reglab/housing_qa huggingface dataset:
TX Ins Code § 1275.003 (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 1275.003. Balance Billing Prohibition Notice

Sec. 1275.003.  BALANCE BILLING PROHIBITION NOTICE.  (a)  The administrator of a health benefit plan to which this chapter applies 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 1275.051, 1275.052, or 1275.053, as applicable;(2)  the total amount the physician or provider may bill the enrollee under the enrollee's health 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)  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 1275.051, 1275.052, or 1275.053, as applicable.|Added by Acts 2021, 87th Leg., R.S., Ch. 1034 (H.B. 3924), Sec. 1, eff. September 1, 2021.|
TX Ins Code § 1275.004 (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 1275.004. Out-of-Network Claim Dispute Resolution

Sec. 1275.004.  OUT-OF-NETWORK CLAIM DISPUTE RESOLUTION.  Chapter 1467 applies to a health benefit plan to which this chapter applies, and the administrator of a health benefit plan to which this chapter applies is an administrator for purposes of that chapter.|Added by Acts 2021, 87th Leg., R.S., Ch. 1034 (H.B. 3924), Sec. 1, eff. September 1, 2021.|
TX Ins Code § 1275.051 (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 B. Payments for Certain Services; Balance Billing Prohibitions|Section 1275.051. Emergency Care Payments

Sec. 1275.051.  EMERGENCY CARE PAYMENTS.  (a)  In this section, "emergency care" has the meaning assigned by Section 1301.155.(b)  The administrator of a health benefit plan to which this chapter applies 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 health benefit 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 2021, 87th Leg., R.S., Ch. 1034 (H.B. 3924), Sec. 1, eff. September 1, 2021.|
TX Ins Code § 1275.052 (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 B. Payments for Certain Services; Balance Billing Prohibitions|Section 1275.052. Out-of-Network Facility-Based Provider Payments

Sec. 1275.052.  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 health benefit plan to which this chapter applies 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 health benefit 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 health benefit 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 2021, 87th Leg., R.S., Ch. 1034 (H.B. 3924), Sec. 1, eff. September 1, 2021.|
TX Ins Code § 1301.002 (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 1301.002. Nonapplicability to Dental Care Benefits

Sec. 1301.002.  NONAPPLICABILITY TO DENTAL CARE BENEFITS.  This chapter does not apply to a provision for dental care benefits in a health insurance policy.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1301.003 (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 1301.003. Preferred Provider Benefit Plans and Exclusive Provider Benefit Plans Permitted

Sec. 1301.003.  PREFERRED PROVIDER BENEFIT PLANS AND EXCLUSIVE PROVIDER BENEFIT PLANS PERMITTED.  A preferred provider benefit plan or an exclusive provider benefit plan that meets the requirements of this chapter is not:(1)  unjust under Chapter 1701;(2)  unfair discrimination under Subchapter A or B, Chapter 544; or(3)  a violation of Subchapter B or C, Chapter 1451.|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. 3, eff. September 1, 2011.|
TX Ins Code § 1301.0041 (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 1301.0041. Applicability

Sec. 1301.0041.  APPLICABILITY.  (a)  Except as otherwise specifically provided by this chapter, this chapter applies to each preferred provider benefit plan in which an insurer provides, through the insurer's health insurance policy, for the payment of a level of coverage that is different depending on whether an insured uses a preferred provider or a nonpreferred provider.(b)  Unless otherwise specified, an exclusive provider benefit plan is subject to this chapter in the same manner as a preferred provider benefit plan.(c)  This chapter does not apply to:(1)  the child health plan program under Chapter 62, Health and Safety Code; or(2)  a Medicaid managed care program under Chapter 533, Government Code.|Added by Acts 2007, 80th Leg., R.S., Ch. 730 (H.B. 2636), Sec. 3B.0271(b), eff. September 1, 2007.Added by Acts 2007, 80th Leg., R.S., Ch. 921 (H.B. 3167), Sec. 9.0271(b), eff. September 1, 2007.Amended by: Acts 2011, 82nd Leg., R.S., Ch. 288 (H.B. 1772), Sec. 4, eff. September 1, 2011.|
TX Ins Code § 1301.0042 (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 1301.0042. Applicability of Insurance Law

Sec. 1301.0042.  APPLICABILITY OF INSURANCE LAW.  (a)  Except as provided by Subsection (b), a provision of this code or another insurance law of this state that applies to a preferred provider benefit plan applies to an exclusive provider benefit plan except to the extent that the commissioner determines the provision to be inconsistent with the function and purpose of an exclusive provider benefit plan.(b)  An exclusive provider benefit plan may not provide dental care benefits.|Added by Acts 2011, 82nd Leg., R.S., Ch. 288 (H.B. 1772), Sec. 5, eff. September 1, 2011.|
TX Ins Code § 1301.0045 (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 1301.0045. Construction of Chapter

