reglab/housing_qa huggingface dataset:
TX Ins Code § 1253.058 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle B - Group Health Coverage|Chapter 1253 - Cancellation of Group Coverage in Certain Circumstances|Subchapter B. Continuation of Group Accident and Health Insurance Policies During Labor Dispute|Section 1253.058. Premium Rate Change Not Limited

Sec. 1253.058.  PREMIUM RATE CHANGE NOT LIMITED.  (a)  This subchapter does not limit any right of the insurer under a policy to increase or decrease a premium rate before, during, or after a work stoppage if the insurer would be entitled to increase the premium rate had a work stoppage not occurred.(b)  A change in a premium rate made in accordance with this section takes effect on a date that is determined by the insurer in accordance with the terms of the policy.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1253.059 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle B - Group Health Coverage|Chapter 1253 - Cancellation of Group Coverage in Certain Circumstances|Subchapter B. Continuation of Group Accident and Health Insurance Policies During Labor Dispute|Section 1253.059. Limitations on Continuation of Coverage

Sec. 1253.059.  LIMITATIONS ON CONTINUATION OF COVERAGE.  This subchapter does not require the continuation of coverage under a policy for any loss of time benefits included in the policy or the continuation of other coverage for a period:(1)  longer than six months after a work stoppage occurs;(2)  beyond the time that 75 percent of the covered employees continue the coverage;  or(3)  as to an individual covered employee, beyond the time that the employee takes a full-time job with another employer.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1253.060 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle B - Group Health Coverage|Chapter 1253 - Cancellation of Group Coverage in Certain Circumstances|Subchapter B. Continuation of Group Accident and Health Insurance Policies During Labor Dispute|Section 1253.060. Other Provisions; Commissioner Approval Required

Sec. 1253.060.  OTHER PROVISIONS;  COMMISSIONER APPROVAL REQUIRED.  A policy may contain any other provision relating to continuation of policy coverage during a work stoppage that the commissioner approves.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1271.001 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle C - Managed Care|Chapter 1271 - Benefits Provided by Health Maintenance Organizations; Evidence of Coverage; Charges|Subchapter A. General Provisions|Section 1271.001. Applicability of Definitions

Sec. 1271.001.  APPLICABILITY OF DEFINITIONS.  In this chapter, terms defined by Section 843.002 have the meanings assigned by that section.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1271.002 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle C - Managed Care|Chapter 1271 - Benefits Provided by Health Maintenance Organizations; Evidence of Coverage; Charges|Subchapter A. General Provisions|Section 1271.002. Right to Evidence of Coverage; Issuance

Sec. 1271.002.  RIGHT TO EVIDENCE OF COVERAGE;  ISSUANCE.  (a)  Each enrollee residing in this state is entitled to evidence of coverage under a health care plan.(b)  The health maintenance organization shall issue the evidence of coverage, except as provided by Subsection (c).(c)  If the enrollee obtains coverage under a health care plan through an insurance policy or a contract issued by a group hospital service corporation, whether by option or otherwise, the insurer or the group hospital service corporation shall issue the evidence of coverage.(d)  By agreement between the health maintenance organization, insurer, or group hospital service corporation and the subscriber or person entitled to receive the evidence of coverage, policy, or contract, the evidence of coverage required by this section may be delivered electronically.|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. 11.032(a), eff. September 1, 2005.|
TX Ins Code § 1271.003 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle C - Managed Care|Chapter 1271 - Benefits Provided by Health Maintenance Organizations; Evidence of Coverage; Charges|Subchapter A. General Provisions|Section 1271.003. Evidence of Coverage Not Health Insurance Policy

Sec. 1271.003.  EVIDENCE OF COVERAGE NOT HEALTH INSURANCE POLICY.  An evidence of coverage is not a health insurance policy as that term is defined by this code.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1271.004 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle C - Managed Care|Chapter 1271 - Benefits Provided by Health Maintenance Organizations; Evidence of Coverage; Charges|Subchapter A. General Provisions|Section 1271.004. Individual Health Care Plan

