reglab/statecodes huggingface dataset:
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle C - Managed Care › Chapter 1272 - Delegation of Certain Functions by Health Maintenance Organization › Subchapter E. Compliance › Section 1272.208. Authority of Commissioner to Issue Order

Sec. 1272.208.  AUTHORITY OF COMMISSIONER TO ISSUE ORDER.  (a)  Regardless of whether a delegated entity complies with a request for corrective action under Section 1272.207, the commissioner may order a health maintenance organization with which the entity has entered into a delegation agreement to take any action the commissioner determines is necessary to ensure that the health maintenance organization is complying with this chapter, Chapter 843, 1271, or 1367, Subchapter A, Chapter 1452, or Subchapter B, Chapter 1507.
(b)  Actions the commissioner may order a health maintenance organization to take under this section include:
(1)  reassuming the functions delegated to the delegated entity, including claims payments for services previously provided to enrollees;
(2)  temporarily or permanently ceasing assignment of new enrollees to the entity;
(3)  temporarily or permanently transferring enrollees to alternative delivery systems to receive services;  or
(4)  terminating the delegation agreement with the entity.
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. 11.074(h), eff. September 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle C - Managed Care › Chapter 1272 - Delegation of Certain Functions by Health Maintenance Organization › Subchapter E. Compliance › Section 1272.209. Public Documents

Sec. 1272.209.  PUBLIC DOCUMENTS.  (a)  Except as provided by Subsection (b), a report required under Section 1272.205(b) or corrective plan required under Section 1272.206 is a public document.
(b)  Health care provider fee schedules, prices, costs of care, or other information that is not relevant to the monitoring plan or is confidential by law is not a public document under this section.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle C - Managed Care › Chapter 1272 - Delegation of Certain Functions by Health Maintenance Organization › Subchapter E. Compliance › Section 1272.210. Record of Complaints; Report

Sec. 1272.210.  RECORD OF COMPLAINTS;  REPORT.  (a)  The department shall:
(1)  maintain enrollee and provider complaints in a manner that identifies complaints made about limited provider networks and delegated entities;  and
(2)  periodically issue a report on the complaints that includes a list of complaints organized by:
(A)  category;
(B)  action taken on the complaint;  and
(C)  entity or network name and type.
(b)  The department shall make available to the public the report and information to assist the public in evaluating the information contained in the report.
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 C - Managed Care › Chapter 1272 - Delegation of Certain Functions by Health Maintenance Organization › Subchapter E. Compliance › Section 1272.211. Rules

Sec. 1272.211.  RULES.  The commissioner may adopt rules as necessary to implement this subchapter.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle C - Managed Care › Chapter 1272 - Delegation of Certain Functions by Health Maintenance Organization › Subchapter F. Penalties › Section 1272.251. Applicability of Subchapter

Sec. 1272.251.  APPLICABILITY OF SUBCHAPTER.  This subchapter does not apply to a group model health maintenance organization, as defined by Section 843.111.
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 C - Managed Care › Chapter 1272 - Delegation of Certain Functions by Health Maintenance Organization › Subchapter F. Penalties › Section 1272.252. Suspension or Revocation of License of Third-Party Administrator or Utilization Review Agent

Sec. 1272.252.  SUSPENSION OR REVOCATION OF LICENSE OF THIRD-PARTY ADMINISTRATOR OR UTILIZATION REVIEW AGENT.  Notwithstanding any other provision of this code or another insurance law of this state, the commissioner may suspend or revoke the license of a third-party administrator or utilization review agent that fails to comply with Subchapter B, C, or E.
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 C - Managed Care › Chapter 1272 - Delegation of Certain Functions by Health Maintenance Organization › Subchapter F. Penalties › Section 1272.253. Sanctions and Penalties Against Health Maintenance Organization

Sec. 1272.253.  SANCTIONS AND PENALTIES AGAINST HEALTH MAINTENANCE ORGANIZATION.  The commissioner may impose sanctions or penalties under Chapters 82, 83, and 84 on a health maintenance organization that does not provide in a timely manner information required by Subchapter C.
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 C - Managed Care › Chapter 1272 - Delegation of Certain Functions by Health Maintenance Organization › Subchapter F. Penalties › Section 1272.254. Contractual Penalties Required

Sec. 1272.254.  CONTRACTUAL PENALTIES REQUIRED.  A health maintenance organization by contract shall establish penalties for a delegated entity that does not provide in a timely manner information required under a monitoring plan established under Section 1272.053.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle C - Managed Care › Chapter 1272 - Delegation of Certain Functions by Health Maintenance Organization › Subchapter F. Penalties › Section 1272.255. Rules

Sec. 1272.255.  RULES.  The commissioner may adopt rules as necessary to implement this subchapter.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle C - Managed Care › Chapter 1272 - Delegation of Certain Functions by Health Maintenance Organization › Subchapter G. Provision of Services by Limited Provider Network or Delegated Entity › Section 1272.301. Access to Out-of-Network Services

