reglab/statecodes huggingface dataset:
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1467 - Out-of-Network Claim Dispute Resolution › Subchapter D. Complaints; Consumer Protection › Section 1467.151. Consumer Protection; Rules

Sec. 1467.151.  CONSUMER PROTECTION; RULES.
(a)  The commissioner and the Texas Medical Board or other regulatory agency, as appropriate, shall adopt rules regulating the investigation and review of a complaint filed that relates to the settlement of an out-of-network health benefit claim that is subject to this chapter.  The rules adopted under this section must:
(1)  distinguish among complaints for out-of-network coverage or payment and give priority to investigating allegations of delayed health care or medical care;
(2)  develop a form for filing a complaint; and
(3)  ensure that a complaint is not dismissed without appropriate consideration.
(b)  The department and the Texas Medical Board or other appropriate regulatory agency shall maintain information on each complaint filed that concerns a claim, arbitration, or mediation subject to this chapter, including:
(1)  the type of services or supplies that gave rise to the dispute;
(2)  the type and specialty, if any, of the out-of-network provider who provided the out-of-network service or supply;
(3)  the county and metropolitan area in which the health care or medical service or supply was provided;
(4)  whether the health care or medical service or supply was for emergency care; and
(5)  any other information about:
(A)  the health benefit plan issuer or administrator that the commissioner by rule requires; or
(B)  the out-of-network provider that the Texas Medical Board or other appropriate regulatory agency by rule requires.
(c)  The information collected and maintained under Subsection (b) is public information as defined by Section 552.002, Government Code, and may not include personally identifiable information or health care or medical information.
(d)  Repealed by Acts 2019, 86th Leg., R.S., Ch. 1342 (S.B. 1264), Sec. 3.03(11), eff. September 1, 2019.
Added by Acts 2009, 81st Leg., R.S., Ch. 1290 (H.B. 2256), Sec. 1, eff. June 19, 2009.
Amended by:
Acts 2017, 85th Leg., R.S., Ch. 100 (S.B. 507), Sec. 16, eff. September 1, 2017.
Acts 2019, 86th Leg., R.S., Ch. 1342 (S.B. 1264), Sec. 2.17, eff. September 1, 2019.
Acts 2019, 86th Leg., R.S., Ch. 1342 (S.B. 1264), Sec. 3.03(11), eff. September 1, 2019.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle G - Health Coverage Availability › Chapter 1501 - Health Insurance Portability and Availability Act › Subchapter A. General Provisions › Section 1501.001. Short Title

Sec. 1501.001.  SHORT TITLE.  This chapter may be cited as the Health Insurance Portability and Availability 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 G - Health Coverage Availability › Chapter 1501 - Health Insurance Portability and Availability Act › Subchapter A. General Provisions › Section 1501.003. Applicability: Small Employer Health Benefit Plans

Sec. 1501.003.  APPLICABILITY:  SMALL EMPLOYER HEALTH BENEFIT PLANS.  An individual or group health benefit plan is a small employer health benefit plan subject to Subchapters C-H if it provides health care benefits covering two or more employees of a small employer and:
(1)  the employer pays a portion of the premium or benefits;
(2)  the employer or a covered individual treats the health benefit plan as part of a plan or program for purposes of Section 106 or 162, Internal Revenue Code of 1986 (26 U.S.C. Section 106 or 162); or
(3)  the health benefit plan is an employee welfare benefit plan under 29 C.F.R. Section 2510.3-1(j).
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
Amended by:
Acts 2013, 83rd Leg., R.S., Ch. 199 (S.B. 1332), Sec. 2, eff. September 1, 2013.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle G - Health Coverage Availability › Chapter 1501 - Health Insurance Portability and Availability Act › Subchapter A. General Provisions › Section 1501.004. Applicability: Large Employer Health Benefit Plans

Sec. 1501.004.  APPLICABILITY:  LARGE EMPLOYER HEALTH BENEFIT PLANS.  An individual or group health benefit plan is a large employer health benefit plan subject to Subchapters C and M if the plan provides health care benefits to employees of a large employer and:
(1)  the employer pays a portion of the premium or benefits;
(2)  the employer or a covered individual treats the health benefit plan as part of a plan or program for purposes of Section 106 or 162, Internal Revenue Code of 1986 (26 U.S.C. Section 106 or 162); or
(3)  the health benefit plan is an employee welfare benefit plan under 29 C.F.R. Section 2510.3-1(j).
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
Amended by:
Acts 2013, 83rd Leg., R.S., Ch. 199 (S.B. 1332), Sec. 3, eff. September 1, 2013.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle G - Health Coverage Availability › Chapter 1501 - Health Insurance Portability and Availability Act › Subchapter A. General Provisions › Section 1501.005. Exception: Certain Individually Underwritten Policies

