reglab/statecodes huggingface dataset:
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1203 - Coordination of Benefits Provisions › Subchapter B. Dental Insurance › Section 1203.052. Coordination of Benefits Between Primary and Secondary Insurers

Sec. 1203.052.  COORDINATION OF BENEFITS BETWEEN PRIMARY AND SECONDARY INSURERS.  (a)  This section applies if:
(1)  an insured is covered by at least two different insurance policies; and
(2)  each policy provides the insured dental benefits.
(b)  The primary insurer, as determined under a coordination of benefits provision applicable to the policies, is responsible for dental expenses covered under the insurance policy issued by the primary insurer up to the full amount of any policy limit applicable to the covered dental expenses.
(c)  Before the policy limit described by Subsection (b) is reached, the secondary insurer, as determined under a coordination of benefits provision applicable to the policies, is responsible only for dental expenses covered under the insurance policy issued by the secondary insurer that are not covered under the policy issued by the primary insurer.
(d)  After the policy limit described by Subsection (b) has been reached, the secondary insurer, in addition to the responsibility described by Subsection (c), is responsible for any dental expenses covered by both policies that exceed the policy limit described by Subsection (b), not to exceed the policy limit of the secondary policy.
Added by Acts 2015, 84th Leg., R.S., Ch. 572 (H.B. 3024), Sec. 1, eff. September 1, 2015.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1203 - Coordination of Benefits Provisions › Subchapter B. Dental Insurance › Section 1203.053. Certain Coordination of Benefits Provisions Prohibited

Sec. 1203.053.  CERTAIN COORDINATION OF BENEFITS PROVISIONS PROHIBITED.  An insurance policy subject to this subchapter may not be delivered, issued for delivery, or renewed in this state if:
(1)  a provision of the policy excludes or reduces the payment of benefits for dental expenses to or on behalf of an insured;
(2)  the reason for the exclusion or reduction is that dental benefits are payable or have been paid to or on behalf of the insured under another insurance policy; and
(3)  the exclusion or reduction would apply before the full amount of the dental expenses incurred by the insured and covered by both policies have been paid or reimbursed or the full amount of the applicable policy limit of the policy containing the exclusion or reduction is reached.
Added by Acts 2015, 84th Leg., R.S., Ch. 572 (H.B. 3024), Sec. 1, eff. September 1, 2015.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1203 - Coordination of Benefits Provisions › Subchapter B. Dental Insurance › Section 1203.054. Certain Coordination of Benefits Provisions Void

Sec. 1203.054.  CERTAIN COORDINATION OF BENEFITS PROVISIONS VOID.  A provision of an insurance policy that violates Section 1203.053 is void.
Added by Acts 2015, 84th Leg., R.S., Ch. 572 (H.B. 3024), Sec. 1, eff. September 1, 2015.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1203 - Coordination of Benefits Provisions › Subchapter C. Vision and Eye Care Benefits › Section 1203.101. Definitions

Sec. 1203.101.  DEFINITIONS.  In this subchapter:
(1)  "Eye care expenses" means expenses related to vision or medical eye care services, procedures, or products.
(2)  "Health benefit plan" means a policy, agreement, contract, or evidence of coverage that provides comprehensive medical coverage.
(3)  "Vision benefit plan" means a limited-scope policy, agreement, contract, or evidence of coverage that provides coverage for eye care expenses but does not provide comprehensive medical coverage.
Added by Acts 2023, 88th Leg., R.S., Ch. 15 (S.B. 861), Sec. 1, eff. September 1, 2023.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1203 - Coordination of Benefits Provisions › Subchapter C. Vision and Eye Care Benefits › Section 1203.102. Applicability of Subchapter

Sec. 1203.102.  APPLICABILITY OF SUBCHAPTER.  This subchapter applies only to a health benefit plan or vision benefit plan that provides or arranges for benefits for vision or medical eye care services, procedures, or products, including an individual, group, blanket, or franchise insurance policy or insurance agreement, a group hospital service contract, an evidence of coverage, or a vision benefit plan offered by:
(1)  an insurance company;
(2)  a group hospital service corporation operating under Chapter 842;
(3)  a health maintenance organization operating under Chapter 843;
(4)  a stipulated premium company operating under Chapter 884;
(5)  a fraternal benefit society operating under Chapter 885;
(6)  a Lloyd's plan operating under Chapter 941;
(7)  an exchange operating under Chapter 942; or
(8)  a person or entity that provides a vision benefit plan.
Added by Acts 2023, 88th Leg., R.S., Ch. 15 (S.B. 861), Sec. 1, eff. September 1, 2023.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1203 - Coordination of Benefits Provisions › Subchapter C. Vision and Eye Care Benefits › Section 1203.103. Exception