Sec. 1272.301.  ACCESS TO OUT-OF-NETWORK SERVICES.  (a)  A contract between a health maintenance organization and a limited provider network or delegated entity must provide that:
(1)  if medically necessary covered services are not available through network physicians or providers, the limited provider network or delegated entity, on the request of a network physician or provider, shall:
(A)  allow a referral to a non-network physician or provider;  and
(B)  fully reimburse the non-network physician or provider at the usual and customary rate or an agreed rate;  and
(2)  before the limited provider network or delegated entity may deny a referral to a non-network physician or provider, a specialist of the same or similar specialty as the type of physician or provider to whom the referral is requested must conduct a review of the request.
(b)  The limited provider network or delegated entity shall allow the referral within the time appropriate to the circumstances relating to the delivery of the services and the condition of the enrollee who is a patient, but not later than the fifth business day after the date the network or entity receives any reasonably requested documentation.
(c)  An enrollee may not be required to change the enrollee's primary care physician or specialist providers to receive medically necessary covered services that are not available within the limited provider network or through the delegated entity.
(d)  A denial of out-of-network services under this section is subject to appeal under Chapter 4201.
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.005, eff. April 1, 2009.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle C - Managed Care › Chapter 1273 - Point-of-Service Plans › Subchapter A. Blended Contracts › Section 1273.001. Definitions

Sec. 1273.001.  DEFINITIONS.  In this subchapter:
(1)  "Blended contract" means a single document, including a single contract policy, certificate, or evidence of coverage, that provides a combination of indemnity and health maintenance organization benefits.
(2)  "Health maintenance organization" has the meaning assigned by Section 843.002.
(3)  "Insurer" means an insurance company, association, or organization authorized to engage in business in this state under Chapter 841, 842, 861, 881, 882, 883, 884, 885, 886, 887, 888, 941, 942, or 982.
(4)  "Point-of-service plan" means an arrangement under which:
(A)  an enrollee chooses to obtain benefits or services through:
(i)  a health maintenance organization delivery network, including a limited provider network; or
(ii)  a non-network delivery system outside the health maintenance organization delivery network, including an exclusive provider benefit plan under Chapter 1301 or a limited provider network, that is administered under an indemnity benefit arrangement for the cost of health care services; or
(B)  indemnity benefits for the cost of health care services are provided by an insurer or group hospital service corporation in conjunction with network benefits arranged or provided by a health maintenance organization.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
Amended by:
Acts 2011, 82nd Leg., R.S., Ch. 288 (H.B. 1772), Sec. 1, eff. September 1, 2011.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle C - Managed Care › Chapter 1273 - Point-of-Service Plans › Subchapter A. Blended Contracts › Section 1273.002. Point-of-Service Plan

Sec. 1273.002.  POINT-OF-SERVICE PLAN.  An insurer may contract with a health maintenance organization to provide benefits under a point-of-service plan, including optional coverage for out-of-area services or out-of-network care.
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 C - Managed Care › Chapter 1273 - Point-of-Service Plans › Subchapter A. Blended Contracts › Section 1273.003. Blended Contract

Sec. 1273.003.  BLENDED CONTRACT.  (a)  A health maintenance organization and an insurer may offer a blended contract.  The use of a blended contract is limited to point-of-service arrangements between a health maintenance organization and an insurer.
(b)  A blended contract delivered, issued, or used in this state is subject to, and must be filed with the department for approval as provided by, Chapter 1701 and Section 1271.101.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle C - Managed Care › Chapter 1273 - Point-of-Service Plans › Subchapter A. Blended Contracts › Section 1273.004. Limited Benefits and Services; Cost-Sharing Provisions

Sec. 1273.004.  LIMITED BENEFITS AND SERVICES;  COST-SHARING PROVISIONS.  Indemnity benefits and services provided under a point-of-service plan may be limited to those services described by the blended contract and may be subject to different cost-sharing provisions.  The cost-sharing provisions for indemnity benefits may be higher than the cost-sharing provisions for in-network health maintenance organization coverage.  For an enrollee in a limited provider network, higher cost-sharing may be imposed only when the enrollee obtains benefits or services outside the health maintenance organization delivery network.
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 C - Managed Care › Chapter 1273 - Point-of-Service Plans › Subchapter A. Blended Contracts › Section 1273.005. Rules

Sec. 1273.005.  RULES.  The commissioner may adopt rules to implement this subchapter.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle C - Managed Care › Chapter 1273 - Point-of-Service Plans › Subchapter B. Availability of Health Benefit Coverage Options › Section 1273.051. Definitions

