reglab/housing_qa huggingface dataset:
TX Ins Code § 1451.154 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle F - Physicians and Health Care Providers|Chapter 1451 - Access to Certain Practitioners and Facilities|Subchapter D. Access to Optometrists and Ophthalmologists Used Under Managed Care Plan|Section 1451.154. Participation of Therapeutic Optometrist

Sec. 1451.154.  PARTICIPATION OF THERAPEUTIC OPTOMETRIST.  (a)  In this section:(1)  "Medical panel" means the health care practitioners who are listed as participating providers in a managed care plan or who a patient seeking diagnosis or treatment of a medical disease, disorder, or condition is encouraged or required to use under a managed care plan.(2)  "Vision panel" means the optometrists, therapeutic optometrists, and ophthalmologists who are listed as participating providers for routine eye examinations under a managed care plan or who a patient seeking a routine eye examination is encouraged or required to use under a managed care plan.(b)  A managed care plan must allow a therapeutic optometrist who is on one or more of the plan's vision panels to be a fully participating provider on the plan's medical panels to the full extent of the therapeutic optometrist's license to practice therapeutic optometry.(c)  A therapeutic optometrist who is included in a managed care plan's medical panels under Subsection (b) must:(1)  abide by the terms and conditions of the managed care plan;(2)  satisfy the managed care plan's credentialing standards for therapeutic optometrists;(3)  provide proof that the Texas Optometry Board considers the therapeutic optometrist's license to practice therapeutic optometry to be in good standing; and(4)  comply with the requirements of the Controlled Substances Registration Program operated by the Department of Public Safety.(d)  A managed care plan may charge a participating therapeutic optometrist:(1)  any reasonable credentialing costs associated with the therapeutic optometrist's being included in the managed care plan's medical panel; and(2)  a one-time administrative fee not to exceed $200 for expenses incurred in adding the therapeutic optometrist to the managed care plan's medical panel.|Added by Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.044(a), eff. September 1, 2005.|
TX Ins Code § 1451.155 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle F - Physicians and Health Care Providers|Chapter 1451 - Access to Certain Practitioners and Facilities|Subchapter D. Access to Optometrists and Ophthalmologists Used Under Managed Care Plan|Section 1451.155. Contracts With Optometrists or Therapeutic Optometrists

Sec. 1451.155.  CONTRACTS WITH OPTOMETRISTS OR THERAPEUTIC OPTOMETRISTS.  (a)  In this section:(1)  "Covered product or service" means a vision care product or service for which reimbursement is available under an enrollee's managed care plan contract or for which reimbursement is available subject to a contractual limitation, including:(A)  a deductible;(B)  a copayment;(C)  coinsurance;(D)  a waiting period;(E)  an annual or lifetime maximum limit;(F)  a frequency limitation; or(G)  an alternative benefit payment.(2)  "Vision care product or service" means a product or service provided within the scope of the practice of optometry or therapeutic optometry under Chapter 351, Occupations Code.(b)  A contract between an insurer and an optometrist or therapeutic optometrist may not limit the fee the optometrist or therapeutic optometrist may charge for a product or service that is not a covered product or service.(c)  A contract between an insurer and an optometrist or therapeutic optometrist may not require a discount on a product or service that is not a covered product or service.|Added by Acts 2013, 83rd Leg., R.S., Ch. 755 (S.B. 632), Sec. 1, eff. September 1, 2013.|
TX Ins Code § 1451.156 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle F - Physicians and Health Care Providers|Chapter 1451 - Access to Certain Practitioners and Facilities|Subchapter D. Access to Optometrists and Ophthalmologists Used Under Managed Care Plan|Section 1451.156. Prohibited Conduct

Sec. 1451.156.  PROHIBITED CONDUCT.  (a)  A managed care plan, as described by Section 1451.152(a), may not directly or indirectly:(1)  control or attempt to control the professional judgment, manner of practice, or practice of an optometrist or therapeutic optometrist;(2)  employ an optometrist or therapeutic optometrist to provide a vision care product or service as defined by Section 1451.155;(3)  pay an optometrist or therapeutic optometrist for a service not provided;(4)  restrict or limit an optometrist's or therapeutic optometrist's choice of sources or suppliers of services or materials, including optical laboratories used by the optometrist or therapeutic optometrist to provide services or materials to a patient; or(5)  require an optometrist or therapeutic optometrist to disclose a patient's confidential or protected health information unless the disclosure is authorized by the patient or permitted without authorization under the Health Insurance Portability and Accountability Act of 1996 (42 U.S.C. Section 1320d et seq.) or under Section 602.053.(b)  Subsection (a)(2) does not prohibit a managed care plan from employing an optometrist or therapeutic optometrist for utilization review or for operations of the managed care plan.(c)  Subsection (a)(3) does not prohibit the use of capitation as a method of payment.(d)  Subsection (a)(4) does not restrict or limit a managed care plan's determination of specific amounts of coverage or reimbursement for the use of network or out-of-network suppliers or laboratories.(e)  An optometrist or therapeutic optometrist must disclose to a patient any business interest the optometrist or therapeutic optometrist has in an out-of-network supplier or manufacturer to which the optometrist or therapeutic optometrist refers the patient.(f)  This section shall be liberally construed to prevent managed care plans from controlling or attempting to control the professional judgment, manner of practice, or practice of an optometrist or therapeutic optometrist.|Added by Acts 2015, 84th Leg., R.S., Ch. 1271 (S.B. 684), Sec. 3, eff. September 1, 2015.|
TX Ins Code § 1451.201 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle F - Physicians and Health Care Providers|Chapter 1451 - Access to Certain Practitioners and Facilities|Subchapter E. Dental Care Benefits in Health Insurance Policies or Employee Benefit Plans|Section 1451.201. Definitions