Sec. 1501.005.  EXCEPTION:  CERTAIN INDIVIDUALLY UNDERWRITTEN POLICIES.  Except as provided by Section 1501.003 or 1501.004, this chapter does not apply to an individual health insurance policy that is subject to individual underwriting, even if the premium is paid through a payroll deduction method.
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 G - Health Coverage Availability › Chapter 1501 - Health Insurance Portability and Availability Act › Subchapter A. General Provisions › Section 1501.006. Certification

Sec. 1501.006.  CERTIFICATION.  (a)  In accordance with rules adopted by the commissioner, each health benefit plan issuer shall certify that the issuer is offering, delivering, issuing for delivery, or renewing, or that the issuer intends to offer, deliver, issue for delivery, or renew:
(1)  a health benefit plan to or through a small employer in this state that is subject to this chapter;  or
(2)  a health benefit plan to or through a large employer in this state that is subject to this chapter.
(b)  A health benefit plan issuer must submit a revised certification to the commissioner only if the issuer changes its status as a small or large employer health benefit plan issuer or changes its intent to become a small or large employer health benefit plan issuer to the extent that its previous certification ceases to be accurate.
(c)  The certification must include a statement that the health benefit plan issuer is complying with this chapter to the extent it applies to the issuer.
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 G - Health Coverage Availability › Chapter 1501 - Health Insurance Portability and Availability Act › Subchapter A. General Provisions › Section 1501.007. Affiliates

Sec. 1501.007.  AFFILIATES.  (a)  In this section, "affiliate" has the meaning described by Section 823.003.
(b)  For purposes of this chapter, health benefit plan issuers that are affiliates or that are eligible to file a consolidated tax return are considered to be one issuer, and a restriction imposed by this chapter applies as if the health benefit plans delivered or issued for delivery to small employers in this state by the affiliates were issued by one issuer.
(c)  Notwithstanding Subsection (b), a health maintenance organization that is an affiliate is considered to be a separate health benefit plan issuer for purposes of this chapter.
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 G - Health Coverage Availability › Chapter 1501 - Health Insurance Portability and Availability Act › Subchapter A. General Provisions › Section 1501.008. Late Enrollees

Sec. 1501.008.  LATE ENROLLEES.  (a)  For purposes of this chapter, an employee or dependent eligible for enrollment in a small or large employer's health benefit plan is a late enrollee if the individual requests enrollment after the expiration of:
(1)  the initial enrollment period established under the terms of the first plan for which the individual was eligible through the small or large employer;  or
(2)  an open enrollment period under Section 1501.156(a) or 1501.606(a).
(b)  An employee or dependent eligible for enrollment is not a late enrollee if the individual:
(1)  was covered under another health benefit plan or self-funded employer health benefit plan at the time the individual was eligible to enroll;
(2)  declined enrollment in writing, at the time of the initial eligibility for enrollment, stating that coverage under another health benefit plan or self-funded employer health benefit plan was the reason for declining enrollment;
(3)  has lost coverage under the other health benefit plan or self-funded employer health benefit plan as a result of:
(A)  the termination of employment;
(B)  a reduction in the number of hours of employment;
(C)  the termination of the other plan's coverage;
(D)  the termination of contributions toward the premium made by the employer;  or
(E)  the death of a spouse or divorce;  and
(4)  requests enrollment not later than the 31st day after the date coverage under the other health benefit plan or self-funded employer health benefit plan terminates.
(c)  An employee or dependent eligible for enrollment is also not a late enrollee if the individual is:
(1)  employed by an employer that offers multiple health benefit plans and the individual elects a different health benefit plan during an open enrollment period;
(2)  a spouse for whom a court has ordered coverage under a covered employee's plan and the request for enrollment of the spouse is made not later than the 31st day after the date the court order is issued;
(3)  a child for whom a court has ordered coverage under a covered employee's plan and the request for enrollment is made not later than the 31st day after the date the employer receives the court order;  or
(4)  a child of a covered employee who has lost coverage under Title XIX of the Social Security Act (42 U.S.C. Section 1396 et seq.), other than coverage consisting solely of benefits under Section 1928 of that Act (42 U.S.C. Section 1396s), or under Chapter 62, Health and Safety Code, and the request for enrollment is made not later than the 31st day after the date on which the child loses coverage.
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 G - Health Coverage Availability › Chapter 1501 - Health Insurance Portability and Availability Act › Subchapter A. General Provisions › Section 1501.009. School District Election