Sec. 1273.051.  DEFINITIONS.  In this subchapter:
(1)  "Employee" means an individual employed by an employer.
(2)  "Health benefit plan" has the meaning assigned by Section 1501.002.
(3)  "Non-network plan" means health benefit coverage that provides an enrollee an opportunity to obtain health care services through a health delivery system other than a health maintenance organization delivery network, as defined by Section 843.002.
(4)  "Point-of-service plan" means an arrangement under which an enrollee chooses to obtain benefits or services through:
(A)  a health maintenance organization delivery network, including a limited provider network;  or
(B)  a non-network delivery system outside the health maintenance organization delivery network, including a limited provider network, that is administered under an indemnity benefit arrangement for the cost of health care services.
(5)  "Preferred provider benefit plan" means an insurance policy issued under Chapter 1301.
(6)  "Small employer health benefit plan" has the meaning assigned by Section 1501.002.
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 C - Managed Care › Chapter 1273 - Point-of-Service Plans › Subchapter B. Availability of Health Benefit Coverage Options › Section 1273.052. Offer of Coverage Through Non-Network Plan Required

Sec. 1273.052.  OFFER OF COVERAGE THROUGH NON-NETWORK PLAN REQUIRED.  (a)  Except as provided by Subsection (b), if the only health benefit coverage offered under an employer's health benefit plan is a network-based delivery system of coverage offered by one or more health maintenance organizations, each health maintenance organization offering coverage must offer to all eligible employees, at the time of enrollment and at least annually, the opportunity to obtain coverage through a non-network plan.
(b)  Each health maintenance organization to which Subsection (a) applies may enter into an agreement designating one or more of those health maintenance organizations to offer the coverage required by Subsection (a) for eligible employees of the employer.
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 C - Managed Care › Chapter 1273 - Point-of-Service Plans › Subchapter B. Availability of Health Benefit Coverage Options › Section 1273.053. Coverage Options

Sec. 1273.053.  COVERAGE OPTIONS.  The coverage required to be offered under this subchapter may be provided through:
(1)  a point-of-service plan;
(2)  a preferred provider benefit plan;  or
(3)  any coverage arrangement that provides an enrollee with access to services outside the health maintenance organization's or limited provider network's delivery network.
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 C - Managed Care › Chapter 1273 - Point-of-Service Plans › Subchapter B. Availability of Health Benefit Coverage Options › Section 1273.054. Premium for Coverage Options

Sec. 1273.054.  PREMIUM FOR COVERAGE OPTIONS.  The premium for coverage required to be offered under this subchapter must be based on the actuarial value of that coverage and may be different from the premium for coverage otherwise offered by the health maintenance organization.
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 C - Managed Care › Chapter 1273 - Point-of-Service Plans › Subchapter B. Availability of Health Benefit Coverage Options › Section 1273.055. Cost-Sharing Provisions

Sec. 1273.055.  COST-SHARING PROVISIONS.  (a)  Different cost-sharing provisions may be imposed for a point-of-service plan offered under this subchapter, and those provisions may be higher than the cost-sharing provisions for in-network health maintenance organization coverage.  For an enrollee in a limited provider network, higher cost-sharing may be imposed only when the enrollee obtains benefits or services outside the health maintenance organization delivery network.
(b)  An employee who chooses the non-network plan is responsible for any additional costs for the non-network plan, and the employer may impose a reasonable administrative fee for providing the non-network 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 C - Managed Care › Chapter 1273 - Point-of-Service Plans › Subchapter B. Availability of Health Benefit Coverage Options › Section 1273.056. Exceptions

Sec. 1273.056.  EXCEPTIONS.  This subchapter does not apply to:
(1)  a small employer health benefit plan;  or
(2)  a group model health maintenance organization that is a nonprofit, state-certified health maintenance organization that:
(A)  provides the majority of its professional services through a single group medical practice that is governed by a board composed entirely of physicians;  and
(B)  educates medical students or resident physicians through a contract with the medical school component of a Texas state-supported college or university accredited by the Accreditation Council on Graduate Medical Education or the American Osteopathic Association.
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 C - Managed Care › Chapter 1273 - Point-of-Service Plans › Subchapter B. Availability of Health Benefit Coverage Options › Section 1273.057. Rules

Sec. 1273.057.  RULES.  The commissioner shall adopt rules necessary to administer this subchapter.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle C - Managed Care › Chapter 1274 - Electronic Transmission of Eligibility and Payment Status › Section 1274.0015. Exemption

Sec. 1274.0015.  EXEMPTION.  This chapter does not apply to a single-service health maintenance organization that provides coverage only for dental or vision benefits.
Added by Acts 2005, 79th Leg., Ch. 880 (S.B. 1149), Sec. 1, eff. September 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle C - Managed Care › Chapter 1274 - Electronic Transmission of Eligibility and Payment Status › Section 1274.002. Transmission of Enrollee Eligibility and Payment Status