Sec. 1301.0045.  CONSTRUCTION OF CHAPTER.  (a) Except as provided by Section 1301.0046, this chapter may not be construed to limit the level of reimbursement or the level of coverage, including deductibles, copayments, coinsurance, or other cost-sharing provisions, that are applicable to preferred providers or, for plans other than exclusive provider benefit plans, nonpreferred providers.(b)  Except as provided by Sections 1301.0052, 1301.0053, 1301.155, 1301.164, and 1301.165, this chapter may not be construed to require an exclusive provider benefit plan to compensate a nonpreferred provider for services provided to an insured.|Added by Acts 2005, 79th Leg., Ch. 1221 (H.B. 1030), Sec. 1, eff. September 1, 2005.Amended by: Acts 2011, 82nd Leg., R.S., Ch. 288 (H.B. 1772), Sec. 6, eff. September 1, 2011.Acts 2019, 86th Leg., R.S., Ch. 1342 (S.B. 1264), Sec. 1.05, eff. September 1, 2019.|
TX Ins Code § 1301.0046 (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 1301.0046. Coinsurance Requirements for Services of Nonpreferred Providers

Sec. 1301.0046.  COINSURANCE REQUIREMENTS FOR SERVICES OF NONPREFERRED PROVIDERS.  The insured's coinsurance applicable to payment to nonpreferred providers may not exceed 50 percent of the total covered amount applicable to the medical or health care services.  This section does not apply to an exclusive provider benefit plan.|Added by Acts 2005, 79th Leg., Ch. 1221 (H.B. 1030), Sec. 1, eff. September 1, 2005.Amended by: Acts 2011, 82nd Leg., R.S., Ch. 288 (H.B. 1772), Sec. 7, eff. September 1, 2011.|
TX Ins Code § 1301.005 (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 1301.005. Availability of Preferred Providers

Sec. 1301.005.  AVAILABILITY OF PREFERRED PROVIDERS.  (a)  An insurer offering a preferred provider benefit plan shall ensure that both preferred provider benefits and basic level benefits are reasonably available to all insureds within a designated service area. This subsection does not apply to an exclusive provider benefit plan.(b)  If services are not available through a preferred provider within a designated service area under a preferred provider benefit plan or an exclusive provider benefit plan, an insurer shall reimburse a physician or health care provider who is not a preferred provider at the same percentage level of reimbursement as a preferred provider would have been reimbursed had the insured been treated by a preferred provider.(c)  Subsection (b) does not require reimbursement at a preferred level of coverage solely because an insured resides out of the service area and chooses to receive services from a provider other than a preferred provider for the insured's own convenience.|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. 8, eff. September 1, 2011.|
TX Ins Code § 1301.0051 (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 1301.0051. Exclusive Provider Benefit Plans: Quality Improvement and Utilization Management

Sec. 1301.0051.  EXCLUSIVE PROVIDER BENEFIT PLANS: QUALITY IMPROVEMENT AND UTILIZATION MANAGEMENT.  (a) An insurer that offers an exclusive provider benefit plan shall establish procedures to ensure that health care services are provided to insureds under reasonable standards of quality of care that are consistent with prevailing professionally recognized standards of care or practice. The procedures must include:(1)  mechanisms to ensure availability, accessibility, quality, and continuity of care;(2)  subject to Section 1301.059, a continuing quality improvement program to monitor and evaluate services provided under the plan, including primary and specialist physician services and ancillary and preventive health care services, provided in institutional or noninstitutional settings;(3)  a method of recording formal proceedings of quality improvement program activities and maintaining quality improvement program documentation in a confidential manner;(4)  subject to Section 1301.059, a physician review panel to assist the insurer in reviewing medical guidelines or criteria;(5)  a patient record system that facilitates documentation and retrieval of clinical information for the insurer's evaluation of continuity and coordination of services and assessment of the quality of services provided to insureds under the plan;(6)  a mechanism for making available to the commissioner the clinical records of insureds for examination and review by the commissioner on request of the commissioner; and(7)  a specific procedure for the periodic reporting of quality improvement program activities to:(A)  the governing body and appropriate staff of the insurer; and(B)  physicians and health care providers that provide health care services under the plan.(b)  Minutes of a formal proceeding of the quality improvement program established under Subsection (a) shall be made available to the commissioner on request of the commissioner.(c)  Insured records made available to the commissioner under Subsection (a)(6) are confidential and privileged, and are not subject to Chapter 552, Government Code, or to subpoena, except to the extent necessary for the commissioner to enforce this chapter.|Added by Acts 2011, 82nd Leg., R.S., Ch. 288 (H.B. 1772), Sec. 9, eff. September 1, 2011.|
TX Ins Code § 1301.0052 (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 1301.0052. Exclusive Provider Benefit Plans: Referrals for Medically Necessary Services

