reglab/statecodes huggingface dataset:
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 1208.002. Disclosure Required

Sec. 1208.002.  DISCLOSURE REQUIRED.  After an oral or written request by an insured or enrollee of a health benefit plan, the plan issuer shall provide to the insured or enrollee the name or employee identifier of the issuer's employee who is available to respond to questions or other communication from the insured or enrollee relating to coverage and benefits provided under the plan to the insured or enrollee.  The issuer shall also provide:
(1)  the employee's mailing address;
(2)  the municipality and state of the employee's business location;  and
(3)  the employee's job title.
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 1210 - Notice of Certain Policy Provisions › Section 1210.001. Notice Required

Sec. 1210.001.  NOTICE REQUIRED.  A policy, contract, or certificate of insurance that insures against loss resulting from sickness or accidental bodily injury and that is subject to an increase in the premium at time of renewal or to nonrenewal on the insured attaining a certain age may not be delivered, issued, or used in this state unless the document contains on the first page above the policy provisions a printed notice in 10-point type that states that the policy, contract, or certificate is subject to either or both conditions.
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 1211 - Waivers Regarding Certain Federal Health Plans › Section 1211.001. Waiver of Certain Provisions for Certain Federal Plans

INSURANCE CODE
TITLE 8. HEALTH INSURANCE AND OTHER HEALTH COVERAGES
SUBTITLE A. HEALTH COVERAGE IN GENERAL
CHAPTER 1211.  WAIVERS REGARDING CERTAIN FEDERAL HEALTH PLANS
Sec. 1211.001.  WAIVER OF CERTAIN PROVISIONS FOR CERTAIN FEDERAL PLANS.  If the commissioner of insurance, in consultation with the commissioner of health and human services, determines that a provision of Section 843.209 or 843.321, Subchapter J, Chapter 843, Chapter 1213, Subchapter C or C-1, Chapter 1301, or Section 1301.008, 1301.069, or 1301.162 will cause a negative fiscal impact on the state with respect to providing benefits or services under Subchapter XIX, Social Security Act (42 U.S.C. Section 1396 et seq.), as amended, or Subchapter XXI, Social Security Act (42 U.S.C. Section 1397aa et seq.), as amended, the commissioner of insurance by rule shall waive the application of that provision to the providing of those benefits or services.
Added by Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.027(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 1213 - Electronic Health Care Transactions › Section 1213.001. Definition of Health Benefit Plan

Sec. 1213.001.  DEFINITION OF HEALTH BENEFIT PLAN.  (a)  In this chapter, "health benefit plan" means a plan that provides benefits for medical, surgical, or other treatment expenses incurred as a result of a health condition, a mental health condition, an accident, sickness, or substance abuse, 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 insurance company operating under Chapter 884;
(5)  a Lloyd's plan operating under Chapter 941;
(6)  an exchange operating under Chapter 942;
(7)  a health maintenance organization operating under Chapter 843;
(8)  a multiple employer welfare arrangement that holds a certificate of authority under Chapter 846; or
(9)  an approved nonprofit health corporation that holds a certificate of authority under Chapter 844.
(b)  The term includes:
(1)  a small employer health benefit plan written under Chapter 1501; and
(2)  a health benefit plan offered under Chapter 1551, 1575, 1579, or 1601.
Added by Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.029(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 1213 - Electronic Health Care Transactions › Section 1213.002. Electronic Submission of Claims

Sec. 1213.002.  ELECTRONIC SUBMISSION OF CLAIMS.  (a)  The issuer of a health benefit plan by contract may require that a health care professional licensed or registered under the Occupations Code or a health care facility licensed under the Health and Safety Code electronically submit a health care claim or equivalent encounter information, a referral certification, or an authorization or eligibility transaction.  The health benefit plan issuer shall comply with the standards for electronic transactions required by this section and established by the commissioner by rule.
(b)  The issuer of a health benefit plan by contract shall establish a default method to submit claims in a nonelectronic format if there is a system failure or failures or a catastrophic event substantially interferes with the normal business operations of the physician, provider, or health benefit plan or its agents.  The health benefit plan issuer shall comply with the standards for nonelectronic transactions established by the commissioner by rule.
Added by Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.029(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 1213 - Electronic Health Care Transactions › Section 1213.003. Electronic Submission of Claims: Waiver