Sec. 1203.103.  EXCEPTION.  This subchapter does not apply to a supplemental insurance policy that only pays benefits directly to the policyholder.
Added by Acts 2023, 88th Leg., R.S., Ch. 15 (S.B. 861), Sec. 1, eff. September 1, 2023.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1203 - Coordination of Benefits Provisions › Subchapter C. Vision and Eye Care Benefits › Section 1203.104. Coordination of Benefits Between Primary and Secondary Plan Issuers

Sec. 1203.104.  COORDINATION OF BENEFITS BETWEEN PRIMARY AND SECONDARY PLAN ISSUERS.  (a)  This section applies if:
(1)  an enrollee is covered by at least two different health benefit plans or vision benefit plans; and
(2)  each plan provides the enrollee coverage for the same vision or medical eye care services, procedures, or products.
(b)  The issuer of the primary health benefit plan or vision benefit plan, as determined under a coordination of benefits provision applicable to the plan, is responsible for eye care expenses covered under the plan up to the full amount of any plan coverage limit applicable to the covered eye care expenses.
(c)  Before the plan coverage limit described by Subsection (b) is reached, the issuer of a secondary health benefit plan or vision benefit plan, as determined under a coordination of benefits provision applicable to the plan, is responsible only for eye care expenses covered under the plan that are not covered under the health benefit plan or vision benefit plan issued by the primary plan issuer.
(d)  After the plan coverage limit described by Subsection (b) has been reached, the secondary plan issuer, in addition to the responsibilities described by Subsection (c), is responsible for any eye care expenses covered by both plans that exceed the plan coverage limit described by Subsection (b) up to the coverage limit of the secondary plan.
(e)  When an enrollee is covered by more than one health benefit plan or vision benefit plan that provides benefits for eye care expenses, the enrollee may use each plan on the same date of service up to the coverage limit of each plan.
(f)  A vision benefit plan issuer shall coordinate benefits with a health benefit plan issuer if both provide benefits for eye care expenses.
(g)  A vision benefit plan issuer may not require a claim denial before adjudicating a claim up to the coverage limit of the plan.
(h)  Nothing in this section prevents a secondary plan issuer from requiring proof that a related claim has been submitted to a primary plan issuer for purposes of determining the remaining balance up to the secondary plan's coverage limits.
(i)  If a secondary plan issuer requires proof that a related claim has been submitted to a primary plan issuer as described by Subsection (h), the mechanism of providing proof must be through an online submission.
Added by Acts 2023, 88th Leg., R.S., Ch. 15 (S.B. 861), Sec. 1, eff. September 1, 2023.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1203 - Coordination of Benefits Provisions › Subchapter C. Vision and Eye Care Benefits › Section 1203.105. Certain Coordination of Benefits Provisions Prohibited

Sec. 1203.105.  CERTAIN COORDINATION OF BENEFITS PROVISIONS PROHIBITED.  (a)  A health benefit plan or vision benefit plan subject to this subchapter may not be delivered, issued for delivery, or renewed in this state if:
(1)  a provision of the plan excludes or reduces the payment of benefits for eye care expenses to or on behalf of an enrollee;
(2)  the reason for the exclusion or reduction is that eye care benefits are payable or have been paid to or on behalf of the enrollee under another plan; and
(3)  the exclusion or reduction would apply before the full amount of the eye care expenses incurred by the enrollee and covered by both plans have been paid or reimbursed or the full amount of the applicable coverage limit of the plan containing the exclusion or reduction is reached.
(b)  Nothing in this section requires a secondary plan issuer to pay an amount that, when added to a payment amount made by a primary plan issuer, would exceed the usual and customary billed charges of the health care provider.
Added by Acts 2023, 88th Leg., R.S., Ch. 15 (S.B. 861), Sec. 1, eff. September 1, 2023.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1203 - Coordination of Benefits Provisions › Subchapter C. Vision and Eye Care Benefits › Section 1203.106. Certain Coordination of Benefits Provisions Void

Sec. 1203.106.  CERTAIN COORDINATION OF BENEFITS PROVISIONS VOID.  A provision of a health benefit plan or vision benefit plan that violates this subchapter is void.
Added by Acts 2023, 88th Leg., R.S., Ch. 15 (S.B. 861), Sec. 1, eff. September 1, 2023.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1203 - Coordination of Benefits Provisions › Subchapter C. Vision and Eye Care Benefits › Section 1203.107. Rules