Sec. 1501.009.  SCHOOL DISTRICT ELECTION.  (a)  An independent school district may elect to participate as a small employer without regard to the number of employees in the district.  An independent school district that makes the election is treated as a small employer under this chapter for all purposes.
(b)  An independent school district that is participating in the uniform group coverage program established under Chapter 1579 may not participate in the small employer market under this section for health insurance coverage and may not renew a health insurance contract obtained in accordance with this section after the date on which the program of coverages provided under Chapter 1579 is implemented.  This subsection does not affect a contract for the provision of optional coverages not included in a health benefit plan under this chapter.
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. 2G.014, eff. April 1, 2009.
Acts 2013, 83rd Leg., R.S., Ch. 199 (S.B. 1332), Sec. 4, eff. September 1, 2013.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle G - Health Coverage Availability › Chapter 1501 - Health Insurance Portability and Availability Act › Subchapter A. General Provisions › Section 1501.0095. School District Employee Election

Sec. 1501.0095.  SCHOOL DISTRICT EMPLOYEE ELECTION.  (a)  Notwithstanding any other provision of this chapter, a school district employee who is eligible for coverage under a large or small employer health benefit plan providing coverage to the school district's employees and who is the spouse of another school district employee covered under the plan may elect whether to be treated under the plan as:
(1)  an employee; or
(2)  the dependent of the other employee.
(b)  The commissioner shall adopt rules under Section 1501.010 governing the manner in which an election under this section must be made.
Added by Acts 2005, 79th Leg., Ch. 998 (H.B. 407), Sec. 1, eff. June 18, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle G - Health Coverage Availability › Chapter 1501 - Health Insurance Portability and Availability Act › Subchapter A. General Provisions › Section 1501.010. General Rules

Sec. 1501.010.  GENERAL RULES.  The commissioner shall adopt rules necessary to:
(1)  implement this chapter;  and
(2)  meet the minimum requirements of federal law, including regulations.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle G - Health Coverage Availability › Chapter 1501 - Health Insurance Portability and Availability Act › Subchapter A. General Provisions › Section 1501.011. Determination of Employer Status for Certain Employers

Sec. 1501.011.  DETERMINATION OF EMPLOYER STATUS FOR CERTAIN EMPLOYERS.  (a)  For an employer that did not exist throughout the calendar year preceding the year in which the determination of whether the employer is a small employer is made, the determination is based on the average number of employees the employer reasonably expects to employ on business days in the calendar year in which the determination is made.
(b)  For an employer that did not exist throughout the calendar year preceding the year in which the determination of whether the employer is a large employer is made, the determination is based on the average number of employees the employer reasonably expects to employ on business days in the calendar year in which the determination is made.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
Amended by:
Acts 2013, 83rd Leg., R.S., Ch. 199 (S.B. 1332), Sec. 5, eff. September 1, 2013.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle G - Health Coverage Availability › Chapter 1501 - Health Insurance Portability and Availability Act › Subchapter B. Coalitions and Cooperatives › Section 1501.051. Definitions

Sec. 1501.051.  DEFINITIONS.  In this subchapter:
(1)  "Board of directors" means the board of directors elected by a private purchasing cooperative or a health group cooperative.
(2)  "Board of trustees" means the board of trustees of the Texas cooperative.
(3)  "Cooperative" means a private purchasing cooperative or a health group cooperative established under this subchapter.
(3-a)  "Eligible single-employee business" means a business entity that:
(A)  is owned and operated by a sole proprietor;
(B)  employed an average of fewer than two employees on business days during the preceding calendar year; and
(C)  is eligible to participate in a cooperative under this subchapter in accordance with Section 1501.066.
(3-b)  "Expanded service area" means any area larger than one county in which a health group cooperative offers coverage.
(4)  "Texas cooperative" means the Texas Health Benefits Purchasing Cooperative established under Section 1501.052.
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. 11.048(a), eff. September 1, 2005.
Acts 2011, 82nd Leg., R.S., Ch. 1067 (S.B. 859), Sec. 1, eff. June 17, 2011.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle G - Health Coverage Availability › Chapter 1501 - Health Insurance Portability and Availability Act › Subchapter B. Coalitions and Cooperatives › Section 1501.052. Texas Health Benefits Purchasing Cooperative; Board of Trustees

Sec. 1501.052.  TEXAS HEALTH BENEFITS PURCHASING COOPERATIVE;  BOARD OF TRUSTEES.  (a)  The Texas Health Benefits Purchasing Cooperative is a nonprofit corporation established to make health care coverage available to small and large employers and their eligible employees and the eligible employees' dependents.
(b)  The Texas cooperative is administered by a board of trustees of five members appointed by the governor with the advice and consent of the senate.  Two members must represent employers, two members must represent employees, and one member must represent the public.
(c)  Members of the board of trustees serve staggered six-year terms, with the terms of one or two members expiring February 1 of each odd-numbered year.
(d)  A member of the board of trustees may not be compensated for serving on the board but is entitled to reimbursement for actual expenses incurred in performing functions as a member of the board as provided by the General Appropriations Act.
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. 11.049(a), eff. September 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle G - Health Coverage Availability › Chapter 1501 - Health Insurance Portability and Availability Act › Subchapter B. Coalitions and Cooperatives › Section 1501.053. Texas Health Benefits Purchasing Cooperative: Executive Director and Other Employees

