reglab/housing_qa huggingface dataset:
TX Ins Code § 1301.0058 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle D - Provider Plans|Chapter 1301 - Preferred Provider Benefit Plans|Subchapter A. General Provisions|Section 1301.0058. Protected Communications by Preferred Providers

Sec. 1301.0058.  PROTECTED COMMUNICATIONS BY PREFERRED PROVIDERS.  (a)  An insurer may not in any manner prohibit, attempt to prohibit, penalize, terminate, or otherwise restrict a preferred provider from communicating with an insured about the availability of out-of-network providers for the provision of the insured's medical or health care services.(b)  An insurer may not terminate the contract of or otherwise penalize a preferred provider solely because the provider's patients use out-of-network providers for medical or health care services.(c)  An insurer's contract with a preferred provider may require that, except in a case of a medical emergency as determined by the preferred provider, before the provider may make an out-of-network referral for an insured, the preferred provider inform the insured:(1)  that:(A)  the insured may choose a preferred provider or an out-of-network provider; and(B)  if the insured chooses the out-of-network provider the insured may incur higher out-of-pocket expenses; and(2)  whether the preferred provider has a financial interest in the out-of-network provider.|Added by Acts 2015, 84th Leg., R.S., Ch. 275 (H.B. 574), Sec. 5, eff. September 1, 2015.|
TX Ins Code § 1301.006 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle D - Provider Plans|Chapter 1301 - Preferred Provider Benefit Plans|Subchapter A. General Provisions|Section 1301.006. Availability of and Accessibility to Health Care Services

Sec. 1301.006.  AVAILABILITY OF AND ACCESSIBILITY TO HEALTH CARE SERVICES.  (a)  An insurer that markets a preferred provider benefit plan shall contract with physicians and health care providers to ensure that all medical and health care services and items contained in the package of benefits for which coverage is provided, including treatment of illnesses and injuries, will be provided under the health insurance policy in a manner ensuring availability of and accessibility to adequate personnel, specialty care, and facilities.(b)  A contract between an insurer that markets a plan regulated under this chapter and an institutional provider may not, as a condition of staff membership or privileges, require a physician or other practitioner to enter into a preferred provider contract.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.Amended by: Acts 2011, 82nd Leg., 1st C.S., Ch. 7 (S.B. 7), Sec. 10.01, eff. September 28, 2011.|
TX Ins Code § 1301.0061 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle D - Provider Plans|Chapter 1301 - Preferred Provider Benefit Plans|Subchapter A. General Provisions|Section 1301.0061. Terms of Enrollee Eligibility

Sec. 1301.0061.  TERMS OF ENROLLEE ELIGIBILITY.  (a)  A contract between an insurer and a group policyholder under a preferred provider benefit plan must provide that:(1)  in addition to any other premiums for which the group policyholder is liable, the group policyholder is liable for an individual insured's premiums from the time the individual is no longer part of the group eligible for coverage under the policy until the end of the month in which the policyholder notifies the insurer that the individual is no longer part of the group eligible for coverage under the policy; and(2)  the individual remains covered under the policy until the end of that period.(b)  Each insurer that enters into a contract described by Subsection (a) shall notify the group policyholder periodically as provided by this section that the policyholder is liable for premiums on an individual who is no longer part of the group eligible for coverage until the insurer receives notification of termination of the individual's eligibility for coverage.(c)  If the insurer charges the group policyholder on a monthly basis for the premiums, the insurer shall include the notice required by Subsection (b) in each monthly statement sent to the group policyholder.  If the insurer charges the group policyholder on other than a monthly basis for the premiums, the insurer shall notify the group policyholder periodically in the manner prescribed by the commissioner by rule.(d)  The notice required by Subsection (b) must include a description of methods preferred by the insurer for notification by a group policyholder of an individual's termination from coverage eligibility.|Added by Acts 2005, 79th Leg., Ch. 669 (S.B. 51), Sec. 1, eff. September 1, 2005.Amended by: Acts 2009, 81st Leg., R.S., Ch. 1217 (S.B. 1143), Sec. 2, eff. September 1, 2009.|
TX Ins Code § 1301.007 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle D - Provider Plans|Chapter 1301 - Preferred Provider Benefit Plans|Subchapter A. General Provisions|Section 1301.007. Rules

Sec. 1301.007.  RULES.  The commissioner shall adopt rules as necessary to:(1)  implement this chapter; and(2)  ensure reasonable accessibility and availability of preferred provider services to residents of this state.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.Amended by: Acts 2005, 79th Leg., Ch. 1221 (H.B. 1030), Sec. 2, eff. September 1, 2005.|
TX Ins Code § 1301.008 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle D - Provider Plans|Chapter 1301 - Preferred Provider Benefit Plans|Subchapter A. General Provisions|Section 1301.008. Conflict With Other Law

