§ 88.001.Definitions

Ten definitions, and one of them draws the line the whole chapter depends on.

"Health care treatment decision" means "a determination made when medical services are actually provided by the health care plan" and a decision which affects the quality of the diagnosis, care, or treatment provided to the plan's insureds or enrollees.

That separates treatment decisions from coverage decisions. Deciding what a plan pays for is a benefits determination; deciding how care is delivered when it is being delivered is a treatment decision. Only the second is within this chapter.

The distinction has carried enormous weight, because federal ERISA preemption reaches benefits determinations under employer plans and the chapter's own ERISA exclusion now says so expressly.

"Ordinary care" is defined against the entity itself — that degree of care a carrier, HMO, or managed care entity of ordinary prudence would use under the same or similar circumstances — with a separate limb for employees and agents.

"Managed care entity" is broad: any entity that delivers, administers, or assumes risk for health care services with systems to control or influence the quality, accessibility, utilization, or costs for a defined enrollee population. It excludes an employer purchasing coverage for its employees.

"Appropriate and medically necessary" is set by physicians and health care providers in accordance with the prevailing practices and standards of the medical profession and community — not by the plan.