reglab/housing_qa huggingface dataset:
TX Ins Code § 1301.138 (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 C. -1. Other Provisions Relating to Payment of Claims|Section 1301.138. Applicability to Entities Contracting With Insurer

Sec. 1301.138.  APPLICABILITY TO ENTITIES CONTRACTING WITH INSURER.  This subchapter applies to a person described by Section 1301.109.|Added by Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.037(b), eff. September 1, 2005.|
TX Ins Code § 1301.139 (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 C. -1. Other Provisions Relating to Payment of Claims|Section 1301.139. Legislative Declaration

Sec. 1301.139.  LEGISLATIVE DECLARATION.  It is the intent of the legislature that the requirements contained in this subchapter regarding payment of claims to preferred providers who are pharmacists or pharmacies apply to all insurers and pharmacy benefit managers unless otherwise prohibited by federal law.|Added by Acts 2011, 82nd Leg., R.S., Ch. 798 (H.B. 2292), Sec. 12, eff. September 1, 2011.|
TX Ins Code § 1301.151 (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 D. Relations Between Insureds and Preferred Providers|Section 1301.151. Insured's Right to Treatment

Sec. 1301.151.  INSURED'S RIGHT TO TREATMENT.  Each insured is entitled to treatment and diagnostic techniques that are prescribed by the physician or health care provider included in the preferred provider benefit plan.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1301.152 (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 D. Relations Between Insureds and Preferred Providers|Section 1301.152. Continuing Care in General

Sec. 1301.152.  CONTINUING CARE IN GENERAL.  (a)  An insurer shall establish reasonable procedures for ensuring a transition of insureds to physicians or health care providers and for continuity of treatment.(b)  An insurer shall:(1)  provide, subject to Section 1301.160, reasonable advance notice to an insured of the impending termination of the participation in the plan of a physician or health care provider who is currently treating the insured;  and(2)  in the event of termination of a preferred provider's participation in the plan, make available to the insured a current listing of preferred providers.(c)  A contract between an insurer and a physician or health care provider must include a procedure for resolving disputes regarding the necessity for continued treatment by the physician or provider.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1301.153 (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 D. Relations Between Insureds and Preferred Providers|Section 1301.153. Continuity of Care

Sec. 1301.153.  CONTINUITY OF CARE.  (a)  In this section:(1)  "Life-threatening" means a disease or condition for which the likelihood of death is probable unless the course of the disease or condition is interrupted.(2)  "Special circumstances" means a condition regarding which the treating physician or health care provider reasonably believes that discontinuing care by the treating physician or provider could cause harm to the insured.  Examples of an insured who has a special circumstance include an insured with a disability, acute condition, or life-threatening illness or an insured who is past the 24th week of pregnancy.(b)  Each contract between an insurer and a physician or health care provider must provide that the termination of the physician's or provider's participation in a preferred provider benefit plan, except for reason of medical competence or professional behavior, does not:(1)  release the physician or health care provider from the generally recognized obligation to:(A)  treat an insured whom the physician or provider is currently treating;  and(B)  cooperate in arranging for appropriate referrals;  or(2)  release the insurer from the obligation to reimburse the physician or health care provider or, if applicable, the insured, at the same preferred provider rate if, at the time a physician's or provider's participation is terminated, an insured whom the physician or provider is currently treating has special circumstances in accordance with the dictates of medical prudence.(c)  The treating physician or health care provider shall identify a special circumstance.  The treating physician or health care provider shall:(1)  request that the insured be permitted to continue treatment under the physician's or provider's care;  and(2)  agree not to seek payment from the insured of any amount for which the insured would not be responsible if the physician or provider were still a preferred provider.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1301.154 (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 D. Relations Between Insureds and Preferred Providers|Section 1301.154. Obligation for Continuity of Care of Insurer