Sec. 1203.107.  RULES.  The commissioner may adopt rules necessary to implement this subchapter.
Added by Acts 2023, 88th Leg., R.S., Ch. 15 (S.B. 861), Sec. 1, eff. September 1, 2023.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1204 - Procedures for Payment of Certain Health and Accident Insurance Policy or Plan Benefits › Subchapter A. Payments to Certain Public Hospitals › Section 1204.001. Nonapplicability to Certain Facilities

Sec. 1204.001.  NONAPPLICABILITY TO CERTAIN FACILITIES.  This subchapter does not apply to indigent care or chronic disease care provided in or by an eleemosynary institution, sanitarium, sanitorium, mental health treatment facility, tuberculosis treatment facility, or cancer treatment facility that is owned or controlled by the state or by a unit of local government.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1204 - Procedures for Payment of Certain Health and Accident Insurance Policy or Plan Benefits › Subchapter A. Payments to Certain Public Hospitals › Section 1204.002. Benefits Payable for Treatment Provided by Hospital Owned by State or Unit of Local Government

Sec. 1204.002.  BENEFITS PAYABLE FOR TREATMENT PROVIDED BY HOSPITAL OWNED BY STATE OR UNIT OF LOCAL GOVERNMENT.  An insurance policy providing hospital, nursing, medical, or surgical coverage that is issued or delivered in this state after August 27, 1973, may not include a provision that prevents the payment of benefits for expenses of a nonindigent patient incurred in a hospital facility that:
(1)  is owned or controlled by the state or by a unit of local government;  and
(2)  regularly and customarily demands and collects from nonindigent persons payment for those expenses.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1204 - Procedures for Payment of Certain Health and Accident Insurance Policy or Plan Benefits › Subchapter B. Assignment of Benefit Payments › Section 1204.051. Definitions

Sec. 1204.051.  DEFINITIONS.  In this subchapter:
(1)  "Covered person" means a person who is insured or covered by a health insurance policy or is a participant in an employee benefit plan.  The term includes:
(A)  a person covered by a health insurance policy because the person is an eligible dependent;  and
(B)  an eligible dependent of a participant in an employee benefit plan.
(2)  "Employee benefit plan" or "plan" means a plan, fund, or program established or maintained by an employer, an employee organization, or both, to the extent that it provides, through the purchase of insurance or otherwise, health care services to employees, participants, or the dependents of employees or participants.
(3)  "Health care provider" means a person who provides health care services under a license, certificate, registration, or other similar evidence of regulation issued by this or another state of the United States.
(4)  "Health care service" means a service to diagnose, prevent, alleviate, cure, or heal a human illness or injury that is provided to a covered person by a physician or other health care provider.
(5)  "Health insurance policy" means an individual, group, blanket, or franchise insurance policy, or an insurance agreement, that provides reimbursement or indemnity for health care expenses incurred as a result of an accident or sickness.
(6)  "Insurer" means an insurance company, association, or organization authorized to engage in business in this state under Chapter 841, 861, 881, 882, 883, 884, 885, 886, 887, 888, 941, 942, or 982.
(7)  "Person" means an individual, association, partnership, corporation, or other legal entity.
(8)  "Physician" means an individual licensed to practice medicine in this or another state of the United States.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1204 - Procedures for Payment of Certain Health and Accident Insurance Policy or Plan Benefits › Subchapter B. Assignment of Benefit Payments › Section 1204.052. Applicability to Certain Plans or Programs

Sec. 1204.052.  APPLICABILITY TO CERTAIN PLANS OR PROGRAMS.  This subchapter applies to:
(1)  an employee benefit plan, to the extent not preempted by the Employee Retirement Income Security Act of 1974 (29 U.S.C. Section 1001 et seq.);
(2)  benefit programs under Chapters 1551 and 1601, to the extent that the benefit programs are self-insuring;  and
(3)  insurance coverage provided under Chapter 1575.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1204 - Procedures for Payment of Certain Health and Accident Insurance Policy or Plan Benefits › Subchapter B. Assignment of Benefit Payments › Section 1204.053. Assignment of Benefits

