The 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);
Cont'd...