Sec. 1501.053.  TEXAS HEALTH BENEFITS PURCHASING COOPERATIVE:  EXECUTIVE DIRECTOR AND OTHER EMPLOYEES.  (a)  The board of trustees shall employ an executive director.  The executive director may hire other employees of the Texas cooperative as necessary.
(b)  Salaries for employees of the Texas cooperative and related costs may be paid from administrative fees collected from employers and participating health benefit plan issuers or other sources of funding arranged by the Texas cooperative.
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 G - Health Coverage Availability › Chapter 1501 - Health Insurance Portability and Availability Act › Subchapter B. Coalitions and Cooperatives › Section 1501.054. Regional Subdivisions of Texas Health Benefits Purchasing Cooperative

Sec. 1501.054.  REGIONAL SUBDIVISIONS OF TEXAS HEALTH BENEFITS PURCHASING COOPERATIVE.  The board of trustees may:
(1)  develop regional subdivisions of the Texas cooperative;  and
(2)  authorize each subdivision to separately exercise the powers and duties of a cooperative.
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 G - Health Coverage Availability › Chapter 1501 - Health Insurance Portability and Availability Act › Subchapter B. Coalitions and Cooperatives › Section 1501.055. Applicability of Public Information Law to Texas Health Benefits Purchasing Cooperative

Sec. 1501.055.  APPLICABILITY OF PUBLIC INFORMATION LAW TO TEXAS HEALTH BENEFITS PURCHASING COOPERATIVE.  The Texas cooperative is subject to the public information law, Chapter 552, Government Code.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle G - Health Coverage Availability › Chapter 1501 - Health Insurance Portability and Availability Act › Subchapter B. Coalitions and Cooperatives › Section 1501.056. Private Purchasing Cooperatives and Health Group Cooperatives

Sec. 1501.056.  PRIVATE PURCHASING COOPERATIVES AND HEALTH GROUP COOPERATIVES.  (a)  Two or more small or large employers may form a private purchasing cooperative to purchase small or large employer health benefit plans.  Subject to Subsection (d), a person may form a health group cooperative to purchase employer health benefit plans.  A cooperative must be organized as a nonprofit corporation and has the rights and duties provided by the Texas Non-Profit Corporation Act (Article 1396-1.01 et seq., Vernon's Texas Civil Statutes).
(b)  On receipt of a certificate of incorporation or certificate of authority from the secretary of state, the cooperative shall file written notice of the receipt of the certificate and a copy of the cooperative's organizational documents with the commissioner.
(c)  Repealed by Acts 2015, 84th Leg., R.S., Ch. 42 , Sec. 3.01(5), eff. September 1, 2015.
(d)  A health benefit plan issuer may not form, or be a member of, a health group cooperative.  A health benefit plan issuer may associate with a sponsoring entity, such as a business association, chamber of commerce, or other organization representing employers or serving an analogous function, to assist the sponsoring entity in forming a health group cooperative.
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. 11.050(a), eff. September 1, 2005.
Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.050(b), eff. September 1, 2005.
Acts 2015, 84th Leg., R.S., Ch. 42 (S.B. 784), Sec. 3.01(5), eff. September 1, 2015.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle G - Health Coverage Availability › Chapter 1501 - Health Insurance Portability and Availability Act › Subchapter B. Coalitions and Cooperatives › Section 1501.057. Immunity

Sec. 1501.057.  IMMUNITY.  (a)  The Texas cooperative or a member of the board of trustees, the executive director, or an employee or agent of the Texas cooperative is not liable for:
(1)  an act performed in good faith in the execution of duties in connection with the cooperative;  or
(2)  an independent action of a small employer health benefit plan issuer or a person who provides health care services under a health benefit plan.
(b)  A private purchasing cooperative, a health group cooperative, or a member of the board of directors, the executive director, or an employee or agent of the private purchasing or health group cooperative is not liable for:
(1)  an act performed in good faith in the execution of duties in connection with the private purchasing or health group cooperative; or
(2)  an independent action of a small or large employer health benefit plan issuer or a person who provides health care services under a health benefit plan.
(c)  A health group cooperative or a member of the board of directors, the executive director, or an employee or agent of the health group cooperative is not liable for failure to arrange for coverage of any particular illness, disease, or health condition.
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. 11.050(c), eff. September 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle G - Health Coverage Availability › Chapter 1501 - Health Insurance Portability and Availability Act › Subchapter B. Coalitions and Cooperatives › Section 1501.0575. Voluntary Participation by Issuer in Cooperative