Sec. 1274.002.  TRANSMISSION OF ENROLLEE ELIGIBILITY AND PAYMENT STATUS.  (a)  Each health benefit plan issuer shall, upon the participating provider's submission of the patient's name, relationship to the primary enrollee, and birth date, make available telephonically, electronically, or by an Internet website portal to each participating provider information maintained in the ordinary course of business and sufficient for the provider to determine at the time of the enrollee's visit information concerning:
(1)  the enrollee, including:
(A)  the enrollee's identification number assigned by the health benefit plan issuer;
(B)  the name of the enrollee and all covered dependents, if appropriate;
(C)  the birth date of the enrollee and the birth dates of all covered dependents, if appropriate;
(D)  the gender of the enrollee and the gender of each covered dependent, if appropriate; and
(E)  the current enrollment and eligibility status of the enrollee under the health benefit plan;
(2)  the enrollee's benefits, including:
(A)  whether a specific type or category of service is a covered benefit; and
(B)  excluded benefits or limitations, both group and individual; and
(3)  the enrollee's financial information, including:
(A)  copayment requirements, if any; and
(B)  the unmet amount of the enrollee's deductible or enrollee financial responsibility.
(b)  Information required to be made available under this section may be made available only to a participating provider who is authorized under state and federal law to receive personally identifiable information on an enrollee or dependent.
Added by Acts 2005, 79th Leg., Ch. 880 (S.B. 1149), Sec. 1, eff. September 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle C - Managed Care › Chapter 1274 - Electronic Transmission of Eligibility and Payment Status › Section 1274.003. Certain Charges Prohibited

Sec. 1274.003.  CERTAIN CHARGES PROHIBITED.  A health benefit plan issuer may not directly or indirectly charge or hold a physician, health care provider, or enrollee responsible for a fee for making available or accessing information under this chapter.
Added by Acts 2005, 79th Leg., Ch. 880 (S.B. 1149), Sec. 1, eff. September 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle C - Managed Care › Chapter 1274 - Electronic Transmission of Eligibility and Payment Status › Section 1274.004. Rules

Sec. 1274.004.  RULES.  (a)  The commissioner shall adopt rules as necessary to implement this chapter.
(b)  Before adopting rules under this section, the commissioner shall consult and receive advice from the technical advisory committee on claims processing established under Chapter 1212.
Added by Acts 2005, 79th Leg., Ch. 880 (S.B. 1149), Sec. 1, eff. September 1, 2005.
Amended by:
Acts 2007, 80th Leg., R.S., Ch. 730 (H.B. 2636), Sec. 2G.006, eff. April 1, 2009.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle C - Managed Care › Chapter 1274 - Electronic Transmission of Eligibility and Payment Status › Section 1274.005. Waiver of Certain Provisions for Certain Federal Plans

Sec. 1274.005.  WAIVER OF CERTAIN PROVISIONS FOR CERTAIN FEDERAL PLANS.  If the commissioner, in consultation with the commissioner of health and human services, determines that a provision of Section 1274.002 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.), or Subchapter XXI, Social Security Act (42 U.S.C. Section 1397aa et seq.), 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. 880 (S.B. 1149), Sec. 1, eff. September 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle C - Managed Care › Chapter 1275 - Balance Billing Prohibitions and Out-of-Network Claim Dispute Resolution for Certain Plans › Subchapter A. General Provisions › Section 1275.001. Definitions

Sec. 1275.001.  DEFINITIONS.  In this chapter:
(1)  "Enrollee" means an individual enrolled in a health benefit plan to which this chapter applies.
(2)  "Usual and customary rate" means the relevant allowable amount as described by the applicable master benefit plan document.
Added by Acts 2021, 87th Leg., R.S., Ch. 1034 (H.B. 3924), Sec. 1, eff. September 1, 2021.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle C - Managed Care › Chapter 1275 - Balance Billing Prohibitions and Out-of-Network Claim Dispute Resolution for Certain Plans › Subchapter A. General Provisions › Section 1275.002. Applicability of Chapter

Sec. 1275.002.  APPLICABILITY OF CHAPTER.  This chapter applies only to:
(1)  a health benefit plan offered by a nonprofit agricultural organization under Chapter 1682; and
(2)  a health benefit plan:
(A)  that is a self-insured or self-funded plan established by an employer for the benefit of the employer's employees in accordance with the Employee Retirement Income Security Act of 1974 (29 U.S.C. Section 1001 et seq.); and
(B)  for which the plan sponsor has made an election, submitted to the commissioner in the form and manner prescribed by the commissioner, to apply this chapter to the plan for the relevant plan year.
Added by Acts 2021, 87th Leg., R.S., Ch. 1034 (H.B. 3924), Sec. 1, eff. September 1, 2021.
Amended by:
Acts 2023, 88th Leg., R.S., Ch. 696 (H.B. 1592), Sec. 1, eff. September 1, 2023.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle C - Managed Care › Chapter 1275 - Balance Billing Prohibitions and Out-of-Network Claim Dispute Resolution for Certain Plans › Subchapter A. General Provisions › Section 1275.003. Balance Billing Prohibition Notice