Sec. 1213.003.  ELECTRONIC SUBMISSION OF CLAIMS: WAIVER.  (a)  A contract between the issuer of a health benefit plan and a health care professional or health care facility must provide for a waiver of any requirement for electronic submission established under this chapter.
(b)  The commissioner shall establish circumstances under which a waiver is required, including:
(1)  circumstances in which no method is available for the submission of claims in electronic form;
(2)  the operation of small physician practices;
(3)  the operation of other small health care provider practices;
(4)  undue hardship, including fiscal or operational hardship; or
(5)  any other special circumstance that would justify a waiver.
(c)  Any health care professional or health care facility that is denied a waiver by the issuer of a health benefit plan may appeal the denial to the commissioner.  The commissioner shall determine whether a waiver must be granted.
(d)  The issuer of a health benefit plan may not refuse to contract or renew a contract with a health care professional or health care facility based in whole or in part on the professional or facility requesting or receiving a waiver or appealing a waiver determination.
Added by Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.029(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 1213 - Electronic Health Care Transactions › Section 1213.004. Mode of Transmission

Sec. 1213.004.  MODE OF TRANSMISSION.  The issuer of a health benefit plan may not by contract limit the mode of electronic transmission that a health care professional or health care facility may use to submit information under this chapter.
Added by Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.029(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 1213 - Electronic Health Care Transactions › Section 1213.005. Certain Charges Prohibited

Sec. 1213.005.  CERTAIN CHARGES PROHIBITED.  A health benefit plan may not directly or indirectly charge or hold a health care professional, health care facility, or person enrolled in a health benefit plan responsible for a fee for the adjudication of a claim.
Added by Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.029(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 1213 - Electronic Health Care Transactions › Section 1213.006. Rules

Sec. 1213.006.  RULES.  The commissioner may adopt rules as necessary to implement this chapter.  The commissioner may not require any data element for electronically filed claims that is not required to comply with federal law.
Added by Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.029(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 1214 - Advertising for Certain Health Benefits › Section 1214.001. Applicability of Chapter

Sec. 1214.001.  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 agreement, a group hospital service contract, or an individual or group evidence of coverage issued by:
(1)  an insurance company;
(2)  a group hospital service corporation operating under Chapter 842;
(3)  a health maintenance organization operating under Section 1367.053, Subchapter A, Chapter 1452, Subchapter B, Chapter 1507, Chapter 222, 251, or 258, as applicable to a health maintenance organization, Chapter 843, Chapter 1271, and Chapter 1272; or
(4)  an approved nonprofit health corporation holding a certificate of authority under Chapter 844.
Added by Acts 2007, 80th Leg., R.S., Ch. 730 (H.B. 2636), Sec. 1G.001, eff. April 1, 2009.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1214 - Advertising for Certain Health Benefits › Section 1214.002. Exception

Sec. 1214.002.  EXCEPTION.  This chapter does not apply to:
(1)  a health benefit plan that provides coverage:
(A)  only for a specified disease;
(B)  only for accidental death or dismemberment; or
(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; or
(2)  a long-term care insurance policy, including a nursing home fixed indemnity policy, unless the commissioner determines that the policy provides benefits so comprehensive that the policy is a health benefit plan as described by Section 1214.001.
Added by Acts 2007, 80th Leg., R.S., Ch. 730 (H.B. 2636), Sec. 1G.001, eff. April 1, 2009.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1214 - Advertising for Certain Health Benefits › Section 1214.003. Rate Information Disclaimers

Sec. 1214.003.  RATE INFORMATION DISCLAIMERS.  (a)  Subject to Chapter 541 and Section 543.001, an advertisement for a health benefit plan may include rate information without including information about each benefit exclusion or limitation if the advertisement includes prominent disclaimers clearly indicating that:
(1)  the rates are illustrative;
(2)  a person should not send money to the health benefit plan issuer in response to the advertisement;
(3)  a person cannot obtain coverage under the plan until the person completes an application for coverage; and
(4)  benefit exclusions or limitations may apply to the plan.
(b)  An advertisement that states a rate must also indicate the age, gender, and geographic location on which the rate is based.
Added by Acts 2007, 80th Leg., R.S., Ch. 730 (H.B. 2636), Sec. 1G.001, eff. April 1, 2009.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1215 - Reporting of Claims Information › Section 1215.001. Definitions

