Section 21.2102 - DefinitionsThe 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: (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.28 Tex. Admin. Code § 21.2102
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 by Texas Register, Volume 41, Number 44, October 28, 2016, TexReg 8610, eff. 11/2/2016