Text of section effective until September 01, 2025
Sec. 1275.003.  BALANCE BILLING PROHIBITION NOTICE.  (a)  The administrator of a health benefit plan to which this chapter applies shall provide written notice in accordance with this section in an explanation of benefits provided to the enrollee and the physician or health care provider in connection with a health care or medical service or supply or transport provided by an out-of-network provider.  The notice must include:
(1)  a statement of the billing prohibition under Section 1275.051, 1275.052, 1275.053, or 1275.054, as applicable;
(2)  the total amount the physician or provider may bill the enrollee under the enrollee's health benefit plan and an itemization of copayments, coinsurance, deductibles, and other amounts included in that total; and
(3)  for an explanation of benefits provided to the physician or provider, information required by commissioner rule advising the physician or provider of the availability of mediation or arbitration, as applicable, under Chapter 1467.
(b)  The administrator shall provide the explanation of benefits with the notice required by this section to a physician or health care provider not later than the date the administrator makes a payment under Section 1275.051, 1275.052, 1275.053, or 1275.054, as applicable.
Added by Acts 2021, 87th Leg., R.S., Ch. 1034 (H.B. 3924), Sec. 1, eff. September 1, 2021.
Amended by:
Acts 2023, 88th Leg., R.S., Ch. 981 (S.B. 2476), Sec. 4(a), eff. September 1, 2023.
Acts 2023, 88th Leg., R.S., Ch. 981 (S.B. 2476), Sec. 4(b), eff. September 1, 2025.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle C - Managed Care › Chapter 1275 - Balance Billing Prohibitions and Out-of-Network Claim Dispute Resolution for Certain Plans › Subchapter A. General Provisions › Section 1275.003. Balance Billing Prohibition Notice

Text of section effective on September 01, 2025
Sec. 1275.003.  BALANCE BILLING PROHIBITION NOTICE.  (a)  The administrator of a health benefit plan to which this chapter applies shall provide written notice in accordance with this section in an explanation of benefits provided to the enrollee and the physician or health care provider in connection with a health care or medical service or supply provided by an out-of-network provider.  The notice must include:
(1)  a statement of the billing prohibition under Section 1275.051, 1275.052, or 1275.053, as applicable;
(2)  the total amount the physician or provider may bill the enrollee under the enrollee's health benefit plan and an itemization of copayments, coinsurance, deductibles, and other amounts included in that total; and
(3)  for an explanation of benefits provided to the physician or provider, information required by commissioner rule advising the physician or provider of the availability of mediation or arbitration, as applicable, under Chapter 1467.
(b)  The administrator shall provide the explanation of benefits with the notice required by this section to a physician or health care provider not later than the date the administrator makes a payment under Section 1275.051, 1275.052, or 1275.053, as applicable.
Added by Acts 2021, 87th Leg., R.S., Ch. 1034 (H.B. 3924), Sec. 1, eff. September 1, 2021.
Amended by:
Acts 2023, 88th Leg., R.S., Ch. 981 (S.B. 2476), Sec. 4(a), eff. September 1, 2023.
Acts 2023, 88th Leg., R.S., Ch. 981 (S.B. 2476), Sec. 4(b), eff. September 1, 2025.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle C - Managed Care › Chapter 1275 - Balance Billing Prohibitions and Out-of-Network Claim Dispute Resolution for Certain Plans › Subchapter A. General Provisions › Section 1275.004. Out-of-Network Claim Dispute Resolution

Sec. 1275.004.  OUT-OF-NETWORK CLAIM DISPUTE RESOLUTION.  Chapter 1467 applies to a health benefit plan to which this chapter applies, and the administrator of a health benefit plan to which this chapter applies is an administrator for purposes of that chapter.
Added by Acts 2021, 87th Leg., R.S., Ch. 1034 (H.B. 3924), Sec. 1, eff. September 1, 2021.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle C - Managed Care › Chapter 1275 - Balance Billing Prohibitions and Out-of-Network Claim Dispute Resolution for Certain Plans › Subchapter B. Payments for Certain Services; Balance Billing Prohibitions › Section 1275.051. Emergency Care Payments