Sec. 1215.001.  DEFINITIONS.  (a)  Except as provided by Subsection (b), in this chapter:
(1)  "Employer" has the meaning assigned by 29 U.S.C. Section 1002(5).
(2)  "Governmental entity" means a state agency or political subdivision of this state.
(3)  "Group health plan" has the meaning assigned by 45 C.F.R. Section 160.103, except that the term does not include disability income or long-term care insurance.
(4)  "Health insurance issuer" has the meaning assigned by 45 C.F.R. Section 160.103.
(5)  "Plan" means an employee welfare benefit plan as defined by 29 U.S.C. Section 1002(1).
(6)  "Plan administrator" means an administrator as defined by 29 U.S.C. Section 1002(16)(A).
(7)  "Plan sponsor" has the meaning assigned by 29 U.S.C. Section 1002(16)(B).
(8)  "Political subdivision" means a county, municipality, school district, special-purpose district, or other subdivision of state government that has jurisdiction limited to a geographic portion of the state.
(9)  "Protected health information" has the meaning assigned by 45 C.F.R. Section 160.103.
(b)  A reference to a federal statute or regulation under Subsection (a) means that statute or regulation as it existed on September 1, 2007, except that the commissioner, by rule, may adopt a definition based on a later amended, enacted, or adopted federal statute or regulation if the commissioner determines that use of the later amended, enacted, or adopted statute or regulation is consistent with the purposes of this chapter and promotes regulatory consistency.
Added by Acts 2007, 80th Leg., R.S., Ch. 700 (H.B. 2015), Sec. 1, eff. September 1, 2007.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1215 - Reporting of Claims Information › Section 1215.002. Applicability of Chapter to Governmental Entity; Applicability of Other Law With Reference to Governmental Entity

Sec. 1215.002.  APPLICABILITY OF CHAPTER TO GOVERNMENTAL ENTITY; APPLICABILITY OF OTHER LAW WITH REFERENCE TO GOVERNMENTAL ENTITY.  (a)  This chapter applies to a governmental entity that enters into a contract with a health insurance issuer that results in the health insurance issuer delivering, issuing for delivery, or renewing a group health plan.
(b)  For purposes of this chapter, a health insurance issuer shall treat a governmental entity described by Subsection (a) as a plan sponsor or plan administrator.
(c)  A report of claim information provided under this section to a governmental entity is confidential and exempt from public disclosure under Chapter 552, Government Code.
Added by Acts 2007, 80th Leg., R.S., Ch. 700 (H.B. 2015), Sec. 1, eff. September 1, 2007.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1215 - Reporting of Claims Information › Section 1215.004. Request for Additional Information

Sec. 1215.004.  REQUEST FOR ADDITIONAL INFORMATION.  (a)  On receipt of the report required by Section 1215.003(a), the plan, plan sponsor, or plan administrator may review the report and, not later than the 10th day after the date the report is received, may make a written request to the health insurance issuer for additional information in accordance with this section for specified individuals.
(b)  With respect to a request for additional information concerning specified individuals for whom claims information has been provided under Section 1215.003(c)(5), the health insurance issuer shall provide additional information on the prognosis or recovery if available and, for individuals in active case management, the most recent case management information, including any future expected costs and treatment plan, that relate to the claims for that individual.
(c)  The health insurance issuer must respond to the request for additional information under this section not later than the 15th day after the date of the request under this section unless the requesting plan, plan sponsor, or plan administrator agrees to a request for additional time.
(d)  The health insurance issuer is not required to produce the report described by this section unless a certification has been provided in accordance with Section 1215.003(e).
Added by Acts 2007, 80th Leg., R.S., Ch. 700 (H.B. 2015), Sec. 1, eff. September 1, 2007.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1215 - Reporting of Claims Information › Section 1215.005. Compliance With Chapter Does Not Create Liability

Sec. 1215.005.  COMPLIANCE WITH CHAPTER DOES NOT CREATE LIABILITY.  A health insurance issuer that releases information, including protected health information, in accordance with this chapter has not violated a standard of care and is not liable for civil damages resulting from, and is not subject to criminal prosecution for, releasing that information.
Added by Acts 2007, 80th Leg., R.S., Ch. 700 (H.B. 2015), Sec. 1, eff. September 1, 2007.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1215 - Reporting of Claims Information › Section 1215.006. Administrative Penalties

Sec. 1215.006.  ADMINISTRATIVE PENALTIES.  A health insurance issuer that does not comply with this chapter is subject to administrative penalties under Chapter 84.
Added by Acts 2007, 80th Leg., R.S., Ch. 700 (H.B. 2015), Sec. 1, eff. September 1, 2007.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1216 - Out-of-Country Coverage Prohibited › Section 1216.001. Definitions