Sec. 1451.201.  DEFINITIONS.  In this subchapter:(1)  "Dental care service" means a service provided to a person to prevent, alleviate, cure, or heal a human dental illness or injury.(2)  "Employee benefit plan" means a plan, fund, or program established or maintained by an employer or employee organization.(3)  "Health insurance policy" means any individual, group, blanket, or franchise insurance policy, insurance agreement, or group hospital service contract.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1451.202 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle F - Physicians and Health Care Providers|Chapter 1451 - Access to Certain Practitioners and Facilities|Subchapter E. Dental Care Benefits in Health Insurance Policies or Employee Benefit Plans|Section 1451.202. Applicability and Construction of Subchapter

Sec. 1451.202.  APPLICABILITY AND CONSTRUCTION OF SUBCHAPTER.  (a)  This subchapter applies only to an employee benefit plan or health insurance policy delivered, issued for delivery, renewed, or contracted for in this state to the extent that:(1)  the employee benefit plan is established or maintained to provide dental care services, through insurance or otherwise, for the plan's participants or the beneficiaries of the plan's participants;  or(2)  the health insurance policy provides benefits for dental care services.(b)  This subchapter does not apply to a health maintenance organization governed by Chapter 843.(c)  The exemptions and exceptions of Sections 881.002 and 881.004 and Article 21.41 do not apply to this subchapter.(d)  This subchapter does not require an employee benefit plan or health insurance policy to provide any type of benefits for dental care expenses.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1451.203 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle F - Physicians and Health Care Providers|Chapter 1451 - Access to Certain Practitioners and Facilities|Subchapter E. Dental Care Benefits in Health Insurance Policies or Employee Benefit Plans|Section 1451.203. Conflicting Provisions

Sec. 1451.203.  CONFLICTING PROVISIONS.  A provision of an employee benefit plan or health insurance policy that conflicts with this subchapter is void to the extent of the conflict.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1451.204 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle F - Physicians and Health Care Providers|Chapter 1451 - Access to Certain Practitioners and Facilities|Subchapter E. Dental Care Benefits in Health Insurance Policies or Employee Benefit Plans|Section 1451.204. Certain Conduct Permitted

Sec. 1451.204.  CERTAIN CONDUCT PERMITTED.  (a)  Notwithstanding any other provision of this subchapter, a dentist may contract directly with a patient to provide dental care services to the patient as authorized by law.(b)  Notwithstanding any other provision of this subchapter, a person providing a health insurance policy or employee benefit plan or an employer or an employee organization may:(1)  make information available to its insureds, beneficiaries, participants, employees, or members regarding dental care services through the distribution of factually accurate information about dental care services and the rates, fees, locations, and hours for the services if the information is distributed on the request of a dentist;(2)  establish an administrative mechanism to facilitate payments for dental care services from an insured, beneficiary, participant, employee, or member to a dentist chosen by the insured, beneficiary, participant, employee, or member;  or(3)  nondiscriminatorily pay or reimburse its insured, beneficiary, participant, employee, or member for the cost of dental care services provided by a dentist chosen by the insured, beneficiary, participant, employee, or member.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1451.205 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle F - Physicians and Health Care Providers|Chapter 1451 - Access to Certain Practitioners and Facilities|Subchapter E. Dental Care Benefits in Health Insurance Policies or Employee Benefit Plans|Section 1451.205. Disclosure of Benefit Terms