Sec. 1271.004.  INDIVIDUAL HEALTH CARE PLAN.  (a)  In this section, "individual health care plan" means a health care plan:(1)  that provides health care services for individuals and their dependents;(2)  under which an enrollee:(A)  pays the premium;  and(B)  is not covered under the contract in accordance with a continuation of services or continuation of benefits requirement applicable under federal or state law;  and(3)  in which the evidence of coverage meets the requirements of the definition of "basic health care services" provided by Section 843.002.(b)  A health maintenance organization may provide an individual health care plan in accordance with this section and Section 1271.307.(c)  A health maintenance organization may limit enrollment in an individual health care plan to individuals who reside or work within the service area for the plan's network.(d)  The commissioner may adopt rules necessary to implement this section and to meet the minimum requirements of federal law, including regulations.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1271.005 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle C - Managed Care|Chapter 1271 - Benefits Provided by Health Maintenance Organizations; Evidence of Coverage; Charges|Subchapter A. General Provisions|Section 1271.005. Applicability of Other Law

Sec. 1271.005.  APPLICABILITY OF OTHER LAW.  (a)  Chapters 1368 and 1652 apply to a health maintenance organization other than a health maintenance organization that offers only a single health care service plan.(b)  Subchapter B, Chapter 1355, applies to a health maintenance organization providing benefits for mental health treatment in a residential treatment center for children and adolescents or crisis stabilization unit to the extent that:(1)  Subchapter B, Chapter 1355, does not conflict with this chapter, Chapter 843, Subchapter A, Chapter 1452, or Subchapter B, Chapter 1507; and(2)  the residential treatment center for children and adolescents or crisis stabilization unit is located within the service area of the health maintenance organization and is subject to inspection and review as required by this chapter, Chapter 843, Subchapter A, Chapter 1452, or Subchapter B, Chapter 1507, or rules adopted under this chapter, Chapter 843, Subchapter A, Chapter 1452, or Subchapter B, Chapter 1507.(c)  A health maintenance organization shall comply with Subchapter B, Chapter 542, with respect to prompt payment to an enrollee.(d)  Notwithstanding any other law, Subchapter C, Chapter 1355, applies to a group contract issued by a health maintenance organization.(e)  Notwithstanding any other law, Section 1201.062 applies to an evidence of coverage issued by a health maintenance organization.|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(b), eff. September 1, 2005.|
TX Ins Code § 1271.006 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle C - Managed Care|Chapter 1271 - Benefits Provided by Health Maintenance Organizations; Evidence of Coverage; Charges|Subchapter A. General Provisions|Section 1271.006. Benefits to Dependent Child and Grandchild

Sec. 1271.006.  BENEFITS TO DEPENDENT CHILD AND GRANDCHILD.  (a)  If children are eligible for coverage under the terms of an evidence of coverage, any limiting age applicable to an unmarried child of an enrollee, including an unmarried grandchild of an enrollee, is 25 years of age.  The limiting age applicable to a child must be stated in the evidence of coverage.(b)  A health maintenance organization may provide benefits under a health care plan to an enrollee's dependent grandchild who is living with and in the household of the enrollee.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1271.007 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle C - Managed Care|Chapter 1271 - Benefits Provided by Health Maintenance Organizations; Evidence of Coverage; Charges|Subchapter A. General Provisions|Section 1271.007. Religious Convictions

Sec. 1271.007.  RELIGIOUS CONVICTIONS.  (a)  This chapter, Chapters 843, 1272, and 1367, Subchapter A, Chapter 1452, and Subchapter B, Chapter 1507, do not require a health maintenance organization, physician, or provider to recommend, offer advice concerning, pay for, provide, assist in, perform, arrange, or participate in providing or performing any health care service that violates the religious convictions of the health maintenance organization, physician, or provider.(b)  A health maintenance organization that limits or denies health care services under this section shall state the limitations in the evidence of coverage as required by Section 1271.052.|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(c), eff. September 1, 2005.|
TX Ins Code § 1271.008 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle C - Managed Care|Chapter 1271 - Benefits Provided by Health Maintenance Organizations; Evidence of Coverage; Charges|Subchapter A. General Provisions|Section 1271.008. Balance Billing Prohibition Notice

Sec. 1271.008.  BALANCE BILLING PROHIBITION NOTICE.  (a)  A health maintenance organization shall provide written notice in accordance with this section in an explanation of benefits provided to the enrollee and the physician or provider in connection with a health care service or supply provided by a non-network physician or provider.  The notice must include:(1)  a statement of the billing prohibition under Section 1271.155, 1271.157, or 1271.158, 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)  A health maintenance organization 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 health maintenance organization makes a payment under Section 1271.155, 1271.157, or 1271.158, as applicable.|Added by Acts 2019, 86th Leg., R.S., Ch. 1342 (S.B. 1264), Sec. 1.02, eff. September 1, 2019.|
TX Ins Code § 1271.051 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle C - Managed Care|Chapter 1271 - Benefits Provided by Health Maintenance Organizations; Evidence of Coverage; Charges|Subchapter B. Contents of Evidence of Coverage|Section 1271.051. Evidence of Coverage: Contract and Certificate Requirements