Sec. 1301.154.  OBLIGATION FOR CONTINUITY OF CARE OF INSURER.  (a)  Except as provided by Subsection (b), Sections 1301.152 and 1301.153 do not extend an insurer's obligation to reimburse the terminated physician or provider or, if applicable, the insured at the preferred provider level of coverage for ongoing treatment of an insured after:(1)  the 90th day after the effective date of the termination;  or(2)  if the insured has been diagnosed as having a terminal illness at the time of the termination, the expiration of the nine-month period after the effective date of the termination.(b)  If an insured is past the 24th week of pregnancy at the time of termination, an insurer's obligation to reimburse, at the preferred provider level of coverage, the physician or provider or, if applicable, the insured, extends through delivery of the child, immediate postpartum care, and the follow-up checkup within the six-week period after delivery.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1301.156 (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 D. Relations Between Insureds and Preferred Providers|Section 1301.156. Payment of Claims to Insured

Sec. 1301.156.  PAYMENT OF CLAIMS TO INSURED.  An insurer shall comply with Subchapter B, Chapter 542, with respect to prompt payment to insureds.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1301.157 (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 D. Relations Between Insureds and Preferred Providers|Section 1301.157. Plain Language Requirements

Sec. 1301.157.  PLAIN LANGUAGE REQUIREMENTS.  Each health insurance policy, health benefit plan certificate, endorsement, amendment, application, or rider must:(1)  be written in plain language;(2)  be in a readable and understandable format;  and(3)  comply with all applicable requirements relating to minimum readability requirements.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1301.158 (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 D. Relations Between Insureds and Preferred Providers|Section 1301.158. Information Concerning Preferred Provider Benefit Plans

Sec. 1301.158.  INFORMATION CONCERNING PREFERRED PROVIDER BENEFIT PLANS.  (a)  In this section, "prospective insured" means:(1)  for group coverage, an individual or an individual's dependent who is eligible for coverage under a health insurance policy issued to the group;  or(2)  for individual coverage, an individual or an individual's dependent who is eligible for coverage and who has expressed an interest in purchasing an individual health insurance policy.(b)  An insurer shall provide to a current or prospective group contract holder or current or prospective insured on request an accurate written description of the terms of the health insurance policy to allow the current or prospective group contract holder or current or prospective insured to make comparisons and an informed decision before selecting among health care plans.  The description must be in a readable and understandable format as prescribed by the commissioner and must include a current list of preferred providers.  The insurer may satisfy this requirement by providing its handbook if:(1)  the handbook's content is substantively similar to and achieves the same level of disclosure as the written description prescribed by the commissioner;  and(2)  the current list of preferred providers is provided.(c)  An insurer or an agent or representative of an insurer may not use or distribute, or permit the use or distribution of, information for prospective insureds that is untrue or misleading.(d)  An insurer shall provide to an insured on request information on:(1)  whether a physician or other health care provider is a participating provider in the insurer's preferred provider network;(2)  whether proposed health care services are covered by the health insurance policy;(3)  what the insured's personal responsibility will be for payment of applicable copayment or deductible amounts; and(4)  coinsurance amounts owed based on the provider's contracted rate for in-network services or the insurer's usual and customary reimbursement rate for out-of-network services.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.Amended by: Acts 2007, 80th Leg., R.S., Ch. 997 (S.B. 1731), Sec. 14, eff. September 1, 2007.|
TX Ins Code § 1301.1581 (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 D. Relations Between Insureds and Preferred Providers|Section 1301.1581. Information Concerning Exclusive Provider Benefit Plans