Sec. 1204.053.  ASSIGNMENT OF BENEFITS.  (a)  An insurer may not deliver, renew, or issue for delivery in this state a health insurance policy that prohibits or restricts a covered person from making a written assignment of benefits to a physician or other health care provider who provides health care services to the person.
(b)  This section does not:
(1)  provide a coverage or benefit that is not otherwise available under the health insurance policy;
(2)  allow assignment of a benefit to:
(A)  a person who is not legally entitled to receive such a direct payment;  or
(B)  another person if, under the health insurance policy or plan, the benefit must be provided to the covered person by a physician or other health care provider who is a contractor or preferred provider under the policy;  or
(3)  prohibit an insurer from verifying, through the insurer's normal process, the health care services the physician or other health care provider provides to the covered person.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1204 - Procedures for Payment of Certain Health and Accident Insurance Policy or Plan Benefits › Subchapter B. Assignment of Benefit Payments › Section 1204.054. Payment of Benefits According to Assignment

Sec. 1204.054.  PAYMENT OF BENEFITS ACCORDING TO ASSIGNMENT.  An insurer shall pay benefits directly to a physician or other health care provider, and the insurer is relieved of the obligation to pay, and of any liability for paying, those benefits to the covered person if:
(1)  the covered person makes a written assignment of those benefits payable to the physician or other health care provider;  and
(2)  the assignment is obtained by or delivered to the insurer with the claim for benefits.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1204 - Procedures for Payment of Certain Health and Accident Insurance Policy or Plan Benefits › Subchapter B. Assignment of Benefit Payments › Section 1204.055. Contractual Responsibility for Deductibles and Copayments

Sec. 1204.055.  CONTRACTUAL RESPONSIBILITY FOR DEDUCTIBLES AND COPAYMENTS.  (a)  The payment of benefits under an assignment does not relieve a covered person of a contractual obligation to pay a deductible or copayment.
(b)  A physician or other health care provider may not waive a deductible or copayment by the acceptance of an assignment.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1204 - Procedures for Payment of Certain Health and Accident Insurance Policy or Plan Benefits › Subchapter C. Uniform Claim Billing Forms › Section 1204.101. Definitions

Sec. 1204.101.  DEFINITIONS.  In this subchapter:
(1)  "Health benefit plan" means a group, blanket, or franchise insurance policy, a group hospital service contract, or a group subscriber contract or evidence of coverage issued by a health maintenance organization, that provides benefits for health care services.
(2)  "Health benefit plan issuer" means an entity authorized under this code or another insurance law of this state that provides health insurance or health benefits in this state, including:
(A)  an insurance company;
(B)  a group hospital service corporation operating under Chapter 842;
(C)  a health maintenance organization operating under Chapter 843;  and
(D)  a stipulated premium company operating under Chapter 884.
(3)  "Provider" means a person who provides health care under a license issued by this state.  The term includes a health care practitioner listed in Section 1451.001 and a nurse first assistant, as defined by Section 1451.101.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1204 - Procedures for Payment of Certain Health and Accident Insurance Policy or Plan Benefits › Subchapter C. Uniform Claim Billing Forms › Section 1204.102. Required Claim Billing Forms

Sec. 1204.102.  REQUIRED CLAIM BILLING FORMS.  A provider who seeks payment or reimbursement under a health benefit plan and the health benefit plan issuer that issued the plan shall use uniform claim billing form UB-82/HCFA or HCFA 1500, or a successor to one of those forms, as developed by the National Uniform Billing Committee or its successor.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1204 - Procedures for Payment of Certain Health and Accident Insurance Policy or Plan Benefits › Subchapter D. Payments for Certain Publicly Provided Services › Section 1204.151. Definition

Sec. 1204.151.  DEFINITION.  In this subchapter, "policy" means an individual or group policy of accident and health insurance, including a policy issued by a group hospital service corporation operating under Chapter 842.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1204 - Procedures for Payment of Certain Health and Accident Insurance Policy or Plan Benefits › Subchapter D. Payments for Certain Publicly Provided Services › Section 1204.152. Payment for Certain Expenses Incurred by Texas Department of Human Services

Sec. 1204.152.  PAYMENT FOR CERTAIN EXPENSES INCURRED BY TEXAS DEPARTMENT OF HUMAN SERVICES.  Each policy delivered or issued for delivery in this state must provide for the repayment of the actual costs of medical expenses the Texas Department of Human Services pays through medical assistance for an insured person if, under the policy, the insured person is entitled to payment for the medical expenses.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1204 - Procedures for Payment of Certain Health and Accident Insurance Policy or Plan Benefits › Subchapter D. Payments for Certain Publicly Provided Services › Section 1204.153. Payments to Texas Department of Human Services for Certain Children

