Section 26.4 - DefinitionsThe following terms, when used in Subchapters A, C, and D of this chapter, have the following meanings unless the context clearly indicates otherwise.
(1) Affiliation period--As defined in Insurance Code § 1501.104 (concerning Affiliation Period).(2) Agent--A person who may act as an agent for the sale of a health benefit plan under a license issued by TDI.(3) Base premium rate--As defined in Insurance Code § 1501.201 (concerning Definitions).(4) Case characteristics--As defined in Insurance Code § 1501.201.(5) Child-- (A) An unmarried natural child of the employee, including a newborn child;(B) An unmarried adopted child, including a child about whom the insured employee is a party in a suit seeking the adoption of the child;(C) An unmarried natural child or adopted child of the employee's spouse including a child about whom the spouse is a party in a suit seeking the adoption of the child; and(D) Any other child included as an eligible dependent under an employer's benefit plan.(6) Class of business--As defined in Insurance Code § 1501.201.(7) Commissioner--The commissioner of insurance.(8) Consumer choice health benefit plan--A health benefit plan authorized by Insurance Code Chapter 1507 (concerning Consumer Choice of Benefits Plans).(9) Creditable coverage--As defined in Insurance Code § 1205.004 (concerning Creditable Coverage).(10) Dependent--As defined in Insurance Code § 1501.002 (concerning Definitions).(11) Effective date--The first day of coverage under a health benefit plan or, if there is a waiting period, the first day of the waiting period.(12) Eligible dependent--A dependent who meets the requirements for coverage under a small or large employer health benefit plan.(13) Eligible employee--As defined in Insurance Code § 1501.002.(14) Employee--As defined in Insurance Code § 1501.002.(15) Franchise insurance policy--An individual health benefit plan under which a number of individual policies are offered to a selected group of a small or large employer. The rates for the policy may differ from the rate applicable to individually solicited policies of the same type and may differ from the rate applicable to individuals of essentially the same class.(16) Genetic information--As defined in Insurance Code § 546.001 (concerning Definitions).(17) Genetic test--As defined in Insurance Code § 546.001.(18) Gross premiums--The total amount of money collected by the health carrier for health benefit plans during the applicable calendar year or the applicable calendar quarter, including premiums collected: (A) for individual and group health benefit plans issued to employers or their employees; and(B) under certificates issued or delivered to Texas employees of employers, regardless of where the policy is issued or delivered.(19) HMO--Any person governed by the Texas Health Maintenance Organization Act, Insurance Code Chapter 843 (concerning Health Maintenance Organizations), including: (A) a person defined as a health maintenance organization under the Texas Health Maintenance Organization Act;(B) an approved nonprofit health corporation that is certified under Occupations Code § 162.001 (concerning Certification by Board), and that holds a certificate of authority issued by the commissioner under Insurance Code Chapter 844 (concerning Certification of Certain Nonprofit Health Corporations);(C) a statewide rural health care system under Insurance Code Chapter 845 (concerning Statewide Rural Health Care System) that holds a certificate of authority issued by the commissioner; or(D) a nonprofit corporation created and operated by a community center under Health and Safety Code Chapter 534, Subchapter C (concerning Health Maintenance Organizations).(20) Health benefit plan--As defined in Insurance Code § 1501.002.(21) Health carrier--Any entity authorized under the Insurance Code or another insurance law of this state that provides health insurance or health benefits in this state including an insurance company, a group hospital service corporation under Insurance Code Chapter 842 (concerning Group Hospital Service Corporations), an HMO under Insurance Code Chapter 843, or a stipulated premium company under Insurance Code Chapter 884 (concerning Stipulated Premium Insurance Companies).(22) Health insurance coverage--Benefits consisting of medical care (provided directly, through insurance or reimbursement, or otherwise) under any hospital or medical service policy or certificate, hospital or medical service plan contract, or HMO contract.(23) Health-status-related factor--Health status; medical condition, including both physical and mental illnesses; claims experience; receipt of health care; medical history; genetic information; disability; and evidence of insurability, including conditions arising out of acts of domestic violence and tobacco use.(24) Index rate--As defined in Insurance Code § 1501.201.(25) Large employer--As defined in Insurance Code § 1501.002.(26) Large employer carrier--A health carrier, to the extent that carrier is offering, delivering, issuing for delivery, or renewing health benefit plans subject to Insurance Code Chapter 1501 (concerning Health Insurance Portability and Availability Act).(27) Large employer health benefit plan--As defined in Insurance Code § 1501.002.