reglab/housing_qa huggingface dataset:
TX Ins Code § 1579.008 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle H - Health Benefits and Other Coverages for Governmental Employees|Chapter 1579 - Texas School Employees Uniform Group Health Coverage|Subchapter A. General Provisions|Section 1579.008. Coverage Exempt From Insurance Law

Sec. 1579.008.  COVERAGE EXEMPT FROM INSURANCE LAW.  A coverage plan provided under this chapter is exempt from any other insurance law, including common law, that does not expressly apply to the plan or this chapter.|Added by Acts 2005, 79th Leg., Ch. 1359 (S.B. 1691), Sec. 48, eff. September 1, 2005.|
TX Ins Code § 1579.009 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle H - Health Benefits and Other Coverages for Governmental Employees|Chapter 1579 - Texas School Employees Uniform Group Health Coverage|Subchapter A. General Provisions|Section 1579.009. Balance Billing Prohibition Notice

Sec. 1579.009.  BALANCE BILLING PROHIBITION NOTICE.  (a)  The administrator of a managed care plan provided under this chapter shall provide written notice in accordance with this section in an explanation of benefits provided to the enrollee and the physician or health care provider in connection with a health care or medical service or supply provided by an out-of-network provider.  The notice must include:(1)  a statement of the billing prohibition under Section 1579.109, 1579.110, or 1579.111, as applicable;(2)  the total amount the physician or provider may bill the enrollee under the enrollee's managed care 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)  The administrator 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 administrator makes a payment under Section 1579.109, 1579.110, or 1579.111, as applicable.|Added by Acts 2019, 86th Leg., R.S., Ch. 1342 (S.B. 1264), Sec. 1.17, eff. September 1, 2019.|
TX Ins Code § 1579.010 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle H - Health Benefits and Other Coverages for Governmental Employees|Chapter 1579 - Texas School Employees Uniform Group Health Coverage|Subchapter A. General Provisions|Section 1579.010. Information Regarding Appeals

Sec. 1579.010.  INFORMATION REGARDING APPEALS.  The trustee shall develop and distribute informational materials to individuals enrolled in a health coverage plan provided under this chapter regarding:(1)  an enrollee's right to appeal denial of an adverse determination, as defined by Section 4201.002, to an independent review organization;(2)  the procedures for appealing to an independent review organization; and(3)  the assistance available from the trustee in navigating the procedures for appeal.|Added by Acts 2021, 87th Leg., R.S., Ch. 141 (H.B. 1585), Sec. 18, eff. May 26, 2021.|
TX Ins Code § 1579.051 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle H - Health Benefits and Other Coverages for Governmental Employees|Chapter 1579 - Texas School Employees Uniform Group Health Coverage|Subchapter B. Administration|Section 1579.051. Administration of Group Program

Sec. 1579.051.  ADMINISTRATION OF GROUP PROGRAM.  The Teacher Retirement System of Texas, as trustee, shall implement and administer the uniform group coverage program described by this chapter.|Added by Acts 2003, 78th Leg., ch. 1276, Sec. 10A.471(a), eff. Sept. 1, 2003.|
TX Ins Code § 1579.052 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle H - Health Benefits and Other Coverages for Governmental Employees|Chapter 1579 - Texas School Employees Uniform Group Health Coverage|Subchapter B. Administration|Section 1579.052. Authority to Adopt Rules; Other Authority

Sec. 1579.052.  AUTHORITY TO ADOPT RULES;  OTHER AUTHORITY.  (a)  The trustee may adopt rules relating to the program as considered necessary by the trustee.(b)  The trustee may adopt rules to administer the program, including rules relating to adjudication of claims and expelling participants from the program for cause.(c)  The trustee may contract with independent and experienced group insurance consultants and actuaries for advice and counsel in implementing and administering the program.(d)  The trustee may enter into interagency contracts with any agency of the state, including the Employees Retirement System of Texas and the department, for the purpose of assistance in implementing the program.(e)  The trustee shall take the actions it considers necessary to devise, implement, and administer the program.|Added by Acts 2003, 78th Leg., ch. 1276, Sec. 10A.471(a), eff. Sept. 1, 2003.Amended by: Acts 2005, 79th Leg., Ch. 1359 (S.B. 1691), Sec. 49, eff. September 1, 2005.|
TX Ins Code § 1579.053 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle H - Health Benefits and Other Coverages for Governmental Employees|Chapter 1579 - Texas School Employees Uniform Group Health Coverage|Subchapter B. Administration|Section 1579.053. Personnel