Sec. 1275.051.  EMERGENCY CARE PAYMENTS.  (a)  In this section, "emergency care" has the meaning assigned by Section 1301.155.
(b)  The administrator of a health benefit plan to which this chapter applies shall pay for covered emergency care performed by or a covered supply related to that care provided by an out-of-network provider at the usual and customary rate or at an agreed rate.  The administrator shall make a payment required by this subsection directly to the provider not later than, as applicable:
(1)  the 30th day after the date the administrator receives an electronic claim for those services that includes all information necessary for the administrator to pay the claim; or
(2)  the 45th day after the date the administrator receives a nonelectronic claim for those services that includes all information necessary for the administrator to pay the claim.
(c)  For emergency care subject to this section or a supply related to that care, an out-of-network provider or a person asserting a claim as an agent or assignee of the provider may not bill an enrollee in, and the enrollee does not have financial responsibility for, an amount greater than an applicable copayment, coinsurance, and deductible under the enrollee's health benefit plan that:
(1)  is based on:
(A)  the amount initially determined payable by the administrator; or
(B)  if applicable, a modified amount as determined under the administrator's internal appeal process; and
(2)  is not based on any additional amount determined to be owed to the provider under Chapter 1467.
Added by Acts 2021, 87th Leg., R.S., Ch. 1034 (H.B. 3924), Sec. 1, eff. September 1, 2021.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle C - Managed Care › Chapter 1275 - Balance Billing Prohibitions and Out-of-Network Claim Dispute Resolution for Certain Plans › Subchapter B. Payments for Certain Services; Balance Billing Prohibitions › Section 1275.052. Out-of-Network Facility-Based Provider Payments

Sec. 1275.052.  OUT-OF-NETWORK FACILITY-BASED PROVIDER PAYMENTS.  (a)  In this section, "facility-based provider" means a physician or health care provider who provides health care or medical services to patients of a health care facility.
(b)  Except as provided by Subsection (d), the administrator of a health benefit plan to which this chapter applies shall pay for a covered health care or medical service performed for or a covered supply related to that service provided to an enrollee by an out-of-network provider who is a facility-based provider at the usual and customary rate or at an agreed rate if the provider performed the service at a health care facility that is a participating provider.  The administrator shall make a payment required by this subsection directly to the provider not later than, as applicable:
(1)  the 30th day after the date the administrator receives an electronic claim for those services that includes all information necessary for the administrator to pay the claim; or
(2)  the 45th day after the date the administrator receives a nonelectronic claim for those services that includes all information necessary for the administrator to pay the claim.
(c)  Except as provided by Subsection (d), an out-of-network provider who is a facility-based provider or a person asserting a claim as an agent or assignee of the provider may not bill an enrollee receiving a health care or medical service or supply described by Subsection (b) in, and the enrollee does not have financial responsibility for, an amount greater than an applicable copayment, coinsurance, and deductible under the enrollee's health benefit plan that:
(1)  is based on:
(A)  the amount initially determined payable by the administrator; or
(B)  if applicable, a modified amount as determined under the administrator's internal appeal process; and
(2)  is not based on any additional amount determined to be owed to the provider under Chapter 1467.
(d)  This section does not apply to a nonemergency health care or medical service:
(1)  that an enrollee elects to receive in writing in advance of the service with respect to each out-of-network provider providing the service; and
(2)  for which an out-of-network provider, before providing the service, provides a complete written disclosure to the enrollee that:
(A)  explains that the provider does not have a contract with the enrollee's health benefit plan;
(B)  discloses projected amounts for which the enrollee may be responsible; and
(C)  discloses the circumstances under which the enrollee would be responsible for those amounts.
Added by Acts 2021, 87th Leg., R.S., Ch. 1034 (H.B. 3924), Sec. 1, eff. September 1, 2021.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle C - Managed Care › Chapter 1275 - Balance Billing Prohibitions and Out-of-Network Claim Dispute Resolution for Certain Plans › Subchapter B. Payments for Certain Services; Balance Billing Prohibitions › Section 1275.054. Out-of-Network Emergency Medical Services Provider Payments

Sec. 1275.054.  OUT-OF-NETWORK EMERGENCY MEDICAL SERVICES PROVIDER PAYMENTS.  (a)  In this section, "emergency medical services provider" has the meaning assigned by Section 773.003, Health and Safety Code, except that the term does not include an air ambulance.
(b)  Except as provided by Subsection (c), the administrator of a health benefit plan to which this chapter applies shall pay for a covered health care or medical service performed for, or a covered supply or covered transport related to that service provided to, an enrollee by an out-of-network provider who is an emergency medical services provider at:
(1)  if the political subdivision has submitted the rate to the department under Section 38.006, the rate set, controlled, or regulated by the political subdivision in which:
(A)  the service originated; or
(B)  the transport originated if transport is provided; or
(2)  if the political subdivision has not submitted the rate to the department, the lesser of:
(A)  the provider's billed charge; or
(B)  325 percent of the current Medicare rate, including any applicable extenders and modifiers.
(c)  The administrator shall adjust a payment required by Subsection (b)(1) each plan year by increasing the payment by the lesser of the Medicare Inflation Index or 10 percent of the provider's previous calendar year rates.
(d)  The administrator shall make a payment required by this section directly to the provider not later than, as applicable:
(1)  the 30th day after the date the administrator receives an electronic claim for those services that includes all information necessary for the administrator to pay the claim; or
(2)  the 45th day after the date the administrator receives a nonelectronic claim for those services that includes all information necessary for the administrator to pay the claim.
(e)  An out-of-network provider who is an emergency medical services provider or a person asserting a claim as an agent or assignee of the provider may not bill an enrollee receiving a health care or medical service or supply or transport described by Subsection (b) in, and the enrollee does not have financial responsibility for, an amount greater than an applicable copayment, coinsurance, and deductible under the enrollee's health benefit plan that is based on:
(1)  the amount initially determined payable by the administrator; or
(2)  if applicable, the modified amount as determined under the administrator's internal appeal process.
(f)  This section expires September 1, 2025.
Added by Acts 2023, 88th Leg., R.S., Ch. 981 (S.B. 2476), Sec. 5, eff. September 1, 2023.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter A. General Provisions › Section 1301.002. Nonapplicability to Dental Care Benefits