Sec. 1271.051.  EVIDENCE OF COVERAGE:  CONTRACT AND CERTIFICATE REQUIREMENTS.  (a)  An evidence of coverage that is a contract must contain a clear and complete statement of the information required by Sections 1271.052, 1271.053, and 1271.054.(b)  An evidence of coverage that is a certificate must contain a reasonably complete facsimile of the information required by Sections 1271.052, 1271.053, and 1271.054.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1271.052 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle C - Managed Care|Chapter 1271 - Benefits Provided by Health Maintenance Organizations; Evidence of Coverage; Charges|Subchapter B. Contents of Evidence of Coverage|Section 1271.052. Information About Benefits and Limitations

Sec. 1271.052.  INFORMATION ABOUT BENEFITS AND LIMITATIONS.  An evidence of coverage must state:(1)  the health care services, limited health care services, or single health care service to which the enrollee is entitled under the health care plan, limited health care service plan, or single health care service plan;(2)  the issuance of other benefits, if any, to which the enrollee is entitled under the health care plan, limited health care service plan, or single health care service plan;  and(3)  any limitation on the services, kinds of services, benefits, or kinds of benefits to be provided, including any deductible or copayment feature.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1271.053 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle C - Managed Care|Chapter 1271 - Benefits Provided by Health Maintenance Organizations; Evidence of Coverage; Charges|Subchapter B. Contents of Evidence of Coverage|Section 1271.053. Information About Obtaining Services

Sec. 1271.053.  INFORMATION ABOUT OBTAINING SERVICES.  An evidence of coverage must indicate where and in what manner information is available about how to obtain services.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1271.054 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle C - Managed Care|Chapter 1271 - Benefits Provided by Health Maintenance Organizations; Evidence of Coverage; Charges|Subchapter B. Contents of Evidence of Coverage|Section 1271.054. Information About Complaints and Appeals

Sec. 1271.054.  INFORMATION ABOUT COMPLAINTS AND APPEALS.  (a)  An evidence of coverage must contain a clear and understandable description of the health maintenance organization's methods for resolving enrollee complaints, including:(1)  the enrollee's right to appeal denial of an adverse determination to an independent review organization;  and(2)  the procedures for appealing to an independent review organization.(b)  A health maintenance organization may indicate a subsequent change to the methods for resolving enrollee complaints in a separate document issued to the enrollee.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1271.055 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle C - Managed Care|Chapter 1271 - Benefits Provided by Health Maintenance Organizations; Evidence of Coverage; Charges|Subchapter B. Contents of Evidence of Coverage|Section 1271.055. Out-of-Network Services

Sec. 1271.055.  OUT-OF-NETWORK SERVICES.  (a)  An evidence of coverage must contain a provision regarding non-network physicians and providers in accordance with the requirements of this section.(b)  If medically necessary covered services are not available through network physicians or providers, the health maintenance organization, on the request of a network physician or provider and within a reasonable period, shall:(1)  allow referral to a non-network physician or provider;  and(2)  fully reimburse the non-network physician or provider at the usual and customary rate or at an agreed rate.(c)  Before denying a request for a referral to a non-network physician or provider, a health maintenance organization must provide for a review conducted by a specialist of the same or similar type of specialty as the physician or provider to whom the referral is requested.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1271.056 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle C - Managed Care|Chapter 1271 - Benefits Provided by Health Maintenance Organizations; Evidence of Coverage; Charges|Subchapter B. Contents of Evidence of Coverage|Section 1271.056. Unfair or Deceptive Provisions and Statements Prohibited

Sec. 1271.056.  UNFAIR OR DECEPTIVE PROVISIONS AND STATEMENTS PROHIBITED.  An evidence of coverage may not contain a provision or statement that:(1)  is unjust, unfair, inequitable, misleading, or deceptive;(2)  encourages misrepresentation;  or(3)  is untrue, misleading, or deceptive within the meaning of Section 843.204.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1271.057 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle C - Managed Care|Chapter 1271 - Benefits Provided by Health Maintenance Organizations; Evidence of Coverage; Charges|Subchapter B. Contents of Evidence of Coverage|Section 1271.057. Discretionary Clauses Prohibited

