reglab/statecodes huggingface dataset:
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1365 - Loss or Impairment of Speech or Hearing › Subchapter B. Hearing Aid Coverage › Section 1365.052. Exception

Sec. 1365.052.  EXCEPTION.  This subchapter does not apply to:
(1)  a plan that provides coverage:
(A)  for wages or payments in lieu of wages for a period during which an employee is absent from work because of sickness or injury; or
(B)  only for hospital expenses; or
(2)  the state Medicaid program, including the Medicaid managed care program operated under Chapter 533, Government Code.
Added by Acts 2023, 88th Leg., R.S., Ch. 8 (H.B. 109), Sec. 3, eff. September 1, 2023.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1365 - Loss or Impairment of Speech or Hearing › Subchapter B. Hearing Aid Coverage › Section 1365.053. Choice of Hearing Aid

Sec. 1365.053.  CHOICE OF HEARING AID.  (a) A health benefit plan that provides coverage for hearing aids may not deny an enrollee's claim for a hearing aid solely on the basis that the price of the hearing aid is more than the benefit available under the health benefit plan.
(b)  Notwithstanding Section 1367.253(d), this section applies to a health benefit plan subject to Subchapter F, Chapter 1367.
(c)  Nothing in this section requires a health benefit plan to pay an enrollee's claim for a hearing aid in an amount that is more than the benefit available under the health benefit plan.
Added by Acts 2023, 88th Leg., R.S., Ch. 8 (H.B. 109), Sec. 3, eff. September 1, 2023.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1366 - Benefits Related to Fertility and Childbirth › Subchapter A. Coverage for in Vitro Fertilization Procedures › Section 1366.001. Applicability of Subchapter

Sec. 1366.001.  APPLICABILITY OF SUBCHAPTER.  This subchapter applies only to a group health benefit plan that provides benefits for hospital, medical, or surgical expenses incurred as a result of accident or sickness, including a group health insurance policy, health care service contract or plan, or other provision of group health benefits, coverage, or services in this state that is issued, entered into, or provided by:
(1)  an insurer;
(2)  a group hospital service corporation operating under Chapter 842;
(3)  a health maintenance organization operating under Chapter 843;  or
(4)  an employer, multiple employer, union, association, trustee, or other self-funded or self-insured welfare or benefit plan, program, or arrangement.
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 E - Benefits Payable Under Health Coverages › Chapter 1366 - Benefits Related to Fertility and Childbirth › Subchapter A. Coverage for in Vitro Fertilization Procedures › Section 1366.002. Exception

Sec. 1366.002.  EXCEPTION.  This subchapter does not apply to:
(1)  a credit accident and health insurance policy subject to Chapter 1153;
(2)  any group specifically provided for or authorized by law in existence and covered under a policy filed with the State Board of Insurance before April 1, 1975;
(3)  accident and health coverages that are incidental to any form of a group automobile, casualty, property, workers' compensation, or employers' liability policy approved by the commissioner;  or
(4)  any policy or contract of insurance with a state agency, department, or board providing health services:
(A)  to eligible individuals under Chapter 32, Human Resources Code;  or
(B)  under a state plan adopted in accordance with 42 U.S.C. Sections 1396-1396g, as amended, or 42 U.S.C. Section 1397aa et seq., as amended.
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 E - Benefits Payable Under Health Coverages › Chapter 1366 - Benefits Related to Fertility and Childbirth › Subchapter A. Coverage for in Vitro Fertilization Procedures › Section 1366.003. Offer of Coverage Required

Sec. 1366.003.  OFFER OF COVERAGE REQUIRED.  (a)  Subject to this subchapter, an issuer of a group health benefit plan that provides pregnancy-related benefits for individuals covered under the plan shall offer and make available to each holder or sponsor of the plan coverage for services and benefits on an expense incurred, service, or prepaid basis for outpatient expenses that arise from in vitro fertilization procedures.
(b)  Benefits for in vitro fertilization procedures required under this section must be provided to the same extent as benefits provided for other pregnancy-related procedures 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 E - Benefits Payable Under Health Coverages › Chapter 1366 - Benefits Related to Fertility and Childbirth › Subchapter A. Coverage for in Vitro Fertilization Procedures › Section 1366.004. Rejection of Offer