Sec. 1301.0052.  EXCLUSIVE PROVIDER BENEFIT PLANS: REFERRALS FOR MEDICALLY NECESSARY SERVICES. (a) If a covered service is medically necessary and is not available through a preferred provider, the issuer of an exclusive provider benefit plan, on the request of a preferred provider, shall:(1)  approve the referral of an insured to a nonpreferred provider within a reasonable period; and(2)  fully reimburse the nonpreferred provider at the usual and customary rate or at a rate agreed to by the issuer and the nonpreferred provider.(b)  An exclusive provider benefit plan must provide for a review by a health care provider with expertise in the same specialty as or a specialty similar to the type of health care provider to whom a referral is requested under Subsection (a) before the issuer of the plan may deny the referral.|Added by Acts 2011, 82nd Leg., R.S., Ch. 288 (H.B. 1772), Sec. 9, eff. September 1, 2011.|
TX Ins Code § 1301.0053 (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 1301.0053. Exclusive Provider Benefit Plans: Emergency Care

Sec. 1301.0053.  EXCLUSIVE PROVIDER BENEFIT PLANS:  EMERGENCY CARE.  (a)  If an out-of-network provider provides emergency care as defined by Section 1301.155 to an enrollee in an exclusive provider benefit plan, the issuer of the plan shall reimburse the out-of-network provider at the usual and customary rate or at a rate agreed to by the issuer and the out-of-network provider for the provision of the services and any supply related to those services.  The insurer 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 insurer receives an electronic clean claim as defined by Section 1301.101 for those services that includes all information necessary for the insurer to pay the claim; or(2)  the 45th day after the date the insurer receives a nonelectronic clean claim as defined by Section 1301.101 for those services that includes all information necessary for the insurer to pay the claim.(b)  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 insured in, and the insured does not have financial responsibility for, an amount greater than an applicable copayment, coinsurance, and deductible under the insured's exclusive provider benefit plan that:(1)  is based on:(A)  the amount initially determined payable by the insurer; or(B)  if applicable, a modified amount as determined under the insurer's internal appeal process; and(2)  is not based on any additional amount determined to be owed to the provider under Chapter 1467.(c)  This section may not be construed to require the imposition of a penalty under Section 1301.137.|Added by Acts 2011, 82nd Leg., R.S., Ch. 288 (H.B. 1772), Sec. 9, eff. September 1, 2011.Amended by: Acts 2019, 86th Leg., R.S., Ch. 1342 (S.B. 1264), Sec. 1.06, eff. September 1, 2019.|
TX Ins Code § 1301.0055 (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 1301.0055. Network Adequacy Standards

Sec. 1301.0055.  NETWORK ADEQUACY STANDARDS.  The commissioner shall by rule adopt network adequacy standards that:(1)  are adapted to local markets in which an insurer offering a preferred provider benefit plan operates;(2)  ensure availability of, and accessibility to, a full range of contracted physicians and health care providers to provide health care services to insureds; and(3)  on good cause shown, may allow departure from local market network adequacy standards if the commissioner posts on the department's Internet website the name of the preferred provider plan, the insurer offering the plan, and the affected local market.|Added by Acts 2009, 81st Leg., R.S., Ch. 1290 (H.B. 2256), Sec. 2, eff. June 19, 2009.|
TX Ins Code § 1301.0056 (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 1301.0056. Examinations and Fees

Sec. 1301.0056.  EXAMINATIONS AND FEES.  (a)  The commissioner shall examine an insurer to determine the quality and adequacy of a network used by a preferred provider benefit plan or an exclusive provider benefit plan offered by the insurer under this chapter. An insurer is subject to a qualifying examination of the insurer's preferred provider benefit plans and exclusive provider benefit plans and subsequent quality of care and network adequacy examinations by the commissioner at least once every three years and whenever the commissioner considers an examination necessary. Documentation provided to the commissioner during an examination conducted under this section is confidential and is not subject to disclosure as public information under Chapter 552, Government Code.(b)  An insurer examined under this section shall pay the cost of the examination in an amount determined by the commissioner.(c)  The department shall collect an assessment in an amount determined by the commissioner from the insurer at the time of the examination to cover all expenses attributable directly to the examination, including the salaries and expenses of department employees and all reasonable expenses of the department necessary for the administration of this chapter.(d)  The department shall deposit an assessment collected under this section to the credit of the account described by Section 401.156(a).  Money deposited under this subsection shall be used to pay the salaries and expenses of examiners and all other expenses relating to the examination of insurers under this section.|Added by Acts 2011, 82nd Leg., R.S., Ch. 288 (H.B. 1772), Sec. 9, eff. September 1, 2011.Amended by: Acts 2019, 86th Leg., R.S., Ch. 1316 (H.B. 3911), Sec. 1, eff. September 1, 2019.|
TX Ins Code § 1301.0057 (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 1301.0057. Access to Out-of-Network Providers

Sec. 1301.0057.  ACCESS TO OUT-OF-NETWORK PROVIDERS.  An insurer may not terminate, or threaten to terminate, an insured's participation in a preferred provider benefit plan solely because the insured uses an out-of-network provider.|Added by Acts 2015, 84th Leg., R.S., Ch. 275 (H.B. 574), Sec. 5, eff. September 1, 2015.|