(28) Late enrollee-- (A) Any employee or dependent eligible for enrollment who:(i) requests enrollment in a small or large employer's health benefit plan after the expiration of the initial enrollment period established under the terms of the first plan for which that employee or dependent was eligible through the small or large employer, or after the expiration of an open enrollment period under Insurance Code § 1501.156(a) (concerning Employee Enrollment; Waiting Period) and §1501.606(a) (concerning Employee Enrollment; Waiting Period);(ii) does not fall within the exceptions listed in subparagraph (B) of this paragraph; and(iii) is accepted for enrollment and not excluded until the next open enrollment period.(B) An employee or dependent eligible for and requesting enrollment cannot be excluded until the next open enrollment period and, when enrolled, is not a late enrollee, in the following special circumstances: (i) the individual: (I) was covered under another health benefit plan or self-funded employer health benefit plan at the time the individual was eligible to enroll;(II) declines in writing, at the time of initial eligibility, stating that coverage under another health benefit plan or self-funded employer health benefit plan was the reason for declining enrollment;(III) has lost coverage under another health benefit plan or self-funded employer health benefit plan as a result of termination of employment, reduction in the number of hours of employment, termination of the other plan's coverage, termination of contributions toward the premium made by the employer, death of a spouse, or divorce; and(IV) requests enrollment not later than the 31st day after the date on which coverage under the other health benefit plan or self-funded employer health benefit plan terminates;(ii) the individual is employed by an employer who offers multiple health benefit plans and the individual elects a different health benefit plan during an open enrollment period;(iii) a court has ordered coverage to be provided for a spouse under a covered employee's plan and the request for enrollment is made not later than the 31st day after the date on which the court order is issued;(iv) a court has ordered coverage to be provided for a child under an insured's plan and the request for enrollment is made not later than the 31st day after the date on which the employer receives the court order or notification of the court order;(v) the individual is a child of an insured and has lost coverage under Health and Safety Code Chapter 62 (concerning Child Health Plan for Certain Low-Income Children) or Title XIX of the Social Security Act (42 U.S.C. §§ 1396, et seq., concerning Medicaid and CHIP Payment and Access Commission), other than coverage consisting solely of benefits under Section 1928 of that Act (42 U.S.C. § 1396s, concerning Program for Distribution of Pediatric Vaccines);(vi) the individual has a change in family composition due to marriage, birth of a child, adoption of a child, or because an insured becomes a party in a suit for the adoption of a child;(vii) an individual becomes a dependent due to marriage, birth of a child, adoption of a child, or because an insured becomes a party in a suit for the adoption of a child; and(viii) the individual described in clauses (v) - (vii) of this subparagraph requests enrollment no later than the 31st day after the date of the marriage, birth, adoption of the child, loss of the child's coverage, or within 31 days of the date an insured becomes a party in a suit for the adoption of a child.(29) Limited scope dental or vision benefits--Dental or vision benefits that are sold under a separate policy or rider and that are limited in scope to a narrow range or type of benefits that are generally excluded from hospital, medical, or surgical benefits contracts.(30) Medical care--Amounts paid for:(A) the diagnosis, cure, mitigation, treatment, or prevention of disease, or amounts paid for the purpose of affecting any structure or function of the body;(B) transportation primarily for and essential to the medical care described in subparagraph (A) of this paragraph; or(C) insurance covering medical care described in either subparagraph (A) or (B) of this paragraph.(31) Medical condition--Any physical or mental condition including, but not limited to, any condition resulting from illness, injury (whether or not the injury is accidental), pregnancy, or congenital malformation. Genetic information does not constitute a medical condition in the absence of a diagnosis of a condition related to the information.(32) New business premium rate--As defined in Insurance Code § 1501.201.(33) New entrant--An eligible employee, or the dependent of an eligible employee, who becomes eligible for coverage in an employer group after the initial period for enrollment in a health benefit plan. After the initial enrollment period, this includes any employee or dependent who becomes eligible for coverage and who is not a late enrollee.(34) Participation criteria--As defined in Insurance Code § 1501.601 (concerning Participation Criteria).(35) Person--As defined in Insurance Code § 1501.002.(36) Plan year--For purposes of Insurance Code Chapter 1501 and this chapter, a 365-day period that begins on the plan or policy's effective date or a period of one full calendar year, under a health benefit plan providing coverage to small or large employers and their employees, as defined in the plan or policy. Health carriers must use the same definition of plan year in all small or large employer health benefit plans.