Sec. 1216.001.  DEFINITIONS.  In this chapter:
(1)  "Enrollee" means an individual entitled to coverage under a health benefit plan.
(2)  "Foreign country" means a governmental unit other than:
(A)  the United States;
(B)  a state, district, commonwealth, territory, or insular possession of the United States;
(C)  the Panama Canal Zone; or
(D)  the Trust Territory of the Pacific Islands.
(3)  "Health care service" means a service to diagnose, prevent, alleviate, cure, or heal a health condition, sickness, or injury that is provided to an enrollee by a physician or other health care provider.
Added by Acts 2007, 80th Leg., R.S., Ch. 1322 (S.B. 1391), Sec. 1, eff. September 1, 2007.
Renumbered from Insurance Code, Section 1215.001 by Acts 2009, 81st Leg., R.S., Ch. 87 (S.B. 1969), Sec. 27.001(62), eff. September 1, 2009.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1216 - Out-of-Country Coverage Prohibited › Section 1216.002. Applicability of Chapter

Sec. 1216.002.  APPLICABILITY OF CHAPTER.  (a)  This chapter applies only to a health benefit plan that provides benefits for health care services, including medical or surgical expenses, incurred as a result of a health condition, accident, or sickness, including:
(1)  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; or
(E)  a health maintenance organization operating under Chapter 843; and
(2)  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:
(A)  a multiple employer welfare arrangement as defined by Section 3 of that Act; or
(B)  another analogous benefit arrangement.
(b)  For purposes of Subsection (a), a health benefit plan includes a consumer choice of benefits plan issued under Chapter 1507.
Added by Acts 2007, 80th Leg., R.S., Ch. 1322 (S.B. 1391), Sec. 1, eff. September 1, 2007.
Renumbered from Insurance Code, Section 1215.002 by Acts 2009, 81st Leg., R.S., Ch. 87 (S.B. 1969), Sec. 27.001(62), eff. September 1, 2009.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1216 - Out-of-Country Coverage Prohibited › Section 1216.003. Exception

Sec. 1216.003.  EXCEPTION.  This chapter does not apply to:
(1)  a plan that provides coverage:
(A)  only for a specified disease;
(B)  only for accidental death or dismemberment;
(C)  for wages or payments 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)  only for dental or vision care;
(F)  only for indemnity for hospital confinement; or
(G)  only for health care services provided to an enrollee while the enrollee is traveling to, visiting, or residing in a foreign country;
(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 1216.002.
Added by Acts 2007, 80th Leg., R.S., Ch. 1322 (S.B. 1391), Sec. 1, eff. September 1, 2007.
Renumbered from Insurance Code, Section 1215.003 by Acts 2009, 81st Leg., R.S., Ch. 87 (S.B. 1969), Sec. 27.001(62), eff. September 1, 2009.
Renumbered from Insurance Code, Section 1215.003 and amended by Acts 2009, 81st Leg., R.S., Ch. 87 (S.B. 1969), Sec. 27.002(12), eff. September 1, 2009.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1216 - Out-of-Country Coverage Prohibited › Section 1216.004. Out-of-Country Care Prohibited

Sec. 1216.004.  OUT-OF-COUNTRY CARE PROHIBITED.  A health benefit plan issuer may not issue or offer for sale in this state a health benefit plan that requires an enrollee to travel to a foreign country to receive a particular health care service under the health benefit plan.
Added by Acts 2007, 80th Leg., R.S., Ch. 1322 (S.B. 1391), Sec. 1, eff. September 1, 2007.
Renumbered from Insurance Code, Section 1215.004 by Acts 2009, 81st Leg., R.S., Ch. 87 (S.B. 1969), Sec. 27.001(62), eff. September 1, 2009.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1217 - Standard Request Form for Prior Authorization of Health Care Services › Section 1217.001. Definitions