Sec. 1366.004.  REJECTION OF OFFER.  A rejection of an offer under Section 1366.003 to provide coverage for in vitro fertilization procedures must be in writing.
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 E - Benefits Payable Under Health Coverages › Chapter 1366 - Benefits Related to Fertility and Childbirth › Subchapter A. Coverage for in Vitro Fertilization Procedures › Section 1366.005. Conditions Applicable to Coverage

Sec. 1366.005.  CONDITIONS APPLICABLE TO COVERAGE.  The coverage offered under Section 1366.003 is required only if:
(1)  the patient for the in vitro fertilization procedure is an individual covered under the group health benefit plan;
(2)  the fertilization or attempted fertilization of the patient's oocytes is made only with the sperm of the patient's spouse;
(3)  the patient and the patient's spouse have a history of infertility of at least five continuous years' duration or the infertility is associated with:
(A)  endometriosis;
(B)  exposure in utero to diethylstilbestrol (DES);
(C)  blockage of or surgical removal of one or both fallopian tubes;  or
(D)  oligospermia;
(4)  the patient has been unable to attain a successful pregnancy through any less costly applicable infertility treatments for which coverage is available under the group health benefit plan;  and
(5)  the in vitro fertilization procedures are performed at a medical facility that conforms to the minimal standards for programs of in vitro fertilization adopted by the American Society for Reproductive Medicine.
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 E - Benefits Payable Under Health Coverages › Chapter 1366 - Benefits Related to Fertility and Childbirth › Subchapter A. Coverage for in Vitro Fertilization Procedures › Section 1366.006. Certain Issuers of Health Benefit Plans Not Required to Offer Coverage

Sec. 1366.006.  CERTAIN ISSUERS OF HEALTH BENEFIT PLANS NOT REQUIRED TO OFFER COVERAGE.  An insurer, health maintenance organization, or self-insuring employer that is owned by or that is part of an entity, group, or order that is directly affiliated with a bona fide religious denomination that includes as an integral part of its beliefs and practices that in vitro fertilization is contrary to moral principles that the religious denomination considers to be an essential part of its beliefs is not required to offer coverage for in vitro fertilization under Section 1366.003.
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 E - Benefits Payable Under Health Coverages › Chapter 1366 - Benefits Related to Fertility and Childbirth › Subchapter A. Coverage for in Vitro Fertilization Procedures › Section 1366.007. Rules

Sec. 1366.007.  RULES.  The commissioner may adopt rules necessary to administer this subchapter.  A rule adopted under this section is subject to notice and hearing as provided by Section 1201.007 for a rule adopted under Chapter 1201.
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 E - Benefits Payable Under Health Coverages › Chapter 1366 - Benefits Related to Fertility and Childbirth › Subchapter B. Minimum Inpatient Stay Following Birth of Child and Postdelivery Care › Section 1366.051. Short Title

Sec. 1366.051.  SHORT TITLE.  This subchapter may be cited as the Lee Alexandria Hanley Act.
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 E - Benefits Payable Under Health Coverages › Chapter 1366 - Benefits Related to Fertility and Childbirth › Subchapter B. Minimum Inpatient Stay Following Birth of Child and Postdelivery Care › Section 1366.052. Definitions

Sec. 1366.052.  DEFINITIONS.  In this subchapter:
(1)  "Attending physician" means an obstetrician, pediatrician, or other physician who attends a woman who has given birth to a child or who attends a newborn child.
(2)  "Postdelivery care" means postpartum health care services provided in accordance with accepted maternal and neonatal physical assessments.  The term includes parent education, assistance and training in breast-feeding and bottle-feeding, and the performance of any necessary and appropriate clinical tests.
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 E - Benefits Payable Under Health Coverages › Chapter 1366 - Benefits Related to Fertility and Childbirth › Subchapter B. Minimum Inpatient Stay Following Birth of Child and Postdelivery Care › Section 1366.053. Applicability of Subchapter

Sec. 1366.053.  APPLICABILITY OF SUBCHAPTER.  This subchapter 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;
(ii)  an entity 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
(iii)  another analogous benefit arrangement;  or
(2)  is offered by 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 E - Benefits Payable Under Health Coverages › Chapter 1366 - Benefits Related to Fertility and Childbirth › Subchapter B. Minimum Inpatient Stay Following Birth of Child and Postdelivery Care › Section 1366.054. Exception