Sec. 1301.008.  CONFLICT WITH OTHER LAW.  To the extent of any conflict between this chapter and Subchapter C, Chapter 1204, this chapter controls.|Added by Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.037(c), eff. September 1, 2005.|
TX Ins Code § 1301.009 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle D - Provider Plans|Chapter 1301 - Preferred Provider Benefit Plans|Subchapter A. General Provisions|Section 1301.009. Annual Report

Sec. 1301.009.  ANNUAL REPORT.  (a)  Not later than March 1 of each year, an insurer shall file with the commissioner a report relating to the preferred provider benefit plan offered under this chapter and covering the preceding calendar year.(b)  The report shall:(1)  be verified by at least two principal officers;(2)  be in a form prescribed by the commissioner; and(3)  include:(A)  a financial statement of the insurer, including its balance sheet and receipts and disbursements for the preceding calendar year, certified by an independent public accountant;(B)  the number of individuals enrolled during the preceding calendar year, the number of enrollees as of the end of that year, and the number of enrollments terminated during that year; and(C)  a statement of:(i)  an evaluation of enrollee satisfaction;(ii)  an evaluation of quality of care;(iii)  coverage areas;(iv)  accreditation status;(v)  premium costs;(vi)  plan costs;(vii)  premium increases;(viii)  the range of benefits provided;(ix)  copayments and deductibles;(x)  the accuracy and speed of claims payment by the insurer for the plan;(xi)  the credentials of physicians who are preferred providers; and(xii)  the number of preferred providers.(c)  The annual report filed by the insurer shall be made publicly available on the department's website in a user-friendly format that allows consumers to make direct comparisons of the financial and other data reported by insurers under this section.(d)  An insurer providing group coverage of $10 million or less in premiums or individual coverage of $2 million or less in premiums is not required to report the data required under Subsection (b)(3)(C).|Added by Acts 2007, 80th Leg., R.S., Ch. 997 (S.B. 1731), Sec. 10, eff. September 1, 2007.|
TX Ins Code § 1301.010 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle D - Provider Plans|Chapter 1301 - Preferred Provider Benefit Plans|Subchapter A. General Provisions|Section 1301.010. Balance Billing Prohibition Notice

Sec. 1301.010.  BALANCE BILLING PROHIBITION NOTICE.  (a)  An insurer shall provide written notice in accordance with this section in an explanation of benefits provided to the insured and the physician or health care provider in connection with a medical care or health care service or supply provided by an out-of-network provider.  The notice must include:(1)  a statement of the billing prohibition under Section 1301.0053, 1301.155, 1301.164, or 1301.165, as applicable;(2)  the total amount the physician or provider may bill the insured under the insured's preferred provider benefit plan and an itemization of copayments, coinsurance, deductibles, and other amounts included in that total; and(3)  for an explanation of benefits provided to the physician or provider, information required by commissioner rule advising the physician or provider of the availability of mediation or arbitration, as applicable, under Chapter 1467.(b)  An insurer shall provide the explanation of benefits with the notice required by this section to a physician or health care provider not later than the date the insurer makes a payment under Section 1301.0053, 1301.155, 1301.164, or 1301.165, as applicable.|Added by Acts 2019, 86th Leg., R.S., Ch. 1342 (S.B. 1264), Sec. 1.07, eff. September 1, 2019.|
TX Ins Code § 1301.051 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle D - Provider Plans|Chapter 1301 - Preferred Provider Benefit Plans|Subchapter B. Relations With Physicians or Health Care Providers|Section 1301.051. Designation as Preferred Provider

Sec. 1301.051.  DESIGNATION AS PREFERRED PROVIDER.  (a)  An insurer shall afford a fair, reasonable, and equivalent opportunity to apply to be and to be designated as a preferred provider to practitioners and institutional providers and to health care providers other than practitioners and institutional providers, if those other health care providers are included by the insurer as preferred providers, provided that the practitioners, institutional providers, or health care providers:(1)  are licensed to treat injuries or illnesses or to provide services covered by a health insurance policy;  and(2)  comply with the terms established by the insurer for designation as preferred providers.(b)  An insurer may not unreasonably withhold a designation as a preferred provider.(c)  An insurer shall give a physician or health care provider who, on the person's initial application, is not designated as a preferred provider written reasons for denial of the designation.(d)  Unless otherwise limited by this code, this section does not prohibit an insurer from rejecting a physician's or health care provider's application for designation based on a determination that the preferred provider benefit plan has sufficient qualified providers.(e)  An insurer may not withhold a designation to:(1)  a podiatrist described by Section 1301.0521; or(2)  an optometrist, therapeutic optometrist, or ophthalmologist described by Section 1301.0522.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.Amended by: Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.034(a), eff. September 1, 2005.Acts 2015, 84th Leg., R.S., Ch. 1271 (S.B. 684), Sec. 1, eff. September 1, 2015.|
TX Ins Code § 1301.0515 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle D - Provider Plans|Chapter 1301 - Preferred Provider Benefit Plans|Subchapter B. Relations With Physicians or Health Care Providers|Section 1301.0515. Acupuncturist Services

