Section 11.2602 - DefinitionsThe following words and terms, when used in this subchapter, have the following meanings, unless the context clearly indicates otherwise.
(1) Delegated entity--An entity, other than an HMO authorized to do business under Insurance Code Chapter 843 (concerning Health Maintenance Organizations) and Chapter 1272 (concerning to Delegation of Certain Functions by Health Maintenance Organization) and other applicable insurance laws and regulations of this state, that by itself, or through subcontracts with one or more entities, undertakes to arrange for or to provide medical care or health care to an enrollee in exchange for a predetermined payment on a prospective basis and that accepts responsibility to perform on behalf of the HMO any function regulated by Insurance Code Chapter 843 and Chapter 1272 and other applicable insurance laws and regulations of this state. The term does not include an individual physician or a group of employed physicians practicing medicine under one federal tax identification number and whose total claims paid to physicians and providers not employed by the group is less than 20 percent of the total collected revenue of the group calculated on a calendar-year basis.(2) Delegated network--Any delegated entity that assumes total financial risk for more than one of the following categories of health care services: medical care, hospital or other institutional services, or prescription drugs, as defined by Occupations Code § 551.003 (concerning Definitions). The term does not include a delegated entity that shares risk for a category of services with an HMO.(3) Delegated third party--A third party other than a delegated entity that contracts with a delegated entity, either directly or through another third party, to: (A) accept responsibility to perform any function regulated by Insurance Code Chapter 843 and Chapter 1272 and other applicable insurance laws and regulations of this state; or(B) receive, handle, or administer funds, if the receipt, handling, or administration of the funds is directly or indirectly related to a function regulated by Insurance Code Chapter 843 and Chapter 1272 and other applicable insurance laws and regulations of this state.(4) Health care--Any services, including the furnishing to any individual of pharmaceutical services, medical, chiropractic, dental care, hospitalization, or incident to the furnishing of the services, care or hospitalization, as well as the furnishing to any person of any and all other services for the purpose of preventing, alleviating, curing, or healing human illness or injury.28 Tex. Admin. Code § 11.2602
The provisions of this §11.2602 adopted to be effective October 13, 2002, 27 TexReg 9585; amended to be effective February 24, 2005, 30 TexReg 854; amended to be effective November 15, 2006, 31 TexReg 9298; Adopted by Texas Register, Volume 42, Number 16, April 21, 2017, TexReg 2266, eff. 8/1/2017