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Texas Statutes (Last Updated: January 4, 2014) |
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INSURANCE CODE |
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Title 8. HEALTH INSURANCE AND OTHER HEALTH COVERAGES |
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Subtitle G. HEALTH COVERAGE AVAILABILITY |
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Chapter 1506. TEXAS HEALTH INSURANCE POOL |
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Subchapter A. GENERAL PROVISIONS |
Sec. 1506.001. DEFINITIONS
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In this chapter:
(1) "Board" means the board of directors of the pool.
(1-a) "Church plan" has the meaning assigned by Section 3(33), Employee Retirement Income Security Act of 1974 (29 U.S.C. Section 1002(33)).
(1-b) "Creditable coverage" means, with respect to an individual, coverage of the individual provided under any of the following:
(A) a group health plan;
(B) health insurance coverage;
(C) Part A or Part B, Title XVIII, Social Security Act (42 U.S.C. Section 1395c et seq.);
(D) Title XIX, Social Security Act (42 U.S.C. Section 1396 et seq.), other than coverage consisting solely of benefits under Section 1928 of that Act (42 U.S.C. Section 1396s);
(E) 10 U.S.C. Section 1071 et seq.;
(F) a medical care program of the Indian Health Service or a tribal organization;
(G) a state health benefits risk pool;
(H) a health benefits plan offered under 5 U.S.C. Section 8901 et seq.;
(I) a public health plan as defined in federal regulations;
(J) a health benefit plan under Section 5(e), Peace Corps Act (22 U.S.C. Section 2504(e)); or
(K) a state child health plan provided under Title XXI, Social Security Act (42 U.S.C. Section 1397aa et seq.).
(1-c) "Federally defined eligible individual" means an individual:
(A) for whom, as of the date on which the individual seeks coverage under this chapter, the aggregate period of creditable coverage is 18 months or more;
(B) whose most recent prior creditable coverage was under:
(i) a group health plan, governmental plan, or church plan; or
(ii) health insurance coverage offered in connection with a plan described by Subparagraph (i);
(C) who is not eligible for coverage under a group health plan, Part A or Part B, Title XVIII, Social Security Act (42 U.S.C. Section 1395c et seq.), or a state plan under Title XIX, Social Security Act (42 U.S.C. Section 1396 et seq.), or any successor program, and who does not have other health benefit plan coverage;
(D) with respect to whom the most recent coverage within the aggregate creditable coverage was not terminated based on a factor relating to nonpayment of premiums or fraud;
(E) who, if offered the option of continuation coverage under a continuation provision required by Title X, Consolidated Omnibus Budget Reconciliation Act of 1985 (29 U.S.C. Section 1161 et seq.) (COBRA), or under a similar state program, elected that coverage; and
(F) who has exhausted continuation coverage, if elected, under Paragraph (E).
(1-d) "Governmental plan" has the meaning assigned by Section 3(32), Employee Retirement Income Security Act of 1974 (29 U.S.C. Section 1002(32)), and includes any United States governmental plan.
(1-e) "Group health plan" means an employee welfare benefit plan as defined by Section 3(1), Employee Retirement Income Security Act of 1974 (29 U.S.C. Section 1002(1)), to the extent that the plan provides health benefit plan coverage to employees or their dependents as defined under the terms of the plan, directly or through insurance, reimbursement, or otherwise.
(2) "Health benefit arrangement" means a plan, program, contract, or other arrangement through which an employer provides health care services, other than health care services covered through a health benefit plan issuer, to the employer's officers, employees, or other personnel.
(3) "Health benefit plan issuer" means an entity that provides health benefit plan coverage in this state, including stop-loss or excess loss insurance. The term includes:
(A) an insurance company;
(B) a group hospital service corporation operating under Chapter 842;
(C) a fraternal benefit society operating under Chapter 885;
(D) a stipulated premium company operating under Chapter 884;
(E) a health maintenance organization;
(F) an approved nonprofit health corporation that holds a certificate of authority under Chapter 844;
(G) an eligible surplus lines insurer operating under Chapter 981;
(H) an insurer providing stop-loss or excess loss insurance to physicians, health care providers, or hospitals or to any benefit arrangements to the extent permitted by Section 3, Employee Retirement Income Security Act of 1974 (29 U.S.C. Section 1002); and
(I) any other entity providing a plan of health insurance or health benefits subject to state insurance regulation.
(4) "Health maintenance organization" means an entity that holds a certificate of authority to operate under Chapter 843.
(5) "Hospital" means a hospital for which a license is issued under Chapter 241, Health and Safety Code, or that is owned or operated by the federal or state government.
(6) "Physician" means a person licensed to practice medicine in this state under Subtitle B, Title 3, Occupations Code.
(7) "Pool" means the Texas Health Insurance Pool.
(8) "Significant break in coverage" means a period of 63 consecutive days during all of which the individual does not have health benefit plan coverage, except that a waiting period or an affiliation period is not considered in determining a significant break in coverage.