Sec. 1501.0575.  VOLUNTARY PARTICIPATION BY ISSUER IN COOPERATIVE.  A health benefit plan issuer may elect not to participate in a health group cooperative.  The health benefit plan issuer may elect to participate in one or more health group cooperatives and may select the cooperatives in which the issuer will participate.
Added by Acts 2005, 79th Leg., Ch. 823 (S.B. 805), Sec. 1, eff. September 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle G - Health Coverage Availability › Chapter 1501 - Health Insurance Portability and Availability Act › Subchapter B. Coalitions and Cooperatives › Section 1501.058. Powers and Duties of Cooperatives

Sec. 1501.058.  POWERS AND DUTIES OF COOPERATIVES.  (a)  A cooperative shall:
(1)  arrange for small or large employer health benefit plan coverage for small employer groups, large employer groups, and, subject to Section 1501.0581, eligible single-employee businesses that participate in the cooperative by contracting with small or large employer health benefit plan issuers that meet the requirements established by Section 1501.061;
(2)  collect premiums to cover the cost of:
(A)  small or large employer health benefit plan coverage purchased through the cooperative; and
(B)  the cooperative's administrative expenses;
(3)  establish administrative and accounting procedures for the operation of the cooperative;
(4)  establish procedures under which an applicant for or participant in coverage issued through the cooperative may have a grievance reviewed by an impartial person;
(5)  contract with small or large employer health benefit plan issuers to provide services to small or large employers covered through the cooperative; and
(6)  develop and implement a plan to maintain public awareness of the cooperative and publicize the eligibility requirements for, and the procedures for enrollment in, coverage through the cooperative.
(b)  A cooperative may:
(1)  contract with agents to market coverage issued through the cooperative;
(2)  contract with a small or large employer health benefit plan issuer or third-party administrator to provide administrative services to the cooperative;
(3)  negotiate the premiums paid by its members;  and
(4)  offer other ancillary products and services to its members that are customarily offered in conjunction with health benefit plans.
(c)  A cooperative shall comply with:
(1)  federal laws applicable to cooperatives and health benefit plans issued through cooperatives, to the extent required by state law or rules adopted by the commissioner;  and
(2)  state laws applicable to cooperatives and health benefit plans issued through cooperatives.
(d)  To be eligible to exercise the authority granted under Subsection (a)(1), a health group cooperative must have at least 10 participating employers.
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. 11.053(a), eff. September 1, 2005.
Acts 2011, 82nd Leg., R.S., Ch. 1067 (S.B. 859), Sec. 2, eff. June 17, 2011.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle G - Health Coverage Availability › Chapter 1501 - Health Insurance Portability and Availability Act › Subchapter B. Coalitions and Cooperatives › Section 1501.0582. Health Group Cooperative: Expedited Approval Process

Sec. 1501.0582.  HEALTH GROUP COOPERATIVE: EXPEDITED APPROVAL PROCESS.  The department shall develop an expedited approval process for health benefit plan coverage arranged by a health group cooperative.
Added by Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.052(a), eff. September 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle G - Health Coverage Availability › Chapter 1501 - Health Insurance Portability and Availability Act › Subchapter B. Coalitions and Cooperatives › Section 1501.059. Self-Insured or Self-Funded Plan Prohibited

Sec. 1501.059.  SELF-INSURED OR SELF-FUNDED PLAN PROHIBITED.  A cooperative may not self-insure or self-fund any health benefit plan or portion of a 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 G - Health Coverage Availability › Chapter 1501 - Health Insurance Portability and Availability Act › Subchapter B. Coalitions and Cooperatives › Section 1501.060. Scope of Group Coverage

Sec. 1501.060.  SCOPE OF GROUP COVERAGE.  Subchapter B, Chapter 1251, does not limit the type of group that may be covered by a group health benefit plan issued through a cooperative.
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 G - Health Coverage Availability › Chapter 1501 - Health Insurance Portability and Availability Act › Subchapter B. Coalitions and Cooperatives › Section 1501.061. Requirements Applicable to Health Benefit Plan Issuers With Which Cooperative May Contract

