SECTION 21.2102. Definitions

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

(1) Another limited benefit--A plan that provides coverage, singularly or in combination, for benefits for a specifically named disease, accident, or combination of diseases or accidents, including, but not limited to:

(A) heart attack;

(B) stroke;

(C) AIDS; or

(D) travel, farm, or occupational accident.

(2) Carrier--The term includes:

(A) an insurance company, a group hospital service corporation, a fraternal benefit society, a stipulated premium insurance company, a health maintenance organization, a multiple employer welfare arrangement that holds a certificate of authority under Insurance Code Chapter 846, or an approved nonprofit health corporation that holds a certificate of authority issued by the commissioner under Insurance Code Chapter 844;

(B) for the purposes of paragraph (4)(B) and (F) of this section, a reciprocal exchange operating under Insurance Code Chapter 942;

(C) for purposes of paragraph (4)(E) and (F) of this section, a Lloyds plan operating under Insurance Code Chapter 941; and

(D) for purposes of paragraph (4)(E) of this section, a risk pool created under Local Government Code Chapter 172.

(3) Enrollee--A person enrolled in and entitled to coverage under a health benefit plan, including covered dependents.

(4) Health Benefit Plan--Subject to subparagraphs (A), (B), (C), (D), (E), and (F) of this paragraph, a plan that is offered by a carrier and provides benefits for medical or surgical expenses incurred as a result of a health condition, accident, or sickness, including an individual, group, blanket, or franchise insurance policy or insurance agreement; a group hospital service contract; an individual or group evidence of coverage; or any similar coverage document. The term does not include a plan that provides coverage only for accidental death or dismemberment, disability income, supplement to liability insurance, Medicare supplement, workers' compensation, medical payment insurance issued as a part of a motor vehicle insurance policy, or a long-term care policy.

(A) For the inpatient mastectomy coverage notice required by §21.2103(a)(1) of this title (relating to Mandatory Benefit Notices), the definition of health benefit plan includes a plan that provides coverage only for a specific disease or condition for the treatment of breast cancer or for hospitalization. The term does not include a small employer health benefit plan issued under Insurance Code Chapter 1501, Subchapters A - H (concerning Health Insurance Portability and Availability Act).

(B) For the reconstructive surgery after mastectomy notices required by §21.2103(a)(2) of this title, the definition of health benefit plan does not include:

(i) a plan that provides coverage for a specified disease or another limited benefit, except for cancer;

(ii) a plan that provides only credit insurance;

(iii) a plan that provides coverage only for dental or vision care; or

(iv) a plan that provides coverage only for hospital indemnity or other fixed indemnity.

(C) For the prostate cancer examination notice required by §21.2103(a)(3) of this title, the definition of health benefit plan does not include:

(i) a small employer health benefit plan written under Insurance Code Chapter 1501, Subchapters A - H;

(ii) a plan that provides coverage only for a specified disease or another limited benefit; or

(iii) a plan that provides coverage only for hospital indemnity or other fixed indemnity.

(D) For the inpatient maternity and childbirth coverage notice required by §21.2103(a)(4) and (5) of this title, the definition of health benefit plan does not include:

(i) a plan that provides only credit insurance;

(ii) a plan that provides coverage only for a specified disease or another limited benefit;

(iii) a plan that provides coverage only for dental or vision care; or

(iv) a plan that provides coverage only for hospital indemnity or other fixed indemnity.

(E) For the detection of colorectal cancer screening coverage notice required by §21.2103(a)(6) of this title, the definition of health benefit plan does not include:

(i) a small employer health benefit plan written under Insurance Code Chapter 1501, Subchapters A - H;

(ii) a plan that provides coverage only for a specified disease or another limited benefit; or

(iii) a plan that provides coverage only for hospital indemnity or other fixed indemnity.

(F) For the detection of human papillomavirus and cervical cancer screening notice required by §21.2103(a)(7) of this title, the definition of health benefit plan includes a small employer health benefit plan written under Insurance Code Chapter 1501, but does not include:

(i) a plan that provides coverage only for a specified disease or another limited benefit, other than a plan that provides benefits for cancer treatment or similar services;

(ii) a plan that provides coverage only for dental or vision care;

(iii) a plan that provides coverage only for indemnity or for hospital indemnity or other fixed indemnity;

(iv) a credit insurance policy; or

(v) a limited benefit policy that does not provide coverage for physical examinations or wellness exams.

(5) Primary Enrollee--For group coverage, the covered member or employee of the group. For individual coverage, the person first named on the application or enrollment form.

Source Note: The provisions of this §21.2102 adopted to be effective March 29, 1998, 23 TexReg 3009; amended to be effective January 8, 2001, 26 TexReg 202; amended to be effective April 2, 2002, 27 TexReg 2506; amended to be effective January 19, 2006, 31 TexReg 295; amended to be effective November 2, 2016, 41 TexReg 8609