Sec. 1366.054.  EXCEPTION.  This subchapter 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;  or
(G)  only for indemnity for hospital confinement;
(2)  a Medicare supplemental policy as defined by Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss);
(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 1366.053.
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 E - Benefits Payable Under Health Coverages › Chapter 1366 - Benefits Related to Fertility and Childbirth › Subchapter B. Minimum Inpatient Stay Following Birth of Child and Postdelivery Care › Section 1366.055. Coverage for Inpatient Care Required

Sec. 1366.055.  COVERAGE FOR INPATIENT CARE REQUIRED.  (a)  Except as provided by Subsection (b), a health benefit plan that provides maternity benefits, including benefits for childbirth, must provide to a woman who has given birth to a child and the newborn child coverage for inpatient care in a health care facility for not less than:
(1)  48 hours after an uncomplicated vaginal delivery;  and
(2)  96 hours after an uncomplicated delivery by cesarean section.
(b)  A health benefit plan that provides to a woman who has given birth to a child and the newborn child coverage for in-home postdelivery care is not required to provide the coverage required under Subsection (a) unless:
(1)  the attending physician determines that inpatient care is medically necessary;  or
(2)  the woman requests inpatient care.
(c)  For purposes of Subsection (a), the attending physician shall determine whether a delivery is complicated.
(d)  This section does not require a woman who is eligible for coverage under a health benefit plan to:
(1)  give birth to a child in a hospital or other health care facility;  or
(2)  remain under inpatient care in a hospital or other health care facility for any fixed term following the birth of a child.
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 E - Benefits Payable Under Health Coverages › Chapter 1366 - Benefits Related to Fertility and Childbirth › Subchapter B. Minimum Inpatient Stay Following Birth of Child and Postdelivery Care › Section 1366.056. Coverage for Postdelivery Care Required

Sec. 1366.056.  COVERAGE FOR POSTDELIVERY CARE REQUIRED.  (a)  If a decision is made to discharge a woman who has given birth to a child or the newborn child from inpatient care before the expiration of the minimum hours of coverage required under Section 1366.055(a), a health benefit plan must provide to the woman and child coverage for timely postdelivery care.
(b)  The timeliness of the postdelivery care shall be determined in accordance with recognized medical standards for that care.
(c)  The postdelivery care may be provided by a physician, registered nurse, or other appropriate licensed health care provider.
(d)  Subject to Subsection (e), the postdelivery care may be provided at:
(1)  the woman's home;
(2)  a health care provider's office;
(3)  a health care facility;  or
(4)  another location determined to be appropriate under rules adopted by the commissioner.
(e)  The coverage required under this section must give the woman the option to have the care provided in the woman's home.
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 E - Benefits Payable Under Health Coverages › Chapter 1366 - Benefits Related to Fertility and Childbirth › Subchapter B. Minimum Inpatient Stay Following Birth of Child and Postdelivery Care › Section 1366.057. Prohibited Conduct

Sec. 1366.057.  PROHIBITED CONDUCT.  An issuer of a health benefit plan may not:
(1)  modify the terms and conditions of coverage based on a request by an enrollee for less than the minimum coverage required under Section 1366.055(a);
(2)  offer to a woman who has given birth to a child a financial incentive or other compensation the receipt of which is contingent on the waiver by the woman of the minimum coverage required under Section 1366.055(a);
(3)  refuse to accept a physician's recommendation for inpatient care made in consultation with the woman who has given birth to a child if the period of inpatient care recommended by the physician does not exceed the minimum periods recommended in guidelines for perinatal care developed by:
(A)  the American College of Obstetricians and Gynecologists;
(B)  the American Academy of Pediatrics;  or
(C)  another nationally recognized professional association of obstetricians and gynecologists or of pediatricians;
(4)  reduce payments or other forms of reimbursement for inpatient care below the usual and customary rate of reimbursement for that care;  or
(5)  penalize a physician for recommending inpatient care for a woman or the woman's newborn child by:
(A)  refusing to permit the physician to participate as a provider in the health benefit plan;
(B)  reducing payments made to the physician;
(C)  requiring the physician to:
(i)  provide additional documentation;  or
(ii)  undergo additional utilization review;  or
(D)  imposing other analogous sanctions or disincentives.
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 E - Benefits Payable Under Health Coverages › Chapter 1366 - Benefits Related to Fertility and Childbirth › Subchapter B. Minimum Inpatient Stay Following Birth of Child and Postdelivery Care › Section 1366.058. Notice of Coverage