Sec. 1451.205.  DISCLOSURE OF BENEFIT TERMS.  (a)  An employee benefit plan or health insurance policy shall:(1)  if applicable, disclose that the benefit for dental care services offered is limited to the least costly treatment; and(2)  specify in dollars and cents the amount of the payment or reimbursement to be provided for dental care services or define and explain the standard on which payment of benefits or reimbursement for the cost of dental care services is based, such as:(A)  "usual and customary" fees;(B)  "reasonable and customary" fees;(C)  "usual, customary, and reasonable" fees; or(D)  words of similar meaning.(b)  A person or entity who provides or issues an employee benefit plan or health insurance policy or the employer or employee organization, if applicable, shall establish an Internet website to provide resources and information to dentists, insureds, participants, employees, and members.(c)  An employee benefit plan or health insurance policy provider or issuer shall make accessible on the Internet website established under Subsection (b) information about the plan or policy sufficient for patients and dentists to determine the type of dental care services covered by the plan or policy, the percentage of the allowed charges for a covered service that will be paid or reimbursed under the plan or policy, and, for a contracting provider dentist, an estimate of the amount of the payment or reimbursement available for the provider's services under the plan or policy.  Access to the Internet website must be at no charge to patients under the plan or policy and dentists providing dental care services to the patients.(d)  An employee benefit plan or health insurance policy provider or issuer is not required to comply with Subsection (b) or (c) for a plan or policy that:(1)  provides for payment of the benefit for dental care services under the plan or policy:(A)  as an indemnity benefit based on a fixed schedule, regardless of the cost of the dental care service;(B)  on a cash-payment-only basis;(C)  directly to the beneficiary of the plan or policy or to the beneficiary's assigns; and(D)  regardless of other coverage; and(2)  does not provide for a copayment, a deductible, a network, or contracting provider dentists.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.Amended by: Acts 2019, 86th Leg., R.S., Ch. 1290 (H.B. 2486), Sec. 1, eff. September 1, 2019.|
TX Ins Code § 1451.206 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle F - Physicians and Health Care Providers|Chapter 1451 - Access to Certain Practitioners and Facilities|Subchapter E. Dental Care Benefits in Health Insurance Policies or Employee Benefit Plans|Section 1451.206. Payment or Reimbursement of Dentist

Sec. 1451.206.  PAYMENT OR REIMBURSEMENT OF DENTIST.  (a)  The employee benefit plan or health insurance policy shall:(1)  provide:(A)  that payment or reimbursement for a noncontracting provider dentist shall be the same as payment or reimbursement for a contracting provider dentist;(B)  that the party to or beneficiary of the plan or policy may assign the right to payment or reimbursement to the dentist who provides the dental care services; and(C)  one or more methods of payment or reimbursement that provide the dentist 100 percent of the contracted amount of the payment or reimbursement and that do not require the dentist to incur a fee to access the payment or reimbursement; and(2)  disclose on the Internet website required under Section 1451.205 and on request of a dentist or a party to or beneficiary of the plan or policy the fees, if any, associated with the methods of payment or reimbursement available under the plan or policy.(b)  Notwithstanding Subsection (a)(1), the employee benefit plan or health insurance policy is not required to make payment or reimbursement in an amount greater than:(1)  the amount specified in the plan or policy;  or(2)  the fee the providing dentist charges for the dental care services provided.(c)  If the right to payment or reimbursement is assigned as provided by Subsection (a)(2):(1)  payment or reimbursement shall be made directly to the designated dentist;  and(2)  direct payment to the designated dentist discharges the payor's obligation.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.Amended by: Acts 2019, 86th Leg., R.S., Ch. 1290 (H.B. 2486), Sec. 2, eff. September 1, 2019.|
TX Ins Code § 1451.2065 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle F - Physicians and Health Care Providers|Chapter 1451 - Access to Certain Practitioners and Facilities|Subchapter E. Dental Care Benefits in Health Insurance Policies or Employee Benefit Plans|Section 1451.2065. Contracts With Dentists

Sec. 1451.2065.  CONTRACTS WITH DENTISTS.  (a)  In this section, "covered service" means a dental care service for which reimbursement is available under a patient's employee benefit plan or health insurance policy, or for which reimbursement is available subject to a contractual limitation, including:(1)  a deductible;(2)  a copayment;(3)  coinsurance;(4)  a waiting period;(5)  an annual or lifetime maximum limit;(6)  a frequency limitation; or(7)  an alternative benefit payment.(b)  A contract between an insurer and a dentist may not limit the fee the dentist may charge for a service that is not a covered service.|Added by Acts 2011, 82nd Leg., R.S., Ch. 1061 (S.B. 554), Sec. 2, eff. September 1, 2011.|
TX Ins Code § 1451.207 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle F - Physicians and Health Care Providers|Chapter 1451 - Access to Certain Practitioners and Facilities|Subchapter E. Dental Care Benefits in Health Insurance Policies or Employee Benefit Plans|Section 1451.207. Prohibited Conduct