Sec. 1204.153.  PAYMENTS TO TEXAS DEPARTMENT OF HUMAN SERVICES FOR CERTAIN CHILDREN.  (a)  This section applies only to a policy that is delivered, issued for delivery, or renewed in this state and that provides coverage for a child whose parent:
(1)  purchased the policy;  or
(2)  is a member of the group covered under the policy.
(b)  Each policy must include a requirement that, after written notice to the insurer or group hospital service corporation at the insurer's or group hospital service corporation's home office, benefits payable on behalf of a child must be paid to the Texas Department of Human Services if:
(1)  the parent who purchased the policy or who is a group member is required to pay child support by a court order or court-approved agreement and:
(A)  is a possessory conservator of the child under a court order issued in this state;  or
(B)  is not entitled to possession of or access to the child;
(2)  the Texas Department of Human Services is paying benefits on behalf of the child under Chapter 31 or 32, Human Resources Code;  and
(3)  the insurer or group hospital service corporation is notified, through an attachment to the claim for benefits at the time the claim is first submitted to the insurer or group hospital service corporation, that the benefits must be paid directly to the Texas Department of Human Services.
(c)  The commissioner and the Texas Department of Human Services may consult regarding implementation of this section.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1204 - Procedures for Payment of Certain Health and Accident Insurance Policy or Plan Benefits › Subchapter D. Payments for Certain Publicly Provided Services › Section 1204.154. Uniform Provisions

Sec. 1204.154.  UNIFORM PROVISIONS.  (a)  The commissioner shall adopt uniform policy provisions, riders, and endorsements for the policy requirement of Section 1204.153.
(b)  Before the commissioner adopts or makes a change to a provision, rider, or endorsement under Subsection (a), the commissioner shall present each provision, rider, or endorsement, and any amendment to a provision, rider, or endorsement, to the Texas Department of Human Services for comment.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1204 - Procedures for Payment of Certain Health and Accident Insurance Policy or Plan Benefits › Subchapter E. Exclusionary Clauses › Section 1204.201. Prohibition of Exclusion of Certain Medical Assistance Benefits

Sec. 1204.201.  PROHIBITION OF EXCLUSION OF CERTAIN MEDICAL ASSISTANCE BENEFITS.  An individual or group accident and health insurance policy delivered or issued for delivery in this state, including a policy issued by a group hospital service corporation operating under Chapter 842, may not include a provision that excludes or limits the insurer's or group hospital service corporation's coverage from paying benefits covered by Chapter 32, Human Resources Code.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1204 - Procedures for Payment of Certain Health and Accident Insurance Policy or Plan Benefits › Subchapter F. Payment of Benefits to Conservator of Minor › Section 1204.251. Payment to Conservator Other Than Group Member

Sec. 1204.251.  PAYMENT TO CONSERVATOR OTHER THAN GROUP MEMBER.  (a)  An insurer or group hospital service corporation operating under Chapter 842 that delivers, issues for delivery, or renews in this state a group accident and health insurance policy that provides coverage for a minor child who qualifies as a dependent of a group member may pay benefits on the child's behalf to a person who is not a group member if an order providing for the appointment of a possessory or managing conservator of the child has been issued by a court in this or another state.
(b)  A person who is not a group member is entitled to be paid benefits under this section only if the person presents to the insurer or group hospital service corporation, with the claim application:
(1)  written notice that the person is a possessory or managing conservator of the child on whose behalf the claim is made;  and
(2)  a certified copy of a court order designating the person as possessory or managing conservator of the child or other evidence designated by rule of the commissioner that the person is eligible for the benefits as this section provides.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1204 - Procedures for Payment of Certain Health and Accident Insurance Policy or Plan Benefits › Subchapter F. Payment of Benefits to Conservator of Minor › Section 1204.252. Preconditions for Payment; Exceptions

Sec. 1204.252.  PRECONDITIONS FOR PAYMENT;  EXCEPTIONS.  (a)  In accordance with the terms of the policy and this subchapter, an insurer or group hospital service corporation may be required to pay benefits under a group accident and health insurance policy to a person who is not a group member and who complies with:
(1)  Section 1204.251;
(2)  the insurer's or group hospital service corporation's claim application procedures;  and
(3)  department rules.
(b)  Any requirement imposed on a possessory or managing conservator of a child under this subchapter does not apply with regard to:
(1)  an unpaid medical bill for which an assignment of benefits has been exercised, whether in accordance with policy provisions or otherwise;  or
(2)  a claim presented by a group member for which the group member paid any portion of a medical bill that is covered under the policy's terms.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1204 - Procedures for Payment of Certain Health and Accident Insurance Policy or Plan Benefits › Subchapter F. Payment of Benefits to Conservator of Minor › Section 1204.253. Rules

