28 Tex. Admin. Code § 7.1602

Current through Reg. 49, No. 43; October 25, 2024

Section 7.1602 - Definitions

The following words and terms when used in this subchapter shall have the following meanings unless the context clearly indicates otherwise.

(1) Administrator--As defined in the Insurance Code § 4151.001(1). The term includes administrator contractors and administrator subcontractors. The term does not include a person described by the Insurance Code § 4151.002 or § 4151.0021.

(2) Administrative services--Services offered or performed by an administrator.

(3) Administrator contractor--An administrator as defined in the Insurance Code § 4151.001(1) who contracts or enters into an agreement with an administrator subcontractor for the performance of all or a portion of the administrative services the administrator contractor previously agreed to perform on behalf of an insurer, HMO, plan sponsor, or group. The term does not include a person described by the Insurance Code § 4151.002 or § 4151.0021.

(4) Administrator subcontractor--An administrator as defined in the Insurance Code § 4151.001(1) who contracts or enters into an agreement with an administrator contractor for the performance of all or a portion of the administrative services the administrator contractor previously agreed to perform on behalf of an insurer, HMO, plan sponsor, or group. The term does not include a person described by the Insurance Code § 4151.002 or § 4151.0021.

(5) Authorization--A license, permit, certificate of authority, certificate of approval, certificate of registration, or other authorization issued by the department or the division of workers' compensation to engage in an activity regulated under the Insurance Code or the Labor Code.

(6) Claim--A demand for payment, services, or benefits under a plan.

(7) ERISA--The Employee Retirement Income Security Act of 1974, 29 United States Code §1001, et seq., including all implementing federal regulations.

(8) Fiduciary bank account--An account used to hold a premium.

(9) Generally Accepted Accounting Principles--As defined in § 7.85(a)(6) of this chapter (relating to Audited Financial Reports).

(10) Generally Accepted Auditing Standards--As defined in § 7.85(a)(7) of this chapter.

(11) Group--A workers' compensation self-insurance group under the Labor Code Chapter 407A.

(12) Health maintenance organization (HMO)--As defined in the Insurance Code § 843.002(14).

(13) Independent Certified Public Accountant--A person meeting the standards prescribed in the Insurance Code § 401.011(a) and (d).

(14) Insurer--As defined in the Insurance Code § 4151.001(2).

(15) Master services agreement--A written agreement between an administrator and an insurer that generally describes the administrative services to be performed by the administrator on behalf of the insurer but which also addresses additional or customized administrative services to be provided by the administrator for certain specified clients of the insurer.

(16) Person--As defined in the Insurance Code § 4151.001(3).

(17) Plan--A plan, fund, or program established, adopted, or maintained by an insurer, HMO, plan sponsor, or group to the extent that the plan, fund, or program is established, adopted, or maintained to provide:

(A) indemnification or expense reimbursement for any type of life, health, accident, or pharmacy benefit, including health care benefits, health care services, or health insurance;

(B) an individual or group annuity benefit; or

(C) workers' compensation benefits, including a medical benefit, an income benefit, a death benefit, or a burial benefit.

(18) Plan sponsor--A person, other than an insurer, HMO, or group who establishes, adopts, or maintains a plan that covers residents of this state, including a plan established, adopted, or maintained by two or more employers or jointly by one or more employers and one or more employee organizations, an association, a committee, a joint board of trustees, or any similar group of representatives who establish, adopt, or maintain a plan.

(19) Premium--A premium, contribution, return premium, or return contribution.

(20) Records--Books, accounts, records, documents, written agreements, contracts, papers, correspondence, claims files, receipts, bills, accounting and financial information, notes, pleadings, investigatory files, trading partner agreements, or any other written or electronic material directly or indirectly relating to the business of an administrator.

28 Tex. Admin. Code § 7.1602

The provisions of this §7.1602 adopted to be effective June 25, 2009, 34 TexReg 4143