The following words and terms, when used in this subchapter, shall
have the following meanings, unless the context clearly indicates otherwise.
(1) Corresponding benefits--Benefits provided under the indemnity
portion of a point-of-service (POS) plan, as defined in Articles 3.64(a)(4)
and 20A.02(bb) of the Code, that conform to the nature and kind of coverage
provided to an enrollee under the HMO portion of a point-of-service plan.
(2) Cost containment requirements--Provisions in POS indemnity
coverage requiring a specific action, such as the provision of specified information
to the plan, that must be taken by an enrollee or by a physician or a provider
on behalf of the enrollee in order to avoid the imposition of a specified
penalty on the coverage provided under the plan for a proposed service or
(3) In-plan covered services--Health care services, benefits,
and supplies to which an enrollee is entitled under the evidence of coverage
issued by an HMO, including emergency services, approved out-of-network services
and other authorized referrals.
(4) Non-participating physicians and providers--Physicians
and providers that are not part of an HMO delivery network.
(5) Out-of-plan covered benefits--All covered health care services,
benefits, and supplies that are not in-plan covered services. Out-of-plan
covered benefits include health care services, benefits and supplies obtained
from participating physicians and providers under circumstances in which the
enrollee fails to comply with the HMO's requirements for obtaining in-plan
(6) Participating physicians and providers--Physicians and
providers that are part of an HMO delivery network.
(7) Point-of-service blended contract plan (POS blended contract
plan)--A POS plan evidenced by a single contract, policy, certificate or evidence
of coverage that provides a combination of indemnity benefits for which an
indemnity carrier is at risk and services are provided by an HMO under a POS
(8) Point-of-service coverage (POS coverage)--Coverage provided
under a POS plan.
(9) Point-of-service dual contracts plan (POS dual contracts
plan)--A POS plan providing a combination of indemnity benefits and HMO services
through separate contracts, one being the contract, policy or certificate
offered by an indemnity carrier for which the indemnity carrier is at risk
and the other being the evidence of coverage offered by the HMO.
(10) Point-of-service HMO coverage (POS HMO coverage)--Services
provided by an HMO in an evidence of coverage under a POS plan.
(11) Point-of-service indemnity coverage (POS indemnity coverage)--Coverage
for which an indemnity carrier is at risk under a POS plan for self-referred
health care services, benefits and supplies, other than emergency services,
selected at the option of the enrollee, from non-participating physicians
or providers, as well as services, benefits and supplies from participating
physicians or providers under circumstances in which the enrollee fails to
comply with the requirements of the HMO providing the POS HMO coverage under
a POS plan for obtaining in-plan covered services.