Sec. 1204.253.  RULES.  The commissioner may adopt rules to ensure the effective implementation of this subchapter.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1205 - Certification of Creditable Coverage › Section 1205.001. Applicability of Chapter

Sec. 1205.001.  APPLICABILITY OF CHAPTER.  This chapter applies only to a health benefit plan 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 and operating under Chapter 846;  or
(ii)  an analogous benefit arrangement;
(2)  is offered by an approved nonprofit health corporation that holds a certificate of authority under Chapter 844;  or
(3)  is offered by any other entity that:
(A)  is not authorized under this code or another insurance law of this state;  and
(B)  contracts directly for health care services on a risk-sharing basis, including a capitation basis.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1205 - Certification of Creditable Coverage › Section 1205.002. Certification of Coverage

Sec. 1205.002.  CERTIFICATION OF COVERAGE.  (a)  A health benefit plan issuer shall provide a certification of coverage as necessary to determine the period of applicable creditable coverage under that health benefit plan.
(b)  The certification required under this section must be provided in accordance with the standards adopted by rule by the commissioner.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1205 - Certification of Creditable Coverage › Section 1205.003. Rules

Sec. 1205.003.  RULES.  The commissioner shall adopt rules as necessary to:
(1)  implement this chapter and related provisions of this code;  and
(2)  meet the minimum requirements of federal law, including regulations.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1205 - Certification of Creditable Coverage › Section 1205.004. Creditable Coverage

Sec. 1205.004.  CREDITABLE COVERAGE.  (a)  An individual's coverage is creditable coverage for purposes of this chapter if the coverage is provided under:
(1)  a self-funded or self-insured employee welfare benefit plan that:
(A)  provides health benefits;  and
(B)  is established in accordance with the Employee Retirement Income Security Act of 1974 (29 U.S.C. Section 1001 et seq.);
(2)  a group health benefit plan provided by a health insurer or health maintenance organization;
(3)  an individual health insurance policy or evidence of coverage;
(4)  Part A or Part B of Title XVIII of the Social Security Act (42 U.S.C. Section 1395c et seq.);
(5)  Title XIX of the Social Security Act (42 U.S.C. Section 1396 et seq.), other than coverage consisting solely of benefits under Section 1928 of that act (42 U.S.C. Section 1396s);
(6)  10 U.S.C. Section 1071 et seq.;
(7)  a medical care program of the Indian Health Service or of a tribal organization;
(8)  a state health benefits risk pool;
(9)  a health plan offered under 5 U.S.C. Section 8901 et seq.;
(10)  a public health plan as defined by federal regulations;  or
(11)  a health benefit plan under Section 5(e), Peace Corps Act (22 U.S.C. Section 2504(e)).
(b)  For purposes of this chapter, creditable coverage does not include:
(1)  accident-only or disability income insurance or a combination of accident-only and disability income insurance;
(2)  coverage issued as a supplement to liability insurance;
(3)  liability insurance, including general liability insurance and automobile liability insurance;
(4)  workers' compensation insurance or other similar insurance;
(5)  automobile medical payment insurance;
(6)  credit-only insurance;
(7)  coverage for on-site medical clinics;
(8)  other coverage that is:
(A)  similar to the coverage described by this subsection under which benefits for medical care are secondary or incidental to other insurance benefits;  and
(B)  specified by federal regulations;
(9)  coverage that provides limited-scope dental or vision benefits;
(10)  long-term care, nursing home care, home health care, or community-based care coverage or benefits or any combination of those coverages or benefits;
(11)  coverage that provides other limited benefits specified by federal regulations;
(12)  coverage for a specified disease or illness;
(13)  hospital indemnity or other fixed indemnity insurance;  or
(14)  Medicare supplemental health insurance, as defined by Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss), coverage supplemental to the coverage provided under 10 U.S.C. Section 1071 et seq., or other similar supplemental coverage provided under a group plan.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1206 - Denial of Health Benefit Plan Enrollment Based on Existing Coverage Prohibited › Section 1206.001. Applicability of Chapter

