SECTION 354.2302. Definitions

The following words and terms, when used in this subchapter, have the following meanings unless the context clearly indicates otherwise.

(1) Applicant--An individual, or the parent or legal guardian of an individual, who has applied to HHSC or another agency of the state for medical assistance from the Medicaid program.

(2) Capitation payment--A fixed predetermined fee paid to the MCO each month, in accordance with the contract, for each enrolled member in exchange for which the MCO arranges for or provides a defined set of covered services to the member, regardless of the amount of covered services used by the enrolled member.

(3) Coinsurance--A term used to describe the percentage of money an individual is responsible for paying toward health care items or services covered by a health insurer.

(4) Copayment--A set amount of money an individual is required to pay for health care items or services covered by a health insurer.

(5) Deductible--The amount of money an individual is required to pay for health care items or services before the individual's health insurer begins paying for health care items or services.

(6) Designee--An entity to which HHSC has delegated certain functions. A designee may include:

(A) an HHSC contractor;

(B) a health and human services agency; or

(C) a managed care organization (MCO) that contracts with HHSC under Medicaid or CHIP.

(7) Dual Eligible--A recipient who has received, or is eligible to receive, benefits under both the Medicare and Medicaid programs.

(8) Executive Commissioner--The Executive Commissioner of Texas Health and Human Services Commission.

(9) HHSC--The Texas Health and Human Services Commission, or its designee.

(10) Managed care organization (MCO)--A dental MCO or a health care MCO.

(11) Medicaid--The medical assistance program authorized by Title XIX of the Social Security Act, including Medicaid waiver programs.

(12) Medicaid benefits--Includes a range of health care and related services or items provided to certain groups of Medicaid recipients depending on the type of coverage needed and where the individual lives.

(13) Provider--Any individual or entity enrolled with the Medicaid program to provide services to Medicaid recipients for which claims for payment are submitted to HHSC.

(14) Recipient--A person receiving benefits under Medicaid or CHIP.

(15) State Plan--The comprehensive written statement submitted by the single state agency describing the nature and scope of the Medicaid program and giving assurances that the Medicaid program will be administered in compliance with Title XIX requirements and federal regulations.

(16) Third party health insurer--A health insurer or other person or arrangement that is legally responsible by state or federal law or private agreement to pay some or all claims for health care items or services provided to an individual, including self-insured plans, group health plans (as defined in section 607(1) of the Employee Retirement Income Security Act of 1974), service benefit plans, managed care organizations, and pharmacy benefit managers.

(17) Third party resource--Any person, entity, or program, including a third party health insurer, that is or may be liable to pay all or part of the expenditures for medical assistance furnished under the State Plan.

(18) Title IV-D agency--The Office of the Attorney General, the agency in the State of Texas with the responsibility for administering or supervising the administration of the State Plan for child support enforcement under Title IV-D of the Social Security Act.

Source Note: The provisions of this §354.2302 adopted to be effective April 30, 1999, 24 TexReg 3083; amended to be effective June 28, 2000, 25 TexReg 6137; transferred effective September 1, 2001, as published in the Texas Register May 24, 2002, 27 TexReg 4562; amended to be effective March 28, 2004, 29 TexReg 2867; amended to be effective February 22, 2024, 49 TexReg 855