Sec. 1301.0515.  ACUPUNCTURIST SERVICES.  (a)  An insurer offering a preferred provider benefit plan that includes acupuncture in the services covered by the plan may not refuse to provide reimbursement for the performance of a covered acupuncture service solely because the service is provided by an acupuncturist.(b)  This section does not require an insurer to offer acupuncture as a covered service.|Added by Acts 2005, 79th Leg., Ch. 622 (H.B. 2371), Sec. 2, eff. September 1, 2005.|
TX Ins Code § 1301.0516 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle D - Provider Plans|Chapter 1301 - Preferred Provider Benefit Plans|Subchapter B. Relations With Physicians or Health Care Providers|Section 1301.0516. Chiropractic Services

Sec. 1301.0516.  CHIROPRACTIC SERVICES.  (a)  An insurer offering a preferred provider benefit plan that covers a service that is within the scope of a chiropractor's license may not refuse to provide reimbursement for the performance of the covered service solely because the service is provided by a chiropractor.(b)  This section does not require an insurer to cover a particular medical or health care service.(c)  This section does not affect the right of an insurer to determine whether a medical or health care service is medically necessary.(d)  An insurer that violates this section is subject to an administrative penalty as provided by Chapter 84 of not more than $1,000 for each claim that remains unpaid in violation of this section.  Each day a violation continues constitutes a separate violation.|Added by Acts 2019, 86th Leg., R.S., Ch. 116 (S.B. 1739), Sec. 2, eff. September 1, 2019.|
TX Ins Code § 1301.052 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle D - Provider Plans|Chapter 1301 - Preferred Provider Benefit Plans|Subchapter B. Relations With Physicians or Health Care Providers|Section 1301.052. Designation of Advanced Practice Nurse or Physician Assistant as Preferred Provider

Sec. 1301.052.  DESIGNATION OF ADVANCED PRACTICE NURSE OR PHYSICIAN ASSISTANT AS PREFERRED PROVIDER.  An insurer offering a preferred provider benefit plan may not refuse a request made by a physician participating as a preferred provider under the plan and an advanced practice nurse or physician assistant to have the advanced practice nurse or physician assistant included as a preferred provider under the plan if:(1)  the advanced practice nurse or physician assistant is authorized by the physician to provide care under Subchapter B, Chapter 157, Occupations Code;  and(2)  the advanced practice nurse or physician assistant meets the quality of care standards previously established by the insurer for participation in the plan by advanced practice nurses and physician assistants.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1301.0521 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle D - Provider Plans|Chapter 1301 - Preferred Provider Benefit Plans|Subchapter B. Relations With Physicians or Health Care Providers|Section 1301.0521. Designation of Certain Podiatrists as Preferred Providers

Sec. 1301.0521.  DESIGNATION OF CERTAIN PODIATRISTS AS PREFERRED PROVIDERS.  (a)  Notwithstanding Section 1301.051, an insurer may not withhold the designation of preferred provider to a podiatrist licensed by the Texas Department of Licensing and Regulation who:(1)  joins the professional practice of a contracted preferred provider;(2)  applies to the insurer for designation as a preferred provider; and(3)  complies with the terms and conditions of eligibility to be a preferred provider.(b)  A podiatrist designated as a preferred provider under this section must comply with the terms of the preferred provider contract used by the insurer or the insurer's network provider.|Added by Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.035(a), eff. September 1, 2005.Amended by: Acts 2019, 86th Leg., R.S., Ch. 467 (H.B. 4170), Sec. 19.013, eff. September 1, 2019.|
TX Ins Code § 1301.0522 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle D - Provider Plans|Chapter 1301 - Preferred Provider Benefit Plans|Subchapter B. Relations With Physicians or Health Care Providers|Section 1301.0522. Designation of Certain Optometrists, Therapeutic Optometrists, and Ophthalmologists as Preferred Providers

