reglab/housing_qa huggingface dataset:
TX Ins Code § 1272.205 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle C - Managed Care|Chapter 1272 - Delegation of Certain Functions by Health Maintenance Organization|Subchapter E. Compliance|Section 1272.205. Examination by Department; Report

Sec. 1272.205.  EXAMINATION BY DEPARTMENT;  REPORT.  (a)  On receipt of a notice under Section 1272.202 or if complaints are filed with the department, the department may conduct an examination regarding:(1)  any matter contained in the notice;  and(2)  any other matter relating to the financial solvency of the delegated entity or the entity's ability to meet the entity's responsibilities in connection with a function delegated to the entity by the health maintenance organization.(b)  Except as provided by Subsection (c), the department, on completion of an examination under this section, shall report to the delegated entity and the health maintenance organization:(1)  the results of the examination;  and(2)  any action the department determines is necessary to ensure that:(A)  the health maintenance organization meets the health maintenance organization's responsibilities under this code, any other insurance laws of this state, and rules adopted by the commissioner;  and(B)  the entity is able to meet the entity's responsibilities in connection with a function delegated to the entity by the health maintenance organization.(c)  The department may not report to the health maintenance organization information relating to fee schedules, prices, or cost of care or other information not relevant to the monitoring plan.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1272.206 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle C - Managed Care|Chapter 1272 - Delegation of Certain Functions by Health Maintenance Organization|Subchapter E. Compliance|Section 1272.206. Response to Department Report; Corrective Plan

Sec. 1272.206.  RESPONSE TO DEPARTMENT REPORT;  CORRECTIVE PLAN.  The delegated entity and health maintenance organization shall respond to the department's report under Section 1272.205(b) and submit a corrective plan to the department not later than the 30th day after the date of receipt of the report.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1272.207 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle C - Managed Care|Chapter 1272 - Delegation of Certain Functions by Health Maintenance Organization|Subchapter E. Compliance|Section 1272.207. Request for Corrective Action

Sec. 1272.207.  REQUEST FOR CORRECTIVE ACTION.  The department may request at any time that a delegated entity take corrective action to comply with the department's statutory and regulatory requirements that:(1)  relate to a function delegated by the health maintenance organization to the entity;  or(2)  are necessary to ensure the health maintenance organization's compliance with each statutory or regulatory requirement.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1272.208 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle C - Managed Care|Chapter 1272 - Delegation of Certain Functions by Health Maintenance Organization|Subchapter E. Compliance|Section 1272.208. Authority of Commissioner to Issue Order

Sec. 1272.208.  AUTHORITY OF COMMISSIONER TO ISSUE ORDER.  (a)  Regardless of whether a delegated entity complies with a request for corrective action under Section 1272.207, the commissioner may order a health maintenance organization with which the entity has entered into a delegation agreement to take any action the commissioner determines is necessary to ensure that the health maintenance organization is complying with this chapter, Chapter 843, 1271, or 1367, Subchapter A, Chapter 1452, or Subchapter B, Chapter 1507.(b)  Actions the commissioner may order a health maintenance organization to take under this section include:(1)  reassuming the functions delegated to the delegated entity, including claims payments for services previously provided to enrollees;(2)  temporarily or permanently ceasing assignment of new enrollees to the entity;(3)  temporarily or permanently transferring enrollees to alternative delivery systems to receive services;  or(4)  terminating the delegation agreement with the entity.|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. 11.074(h), eff. September 1, 2005.|
TX Ins Code § 1272.209 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle C - Managed Care|Chapter 1272 - Delegation of Certain Functions by Health Maintenance Organization|Subchapter E. Compliance|Section 1272.209. Public Documents

Sec. 1272.209.  PUBLIC DOCUMENTS.  (a)  Except as provided by Subsection (b), a report required under Section 1272.205(b) or corrective plan required under Section 1272.206 is a public document.(b)  Health care provider fee schedules, prices, costs of care, or other information that is not relevant to the monitoring plan or is confidential by law is not a public document under this section.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1272.210 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle C - Managed Care|Chapter 1272 - Delegation of Certain Functions by Health Maintenance Organization|Subchapter E. Compliance|Section 1272.210. Record of Complaints; Report