Sec. 1579.053.  PERSONNEL.  The trustee may hire and compensate employees as necessary to implement the program.|Added by Acts 2003, 78th Leg., ch. 1276, Sec. 10A.471(a), eff. Sept. 1, 2003.|
TX Ins Code § 1579.054 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle H - Health Benefits and Other Coverages for Governmental Employees|Chapter 1579 - Texas School Employees Uniform Group Health Coverage|Subchapter B. Administration|Section 1579.054. Competitive Bidding Requirements; Rules

Sec. 1579.054.  COMPETITIVE BIDDING REQUIREMENTS;  RULES.  A contract to provide group health coverage under this chapter may be awarded only through competitive bidding under rules adopted by the trustee.|Added by Acts 2003, 78th Leg., ch. 1276, Sec. 10A.471(a), eff. Sept. 1, 2003.|
TX Ins Code § 1579.055 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle H - Health Benefits and Other Coverages for Governmental Employees|Chapter 1579 - Texas School Employees Uniform Group Health Coverage|Subchapter B. Administration|Section 1579.055. Contract Award; Considerations

Sec. 1579.055.  CONTRACT AWARD;  CONSIDERATIONS.  (a)  In awarding a contract to provide group benefits under this chapter, the trustee is not required to select the lowest bid and may consider also any relevant criteria, including the bidder's:(1)  ability to service contracts;(2)  past experiences;  and(3)  financial stability.(b)  If the trustee awards a contract to a bidder whose bid deviates from that advertised, the trustee shall record the deviation and fully justify the reason for the deviation in the minutes of the next board meeting.|Added by Acts 2003, 78th Leg., ch. 1276, Sec. 10A.471(a), eff. Sept. 1, 2003.|
TX Ins Code § 1579.057 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle H - Health Benefits and Other Coverages for Governmental Employees|Chapter 1579 - Texas School Employees Uniform Group Health Coverage|Subchapter B. Administration|Section 1579.057. Pharmacy Benefit Manager Contracts

Sec. 1579.057.  PHARMACY BENEFIT MANAGER CONTRACTS.  (a)  In awarding a contract to provide pharmacy benefit manager services under this chapter, the trustee is not required to select the lowest bid but must select a contract that meets the criteria established by this section.(b)  The contract must state that:(1)  the trustee is entitled to audit the pharmacy benefit manager to verify costs and discounts associated with drug claims, pharmacy benefit manager compliance with contract requirements, and services provided by subcontractors;(2)  the audit must be conducted by an independent auditor in accordance with established auditing standards; and(3)  to conduct the audit, the trustee and the independent auditor are entitled access to information related to the services and the costs associated with the services performed under the contract, including access to the pharmacy benefit manager's facilities, records, contracts, medical records, and agreements with subcontractors.(c)  The contract must define the information that the pharmacy benefit manager is required to provide to the trustee concerning the audit of the retail, independent, and mail order pharmacies performing services under the contract and describe how the results of these audits must be reported to the trustee, including how often the results must be reported.  The contract must state whether the pharmacy benefit manager is required to return recovered overpayments to the trustee.(d)  The contract must state that any audit of a mail order pharmacy owned by the pharmacy benefit manager must be conducted by an independent auditor selected by the trustee in accordance with established auditing standards.|Added by Acts 2009, 81st Leg., R.S., Ch. 1207 (S.B. 704), Sec. 7, eff. September 1, 2009.|
TX Ins Code § 1579.101 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle H - Health Benefits and Other Coverages for Governmental Employees|Chapter 1579 - Texas School Employees Uniform Group Health Coverage|Subchapter C. Coverages|Section 1579.101. Plans of Group Coverages