Sec. 1366.058.  NOTICE OF COVERAGE.  (a)  An issuer of a health benefit plan shall provide to each individual enrolled in the plan written notice of the coverage required under this subchapter.
(b)  The notice must be provided in accordance with rules adopted 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 E - Benefits Payable Under Health Coverages › Chapter 1366 - Benefits Related to Fertility and Childbirth › Subchapter B. Minimum Inpatient Stay Following Birth of Child and Postdelivery Care › Section 1366.059. Rules

Sec. 1366.059.  RULES.  The commissioner shall adopt rules necessary to administer 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 E - Benefits Payable Under Health Coverages › Chapter 1366 - Benefits Related to Fertility and Childbirth › Subchapter C. Coverage for Certain Fertility Preservation Services › Section 1366.101. Definition

Sec. 1366.101.  DEFINITION.  In this subchapter, "fertility preservation services":
(1)  means the collection and preservation of sperm, unfertilized oocytes, and ovarian tissue; and
(2)  does not include the storage of such unfertilized genetic materials.
Added by Acts 2023, 88th Leg., R.S., Ch. 819 (H.B. 1649), Sec. 2, eff. September 1, 2023.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1366 - Benefits Related to Fertility and Childbirth › Subchapter C. Coverage for Certain Fertility Preservation Services › Section 1366.102. Applicability of Subchapter

Sec. 1366.102.  APPLICABILITY OF SUBCHAPTER.  (a)  This subchapter 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 issued in this state 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)  an approved nonprofit health corporation that holds a certificate of authority under Chapter 844;
(5)  a multiple employer welfare arrangement that holds a certificate of authority under Chapter 846;
(6)  a stipulated premium company operating under Chapter 884;
(7)  a fraternal benefit society operating under Chapter 885;
(8)  a Lloyd's plan operating under Chapter 941; or
(9)  an exchange operating under Chapter 942.
(b)  Notwithstanding any other law, this subchapter applies to:
(1)  a small employer health benefit plan subject to Chapter 1501, including coverage provided through a health group cooperative under Subchapter B of that chapter; and
(2)  a standard health benefit plan issued under Chapter 1507.
Added by Acts 2023, 88th Leg., R.S., Ch. 819 (H.B. 1649), Sec. 2, eff. September 1, 2023.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1366 - Benefits Related to Fertility and Childbirth › Subchapter C. Coverage for Certain Fertility Preservation Services › Section 1366.103. Exceptions

Sec. 1366.103.  EXCEPTIONS.  This subchapter does not apply to:
(1)  a health benefit plan that provides coverage:
(A)  for wages or payments in lieu of wages for a period during which an employee is absent from work because of sickness or injury; or
(B)  only for hospital expenses;
(2)  Medicaid managed care programs operated under Chapter 533, Government Code;
(3)  Medicaid programs operated under Chapter 32, Human Resources Code; or
(4)  the state child health plan operated under Chapter 62 or 63, Health and Safety Code.
Added by Acts 2023, 88th Leg., R.S., Ch. 819 (H.B. 1649), Sec. 2, eff. September 1, 2023.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1366 - Benefits Related to Fertility and Childbirth › Subchapter C. Coverage for Certain Fertility Preservation Services › Section 1366.104. Required Coverage

Sec. 1366.104.  REQUIRED COVERAGE.  (a)  Subject to Subsection (b), a health benefit plan must provide coverage for fertility preservation services to a covered person who will receive a medically necessary treatment for cancer, including surgery, chemotherapy, or radiation, that the American Society of Clinical Oncology or the American Society for Reproductive Medicine has established may directly or indirectly cause impaired fertility.
(b)  The fertility preservation services described by Subsection (a) must be standard procedures to preserve fertility consistent with established medical practices or professional guidelines published by the American Society of Clinical Oncology or the American Society for Reproductive Medicine.
Added by Acts 2023, 88th Leg., R.S., Ch. 819 (H.B. 1649), Sec. 2, eff. September 1, 2023.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1367 - Coverage of Children › Subchapter A. Newborn Children › Section 1367.001. Applicability of Subchapter

Sec. 1367.001.  APPLICABILITY OF SUBCHAPTER.  This subchapter applies only to a health benefit plan delivered or issued for delivery in this state that is 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 E - Benefits Payable Under Health Coverages › Chapter 1367 - Coverage of Children › Subchapter A. Newborn Children › Section 1367.002. Applicability of General Provisions of Other Law

