extensions that may be elected by the insured without the insurer's consent) that is within 12 months of the date the contract becomes effective.

(19) Significant break in coverage--A period of more than 63 consecutive days during all of which the individual does not have any creditable coverage. A waiting period is not taken into account in determining a significant break in coverage.

(20) Simplified application form--An application form, with or without a question as to the applicant's health at the time of application, but without any questions concerning the insured's health history or medical treatment history.

(21) Waiting period--In regards to an individual who seeks and obtains individual hospital, medical and surgical coverage, the period between the date that the individual files a substantially complete application for coverage and the first day the coverage is effective.

Notes

28 Tex. Admin. Code § 3.3002

The provisions of this §3.3002 adopted to be effective January 26, 1977, 2 TexReg 159; amended to be effective December 22, 1997, 22 TexReg 12503.