Sec. 1301.1581.  INFORMATION CONCERNING EXCLUSIVE PROVIDER BENEFIT PLANS.  (a) In this section, "prospective insured" has the meaning assigned by Section 1301.158.(b)  In addition to the information required to be provided under Section 1301.158, an insurer that offers an exclusive provider benefit plan shall provide to a current or prospective group contract holder or current or prospective insured notice that the benefit plan includes limited coverage for services provided by a physician or health care provider that is not a preferred provider.(c)  An identification card or similar document issued by an insurer to an insured in an exclusive provider benefit plan must display:(1)  the first date on which the insured became insured under the plan;(2)  a toll-free number that a physician or health care provider may use to obtain the date on which the insured became insured under the plan; and(3)  the acronym "EPO" or the phrase "Exclusive Provider Organization" on the card in a location of the insurer's choice.|Added by Acts 2011, 82nd Leg., R.S., Ch. 288 (H.B. 1772), Sec. 10, eff. September 1, 2011.|
TX Ins Code § 1301.159 (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 D. Relations Between Insureds and Preferred Providers|Section 1301.159. Annual List of Preferred Providers

Sec. 1301.159.  ANNUAL LIST OF PREFERRED PROVIDERS.  A current list of preferred providers shall be provided to each insured at least annually.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1301.1591 (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 D. Relations Between Insureds and Preferred Providers|Section 1301.1591. Preferred Provider Information on Internet

Sec. 1301.1591.  PREFERRED PROVIDER INFORMATION ON INTERNET.  (a)  An insurer subject to this chapter that maintains an Internet site shall list on the Internet site the preferred providers, including, if appropriate, mental health providers and substance abuse treatment providers, that insureds may use in accordance with the terms of the insured's preferred provider benefit plan.  The listing must identify those preferred providers who continue to be available to provide services to new patients or clients.(b)  The insurer shall update at least quarterly an Internet site subject to this section.(c)  The commissioner may adopt rules as necessary to implement this section.  The rules may govern the form and content of the information required to be provided under Subsection (a).(d)  Notwithstanding any other provision of this chapter, this section applies to an entity subject to Chapter 941 or 942 and to a multiple employer welfare arrangement that holds a certificate of authority under Chapter 846.|Added by Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.036(a), eff. September 1, 2005.|
TX Ins Code § 1301.160 (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 D. Relations Between Insureds and Preferred Providers|Section 1301.160. Notification of Termination of Participation of Preferred Provider

Sec. 1301.160.  NOTIFICATION OF TERMINATION OF PARTICIPATION OF PREFERRED PROVIDER.  (a)  If a practitioner's participation in a preferred provider benefit plan is terminated for a reason other than at the practitioner's request, an insurer may not notify insureds of the termination until the later of:(1)  the effective date of the termination;  or(2)  the time at which a review panel makes a formal recommendation regarding the termination.(b)  A physician or health care provider that voluntarily terminates the physician's or provider's participation in a preferred provider benefit plan shall provide reasonable notice to each insured under the physician's or provider's care.  The insurer shall provide assistance to the physician or provider in ensuring that the notice requirements of this subsection are met.(c)  If a practitioner's participation in a preferred provider benefit plan is terminated for reasons related to imminent harm, an insurer may notify insureds immediately.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1301.161 (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 D. Relations Between Insureds and Preferred Providers|Section 1301.161. Retaliation Against Insured Prohibited

Sec. 1301.161.  RETALIATION AGAINST INSURED PROHIBITED.  An insurer may not engage in any retaliatory action against an insured, including canceling or refusing to renew a health insurance policy, because the insured or a person acting on the insured's behalf has:(1)  filed a complaint against the insurer or against a preferred provider;  or(2)  appealed a decision of the insurer.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1301.162 (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 D. Relations Between Insureds and Preferred Providers|Section 1301.162. Identification Card

Sec. 1301.162.  IDENTIFICATION CARD.  An identification card or other similar document issued by an insurer regulated by this code and subject to this chapter to an individual insured must display:(1)  the first date on which the individual became insured under the plan; or(2)  a toll-free number a physician or health care provider may use to obtain that date.|Added by Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.037(e), eff. September 1, 2005.|
TX Ins Code § 1301.163 (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 D. Relations Between Insureds and Preferred Providers|Section 1301.163. Applicability of Subchapter to Entities Contracting With Insurer