Sec. 1367.002.  APPLICABILITY OF GENERAL PROVISIONS OF OTHER LAW.  The provisions of Chapter 1201, including provisions relating to the applicability, purpose, and enforcement of that chapter, construction of policies under that chapter, rulemaking under that chapter, and definitions of terms applicable in that chapter, apply to 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 E - Benefits Payable Under Health Coverages › Chapter 1367 - Coverage of Children › Subchapter A. Newborn Children › Section 1367.003. Certain Limitations on Coverage for Newborn Children Prohibited

Sec. 1367.003.  CERTAIN LIMITATIONS ON COVERAGE FOR NEWBORN CHILDREN PROHIBITED.  A health benefit plan that provides maternity benefits or accident and health coverage for additional newborn children may not be issued in this state if the plan excludes or limits:
(1)  initial coverage of a newborn child for a period of time;
(2)  coverage for congenital defects of a newborn child; or
(3)  coverage for administration of the newborn screening tests required by Section 33.011, Health and Safety Code, including for the cost of a newborn screening test kit in the amount provided by the Department of State Health Services on its Internet website under Section 33.019 of that code on the date the test was administered.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
Amended by:
Acts 2019, 86th Leg., R.S., Ch. 599 (S.B. 747), Sec. 5, eff. September 1, 2019.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1367 - Coverage of Children › Subchapter B. Childhood Immunizations › Section 1367.051. Applicability of Subchapter

Sec. 1367.051.  APPLICABILITY OF SUBCHAPTER.  This subchapter 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 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:
(A)  an insurance company;
(B)  a group hospital service corporation operating under Chapter 842;
(C)  a fraternal benefit society operating under Chapter 885;
(D)  a stipulated premium company operating under Chapter 884;
(E)  a health maintenance organization operating under Chapter 843;  or
(F)  a multiple employer welfare arrangement subject to regulation under Chapter 846;
(2)  is offered by an approved nonprofit health corporation that holds a certificate of authority under Chapter 844;  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.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1367 - Coverage of Children › Subchapter B. Childhood Immunizations › Section 1367.052. Exception

Sec. 1367.052.  EXCEPTION.  This subchapter 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;  or
(G)  only for indemnity for hospital confinement;
(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;  or
(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 1367.051.
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 E - Benefits Payable Under Health Coverages › Chapter 1367 - Coverage of Children › Subchapter B. Childhood Immunizations › Section 1367.053. Coverage Required

Sec. 1367.053.  COVERAGE REQUIRED.  (a)  A health benefit plan that provides coverage for a family member of an insured or enrollee shall provide for each covered child from birth through the date of the child's sixth birthday coverage for:
(1)  immunization against:
(A)  diphtheria;
(B)  haemophilus influenzae type b;
(C)  hepatitis B;
(D)  measles;
(E)  mumps;
(F)  pertussis;
(G)  polio;
(H)  rubella;
(I)  tetanus;  and
(J)  varicella;  and
(2)  any other immunization that is required for the child by law.
(b)  For purposes of Subsection (a), a covered child is a child who, as a result of the child's relationship to an insured or enrollee in a health benefit plan, would be entitled to coverage under an accident and health insurance policy under Section 1201.061, 1201.062, 1201.063, or 1201.064.
(c)  In addition to the immunizations required under Subsection (a), a health maintenance organization that issues a health benefit plan shall provide under the plan coverage for immunization against rotovirus and any other immunization required for a child by law.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
Amended by:
Acts 2007, 80th Leg., R.S., Ch. 730 (H.B. 2636), Sec. 3B.0281, eff. September 1, 2007.
Acts 2007, 80th Leg., R.S., Ch. 921 (H.B. 3167), Sec. 9.0281, eff. September 1, 2007.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1367 - Coverage of Children › Subchapter B. Childhood Immunizations › Section 1367.054. Copayment, Deductible, or Coinsurance Requirement Prohibited

Sec. 1367.054.  COPAYMENT, DEDUCTIBLE, OR COINSURANCE REQUIREMENT PROHIBITED.  (a)  Coverage required under Section 1367.053(a) may not be made subject to a deductible, copayment, or coinsurance requirement.
(b)  This section does not prohibit the application of a deductible, copayment, or coinsurance requirement to another service provided at the same time the immunization is administered.
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 E - Benefits Payable Under Health Coverages › Chapter 1367 - Coverage of Children › Subchapter B. Childhood Immunizations › Section 1367.055. Rules