Sec. 1206.001.  APPLICABILITY OF CHAPTER.  This chapter applies only to a health benefit plan, including a small employer health benefit plan written under Chapter 1501, that provides benefits for medical or surgical expenses incurred as a result of a health condition, accident, or sickness, including an individual, group, blanket, or franchise insurance policy or insurance agreement, a group hospital service contract, or an individual or group evidence of coverage or similar coverage document that is offered by:
(1)  an insurance company;
(2)  a group hospital service corporation operating under Chapter 842;
(3)  a fraternal benefit society operating under Chapter 885;
(4)  a stipulated premium company operating under Chapter 884;
(5)  a reciprocal exchange operating under Chapter 942;
(6)  a health maintenance organization operating under Chapter 843;
(7)  a multiple employer welfare arrangement that holds a certificate of authority under Chapter 846;  or
(8)  an approved nonprofit health corporation that holds a certificate of authority under Chapter 844.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1206 - Denial of Health Benefit Plan Enrollment Based on Existing Coverage Prohibited › Section 1206.002. Exception

Sec. 1206.002.  EXCEPTION.  This chapter does not apply to:
(1)  a plan that provides coverage:
(A)  only for a specified disease or for another limited benefit;
(B)  only for accidental death or dismemberment;
(C)  for wages or payments in lieu of wages for a period during which an employee is absent from work because of sickness or injury;
(D)  as a supplement to a liability insurance policy;
(E)  for credit insurance;
(F)  only for dental or vision care;
(G)  only for hospital expenses;
(H)  only for indemnity for hospital confinement;  or
(I)  in accordance with Title XXI of the Social Security Act (42 U.S.C. Section 1397aa et seq.);
(2)  a Medicare supplemental policy as defined by Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss), as amended;
(3)  a workers' compensation insurance policy;
(4)  medical payment insurance coverage provided under a motor vehicle insurance policy;  or
(5)  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 1206.001.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1206 - Denial of Health Benefit Plan Enrollment Based on Existing Coverage Prohibited › Section 1206.003. Denial of Enrollment Prohibited

Sec. 1206.003.  DENIAL OF ENROLLMENT PROHIBITED.  A health benefit plan issuer may not refuse to enroll an individual in the plan solely because the individual is enrolled in another health benefit plan at the time the individual applies for coverage under the plan.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1206 - Denial of Health Benefit Plan Enrollment Based on Existing Coverage Prohibited › Section 1206.004. Violation of Chapter: Unfair Discrimination

Sec. 1206.004.  VIOLATION OF CHAPTER:  UNFAIR DISCRIMINATION.  A health benefit plan issuer who violates this chapter engages in unfair discrimination under Subchapter B, Chapter 544.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1207 - Enrollment of Medical Assistance Recipients and Children Eligible for State Child Health Plan › Section 1207.001. Applicability of Chapter

Sec. 1207.001.  APPLICABILITY OF CHAPTER.  This chapter applies only to a group health benefit plan, including a small employer health benefit plan written under Chapter 1501, a plan provided under Chapter 1551, 1575, or 1601, or a successor to a plan provided under one of those chapters, or a medical savings account plan or other health reimbursement arrangement authorized by law, that provides benefits for medical or surgical expenses incurred as a result of a health condition, accident, or sickness, including a group, blanket, or franchise insurance policy or insurance agreement, a group hospital service contract, or a group evidence of coverage or similar group coverage document that is offered by:
(1)  an insurance company;
(2)  a group hospital service corporation operating under Chapter 842;
(3)  a fraternal benefit society operating under Chapter 885;
(4)  a stipulated premium company operating under Chapter 884;
(5)  a reciprocal exchange operating under Chapter 942;
(6)  a health maintenance organization operating under Chapter 843;
(7)  a multiple employer welfare arrangement that holds a certificate of authority under Chapter 846; or
(8)  an approved nonprofit health corporation that holds a certificate of authority under Chapter 844.
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. 11.025(a), eff. September 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1207 - Enrollment of Medical Assistance Recipients and Children Eligible for State Child Health Plan › Section 1207.002. Enrollment Required