Sec. 1579.101.  PLANS OF GROUP COVERAGES.  (a)  The trustee by rule shall establish plans of group coverages for employees participating in the program and their dependents.(b)  The plans must include at least two tiers of group coverage, with coverage at different levels in each tier, ranging from the catastrophic care coverage plan to the primary care coverage plan.  Each tier must contain a health coverage plan.(c)  The trustee by rule shall define the requirements of each coverage plan and tier of coverage.(d)  Comparable coverage plans of each tier of coverage established must be offered to employees of all participating entities.|Added by Acts 2003, 78th Leg., ch. 1276, Sec. 10A.471(a), eff. Sept. 1, 2003.|
TX Ins Code § 1579.102 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle H - Health Benefits and Other Coverages for Governmental Employees|Chapter 1579 - Texas School Employees Uniform Group Health Coverage|Subchapter C. Coverages|Section 1579.102. Catastrophic Care Coverage Plan

Sec. 1579.102.  CATASTROPHIC CARE COVERAGE PLAN.  The coverage provided under the catastrophic care coverage plan shall be prescribed by the trustee by rule and must provide coverage at least as extensive as the coverage provided under the TRS-Care 1 plan operated under Chapter 1575.|Added by Acts 2003, 78th Leg., ch. 1276, Sec. 10A.471(a), eff. Sept. 1, 2003.Amended by: Acts 2005, 79th Leg., Ch. 1359 (S.B. 1691), Sec. 50, eff. September 1, 2005.|
TX Ins Code § 1579.104 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle H - Health Benefits and Other Coverages for Governmental Employees|Chapter 1579 - Texas School Employees Uniform Group Health Coverage|Subchapter C. Coverages|Section 1579.104. Optional Coverages

Sec. 1579.104.  OPTIONAL COVERAGES.  The trustee may not offer optional coverages, other than optional permanent life insurance, optional long-term care insurance, and optional disability insurance, to employees participating in the program.  This section does not affect the right of a participating entity to offer optional coverages to its employees under terms and conditions established by the participating entity.|Added by Acts 2003, 78th Leg., ch. 1276, Sec. 10A.471(a), eff. Sept. 1, 2003.Reenacted by Acts 2005, 79th Leg., Ch. 1359 (S.B. 1691), Sec. 51(a), eff. September 1, 2005.|
TX Ins Code § 1579.1045 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle H - Health Benefits and Other Coverages for Governmental Employees|Chapter 1579 - Texas School Employees Uniform Group Health Coverage|Subchapter C. Coverages|Section 1579.1045. Alternative Group Health Coverage Prohibited

Sec. 1579.1045.  ALTERNATIVE GROUP HEALTH COVERAGE PROHIBITED.  Notwithstanding any other law, a participating entity may not offer or make available to the entity's employees or their dependents group health coverage not provided under the program.|Added by Acts 2021, 87th Leg., R.S., Ch. 399 (S.B. 1444), Sec. 1, eff. September 1, 2021.|
TX Ins Code § 1579.105 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle H - Health Benefits and Other Coverages for Governmental Employees|Chapter 1579 - Texas School Employees Uniform Group Health Coverage|Subchapter C. Coverages|Section 1579.105. Preexisting Condition Limitation

Sec. 1579.105.  PREEXISTING CONDITION LIMITATION.  During the initial period of eligibility, coverage provided under the program may not be made subject to a preexisting condition limitation.|Added by Acts 2003, 78th Leg., ch. 1276, Sec. 10A.471(a), eff. Sept. 1, 2003.|
TX Ins Code § 1579.106 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle H - Health Benefits and Other Coverages for Governmental Employees|Chapter 1579 - Texas School Employees Uniform Group Health Coverage|Subchapter C. Coverages|Section 1579.106. Prior Authorization for Certain Drugs