Sec. 1301.0522.  DESIGNATION OF CERTAIN OPTOMETRISTS, THERAPEUTIC OPTOMETRISTS, AND OPHTHALMOLOGISTS AS PREFERRED PROVIDERS.  (a)  Notwithstanding Section 1301.051, an insurer may not withhold the designation of preferred provider to an optometrist or therapeutic optometrist licensed by the Texas Optometry Board or an ophthalmologist licensed by the Texas Medical Board who:(1)  joins the professional practice of a contracted preferred provider;(2)  applies to the insurer for designation as a preferred provider; and(3)  complies with the terms and conditions of eligibility to be a preferred provider.(b)  An optometrist, therapeutic optometrist, or ophthalmologist designated as a preferred provider under this section must comply with the terms of the preferred provider contract used by the insurer or the insurer's network provider.|Added by Acts 2015, 84th Leg., R.S., Ch. 1271 (S.B. 684), Sec. 2, eff. September 1, 2015.|
TX Ins Code § 1301.053 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle D - Provider Plans|Chapter 1301 - Preferred Provider Benefit Plans|Subchapter B. Relations With Physicians or Health Care Providers|Section 1301.053. Appeal Relating to Designation as Preferred Provider

Sec. 1301.053.  APPEAL RELATING TO DESIGNATION AS PREFERRED PROVIDER.  (a)  An insurer that does not designate a practitioner as a preferred provider shall provide a reasonable mechanism for reviewing that action.  The review mechanism must incorporate, in an advisory role only, a review panel.(b)  A review panel must be composed of at least three individuals selected by the insurer from a list of participating practitioners and must include one member who is a practitioner in the same or similar specialty as the affected practitioner, if available.  The practitioners contracting with the insurer in the applicable service area shall provide the list of practitioners to the insurer.(c)  On request, the insurer shall provide to the affected practitioner:(1)  the panel's recommendation, if any;  and(2)  a written explanation of the insurer's determination, if that determination is contrary to the panel's recommendation.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1301.054 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle D - Provider Plans|Chapter 1301 - Preferred Provider Benefit Plans|Subchapter B. Relations With Physicians or Health Care Providers|Section 1301.054. Notice to Practitioners of Preferred Provider Benefit Plan

Sec. 1301.054.  NOTICE TO PRACTITIONERS OF PREFERRED PROVIDER BENEFIT PLAN.  (a)  When sponsoring a preferred provider benefit plan, an insurer shall immediately notify each practitioner in the plan's service area of the insurer's intent to offer the plan and of the opportunity to participate.  The notification must be made by publication or in writing to each practitioner.(b)  After establishing a preferred provider benefit plan, an insurer shall annually provide notice of and an opportunity to participate in the plan to practitioners in the plan's service area who do not participate in the plan.(c)  On request, an insurer shall provide to any physician or health care provider information concerning the application process and qualification requirements for participation as a preferred provider in the plan.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1301.055 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle D - Provider Plans|Chapter 1301 - Preferred Provider Benefit Plans|Subchapter B. Relations With Physicians or Health Care Providers|Section 1301.055. Complaint Resolution

Sec. 1301.055.  COMPLAINT RESOLUTION.  (a)  Each contract under a preferred provider benefit plan between an insurer and a physician or other practitioner or a physicians' group must have a mechanism for resolving complaints initiated by an insured, a physician or other practitioner, or a physicians' group.(b)  A complaint resolution mechanism must provide for reasonable due process that includes, in an advisory role only, a review panel selected in the manner described by Section 1301.053(b).|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1301.056 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle D - Provider Plans|Chapter 1301 - Preferred Provider Benefit Plans|Subchapter B. Relations With Physicians or Health Care Providers|Section 1301.056. Restrictions on Payment and Reimbursement

Sec. 1301.056.  RESTRICTIONS ON PAYMENT AND REIMBURSEMENT.  (a)  An insurer or third-party administrator may not reimburse a physician or other practitioner, institutional provider, or organization of physicians and health care providers on a discounted fee basis for covered services that are provided to an insured unless:(1)  the insurer or third-party administrator has contracted with either:(A)  the physician or other practitioner, institutional provider, or organization of physicians and health care providers;  or(B)  a preferred provider organization that has a network of preferred providers and that has contracted with the physician or other practitioner, institutional provider, or organization of physicians and health care providers;(2)  the physician or other practitioner, institutional provider, or organization of physicians and health care providers has agreed to the contract and has agreed to provide health care services under the terms of the contract;  and(3)  the insurer or third-party administrator has agreed to provide coverage for those health care services under the health insurance policy.(b)  A party to a preferred provider contract, including a contract with a preferred provider organization, may not sell, lease, or otherwise transfer information regarding the payment or reimbursement terms of the contract without the express authority of and prior adequate notification to the other contracting parties.  This subsection does not affect the authority of the commissioner of insurance or the commissioner of workers' compensation under this code or Title 5, Labor Code, to request and obtain information.(c)  An insurer or third-party administrator who violates this section:(1)  commits an unfair claim settlement practice in violation of Subchapter A, Chapter 542;  and(2)  is subject to administrative penalties under Chapters 82 and 84.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.Amended by: Acts 2005, 79th Leg., Ch. 265 (H.B. 7), Sec. 6.061, eff. September 1, 2005.|