Sec. 1272.210.  RECORD OF COMPLAINTS;  REPORT.  (a)  The department shall:(1)  maintain enrollee and provider complaints in a manner that identifies complaints made about limited provider networks and delegated entities;  and(2)  periodically issue a report on the complaints that includes a list of complaints organized by:(A)  category;(B)  action taken on the complaint;  and(C)  entity or network name and type.(b)  The department shall make available to the public the report and information to assist the public in evaluating the information contained in the report.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1272.211 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle C - Managed Care|Chapter 1272 - Delegation of Certain Functions by Health Maintenance Organization|Subchapter E. Compliance|Section 1272.211. Rules

Sec. 1272.211.  RULES.  The commissioner may adopt rules as necessary to implement this subchapter.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1272.251 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle C - Managed Care|Chapter 1272 - Delegation of Certain Functions by Health Maintenance Organization|Subchapter F. Penalties|Section 1272.251. Applicability of Subchapter

Sec. 1272.251.  APPLICABILITY OF SUBCHAPTER.  This subchapter does not apply to a group model health maintenance organization, as defined by Section 843.111.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1272.252 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle C - Managed Care|Chapter 1272 - Delegation of Certain Functions by Health Maintenance Organization|Subchapter F. Penalties|Section 1272.252. Suspension or Revocation of License of Third-Party Administrator or Utilization Review Agent

Sec. 1272.252.  SUSPENSION OR REVOCATION OF LICENSE OF THIRD-PARTY ADMINISTRATOR OR UTILIZATION REVIEW AGENT.  Notwithstanding any other provision of this code or another insurance law of this state, the commissioner may suspend or revoke the license of a third-party administrator or utilization review agent that fails to comply with Subchapter B, C, or E.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1272.253 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle C - Managed Care|Chapter 1272 - Delegation of Certain Functions by Health Maintenance Organization|Subchapter F. Penalties|Section 1272.253. Sanctions and Penalties Against Health Maintenance Organization

Sec. 1272.253.  SANCTIONS AND PENALTIES AGAINST HEALTH MAINTENANCE ORGANIZATION.  The commissioner may impose sanctions or penalties under Chapters 82, 83, and 84 on a health maintenance organization that does not provide in a timely manner information required by Subchapter C.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1272.254 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle C - Managed Care|Chapter 1272 - Delegation of Certain Functions by Health Maintenance Organization|Subchapter F. Penalties|Section 1272.254. Contractual Penalties Required

Sec. 1272.254.  CONTRACTUAL PENALTIES REQUIRED.  A health maintenance organization by contract shall establish penalties for a delegated entity that does not provide in a timely manner information required under a monitoring plan established under Section 1272.053.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1272.255 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle C - Managed Care|Chapter 1272 - Delegation of Certain Functions by Health Maintenance Organization|Subchapter F. Penalties|Section 1272.255. Rules

Sec. 1272.255.  RULES.  The commissioner may adopt rules as necessary to implement this subchapter.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1272.301 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle C - Managed Care|Chapter 1272 - Delegation of Certain Functions by Health Maintenance Organization|Subchapter G. Provision of Services by Limited Provider Network or Delegated Entity|Section 1272.301. Access to Out-of-Network Services

Sec. 1272.301.  ACCESS TO OUT-OF-NETWORK SERVICES.  (a)  A contract between a health maintenance organization and a limited provider network or delegated entity must provide that:(1)  if medically necessary covered services are not available through network physicians or providers, the limited provider network or delegated entity, on the request of a network physician or provider, shall:(A)  allow a referral to a non-network physician or provider;  and(B)  fully reimburse the non-network physician or provider at the usual and customary rate or an agreed rate;  and(2)  before the limited provider network or delegated entity may deny a referral to a non-network physician or provider, a specialist of the same or similar specialty as the type of physician or provider to whom the referral is requested must conduct a review of the request.(b)  The limited provider network or delegated entity shall allow the referral within the time appropriate to the circumstances relating to the delivery of the services and the condition of the enrollee who is a patient, but not later than the fifth business day after the date the network or entity receives any reasonably requested documentation.(c)  An enrollee may not be required to change the enrollee's primary care physician or specialist providers to receive medically necessary covered services that are not available within the limited provider network or through the delegated entity.(d)  A denial of out-of-network services under this section is subject to appeal under Chapter 4201.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.Amended by: Acts 2007, 80th Leg., R.S., Ch. 730 (H.B. 2636), Sec. 2G.005, eff. April 1, 2009.|
TX Ins Code § 1273.001 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle C - Managed Care|Chapter 1273 - Point-of-Service Plans|Subchapter A. Blended Contracts|Section 1273.001. Definitions