Sec. 1501.061.  REQUIREMENTS APPLICABLE TO HEALTH BENEFIT PLAN ISSUERS WITH WHICH COOPERATIVE MAY CONTRACT.  A cooperative may contract only with a small or large employer health benefit plan issuer that demonstrates that the issuer:
(1)  is in good standing with the department;
(2)  has the capacity to administer health benefit plans;
(3)  is able to monitor and evaluate the quality and cost-effectiveness of care and applicable procedures;
(4)  is able to conduct utilization management and establish applicable procedures and policies;
(5)  is able to ensure that enrollees have adequate access to health care providers, including adequate numbers and types of providers;
(6)  has a satisfactory grievance procedure and is able to respond to enrollees' calls, questions, and complaints; and
(7)  has financial capacity, either through satisfying financial solvency standards, as applied by the commissioner, or through appropriate reinsurance or other risk-sharing mechanisms.
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. 11.053(b), eff. September 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle G - Health Coverage Availability › Chapter 1501 - Health Insurance Portability and Availability Act › Subchapter B. Coalitions and Cooperatives › Section 1501.062. Cooperative Not Insurer; Agents and Administrators

Sec. 1501.062.  COOPERATIVE NOT INSURER;  AGENTS AND ADMINISTRATORS.  (a)  A cooperative is not an insurer and the employees of the cooperative are not required to be licensed under Title 13.  This exemption from licensure includes a health group cooperative that acts to provide information about and to solicit membership in the cooperative, subject to Section 1501.0581(d).
(b)  An agent or third-party administrator used and compensated by a cooperative must be licensed as required by Title 13.
(c)  An agent used and compensated by a cooperative may market the products and services sponsored by the cooperative without being appointed by each small or large employer health benefit plan issuer participating in the cooperative.  The agent may not market any other product or service of a participating small or large employer health benefit plan issuer that is not sponsored by the cooperative unless the agent has been appointed by that issuer.
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. 11.052(b), eff. September 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle G - Health Coverage Availability › Chapter 1501 - Health Insurance Portability and Availability Act › Subchapter B. Coalitions and Cooperatives › Section 1501.063. Status as Employer

Sec. 1501.063.  STATUS AS EMPLOYER.  (a)  A small employer health coalition that otherwise meets the description of a small employer is considered a single small employer for all purposes under this chapter.
(b)  A health group cooperative that is composed of only small employers, only large employers, or both small and large employers is considered a single employer under this code.
(b-1)  A health group cooperative that is composed only of small employers and that has made the election described by Section 1501.0581(o)(1) in accordance with Subsection (p) of that section shall be treated in the same manner as a small employer for the purposes of this chapter, including for the purposes of any provision relating to premium rates and issuance and renewal of coverage.
(b-2)  A health group cooperative that is composed only of small employers and that has not made the election described by Section 1501.0581(o)(1) in accordance with Subsection (p) of that section, or a health group cooperative that is composed of both small and large employers, may be treated in the same manner as a large employer for the purposes of this chapter, including for the purposes of any provision relating to premium rates and issuance and renewal of coverage.
(b-3)  Except as provided by Section 1501.0581(k), a health group cooperative shall have sole authority to make benefit elections and perform other administrative functions under this code for the cooperative's participating employers.
(c)  Any other cooperative formed under this subchapter is considered an employer solely for the purposes of benefit elections under this code.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
Amended by:
Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.052(c), eff. September 1, 2005.
Acts 2005, 79th Leg., Ch. 823 (S.B. 805), Sec. 3, eff. September 1, 2005.
Acts 2007, 80th Leg., R.S., Ch. 547 (S.B. 1255), Sec. 2, eff. September 1, 2007.
Acts 2011, 82nd Leg., R.S., Ch. 1067 (S.B. 859), Sec. 4, eff. June 17, 2011.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle G - Health Coverage Availability › Chapter 1501 - Health Insurance Portability and Availability Act › Subchapter B. Coalitions and Cooperatives › Section 1501.064. Certain Use of Appropriated Money Prohibited

Sec. 1501.064.  CERTAIN USE OF APPROPRIATED MONEY PROHIBITED.  The Texas cooperative may not use money appropriated by the state to pay or otherwise subsidize any portion of the premium for a small employer covered through the cooperative.
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 G - Health Coverage Availability › Chapter 1501 - Health Insurance Portability and Availability Act › Subchapter B. Coalitions and Cooperatives › Section 1501.065. Certain Actions Based on Risk Characteristics or Health Status Prohibited