Sec. 1217.001.  DEFINITIONS.  In this chapter:
(1)  "Health benefit plan issuer" means an entity authorized under this code or another insurance law of this state that delivers or issues for delivery a health benefit plan or other coverage that is covered under this chapter as described by Section 1217.002.  The term includes:
(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 reciprocal exchange operating under Chapter 942;
(F)  a health maintenance organization operating under Chapter 843;
(G)  a multiple employer welfare arrangement that holds a certificate of authority under Chapter 846; or
(H)  an approved nonprofit health corporation that holds a certificate of authority under Chapter 844.
(2)  "Health care services" includes medical or health care treatments, consultations, procedures, drugs, supplies, imaging and diagnostic services, inpatient and outpatient care, medical devices, and durable medical equipment.  The term does not include prescription drugs as defined by Section 551.003, Occupations Code.
Added by Acts 2013, 83rd Leg., R.S., Ch. 1198 (S.B. 1216), Sec. 1, eff. September 1, 2013.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1217 - Standard Request Form for Prior Authorization of Health Care Services › Section 1217.002. Applicability of Chapter

Sec. 1217.002.  APPLICABILITY OF CHAPTER.  (a)  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 a small or large employer group contract 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.
(b)  This chapter applies to group health coverage made available by a school district in accordance with Section 22.004, Education Code.
(c)  Notwithstanding any provision in Chapter 1551, 1575, 1579, or 1601 or any other law, this chapter applies to:
(1)  a basic coverage plan under Chapter 1551;
(2)  a basic plan under Chapter 1575;
(3)  a primary care coverage plan under Chapter 1579; and
(4)  basic coverage under Chapter 1601.
Text of subsection effective until April 01, 2025
(d)  Notwithstanding any other law, this chapter applies to coverage under:
(1)  the child health plan program under Chapter 62, Health and Safety Code, or the health benefits plan for children under Chapter 63, Health and Safety Code; and
(2)  a Medicaid managed care program operated under Chapter 533, Government Code, or a Medicaid program operated under Chapter 32, Human Resources Code.
Text of subsection effective on April 01, 2025
(d)  Notwithstanding any other law, this chapter applies to coverage under:
(1)  the child health plan program under Chapter 62, Health and Safety Code, or the health benefits plan for children under Chapter 63, Health and Safety Code; and
(2)  a Medicaid managed care program operated under Chapter 540 or 540A, Government Code, as applicable, or a Medicaid program operated under Chapter 32, Human Resources Code.
Added by Acts 2013, 83rd Leg., R.S., Ch. 1198 (S.B. 1216), Sec. 1, eff. September 1, 2013.
Amended by:
Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 2.120, eff. April 1, 2025.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1217 - Standard Request Form for Prior Authorization of Health Care Services › Section 1217.003. Exception

Sec. 1217.003.  EXCEPTION.  This chapter does not apply to:
(1)  a health benefit plan that provides coverage:
(A)  only for a specified disease or for another single benefit;
(B)  only for accidental death or dismemberment;
(C)  only 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; or
(H)  only for indemnity for hospital confinement;
(2)  a Medicare supplemental policy as defined by Section 1882, Social Security Act (42 U.S.C. Section 1395ss);
(3)  medical payment insurance coverage provided under a motor vehicle insurance policy;
(4)  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 1217.002; or
(5)  a workers' compensation insurance policy.
Added by Acts 2013, 83rd Leg., R.S., Ch. 1198 (S.B. 1216), Sec. 1, eff. September 1, 2013.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1217 - Standard Request Form for Prior Authorization of Health Care Services › Section 1217.004. Standard Form

Sec. 1217.004.  STANDARD FORM.  (a)  The commissioner by rule shall:
(1)  prescribe a single, standard form for requesting prior authorization of health care services;
(2)  require a health benefit plan issuer or the agent of the health benefit plan issuer that manages or administers health care services benefits to use the form for any prior authorization required by the plan of health care services; and
(3)  require that the department and a health benefit plan issuer or the agent of the health benefit plan issuer that manages or administers health care services benefits make the form available in paper form and electronically on the website of:
(A)  the department;
(B)  the health benefit plan issuer; and
(C)  the agent of the health benefit plan issuer.
(b)  Not later than the second anniversary of the date national standards for electronic prior authorization of benefits are adopted, a health benefit plan issuer or the agent of the health benefit plan issuer that manages or administers health care services benefits shall exchange prior authorization requests electronically with a physician or health care provider who has electronic capability and who initiates a request electronically.  For requests initiated on paper, a health benefit plan issuer or the agent of the health benefit plan issuer that manages or administers health care services benefits shall accept prior authorization requests using the standard paper form developed pursuant to this chapter.
(c)  In prescribing a form under this section, the commissioner shall:
(1)  develop the form with input from the advisory committee on uniform prior authorization forms for health care services benefits established under Section 1217.005; and
(2)  take into consideration:
(A)  any form for requesting prior authorization of health care services benefits that is widely used in this state or any form currently used by the department;
(B)  request forms for prior authorization of health care services benefits established by the federal Centers for Medicare and Medicaid Services; and
(C)  national standards, or draft standards, pertaining to electronic prior authorization of benefits.
Added by Acts 2013, 83rd Leg., R.S., Ch. 1198 (S.B. 1216), Sec. 1, eff. September 1, 2013.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1217 - Standard Request Form for Prior Authorization of Health Care Services › Section 1217.005. Advisory Committee on Uniform Prior Authorization Forms