Sec. 1579.106.  PRIOR AUTHORIZATION FOR CERTAIN DRUGS.  (a)  In this section, "drug formulary" means a list of drugs preferred for use and eligible for coverage by a health coverage plan.(b)  A health coverage plan provided under this chapter that uses a drug formulary in providing a prescription drug benefit must require prior authorization for coverage of the following categories of prescribed drugs if the specific drug prescribed is not included in the formulary:(1)  a gastrointestinal drug;(2)  a cholesterol-lowering drug;(3)  an anti-inflammatory drug;(4)  an antihistamine drug; and(5)  an antidepressant drug.(c)  Every 12 months the trustee shall submit to the comptroller and the Legislative Budget Board a report regarding any cost savings achieved in the program through implementation of the prior authorization requirement of this section. The report must cover the previous 12-month period.(d)  In the report under Subsection (c), the trustee:(1)  may include any cost savings achieved in the program for coverage of prescribed drugs that are not included in the categories listed in Subsection (b) for which prior authorization is required by a health coverage plan provided under this chapter; and(2)  considering cost and medical necessity, shall identify any categories of prescribed drugs in addition to the categories listed in Subsection (b) for which requiring prior authorization could achieve cost savings.|Added by Acts 2007, 80th Leg., R.S., Ch. 730 (H.B. 2636), Sec. 1G.003, eff. April 1, 2009.Amended by: Acts 2021, 87th Leg., R.S., Ch. 141 (H.B. 1585), Sec. 19, eff. May 26, 2021.|
TX Ins Code § 1579.1061 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle H - Health Benefits and Other Coverages for Governmental Employees|Chapter 1579 - Texas School Employees Uniform Group Health Coverage|Subchapter C. Coverages|Section 1579.1061. Exemption From Preauthorization Requirements for Physicians and Health Care Providers Providing Certain Health Care Services

Sec. 1579.1061.  EXEMPTION FROM PREAUTHORIZATION REQUIREMENTS FOR PHYSICIANS AND HEALTH CARE PROVIDERS PROVIDING CERTAIN HEALTH CARE SERVICES.  A preauthorization process used by a health coverage plan provided under this chapter is subject to the same limitations and requirements provided by Subchapter N, Chapter 4201, for a preauthorization process used by an insurer.|Added by Acts 2021, 87th Leg., R.S., Ch. 1018 (H.B. 3459), Sec. 3, eff. September 1, 2021.|
TX Ins Code § 1579.107 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle H - Health Benefits and Other Coverages for Governmental Employees|Chapter 1579 - Texas School Employees Uniform Group Health Coverage|Subchapter C. Coverages|Section 1579.107. Disease Management Services

Sec. 1579.107.  DISEASE MANAGEMENT SERVICES.  (a)  In this section, "disease management services" means services to assist an individual manage a disease or other chronic health condition, such as heart disease, diabetes, respiratory illness, end-stage renal disease, HIV infection, or AIDS, and with respect to which the trustee identifies populations requiring disease management.(b)  A health coverage plan provided under this chapter must provide disease management services or coverage for disease management services in the manner required by the trustee, including:(1)  patient self-management education;(2)  provider education;(3)  evidence-based models and minimum standards of care;(4)  standardized protocols and participation criteria; and(5)  physician-directed or physician-supervised care.|Added by Acts 2007, 80th Leg., R.S., Ch. 730 (H.B. 2636), Sec. 1G.003, eff. April 1, 2009.|
TX Ins Code § 1579.108 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle H - Health Benefits and Other Coverages for Governmental Employees|Chapter 1579 - Texas School Employees Uniform Group Health Coverage|Subchapter C. Coverages|Section 1579.108. Limitations

Sec. 1579.108.  LIMITATIONS.  The trustee may not contract for or provide a health coverage plan that excludes from participation in the network a general hospital that:(1)  is located in the geographical service area or areas of the health coverage plan that includes a county that:(A)  has a population of at least 100,000 and not more than 210,000; and(B)  is located in the Texas-Louisiana border region, as that term is defined in Section 2056.002(e), Government Code; and(2)  agrees to provide medical and health care services under the plan subject to the same terms as other hospital providers under the plan.|Added by Acts 2007, 80th Leg., R.S., Ch. 730 (H.B. 2636), Sec. 1G.003, eff. April 1, 2009.Amended by: Acts 2011, 82nd Leg., R.S., Ch. 1163 (H.B. 2702), Sec. 58, eff. September 1, 2011.|
TX Ins Code § 1579.109 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle H - Health Benefits and Other Coverages for Governmental Employees|Chapter 1579 - Texas School Employees Uniform Group Health Coverage|Subchapter C. Coverages|Section 1579.109. Emergency Care Payments