Sec. 1501.065.  CERTAIN ACTIONS BASED ON RISK CHARACTERISTICS OR HEALTH STATUS PROHIBITED.  A cooperative may not limit, restrict, or condition an employer's or employee's membership in a cooperative or an employee's choice among benefit plans based on:
(1)  risk characteristics of a group or of any member of a group; or
(2)  health status related factors, duration of coverage, or any similar characteristic related to the health status or experience of a group or of any member of a group.
Added by Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.053(c), eff. September 1, 2005.
Amended by:
Acts 2011, 82nd Leg., R.S., Ch. 1067 (S.B. 859), Sec. 5, eff. June 17, 2011.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle G - Health Coverage Availability › Chapter 1501 - Health Insurance Portability and Availability Act › Subchapter B. Coalitions and Cooperatives › Section 1501.066. Election to Treat Participating Employers Separately for Rating Purposes

Sec. 1501.066.  ELECTION TO TREAT PARTICIPATING EMPLOYERS SEPARATELY FOR RATING PURPOSES.  (a)  Notwithstanding Section 1501.063, a health group cooperative may file with the commissioner, on a form and in the manner prescribed by the commissioner, an election to treat each participating employer within the cooperative as a separate employer for purposes of rating small and large employer health benefit plans, subject to the rating requirements of this code applicable to such plans.  An existing health group cooperative must file the election with the department not later than the 90th day before the date on which the election is to become effective.
(b)  A health group cooperative must provide to all participating and prospective employers, in a manner prescribed by the commissioner, a written notice of the cooperative's election to treat participating employers within the cooperative as separate employers for purposes of rating small and large employer health benefit plans.  Employers participating in the cooperative when such an election is made must be provided notice of the election not later than the 90th day before the date the election is to become effective.  For a participating employer, the notice must contain the quote for the premium rate applicable to the employer as of the date the plan is renewed.  Prospective employers must be provided notice of the election when the prospective employer applies to become a participating employer in the health group cooperative.
(c)  An election under this section is effective on the earliest date after the election is made on which the plan to which the election applies is initially issued or renewed.  The election remains in effect for not less than 12 months after the effective date.
Added by Acts 2011, 82nd Leg., R.S., Ch. 1067 (S.B. 859), Sec. 6, eff. June 17, 2011.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle G - Health Coverage Availability › Chapter 1501 - Health Insurance Portability and Availability Act › Subchapter B. Coalitions and Cooperatives › Section 1501.067. Eligible Single-Employee Business

Sec. 1501.067.  ELIGIBLE SINGLE-EMPLOYEE BUSINESS.  The commissioner shall adopt rules governing the eligibility of a single-employee business to participate in a health group cooperative under this subchapter.  The rules must include provisions to ensure that each eligible single-employee business has a business purpose and was not formed solely to obtain health benefit plan coverage under this subchapter.
Added by Acts 2011, 82nd Leg., R.S., Ch. 1067 (S.B. 859), Sec. 6, eff. June 17, 2011.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle G - Health Coverage Availability › Chapter 1501 - Health Insurance Portability and Availability Act › Subchapter C. Provision of Coverage › Section 1501.101. Geographic Service Areas

Sec. 1501.101.  GEOGRAPHIC SERVICE AREAS.  (a)  Repealed by Acts 2015, 84th Leg., R.S., Ch. 42 , Sec. 3.01(6), eff. September 1, 2015.
(b)  A small employer health benefit plan issuer that refuses to issue a small employer health benefit plan in a geographic service area may not offer a health benefit plan to a small employer in the applicable service area before the fifth anniversary of the date of the refusal.
(c)  A small or large employer health benefit plan issuer is not required to offer or issue a small or large employer health benefit plan to:
(1)  a small or large employer that is not located within a geographic service area of the issuer;
(2)  an employee of a small or large employer who neither resides nor works in the geographic service area of the issuer;  or
(3)  a small or large employer located within a geographic service area of the issuer with respect to which area the issuer demonstrates to the commissioner's satisfaction that the issuer:
(A)  reasonably anticipates that it will not have the capacity to deliver services adequately because of obligations to existing covered individuals;  and
(B)  is acting uniformly without regard to the claims experience of the employer or any health status related factor of employees, employees' dependents, or new employees or dependents who may become eligible for the coverage.
(d)  A small or large employer health benefit plan issuer that is unable to offer coverage in a geographic service area in accordance with a determination made by the commissioner under Subsection (c)(3) may not offer a small or large employer benefit plan, as applicable, in that service area before the 180th day after the later of:
(1)  the date the issuer refuses to offer coverage;  or
(2)  the date the issuer demonstrates to the satisfaction of the commissioner that it has regained the capacity to deliver services to small or large employers in the geographic service area.
(e)  If the commissioner determines that requiring the acceptance of small or large employers under this chapter would place a small or large employer health benefit plan issuer in a financially impaired condition and that the issuer is acting uniformly without regard to the claims experience of the small or large employer or any health status related factors of eligible employees, eligible employees' dependents, or new employees or dependents who may become eligible for the coverage, the issuer may not offer coverage to small or large employers until the later of:
(1)  the 180th day after the date the commissioner makes the determination;  or
(2)  the date the commissioner determines that accepting small or large employers would not place the issuer in a financially impaired condition.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
Amended by:
Acts 2015, 84th Leg., R.S., Ch. 42 (S.B. 784), Sec. 3.01(6), eff. September 1, 2015.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle G - Health Coverage Availability › Chapter 1501 - Health Insurance Portability and Availability Act › Subchapter C. Provision of Coverage › Section 1501.102. Preexisting Condition Provision