Sec. 1217.005.  ADVISORY COMMITTEE ON UNIFORM PRIOR AUTHORIZATION FORMS.  (a)  The commissioner shall appoint a committee to advise the commissioner on the technical, operational, and practical aspects of developing the single, standard prior authorization form required under Section 1217.004 for requesting prior authorization of health care services, including:
(1)  requirements for the health benefit plan issuer or agent of the health benefit plan issuer to acknowledge receipt of the standard form;
(2)  timelines under which the health benefit plan issuer or agent of the health benefit plan issuer must acknowledge receipt of the standard form; and
(3)  implications, including administrative penalties, for the failure of a health benefit plan issuer or agent of a health benefit plan issuer to:
(A)  timely acknowledge receipt of the standard form; or
(B)  use or accept the form.
(b)  The commissioner shall consult the advisory committee with respect to any rule relating to a subject described by Section 1217.004 before adopting the rule and may consult the committee as needed with respect to a subsequent amendment of an adopted rule.
(c)  The advisory committee shall be composed of an equal number of members from each of the following groups of stakeholders:
(1)  physicians;
(2)  health care providers other than physicians;
(3)  hospitals;
(4)  representatives of health benefit plans; and
(5)  Health and Human Services Commission representatives.
(d)  A physician may not serve on the advisory committee as a physician member under Subsection (c)(1) if the physician is or has been employed by or consults or has consulted for an insurance company.
(e)  A member of the advisory committee serves without compensation.
(f)  Section 39.003(a) of this code and Chapter 2110, Government Code, do not apply to the advisory committee.
Added by Acts 2013, 83rd Leg., R.S., Ch. 1198 (S.B. 1216), Sec. 1, eff. September 1, 2013.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1217 - Standard Request Form for Prior Authorization of Health Care Services › Section 1217.006. Failure to Prescribe Standard Form

Sec. 1217.006.  FAILURE TO PRESCRIBE STANDARD FORM.  Nothing in this chapter may be construed as authorizing the commissioner to decline to prescribe the form required by Section 1217.004.
Added by Acts 2013, 83rd Leg., R.S., Ch. 1198 (S.B. 1216), Sec. 1, eff. September 1, 2013.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1217 - Standard Request Form for Prior Authorization of Health Care Services › Section 1217.007. Construction With Other Law

Sec. 1217.007.  CONSTRUCTION WITH OTHER LAW.  Nothing in this chapter may be construed as permitting a health benefit plan issuer or an agent of a health benefit plan issuer to require prior authorization of health care services benefits when otherwise prohibited by law.
Added by Acts 2013, 83rd Leg., R.S., Ch. 1198 (S.B. 1216), Sec. 1, eff. September 1, 2013.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1218 - Coverage for Elective Abortion; Prohibitions and Requirements › Section 1218.001. Definition

Sec. 1218.001.  DEFINITION.  In this chapter, "elective abortion" means an abortion, as defined by Section 245.002, Health and Safety Code, other than an abortion performed due to a medical emergency as defined by Section 171.002, Health and Safety Code.
Added by Acts 2017, 85th Leg., 1st C.S., Ch. 5 (H.B. 214), Sec. 2, eff. December 1, 2017.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1218 - Coverage for Elective Abortion; Prohibitions and Requirements › Section 1218.002. Applicability of Chapter

