Texas Insurance Code

§ 843.002 — DEFINITIONS

IN § 843.002Title 6. ORGANIZATION OF INSURERS AND RELATED ENTITIES · Part C. LIFE, HEALTH, AND ACCIDENT INSURERS AND RELATED ENTITIES · Ch. 843. HEALTH MAINTENANCE ORGANIZATIONS · Art. A. GENERAL PROVISIONS

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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.

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Legislative history

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.