Sec. 1271.057.  DISCRETIONARY CLAUSES PROHIBITED.  (a) An evidence of coverage may not contain a discretionary clause provision.(b)  A discretionary clause provision includes a provision that:(1)  purports or acts to bind the enrollee to, or grant deference in subsequent proceedings to, adverse eligibility or benefit decisions or interpretations of the evidence of coverage by the health maintenance organization; or(2)  specifies:(A)  that an enrollee or other claimant may not contest or appeal a denial of a benefit;(B)  that the health maintenance organization's interpretation of the terms of an evidence of coverage or other form or its decision to deny coverage or the amount of benefits is binding on an enrollee or other claimant;(C)  that in an appeal, the health maintenance organization's decision-making power as to the interpretation of the terms of an evidence of coverage or other form, or as to coverage, is binding; or(D)  a standard of review in any appeal process that gives deference to the original benefit decision or provides standards of interpretation or review that are inconsistent with the laws of this state, including the common law.|Added by Acts 2011, 82nd Leg., R.S., Ch. 560 (H.B. 3017), Sec. 1, eff. June 17, 2011.|
TX Ins Code § 1271.101 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle C - Managed Care|Chapter 1271 - Benefits Provided by Health Maintenance Organizations; Evidence of Coverage; Charges|Subchapter C. Commissioner Approval|Section 1271.101. Approval of Form of Evidence of Coverage or Group Contract

Sec. 1271.101.  APPROVAL OF FORM OF EVIDENCE OF COVERAGE OR GROUP CONTRACT.  (a)  An evidence of coverage or an amendment of an evidence of coverage may not be issued or delivered to a person in this state until the form of the evidence of coverage or amendment has been filed with and approved by the commissioner.(b)  Except as provided by Subsection (c), the form of an evidence of coverage or group contract to be used in this state or an amendment to one of those forms is subject to the filing and approval requirements of Section 1271.102.(c)  If the form of an evidence of coverage or group contract or of an amendment to one of those forms is subject to the jurisdiction of the commissioner under laws governing health insurance or group hospital service corporations, the filing and approval provisions of those laws apply to that form.  However, Subchapters B and E apply to that form to the extent that laws governing health insurance or group hospital service corporations do not apply to the requirements of Subchapters B and E.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1271.102 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle C - Managed Care|Chapter 1271 - Benefits Provided by Health Maintenance Organizations; Evidence of Coverage; Charges|Subchapter C. Commissioner Approval|Section 1271.102. Procedures for Approval of Form of Evidence of Coverage or Group Contract; Withdrawal of Approval

Sec. 1271.102.  PROCEDURES FOR APPROVAL OF FORM OF EVIDENCE OF COVERAGE OR GROUP CONTRACT;  WITHDRAWAL OF APPROVAL.  (a)  The commissioner shall, within a reasonable period, approve the form of an evidence of coverage or group contract or an amendment to one of those forms if the form meets the requirements of this chapter.(b)  If the commissioner does not disapprove a form before the 31st day after the date the form is filed, the form is considered approved.  The commissioner may, by written notice, extend the period for approval or disapproval as necessary for proper consideration of the filing for not more than an additional 30 days.(c)  If the commissioner disapproves a form, the commissioner shall notify the person who filed the form of the reason for the disapproval.(d)  A hearing on the disapproval of a form shall be granted not later than the 30th day after the date the person filing the form makes a written request for a hearing.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1271.103 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle C - Managed Care|Chapter 1271 - Benefits Provided by Health Maintenance Organizations; Evidence of Coverage; Charges|Subchapter C. Commissioner Approval|Section 1271.103. Withdrawal of Approval of Form

Sec. 1271.103.  WITHDRAWAL OF APPROVAL OF FORM.  (a)  After notice and opportunity for hearing, the commissioner may withdraw approval of the form of an evidence of coverage or group contract or an amendment to one of those forms if the commissioner determines that the form violates this chapter, Chapter 843, 1272, or 1367, Subchapter A, Chapter 1452, or Subchapter B, Chapter 1507, or a rule adopted by the commissioner.(b)  If the commissioner withdraws approval of a form under this section, the form may not be issued until it is approved.|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(d), eff. September 1, 2005.|
TX Ins Code § 1271.104 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle C - Managed Care|Chapter 1271 - Benefits Provided by Health Maintenance Organizations; Evidence of Coverage; Charges|Subchapter C. Commissioner Approval|Section 1271.104. Information Required by Commissioner

Sec. 1271.104.  INFORMATION REQUIRED BY COMMISSIONER.  The commissioner may require the submission of any relevant information the commissioner considers necessary in determining whether to approve or disapprove a filing under this subchapter.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|