Sec. 1367.055.  RULES.  The commissioner may adopt rules necessary to implement this subchapter.
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. 11.039, eff. September 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1367 - Coverage of Children › Subchapter C. Hearing Test › Section 1367.101. Applicability of Subchapter

Sec. 1367.101.  APPLICABILITY OF SUBCHAPTER.  (a)  This subchapter 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 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:
(A)  an insurance company;
(B)  a group hospital service corporation operating under Chapter 842;
(C)  a fraternal benefit society operating under Chapter 885;
(D)  a stipulated premium company operating under Chapter 884;
(E)  a health maintenance organization operating under Chapter 843;  or
(F)  a multiple employer welfare arrangement subject to regulation under Chapter 846;
(2)  is offered by an approved nonprofit health corporation that holds a certificate of authority under Chapter 844;  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.
(b)  This subchapter applies to a health benefit plan described by Subsection (a) that provides coverage to a resident of this state, regardless of whether the plan issuer is located in or outside this state.
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 E - Benefits Payable Under Health Coverages › Chapter 1367 - Coverage of Children › Subchapter C. Hearing Test › Section 1367.102. Exception

Sec. 1367.102.  EXCEPTION.  This subchapter 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;  or
(G)  only for indemnity for hospital confinement;
(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;  or
(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 1367.101.
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 E - Benefits Payable Under Health Coverages › Chapter 1367 - Coverage of Children › Subchapter C. Hearing Test › Section 1367.103. Coverage Required

Sec. 1367.103.  COVERAGE REQUIRED.  (a)  A health benefit plan that provides coverage for a family member of an insured or enrollee shall provide to each covered child coverage for:
(1)  a screening test for hearing loss from birth through the date the child is 30 days of age, as provided by Chapter 47, Health and Safety Code;  and
(2)  necessary diagnostic follow-up care related to the screening test from birth through the date the child is 24 months of age.
(b)  For purposes of Subsection (a), a covered child is a child who, as a result of the child's relationship to an insured or enrollee in a health benefit plan, would be entitled to coverage under an accident and health insurance policy under Section 1201.061, 1201.062, 1201.063, or 1201.064.
(c)  This section does not require a health benefit plan to provide the coverage described by this section to a child of an individual residing in this state if the individual is:
(1)  employed outside this state;  and
(2)  covered under a health benefit plan maintained for the individual by the individual's employer as an employment benefit.
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 E - Benefits Payable Under Health Coverages › Chapter 1367 - Coverage of Children › Subchapter C. Hearing Test › Section 1367.104. Copayment or Coinsurance Requirement Permitted; Deductible Requirement or Dollar Limit Prohibited; Notice Required

Sec. 1367.104.  COPAYMENT OR COINSURANCE REQUIREMENT PERMITTED;  DEDUCTIBLE REQUIREMENT OR DOLLAR LIMIT PROHIBITED;  NOTICE REQUIRED.  (a)  Coverage required under this subchapter:
(1)  may be subject to a copayment or coinsurance requirement;  and
(2)  may not be subject to a deductible requirement or a dollar limit.
(b)  The requirements of this section must be stated in the coverage document.
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 E - Benefits Payable Under Health Coverages › Chapter 1367 - Coverage of Children › Subchapter C. Hearing Test › Section 1367.105. Rules

Sec. 1367.105.  RULES.  The commissioner may adopt rules necessary to implement 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 E - Benefits Payable Under Health Coverages › Chapter 1367 - Coverage of Children › Subchapter D. Child Craniofacial Abnormalities › Section 1367.151. Applicability of Subchapter

Sec. 1367.151.  APPLICABILITY OF SUBCHAPTER.  This subchapter 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;
(ii)  an entity 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
(iii)  another analogous benefit arrangement;  or
(2)  is offered by 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 E - Benefits Payable Under Health Coverages › Chapter 1367 - Coverage of Children › Subchapter D. Child Craniofacial Abnormalities › Section 1367.152. Exception

Sec. 1367.152.  EXCEPTION.  This subchapter 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;  or
(G)  only for indemnity for hospital confinement or other hospital expenses;
(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;  or
(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 1367.151.
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 E - Benefits Payable Under Health Coverages › Chapter 1367 - Coverage of Children › Subchapter D. Child Craniofacial Abnormalities › Section 1367.153. Reconstructive Surgery for Craniofacial Abnormalities; Definition Required