Sec. 1301.002.  NONAPPLICABILITY TO DENTAL CARE BENEFITS.  This chapter does not apply to a provision for dental care benefits in a health insurance policy.
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 D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter A. General Provisions › Section 1301.003. Preferred Provider Benefit Plans and Exclusive Provider Benefit Plans Permitted

Sec. 1301.003.  PREFERRED PROVIDER BENEFIT PLANS AND EXCLUSIVE PROVIDER BENEFIT PLANS PERMITTED.  A preferred provider benefit plan or an exclusive provider benefit plan that meets the requirements of this chapter is not:
(1)  unjust under Chapter 1701;
(2)  unfair discrimination under Subchapter A or B, Chapter 544; or
(3)  a violation of Subchapter B or C, Chapter 1451.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
Amended by:
Acts 2011, 82nd Leg., R.S., Ch. 288 (H.B. 1772), Sec. 3, eff. September 1, 2011.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter A. General Provisions › Section 1301.0041. Applicability

Sec. 1301.0041.  APPLICABILITY.  (a)  Except as otherwise specifically provided by this chapter, this chapter applies to each preferred provider benefit plan in which an insurer provides, through the insurer's health insurance policy, for the payment of a level of coverage that is different depending on whether an insured uses a preferred provider or a nonpreferred provider.
(b)  Unless otherwise specified, an exclusive provider benefit plan is subject to this chapter in the same manner as a preferred provider benefit plan.
Text of subsection effective until April 01, 2025
(c)  This chapter does not apply to:
(1)  the child health plan program under Chapter 62, Health and Safety Code; or
(2)  a Medicaid managed care program under Chapter 533, Government Code.
Text of subsection effective on April 01, 2025
(c)  This chapter does not apply to:
(1)  the child health plan program under Chapter 62, Health and Safety Code; or
(2)  a Medicaid managed care program under Chapter 540 or 540A, Government Code, as applicable.
Added by Acts 2007, 80th Leg., R.S., Ch. 730 (H.B. 2636), Sec. 3B.0271(b), eff. September 1, 2007.
Added by Acts 2007, 80th Leg., R.S., Ch. 921 (H.B. 3167), Sec. 9.0271(b), eff. September 1, 2007.
Amended by:
Acts 2011, 82nd Leg., R.S., Ch. 288 (H.B. 1772), Sec. 4, eff. September 1, 2011.
Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 2.122, eff. April 1, 2025.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter A. General Provisions › Section 1301.0042. Applicability of Insurance Law

Sec. 1301.0042.  APPLICABILITY OF INSURANCE LAW.  (a)  Except as provided by Subsection (b), a provision of this code or another insurance law of this state that applies to a preferred provider benefit plan applies to an exclusive provider benefit plan except to the extent that the commissioner determines the provision to be inconsistent with the function and purpose of an exclusive provider benefit plan.
(b)  An exclusive provider benefit plan may not provide dental care benefits.
Added by Acts 2011, 82nd Leg., R.S., Ch. 288 (H.B. 1772), Sec. 5, eff. September 1, 2011.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter A. General Provisions › Section 1301.0045. Construction of Chapter

Sec. 1301.0045.  CONSTRUCTION OF CHAPTER.  (a) Except as provided by Section 1301.0046, this chapter may not be construed to limit the level of reimbursement or the level of coverage, including deductibles, copayments, coinsurance, or other cost-sharing provisions, that are applicable to preferred providers or, for plans other than exclusive provider benefit plans, nonpreferred providers.
Text of subsection effective until September 01, 2025
(b)  Except as provided by Sections 1301.0052, 1301.0053, 1301.155, 1301.164, 1301.165, and 1301.166, this chapter may not be construed to require an exclusive provider benefit plan to compensate a nonpreferred provider for services provided to an insured.
Text of subsection effective on September 01, 2025
(b)  Except as provided by Sections 1301.0052, 1301.0053, 1301.155, 1301.164, and 1301.165, this chapter may not be construed to require an exclusive provider benefit plan to compensate a nonpreferred provider for services provided to an insured.
Added by Acts 2005, 79th Leg., Ch. 1221 (H.B. 1030), Sec. 1, eff. September 1, 2005.
Amended by:
Acts 2011, 82nd Leg., R.S., Ch. 288 (H.B. 1772), Sec. 6, eff. September 1, 2011.
Acts 2019, 86th Leg., R.S., Ch. 1342 (S.B. 1264), Sec. 1.05, eff. September 1, 2019.
Acts 2023, 88th Leg., R.S., Ch. 981 (S.B. 2476), Sec. 6(a), eff. September 1, 2023.
Acts 2023, 88th Leg., R.S., Ch. 981 (S.B. 2476), Sec. 6(b), eff. September 1, 2025.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter A. General Provisions › Section 1301.0046. Coinsurance Requirements for Services of Nonpreferred Providers