Sec. 1501.102.  PREEXISTING CONDITION PROVISION.  (a)  In this section, "creditable coverage" has the meaning assigned by Section 1205.004 and includes coverage provided under:
(1)  a political subdivision health benefits risk pool;  and
(2)  a short-term limited duration coverage plan.
(b)  A preexisting condition provision in a small or large employer health benefit plan may apply only to coverage for a disease or condition for which medical advice, diagnosis, care, or treatment was recommended or received during the six months before the earlier of:
(1)  the effective date of coverage;  or
(2)  the first day of the waiting period.
(c)  A preexisting condition provision in a small or large employer health benefit plan may not apply to expenses incurred on or after the first anniversary of the initial effective date of coverage of the enrollee, including a late enrollee.
(d)  A preexisting condition provision in a small or large employer health benefit plan may not apply to an individual who was continuously covered for an aggregate period of 12 months under creditable coverage that was in effect until a date not more than 63 days before the effective date of coverage under the plan, excluding any waiting period.
(e)  In determining whether a preexisting condition provision applies to an individual covered by a small or large employer health benefit plan, the plan issuer shall credit the time the individual was covered under previous creditable coverage if the previous coverage was in effect at any time during the 12 months preceding the effective date of coverage under the plan.  If the previous coverage was issued under a health benefit plan, any waiting period that applied before that coverage became effective must also be credited against the preexisting condition provision period.
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 G - Health Coverage Availability › Chapter 1501 - Health Insurance Portability and Availability Act › Subchapter C. Provision of Coverage › Section 1501.103. Treatment of Certain Conditions as Preexisting Prohibited

Sec. 1501.103.  TREATMENT OF CERTAIN CONDITIONS AS PREEXISTING PROHIBITED.  (a)  A small or large employer health benefit plan issuer may not treat genetic information as a preexisting condition described by Section 1501.102(b) in the absence of a diagnosis of the condition related to the information.
(b)  A small or large employer health benefit plan issuer may not treat pregnancy as a preexisting condition described by Section 1501.102(b).
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 G - Health Coverage Availability › Chapter 1501 - Health Insurance Portability and Availability Act › Subchapter C. Provision of Coverage › Section 1501.104. Affiliation Period

Sec. 1501.104.  AFFILIATION PERIOD.  (a)  In this section, "affiliation period" means a period that, under a small or large employer health benefit plan offered by a health maintenance organization, must expire before the coverage becomes effective.
(b)  A health maintenance organization may impose an affiliation period if the period is applied uniformly without regard to any health status related factor.  The affiliation period may not exceed:
(1)  two months for an enrollee, other than a late enrollee;  or
(2)  90 days for a late enrollee.
(c)  An affiliation period under a small or large employer health benefit plan must run concurrently with any applicable waiting period under the plan.  A health maintenance organization must credit an affiliation period against any preexisting condition provision period.
(d)  During an affiliation period, a health maintenance organization:
(1)  is not required to provide health care services or benefits to the participant or beneficiary;  and
(2)  may not charge a premium to the participant or beneficiary.
(e)  A health maintenance organization may use an alternative method approved by the commissioner to address adverse selection.
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 G - Health Coverage Availability › Chapter 1501 - Health Insurance Portability and Availability Act › Subchapter C. Provision of Coverage › Section 1501.105. Waiting Period Permitted

Sec. 1501.105.  WAITING PERIOD PERMITTED.  Sections 1501.102-1501.104 do not preclude application of a waiting period that applies to all new enrollees under a small or large employer health benefit 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 G - Health Coverage Availability › Chapter 1501 - Health Insurance Portability and Availability Act › Subchapter C. Provision of Coverage › Section 1501.106. Certain Limitations or Exclusions of Coverage Prohibited

Sec. 1501.106.  CERTAIN LIMITATIONS OR EXCLUSIONS OF COVERAGE PROHIBITED.  (a)  A small or large employer health benefit plan may not limit or exclude, by use of a rider or amendment applicable to a specific individual, coverage by type of illness, treatment, medical condition, or accident.
(b)  This section does not preclude a small or large employer health benefit plan from limiting or excluding coverage for a preexisting condition in accordance with Section 1501.102.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.