Sec. 1273.001.  DEFINITIONS.  In this subchapter:(1)  "Blended contract" means a single document, including a single contract policy, certificate, or evidence of coverage, that provides a combination of indemnity and health maintenance organization benefits.(2)  "Health maintenance organization" has the meaning assigned by Section 843.002.(3)  "Insurer" means an insurance company, association, or organization authorized to engage in business in this state under Chapter 841, 842, 861, 881, 882, 883, 884, 885, 886, 887, 888, 941, 942, or 982.(4)  "Point-of-service plan" means an arrangement under which:(A)  an enrollee chooses to obtain benefits or services through:(i)  a health maintenance organization delivery network, including a limited provider network; or(ii)  a non-network delivery system outside the health maintenance organization delivery network, including an exclusive provider benefit plan under Chapter 1301 or a limited provider network, that is administered under an indemnity benefit arrangement for the cost of health care services; or(B)  indemnity benefits for the cost of health care services are provided by an insurer or group hospital service corporation in conjunction with network benefits arranged or provided by a health maintenance organization.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.Amended by: Acts 2011, 82nd Leg., R.S., Ch. 288 (H.B. 1772), Sec. 1, eff. September 1, 2011.|
TX Ins Code § 1273.002 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle C - Managed Care|Chapter 1273 - Point-of-Service Plans|Subchapter A. Blended Contracts|Section 1273.002. Point-of-Service Plan

Sec. 1273.002.  POINT-OF-SERVICE PLAN.  An insurer may contract with a health maintenance organization to provide benefits under a point-of-service plan, including optional coverage for out-of-area services or out-of-network care.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1273.003 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle C - Managed Care|Chapter 1273 - Point-of-Service Plans|Subchapter A. Blended Contracts|Section 1273.003. Blended Contract

Sec. 1273.003.  BLENDED CONTRACT.  (a)  A health maintenance organization and an insurer may offer a blended contract.  The use of a blended contract is limited to point-of-service arrangements between a health maintenance organization and an insurer.(b)  A blended contract delivered, issued, or used in this state is subject to, and must be filed with the department for approval as provided by, Chapter 1701 and Section 1271.101.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1273.004 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle C - Managed Care|Chapter 1273 - Point-of-Service Plans|Subchapter A. Blended Contracts|Section 1273.004. Limited Benefits and Services; Cost-Sharing Provisions

Sec. 1273.004.  LIMITED BENEFITS AND SERVICES;  COST-SHARING PROVISIONS.  Indemnity benefits and services provided under a point-of-service plan may be limited to those services described by the blended contract and may be subject to different cost-sharing provisions.  The cost-sharing provisions for indemnity benefits may be higher than the cost-sharing provisions for in-network health maintenance organization coverage.  For an enrollee in a limited provider network, higher cost-sharing may be imposed only when the enrollee obtains benefits or services outside the health maintenance organization delivery network.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1273.005 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle C - Managed Care|Chapter 1273 - Point-of-Service Plans|Subchapter A. Blended Contracts|Section 1273.005. Rules

Sec. 1273.005.  RULES.  The commissioner may adopt rules to implement this subchapter.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1273.051 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle C - Managed Care|Chapter 1273 - Point-of-Service Plans|Subchapter B. Availability of Health Benefit Coverage Options|Section 1273.051. Definitions

Sec. 1273.051.  DEFINITIONS.  In this subchapter:(1)  "Employee" means an individual employed by an employer.(2)  "Health benefit plan" has the meaning assigned by Section 1501.002.(3)  "Non-network plan" means health benefit coverage that provides an enrollee an opportunity to obtain health care services through a health delivery system other than a health maintenance organization delivery network, as defined by Section 843.002.(4)  "Point-of-service plan" means an arrangement under which an enrollee chooses to obtain benefits or services through:(A)  a health maintenance organization delivery network, including a limited provider network;  or(B)  a non-network delivery system outside the health maintenance organization delivery network, including a limited provider network, that is administered under an indemnity benefit arrangement for the cost of health care services.(5)  "Preferred provider benefit plan" means an insurance policy issued under Chapter 1301.(6)  "Small employer health benefit plan" has the meaning assigned by Section 1501.002.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1273.052 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle C - Managed Care|Chapter 1273 - Point-of-Service Plans|Subchapter B. Availability of Health Benefit Coverage Options|Section 1273.052. Offer of Coverage Through Non-Network Plan Required