Sec. 1218.002.  APPLICABILITY OF CHAPTER.  (a)  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)  an 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.
(b)  This chapter applies to group health coverage made available by a school district in accordance with Section 22.004, Education Code.
(c)  Notwithstanding any provision in Chapter 1551, 1575, 1579, or 1601 or any other law, this chapter applies to:
(1)  a basic coverage plan under Chapter 1551;
(2)  a basic plan under Chapter 1575;
(3)  a primary care coverage plan under Chapter 1579; and
(4)  basic coverage under Chapter 1601.
(d)  Notwithstanding Section 1501.251 or any other law, this chapter applies to coverage under a small or large employer health benefit plan subject to Chapter 1501.
(e)  Notwithstanding Section 1507.003 or 1507.053 or any other law, this chapter applies to a standard health benefit plan provided under Chapter 1507.
Added by Acts 2017, 85th Leg., 1st C.S., Ch. 5 (H.B. 214), Sec. 2, eff. December 1, 2017.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1218 - Coverage for Elective Abortion; Prohibitions and Requirements › Section 1218.003. Certain Coverage Not Affected

Sec. 1218.003.  CERTAIN COVERAGE NOT AFFECTED.  This chapter does not apply to health benefit plan coverage provided to an enrollee for any abortion other than an elective abortion as defined by Section 1218.001.
Added by Acts 2017, 85th Leg., 1st C.S., Ch. 5 (H.B. 214), Sec. 2, eff. December 1, 2017.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1218 - Coverage for Elective Abortion; Prohibitions and Requirements › Section 1218.004. Coverage by Health Benefit Plan

Sec. 1218.004.  COVERAGE BY HEALTH BENEFIT PLAN.  A health benefit plan may provide coverage for elective abortion only if:
(1)  the coverage is provided to an enrollee separately from other health benefit plan coverage offered by the health benefit plan issuer;
(2)  the enrollee pays the premium for coverage for elective abortion separately from, and in addition to, the premium for other health benefit plan coverage, if any; and
(3)  the enrollee provides a signature for coverage for elective abortion, separately and distinct from the signature required for other health benefit plan coverage, if any, provided to the enrollee by the health benefit plan issuer.
Added by Acts 2017, 85th Leg., 1st C.S., Ch. 5 (H.B. 214), Sec. 2, eff. December 1, 2017.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1218 - Coverage for Elective Abortion; Prohibitions and Requirements › Section 1218.005. Calculation of Premium

Sec. 1218.005.  CALCULATION OF PREMIUM.  (a)  A health benefit plan issuer that provides coverage for elective abortion shall calculate the premium for the coverage so that the premium fully covers the estimated cost of elective abortion per enrollee, determined on an actuarial basis.
(b)  In calculating a premium under Subsection (a), the health benefit plan issuer may not take into account any cost savings in other health benefit plan coverage offered by the health benefit plan issuer that is estimated to result from coverage for elective abortion.
(c)  A health benefit plan issuer may not provide a premium discount to or reduce the premium for an enrollee for other health benefit plan coverage on the basis that the enrollee has coverage for elective abortion.
Added by Acts 2017, 85th Leg., 1st C.S., Ch. 5 (H.B. 214), Sec. 2, eff. December 1, 2017.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1218 - Coverage for Elective Abortion; Prohibitions and Requirements › Section 1218.006. Notice by Issuer

Sec. 1218.006.  NOTICE BY ISSUER.  A health benefit plan issuer that provides coverage for elective abortion shall at the time of enrollment in other health benefit plan coverage provide each enrollee with a notice that:
(1)  coverage for elective abortion is optional and separate from other health benefit plan coverage offered by the health benefit plan issuer;
(2)  the premium cost for coverage for elective abortion is a premium paid separately from, and in addition to, the premium for other health benefit plan coverage offered by the health benefit plan issuer; and
(3)  the enrollee may enroll in a health benefit plan without obtaining coverage for elective abortion.
Added by Acts 2017, 85th Leg., 1st C.S., Ch. 5 (H.B. 214), Sec. 2, eff. December 1, 2017.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1221 - Employer Contributions to Individual Health Insurance Policies › Section 1221.001. Rules; Employer Contributions

Sec. 1221.001.  RULES; EMPLOYER CONTRIBUTIONS.  The commissioner by rule, unless it would violate state or federal law, may develop procedures to allow an employer to make financial contributions to or premium payments for an employee or retiree's individual consumer directed health insurance policy in a manner that eliminates or minimizes the state or federal tax consequences, or provides positive state or federal tax consequences, to the employer.
Added by Acts 2011, 82nd Leg., R.S., Ch. 1067 (S.B. 859), Sec. 7, eff. June 17, 2011.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1222 - Preauthorization for Medical or Health Care Service › Section 1222.0001. Definitions