Sec. 1451.207.  PROHIBITED CONDUCT.  (a)  An employee benefit plan or health insurance policy may not:(1)  interfere with or prevent an individual who is a party to or beneficiary of the plan or policy from selecting a dentist of the individual's choice to provide a dental care service the plan or policy offers if the dentist selected is licensed in this state to provide the service;(2)  deny a dentist the right to participate as a contracting provider under the plan or policy if the dentist is licensed to provide the dental care services the plan or policy offers;(3)  authorize a person to regulate, interfere with, or intervene in the provision of dental care services a dentist provides a patient, including diagnosis, if the dentist practices within the scope of the dentist's license;(4)  require a dentist to make or obtain a dental x-ray or other diagnostic aid in providing dental care services; or(5)  deduct the amount of an overpayment of a claim from a payment or reimbursement for a dental care service provided by a dentist who did not receive the overpayment.(b)  Subsection (a)(4) does not prohibit a request for an existing dental x-ray or other existing diagnostic aid for a determination of benefits payable under an employee benefit plan or health insurance policy.(c)  This section does not prohibit the predetermination of benefits for dental care expenses before the attending dentist provides treatment.  In this subsection, "predetermination" means an estimate by the patient's employee benefit plan or health insurance policy provider or issuer of:(1)  the patient's eligibility under the plan or policy for benefits or covered services;(2)  the amount of the patient's deductible, copayment, or coinsurance related to benefits or covered services; and(3)  the maximum benefit limits for benefits or covered services.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.Amended by: Acts 2019, 86th Leg., R.S., Ch. 1290 (H.B. 2486), Sec. 3, eff. September 1, 2019.|
TX Ins Code § 1451.251 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle F - Physicians and Health Care Providers|Chapter 1451 - Access to Certain Practitioners and Facilities|Subchapter F. Access to Obstetrical or Gynecological Care|Section 1451.251. Definition

Sec. 1451.251.  DEFINITION.  In this subchapter, "enrollee" means an individual enrolled in a health benefit plan.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1451.252 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle F - Physicians and Health Care Providers|Chapter 1451 - Access to Certain Practitioners and Facilities|Subchapter F. Access to Obstetrical or Gynecological Care|Section 1451.252. Applicability of Subchapter

Sec. 1451.252.  APPLICABILITY OF SUBCHAPTER.  This subchapter applies only to a health benefit plan that requires an enrollee to obtain certain specialty health care services through a referral made by a primary care physician or other gatekeeper and that:(1)  provides benefits for medical or surgical expenses incurred as a result of a health condition, accident, or sickness, including:(A)  an individual, group, blanket, or franchise insurance policy or insurance agreement, a group hospital service contract, or an individual or group evidence of coverage that is offered by:(i)  an insurance company;(ii)  a group hospital service corporation operating under Chapter 842;(iii)  a fraternal benefit society operating under Chapter 885;(iv)  a stipulated premium company operating under Chapter 884;  or(v)  a health maintenance organization operating under Chapter 843;  and(B)  to the extent permitted by the Employee Retirement Income Security Act of 1974 (29 U.S.C. Section 1001 et seq.), a health benefit plan that is offered by:(i)  a multiple employer welfare arrangement as defined by Section 3 of that Act;  or(ii)  another analogous benefit arrangement;(2)  is offered by:(A)  an approved nonprofit health corporation that holds a certificate of authority under Chapter 844;  or(B)  an entity that is not authorized under this code or another insurance law of this state that contracts directly for health care services on a risk-sharing basis, including a capitation basis;  or(3)  provides health and accident coverage through a risk pool created under Chapter 172, Local Government Code, notwithstanding Section 172.014, Local Government Code, or any other law.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1451.253 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle F - Physicians and Health Care Providers|Chapter 1451 - Access to Certain Practitioners and Facilities|Subchapter F. Access to Obstetrical or Gynecological Care|Section 1451.253. Exception

Sec. 1451.253.  EXCEPTION.  This subchapter does not apply to:(1)  a plan that provides coverage:(A)  only for a specified disease;(B)  only for accidental death or dismemberment;(C)  for wages or payments instead of wages for a period during which an employee is absent from work because of sickness or injury;  or(D)  as a supplement to a liability insurance policy;(2)  a small employer health benefit plan written under Chapter 1501;(3)  a Medicare supplemental policy as defined by Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss);(4)  a workers' compensation insurance policy;(5)  medical payment insurance coverage provided under a motor vehicle insurance policy;(6)  a long-term care insurance policy, including a nursing home fixed indemnity policy, unless the commissioner determines that the policy provides benefit coverage so comprehensive that the policy is a health benefit plan as described by Section 1451.252;  or(7)  any health benefit plan that does not provide:(A)  benefits related to pregnancy;  or(B)  well-woman care benefits.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1451.254 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle F - Physicians and Health Care Providers|Chapter 1451 - Access to Certain Practitioners and Facilities|Subchapter F. Access to Obstetrical or Gynecological Care|Section 1451.254. Rules

Sec. 1451.254.  RULES.  The commissioner shall adopt rules necessary to implement this subchapter.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|