Sec. 1579.109.  EMERGENCY CARE PAYMENTS.  (a)  In this section, "emergency care" has the meaning assigned by Section 1301.155.(b)  The administrator of a managed care plan provided under this chapter shall pay for covered emergency care performed by or a covered supply related to that care provided by an out-of-network provider at the usual and customary rate or at an agreed rate.  The administrator shall make a payment required by this subsection directly to the provider not later than, as applicable:(1)  the 30th day after the date the administrator receives an electronic claim for those services that includes all information necessary for the administrator to pay the claim; or(2)  the 45th day after the date the administrator receives a nonelectronic claim for those services that includes all information necessary for the administrator to pay the claim.(c)  For emergency care subject to this section or a supply related to that care, an out-of-network provider or a person asserting a claim as an agent or assignee of the provider may not bill an enrollee in, and the enrollee does not have financial responsibility for, an amount greater than an applicable copayment, coinsurance, and deductible under the enrollee's managed care plan that:(1)  is based on:(A)  the amount initially determined payable by the administrator; or(B)  if applicable, a modified amount as determined under the administrator's internal appeal process; and(2)  is not based on any additional amount determined to be owed to the provider under Chapter 1467.|Added by Acts 2019, 86th Leg., R.S., Ch. 1342 (S.B. 1264), Sec. 1.18, eff. September 1, 2019.|
TX Ins Code § 1579.110 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle H - Health Benefits and Other Coverages for Governmental Employees|Chapter 1579 - Texas School Employees Uniform Group Health Coverage|Subchapter C. Coverages|Section 1579.110. Out-of-Network Facility-Based Provider Payments

Sec. 1579.110.  OUT-OF-NETWORK FACILITY-BASED PROVIDER PAYMENTS.  (a)  In this section, "facility-based provider" means a physician or health care provider who provides health care or medical services to patients of a health care facility.(b)  Except as provided by Subsection (d), the administrator of a managed care plan provided under this chapter shall pay for a covered health care or medical service performed for or a covered supply related to that service provided to an enrollee by an out-of-network provider who is a facility-based provider at the usual and customary rate or at an agreed rate if the provider performed the service at a health care facility that is a participating provider.  The administrator shall make a payment required by this subsection directly to the provider not later than, as applicable:(1)  the 30th day after the date the administrator receives an electronic claim for those services that includes all information necessary for the administrator to pay the claim; or(2)  the 45th day after the date the administrator receives a nonelectronic claim for those services that includes all information necessary for the administrator to pay the claim.(c)  Except as provided by Subsection (d), an out-of-network provider who is a facility-based provider or a person asserting a claim as an agent or assignee of the provider may not bill an enrollee receiving a health care or medical service or supply described by Subsection (b) in, and the enrollee does not have financial responsibility for, an amount greater than an applicable copayment, coinsurance, and deductible under the enrollee's managed care plan that:(1)  is based on:(A)  the amount initially determined payable by the administrator; or(B)  if applicable, a modified amount as determined under the administrator's internal appeal process; and(2)  is not based on any additional amount determined to be owed to the provider under Chapter 1467.(d)  This section does not apply to a nonemergency health care or medical service:(1)  that an enrollee elects to receive in writing in advance of the service with respect to each out-of-network provider providing the service; and(2)  for which an out-of-network provider, before providing the service, provides a complete written disclosure to the enrollee that:(A)  explains that the provider does not have a contract with the enrollee's managed care plan;(B)  discloses projected amounts for which the enrollee may be responsible; and(C)  discloses the circumstances under which the enrollee would be responsible for those amounts.|Added by Acts 2019, 86th Leg., R.S., Ch. 1342 (S.B. 1264), Sec. 1.18, eff. September 1, 2019.|