Sec. 1301.0046.  COINSURANCE REQUIREMENTS FOR SERVICES OF NONPREFERRED PROVIDERS.  The insured's coinsurance applicable to payment to nonpreferred providers may not exceed 50 percent of the total covered amount applicable to the medical or health care services.  This section does not apply to an exclusive provider benefit plan.
Added by Acts 2005, 79th Leg., Ch. 1221 (H.B. 1030), Sec. 1, eff. September 1, 2005.
Amended by:
Acts 2011, 82nd Leg., R.S., Ch. 288 (H.B. 1772), Sec. 7, eff. September 1, 2011.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter A. General Provisions › Section 1301.005. Availability of Preferred Providers; Service Area Limitations

Sec. 1301.005.  AVAILABILITY OF PREFERRED PROVIDERS; SERVICE AREA LIMITATIONS.  (a)  An insurer offering a preferred provider benefit plan shall ensure that both preferred provider benefits and basic level benefits, including benefits for emergency care, as defined by Section 1301.155, and post-emergency stabilization care, are reasonably available to all insureds within a designated service area.  This subsection does not apply to an exclusive provider benefit plan.
(b)  If services are not available through a preferred provider within a designated service area under a preferred provider benefit plan or an exclusive provider benefit plan, an insurer shall reimburse a physician or health care provider who is not a preferred provider at the same percentage level of reimbursement as a preferred provider would have been reimbursed had the insured been treated by a preferred provider.
(c)  Subsection (b) does not require reimbursement at a preferred level of coverage solely because an insured resides out of the service area and chooses to receive services from a provider other than a preferred provider for the insured's own convenience.
(d)  A service area, other than a statewide service area, may include noncontiguous geographic areas but may not divide a county.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
Amended by:
Acts 2011, 82nd Leg., R.S., Ch. 288 (H.B. 1772), Sec. 8, eff. September 1, 2011.
Acts 2023, 88th Leg., R.S., Ch. 740 (H.B. 3359), Sec. 2, eff. September 1, 2023.
Acts 2023, 88th Leg., R.S., Ch. 740 (H.B. 3359), Sec. 3, eff. September 1, 2023.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter A. General Provisions › Section 1301.0051. Exclusive Provider Benefit Plans: Quality Improvement and Utilization Management

Sec. 1301.0051.  EXCLUSIVE PROVIDER BENEFIT PLANS: QUALITY IMPROVEMENT AND UTILIZATION MANAGEMENT.  (a) An insurer that offers an exclusive provider benefit plan shall establish procedures to ensure that health care services are provided to insureds under reasonable standards of quality of care that are consistent with prevailing professionally recognized standards of care or practice. The procedures must include:
(1)  mechanisms to ensure availability, accessibility, quality, and continuity of care;
(2)  subject to Section 1301.059, a continuing quality improvement program to monitor and evaluate services provided under the plan, including primary and specialist physician services and ancillary and preventive health care services, provided in institutional or noninstitutional settings;
(3)  a method of recording formal proceedings of quality improvement program activities and maintaining quality improvement program documentation in a confidential manner;
(4)  subject to Section 1301.059, a physician review panel to assist the insurer in reviewing medical guidelines or criteria;
(5)  a patient record system that facilitates documentation and retrieval of clinical information for the insurer's evaluation of continuity and coordination of services and assessment of the quality of services provided to insureds under the plan;
(6)  a mechanism for making available to the commissioner the clinical records of insureds for examination and review by the commissioner on request of the commissioner; and
(7)  a specific procedure for the periodic reporting of quality improvement program activities to:
(A)  the governing body and appropriate staff of the insurer; and
(B)  physicians and health care providers that provide health care services under the plan.
(b)  Minutes of a formal proceeding of the quality improvement program established under Subsection (a) shall be made available to the commissioner on request of the commissioner.
(c)  Insured records made available to the commissioner under Subsection (a)(6) are confidential and privileged, and are not subject to Chapter 552, Government Code, or to subpoena, except to the extent necessary for the commissioner to enforce this chapter.
Added by Acts 2011, 82nd Leg., R.S., Ch. 288 (H.B. 1772), Sec. 9, eff. September 1, 2011.