Sec. 1301.163.  APPLICABILITY OF SUBCHAPTER TO ENTITIES CONTRACTING WITH INSURER.  This subchapter applies to a person to whom an insurer contracts to:(1)  process or pay claims;(2)  obtain the services of physicians or other providers to provide health care services to enrollees; or(3)  issue verifications or preauthorizations.|Added by Acts 2007, 80th Leg., R.S., Ch. 997 (S.B. 1731), Sec. 15, eff. September 1, 2007.|
TX Ins Code § 1301.164 (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 D. Relations Between Insureds and Preferred Providers|Section 1301.164. Out-of-Network Facility-Based Providers

Sec. 1301.164.  OUT-OF-NETWORK FACILITY-BASED PROVIDERS.  (a)  In this section, "facility-based provider" means a physician or health care provider who provides medical care or health care services to patients of a health care facility.(b)  Except as provided by Subsection (d), an insurer shall pay for a covered medical care or health care service performed for or a covered supply related to that service provided to an insured 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 preferred provider.  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.(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 insured receiving a medical care or health care service or supply described by Subsection (b) in, and the insured does not have financial responsibility for, an amount greater than an applicable copayment, coinsurance, and deductible under the insured's preferred 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.(d)  This section does not apply to a nonemergency health care or medical service:(1)  that an insured 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 insured that:(A)  explains that the provider does not have a contract with the insured's preferred provider benefit plan;(B)  discloses projected amounts for which the insured may be responsible; and(C)  discloses the circumstances under which the insured would be responsible for those amounts.(e)  This section may not be construed to require the imposition of a penalty under Section 1301.137.|Added by Acts 2019, 86th Leg., R.S., Ch. 1342 (S.B. 1264), Sec. 1.09, eff. September 1, 2019.|
TX Ins Code § 1301.201 (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 E. Certain Health Care Providers|Section 1301.201. Contracts With and Reimbursement for Nurse First Assistants

Sec. 1301.201.  CONTRACTS WITH AND REIMBURSEMENT FOR NURSE FIRST ASSISTANTS.  A preferred provider may not refuse to:(1)  contract with a nurse first assistant, as defined by Section 301.1525, Occupations Code, to be included in the provider's network;  or(2)  reimburse the nurse first assistant for a covered service that a physician has requested the nurse first assistant to perform.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1301.202 (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 E. Certain Health Care Providers|Section 1301.202. Contracts With Hospitals

Sec. 1301.202.  CONTRACTS WITH HOSPITALS.  (a)  An insurer that contracts with hospitals to provide services to insureds under a preferred provider benefit plan may not deny a hospital the opportunity to participate in providing health care services as a preferred provider solely because the hospital is not accredited by the Joint Commission on Accreditation of Healthcare Organizations or another specified national accrediting body. If a hospital is certified by the Medicare program, Title XVIII of the Social Security Act (42 U.S.C. Section 1395 et seq.), or accredited by the Joint Commission on Accreditation of Healthcare Organizations or another national accrediting body, an insurer shall accept that certification or accreditation.(b)  This section does not limit an insurer's authority to establish other reasonable terms under which a hospital may provide health care services to individuals covered by a preferred provider benefit plan.(c)  On the request of a hospital, the commissioner shall conduct an investigation, review, hearing, or other proceeding to determine whether an insurer is complying with this section.(d)  The commissioner shall take reasonable action to ensure compliance with this section, including issuing orders and imposing sanctions.|Added by Acts 2005, 79th Leg., Ch. 1305 (H.B. 2999), Sec. 1, eff. June 18, 2005.|
TX Ins Code § 1305.001 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle D - Provider Plans|Chapter 1305 - Workers' Compensation Health Care Networks|Subchapter A. General Provisions|Section 1305.001. Short Title

Sec. 1305.001.  SHORT TITLE.  This chapter may be cited as the Workers' Compensation Health Care Network Act.|Added by Acts 2005, 79th Leg., Ch. 265 (H.B. 7), Sec. 4.02, eff. September 1, 2005.|