(37) Point-of-service coverage--Coverage provided under a point-of-service plan as described in § 21.2901 of this title (relating to Definitions) and as permitted by Insurance Code § 1501.255 (concerning Health Maintenance Organization Plans).(38) Point-of-service option--Coverage that complies with the out-of-plan coverage set forth in either Chapter 11, Subchapter Z of this title (relating to Point-of-Service Riders), or Chapter 21, Subchapter U of this title (relating to Arrangements Between Indemnity Carriers and HMOs for Point-of-Service Coverage), and that allows the enrollee to access out-of-plan coverage at the option of the enrollee.(39) Point-of-service plan--As defined in Insurance Code § 1273.051 (concerning Definitions).(40) Postmark--A date stamp by the U.S. Postal Service or other delivery entity, including any electronic delivery available.(41) Preexisting condition provision--As defined in Insurance Code § 1501.002.(42) Premium--As defined in Insurance Code § 1501.002.(43) Premium rate quote--A statement of the premium a health carrier offers and will accept to make coverage effective for a small or large employer.(44) Public health plan--Any plan established or maintained by a state, county, or other political subdivision of a state that provides health insurance coverage to individuals.(45) Qualified actuary--An actuary who is a member: (A) of the Society of Actuaries; and(B) in good standing of the American Academy of Actuaries.(46) Rating period--As defined in Insurance Code § 1501.201.(47) Reinsured carrier--A small employer carrier participating in the Texas Health Reinsurance System.(48) Renewal date--For each small or large employer's health benefit plan, the earlier of the date, if any, specified in the plan for renewal; the policy anniversary date; or the date the small or large employer's plan is changed. To determine the renewal date for employer association or multiple employer trust group health benefit plans, health carriers may use the date specified for renewal, or the policy anniversary date, of either the master contract or the contract or certificate of coverage of each small or large employer in the association or trust. Health carriers must use the same method of determining renewal dates for all small or large employer health benefit plans. A change in the premium rate is not considered a renewal if the change is due solely: (A) to the addition or deletion of an employee or dependent if the deletion is due to a request by the employee, death or retirement of the employee or dependent, termination of employment of the employee, or because a dependent is no longer eligible; or(B) to fraud or intentional misrepresentation of a material fact by a small or large employer or an eligible employee or dependent.(49) Risk-assuming carrier--A risk-assuming health benefit plan issuer as defined in Insurance Code § 1501.301 (concerning Definitions).(50) Risk characteristic--The health-status-related factors, duration of coverage, or any similar characteristic, except genetic information, related to the health status or experience of a small employer group or of any member of that group.(51) Risk load--The percentage above the applicable base premium rate that is charged by a small employer carrier to a small employer to reflect the risk characteristics of that group. A small employer carrier may not use genetic information to alter or otherwise affect risk load.(52) Short-term limited duration insurance--Health insurance coverage provided under a contract with an issuer that:(A) has an expiration date specified in the contract, taking into account any extensions that may be elected by the policyholder without the issuer's consent; and(B) is within 12 months of the date the contract becomes effective.(53) Significant break in coverage--A period of 63 consecutive days during which the individual does not have creditable coverage. Neither a waiting period nor an affiliation period is counted in determining a significant break in coverage.(54) Small employer--As defined in Insurance Code § 1501.002. A small employer includes an independent school district that elects to participate in the small employer market under Insurance Code § 1501.009 (concerning School District Election).(55) Small employer carrier--A health carrier, to the extent that health carrier is offering, delivering, issuing for delivery, or renewing, under Insurance Code § 1501.003 (concerning Applicability: Small Employer Health Benefit Plans), health benefit plans subject to Insurance Code Chapter 1501.(56) Small employer health benefit plan--As defined in Insurance Code § 1501.002.(57) State-mandated health benefits--As defined in § 21.3502 of this title (relating to Definitions).(58) TDI--The Texas Department of Insurance.(59) Waiting period--As defined in Insurance Code § 1501.002. If an employee or dependent enrolls as a late enrollee, under special circumstances that except the employee or dependent from the definition of late enrollee, or during an open enrollment period, any period of eligibility before the effective date of enrollment is not a waiting period.28 Tex. Admin. Code § 26.4
The provisions of this §26.4 adopted to be effective December 30, 1993, 18 TexReg 9375; amended to be effective April 9, 1996, 21 TexReg 2648; amended to be effective March 5, 1998, 23 TexReg 2297; amended to be effective July 10, 2001, 26 TexReg 5016; amended to be effective April 6, 2005, 30 TexReg 1931; Amended by Texas Register, Volume 42, Number 19, May 12, 2017, TexReg 2546, eff. 5/17/2017