Sec. 1367.153.  RECONSTRUCTIVE SURGERY FOR CRANIOFACIAL ABNORMALITIES;  DEFINITION REQUIRED.  A health benefit plan that provides coverage for a child who is younger than 18 years of age must define "reconstructive surgery for craniofacial abnormalities" under the plan to mean surgery to improve the function of, or to attempt to create a normal appearance of, an abnormal structure caused by congenital defects, developmental deformities, trauma, tumors, infections, or disease.
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 E - Benefits Payable Under Health Coverages › Chapter 1367 - Coverage of Children › Subchapter D. Child Craniofacial Abnormalities › Section 1367.154. Rules

Sec. 1367.154.  RULES.  The commissioner shall adopt rules necessary to administer 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 E - Benefits Payable Under Health Coverages › Chapter 1367 - Coverage of Children › Subchapter E. Developmental Delays › Section 1367.201. Definition

Sec. 1367.201.  DEFINITION.  In this subchapter, rehabilitative and habilitative therapies include:
(1)  occupational therapy evaluations and services;
(2)  physical therapy evaluations and services;
(3)  speech therapy evaluations and services; and
(4)  dietary or nutritional evaluations.
Added by Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.040(a), eff. September 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1367 - Coverage of Children › Subchapter E. Developmental Delays › Section 1367.202. Applicability of Subchapter

Sec. 1367.202.  APPLICABILITY OF SUBCHAPTER.  This subchapter 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 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:
(A)  an insurance company;
(B)  a group hospital service corporation operating under Chapter 842;
(C)  a fraternal benefit society operating under Chapter 885;
(D)  a stipulated premium company operating under Chapter 884;
(E)  a health maintenance organization operating under Chapter 843; or
(F)  a multiple employer welfare arrangement subject to regulation under Chapter 846;
(2)  is offered by an approved nonprofit health corporation that holds a certificate of authority under Chapter 844; 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 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.040(a), eff. September 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1367 - Coverage of Children › Subchapter E. Developmental Delays › Section 1367.203. Exception

Sec. 1367.203.  EXCEPTION.  This subchapter 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; or
(G)  only for indemnity for hospital confinement;
(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; or
(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 1367.202.
Added by Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.040(a), eff. September 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1367 - Coverage of Children › Subchapter E. Developmental Delays › Section 1367.204. Offer of Coverage Required

Sec. 1367.204.  OFFER OF COVERAGE REQUIRED.  (a)  A health benefit plan issuer must offer coverage that complies with this subchapter.
(b)  The individual or group policy or contract holder may reject coverage required to be offered under this section.
Added by Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.040(a), eff. September 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1367 - Coverage of Children › Subchapter E. Developmental Delays › Section 1367.205. Coverage of Certain Therapies

Sec. 1367.205.  COVERAGE OF CERTAIN THERAPIES.  (a)  A health benefit plan that provides coverage for rehabilitative and habilitative therapies under this subchapter may not prohibit or restrict payment for covered services provided to a child and determined to be necessary to and provided in accordance with an individualized family service plan issued by the Interagency Council on Early Childhood Intervention under Chapter 73, Human Resources Code.
(b)  Rehabilitative and habilitative therapies described by Subsection (a) must be covered in the amount, duration, scope, and service setting established in the child's individualized family service plan.
(c)  A child is entitled to benefits under this subchapter if the child, as a result of the child's relationship to an insured or enrollee in a health benefit plan, would be entitled to coverage under an accident and health insurance policy under Section 1201.061, 1201.062, 1201.063, or 1201.064.
Added by Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.040(a), eff. September 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1367 - Coverage of Children › Subchapter E. Developmental Delays › Section 1367.206. Prohibited Actions

Sec. 1367.206.  PROHIBITED ACTIONS.  Under the coverage required to be offered under this subchapter, a health benefit plan issuer may not:
(1)  apply the cost of rehabilitative and habilitative therapies described by Section 1367.205(a) to an annual or lifetime maximum plan benefit or similar provision under the plan; or
(2)  use the cost of rehabilitative or habilitative therapies described by Section 1367.205(a) as the sole justification for:
(A)  increasing plan premiums; or
(B)  terminating the insured's or enrollee's participation in the plan.
Added by Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.040(a), eff. September 1, 2005.