Sec. 1222.0001.  DEFINITIONS.  In this chapter:
(1)  "Health benefit plan" means a plan to which this chapter applies under Section 1222.0002.
(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.
(3)  "Preauthorization" has the meaning assigned by Section 1301.001.
Added by Acts 2019, 86th Leg., R.S., Ch. 488 (H.B. 3041), Sec. 1, eff. September 1, 2019.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1222 - Preauthorization for Medical or Health Care Service › Section 1222.0003. Preauthorization Renewal Request

Sec. 1222.0003.  PREAUTHORIZATION RENEWAL REQUEST.  A health benefit plan issuer that requires preauthorization as a condition of payment for a medical or health care service shall provide a preauthorization renewal process that allows a renewal of an existing preauthorization to be requested by a physician or health care provider at least 60 days before the date the preauthorization expires.
Added by Acts 2019, 86th Leg., R.S., Ch. 488 (H.B. 3041), Sec. 1, eff. September 1, 2019.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1222 - Preauthorization for Medical or Health Care Service › Section 1222.0004. Determination Required

Sec. 1222.0004.  DETERMINATION REQUIRED.  If a health benefit plan issuer receives a preauthorization renewal request before the existing preauthorization expires, the health benefit plan issuer shall, if practicable, review the request and issue a determination indicating whether the medical or health care service is preauthorized before the existing preauthorization expires.
Added by Acts 2019, 86th Leg., R.S., Ch. 488 (H.B. 3041), Sec. 1, eff. September 1, 2019.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1223 - Verification of Health Benefits › Section 1223.001. Applicability of Chapter

Sec. 1223.001.  APPLICABILITY OF CHAPTER.  (a)  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 issued 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 Lloyd's plan operating under Chapter 941; or
(8)  an exchange operating under Chapter 942.
(b)  Notwithstanding any other law, this chapter 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;
(2)  a standard health benefit plan issued under Chapter 1507;
(3)  a basic coverage plan under Chapter 1551;
(4)  a basic plan under Chapter 1575;
(5)  a primary care coverage plan under Chapter 1579;
(6)  a plan providing basic coverage under Chapter 1601;
(7)  alternative health benefit coverage offered by a subsidiary of the Texas Mutual Insurance Company under Subchapter M, Chapter 2054;
(8)  group health coverage made available by a school district in accordance with Section 22.004, Education Code;
(9)  a regional or local health care program operated under Section 75.104, Health and Safety Code; and
(10)  a self-funded health benefit plan sponsored by a professional employer organization under Chapter 91, Labor Code.
(c)  This chapter does not apply to the state Medicaid program, including the Medicaid managed care program operated under Chapter 533, Government Code, or the child health plan program operated under Chapter 62, Health and Safety Code.
Added by Acts 2023, 88th Leg., R.S., Ch. 881 (H.B. 4500), Sec. 1, eff. January 1, 2024.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1223 - Verification of Health Benefits › Section 1223.002. Internet Website for Verification Required for Emergency Physicians and Health Care Providers

Sec. 1223.002.  INTERNET WEBSITE FOR VERIFICATION REQUIRED FOR EMERGENCY PHYSICIANS AND HEALTH CARE PROVIDERS.  (a)  A health benefit plan issuer shall maintain and make available a secure system on the issuer's Internet website that allows a physician or health care provider for a hospital or freestanding emergency medical care facility to determine at any time:
(1)  whether the physician's or provider's patient is covered by the issuer's health benefit plan; and
(2)  the deductible, copayment, or coinsurance for which the patient is responsible.
(b)  A health benefit plan issuer may provide the information described by Subsection (a) through:
(1)  an existing Internet portal that is available at all times; or
(2)  an Internet portal that is:
(A)  provided by a third party contracting with the issuer; and
(B)  available at all times.
Added by Acts 2023, 88th Leg., R.S., Ch. 881 (H.B. 4500), Sec. 1, eff. January 1, 2024.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle B - Group Health Coverage › Chapter 1251 - Group and Blanket Health Insurance › Subchapter A. General Provisions › Section 1251.001. Definitions

Sec. 1251.001.  DEFINITIONS.  In this chapter:
(1)  "Blanket accident and health insurance" means accident, health, or accident and health insurance covering a group described by Subchapter H.
(2)  "Group accident and health insurance" means accident, health, or accident and health insurance covering a group described by Subchapter B.
(3)  "Group hospital service corporation" means a corporation operating under Chapter 842.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.