Sec. 1207.002.  ENROLLMENT REQUIRED.  (a)  A group health benefit plan issuer shall permit an individual who is otherwise eligible for enrollment in the plan to enroll in the plan, without regard to any enrollment period restriction, on receipt of written notice from the Health and Human Services Commission that the individual is:
(1)  a recipient of medical assistance under the state Medicaid program and is a participant in the health insurance premium payment reimbursement program under Section 32.0422, Human Resources Code; or
(2)  a child eligible for the state child health plan under Chapter 62, Health and Safety Code, and eligible to participate in the health insurance premium assistance program under Section 62.059, Health and Safety Code.
(b)  A group health benefit plan issuer shall permit an individual who is otherwise eligible for enrollment in the plan to enroll in the plan, without regard to any enrollment period restriction, if the individual:
(1)  becomes ineligible for medical assistance under the state Medicaid program or enrollment in the state child health plan under Chapter 62, Health and Safety Code, after initially establishing eligibility; and
(2)  provides a written request for enrollment in the group health benefit plan not later than the 30th day after the date the individual's eligibility for the state Medicaid program or the state child health plan terminated.
(c)  If an individual described by Subsection (a)(1) or (2) or Subsection (b) is not eligible to enroll in the group health benefit plan unless a family member of the individual is also enrolled in the plan, the plan issuer, on receipt of written notice under Subsection (a) or a written request under Subsection (b), shall enroll both the individual and the family member in the plan.
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. 11.026(a), eff. September 1, 2005.
Acts 2007, 80th Leg., R.S., Ch. 268 (S.B. 10), Sec. 24(a), eff. September 1, 2007.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1207 - Enrollment of Medical Assistance Recipients and Children Eligible for State Child Health Plan › Section 1207.003. Effective Date of Enrollment

Sec. 1207.003.  EFFECTIVE DATE OF ENROLLMENT.  (a)  Unless enrollment occurs during an established enrollment period, enrollment in a group health benefit plan under Section 1207.002 takes effect on:
(1)  the eligibility enrollment date specified in the written notice from the Health and Human Services Commission under Section 1207.002(a); or
(2)  the first day of the first calendar month that begins at least 30 days after the date written notice or a written request is received by the plan issuer under Section 1207.002(a) or (b), as applicable.
(b)  Notwithstanding Subsection (a), the individual must comply with a waiting period required under the state child health plan under Chapter 62, Health and Safety Code, or under the health insurance premium assistance program under Section 62.059, Health and Safety Code, as applicable.
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. 11.026(a), eff. September 1, 2005.
Acts 2007, 80th Leg., R.S., Ch. 268 (S.B. 10), Sec. 24(b), eff. September 1, 2007.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1207 - Enrollment of Medical Assistance Recipients and Children Eligible for State Child Health Plan › Section 1207.004. Termination of Enrollment

Sec. 1207.004.  TERMINATION OF ENROLLMENT.  (a)  Notwithstanding any other requirement of a group health benefit plan, the plan issuer shall permit an individual who is enrolled in the plan under Section 1207.002(a)(1), and any family member of the individual enrolled under Section 1207.002(c), to terminate enrollment in the plan not later than the 60th day after the date on which the individual provides satisfactory proof to the issuer that the individual is no longer:
(1)  a recipient of medical assistance under the state Medicaid program; or
(2)  a participant in the health insurance premium payment reimbursement program under Section 32.0422, Human Resources Code.
(b)  Notwithstanding any other requirement of a group health benefit plan, the plan issuer shall permit an individual who is enrolled in the plan under Section 1207.002(a)(2), and any family member of the individual enrolled under Section 1207.002(c), to terminate enrollment in the plan not later than the 60th day after the date on which the individual provides a written request to disenroll from the plan because the individual no longer wishes to participate in the health insurance premium assistance program under Section 62.059, Health and Safety Code.
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. 11.026(a), eff. September 1, 2005.
Acts 2007, 80th Leg., R.S., Ch. 268 (S.B. 10), Sec. 24(c), eff. September 1, 2007.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1208 - Identity of Available Employee of Health Benefit Plan Issuer › Section 1208.001. Applicability of Chapter

Sec. 1208.001.  APPLICABILITY OF CHAPTER.  This chapter applies only to a health benefit plan that provides benefits for medical or surgical expenses incurred as a result of a health condition, accident, or sickness, including an individual, group, blanket, or franchise insurance policy or insurance agreement, a group hospital service contract, or an individual or group evidence of coverage or similar coverage document that is offered by:
(1)  an insurance company;
(2)  a group hospital service corporation operating under Chapter 842;
(3)  a fraternal benefit society operating under Chapter 885;
(4)  a stipulated premium company operating under Chapter 884;
(5)  a reciprocal exchange operating under Chapter 942;
(6)  a health maintenance organization operating under Chapter 843;
(7)  a multiple employer welfare arrangement that holds a certificate of authority under Chapter 846;  or
(8)  an approved nonprofit health corporation that holds a certificate of authority under Chapter 844.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.