Sec. 1273.052.  OFFER OF COVERAGE THROUGH NON-NETWORK PLAN REQUIRED.  (a)  Except as provided by Subsection (b), if the only health benefit coverage offered under an employer's health benefit plan is a network-based delivery system of coverage offered by one or more health maintenance organizations, each health maintenance organization offering coverage must offer to all eligible employees, at the time of enrollment and at least annually, the opportunity to obtain coverage through a non-network plan.(b)  Each health maintenance organization to which Subsection (a) applies may enter into an agreement designating one or more of those health maintenance organizations to offer the coverage required by Subsection (a) for eligible employees of the employer.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1273.053 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle C - Managed Care|Chapter 1273 - Point-of-Service Plans|Subchapter B. Availability of Health Benefit Coverage Options|Section 1273.053. Coverage Options

Sec. 1273.053.  COVERAGE OPTIONS.  The coverage required to be offered under this subchapter may be provided through:(1)  a point-of-service plan;(2)  a preferred provider benefit plan;  or(3)  any coverage arrangement that provides an enrollee with access to services outside the health maintenance organization's or limited provider network's delivery network.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1273.054 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle C - Managed Care|Chapter 1273 - Point-of-Service Plans|Subchapter B. Availability of Health Benefit Coverage Options|Section 1273.054. Premium for Coverage Options

Sec. 1273.054.  PREMIUM FOR COVERAGE OPTIONS.  The premium for coverage required to be offered under this subchapter must be based on the actuarial value of that coverage and may be different from the premium for coverage otherwise offered by the health maintenance organization.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1273.055 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle C - Managed Care|Chapter 1273 - Point-of-Service Plans|Subchapter B. Availability of Health Benefit Coverage Options|Section 1273.055. Cost-Sharing Provisions

Sec. 1273.055.  COST-SHARING PROVISIONS.  (a)  Different cost-sharing provisions may be imposed for a point-of-service plan offered under this subchapter, and those provisions may be higher than the cost-sharing provisions for in-network health maintenance organization coverage.  For an enrollee in a limited provider network, higher cost-sharing may be imposed only when the enrollee obtains benefits or services outside the health maintenance organization delivery network.(b)  An employee who chooses the non-network plan is responsible for any additional costs for the non-network plan, and the employer may impose a reasonable administrative fee for providing the non-network plan.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1273.056 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle C - Managed Care|Chapter 1273 - Point-of-Service Plans|Subchapter B. Availability of Health Benefit Coverage Options|Section 1273.056. Exceptions

Sec. 1273.056.  EXCEPTIONS.  This subchapter does not apply to:(1)  a small employer health benefit plan;  or(2)  a group model health maintenance organization that is a nonprofit, state-certified health maintenance organization that:(A)  provides the majority of its professional services through a single group medical practice that is governed by a board composed entirely of physicians;  and(B)  educates medical students or resident physicians through a contract with the medical school component of a Texas state-supported college or university accredited by the Accreditation Council on Graduate Medical Education or the American Osteopathic Association.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1273.057 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle C - Managed Care|Chapter 1273 - Point-of-Service Plans|Subchapter B. Availability of Health Benefit Coverage Options|Section 1273.057. Rules

Sec. 1273.057.  RULES.  The commissioner shall adopt rules necessary to administer this subchapter.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1275.001 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle C - Managed Care|Chapter 1275 - Balance Billing Prohibitions and Out-of-Network Claim Dispute Resolution for Certain Plans|Subchapter A. General Provisions|Section 1275.001. Definitions

Sec. 1275.001.  DEFINITIONS.  In this chapter:(1)  "Enrollee" means an individual enrolled in a health benefit plan to which this chapter applies.(2)  "Usual and customary rate" means the relevant allowable amount as described by the applicable master benefit plan document.|Added by Acts 2021, 87th Leg., R.S., Ch. 1034 (H.B. 3924), Sec. 1, eff. September 1, 2021.|
TX Ins Code § 1275.002 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle C - Managed Care|Chapter 1275 - Balance Billing Prohibitions and Out-of-Network Claim Dispute Resolution for Certain Plans|Subchapter A. General Provisions|Section 1275.002. Applicability of Chapter

Sec. 1275.002.  APPLICABILITY OF CHAPTER.  This chapter applies to a health benefit plan offered by a nonprofit agricultural organization under Chapter 1682.|Added by Acts 2021, 87th Leg., R.S., Ch. 1034 (H.B. 3924), Sec. 1, eff. September 1, 2021.|