reglab/statecodes huggingface dataset:
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1358 - Diabetes › Subchapter A. Guidelines for Diabetes Care; Minimum Coverage Required › Section 1358.003. Exception

Sec. 1358.003.  EXCEPTION.  This subchapter does not apply to:
(1)  a plan that provides coverage:
(A)  only for a specified disease;
(B)  only for accidental death or dismemberment;
(C)  for wages or payments in lieu of wages for a period during which an employee is absent from work because of sickness or injury;
(D)  as a supplement to a liability insurance policy;
(E)  only for dental or vision care;  or
(F)  only for indemnity for hospital confinement;
(2)  a small employer health benefit plan written under Chapter 1501;
(3)  a Medicare supplemental policy as defined by Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss);
(4)  a workers' compensation insurance policy;
(5)  medical payment insurance coverage provided under a motor vehicle insurance policy;  or
(6)  a long-term care insurance policy, including a nursing home fixed indemnity policy, unless the commissioner determines that the policy provides benefit coverage so comprehensive that the policy is a health benefit plan as described by Section 1358.002.
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 E - Benefits Payable Under Health Coverages › Chapter 1358 - Diabetes › Subchapter A. Guidelines for Diabetes Care; Minimum Coverage Required › Section 1358.004. Adoption of Minimum Standards

Sec. 1358.004.  ADOPTION OF MINIMUM STANDARDS.  The commissioner, in consultation with the Texas Diabetes Council, by rule shall adopt minimum standards for coverage provided to an enrollee with diabetes.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1358 - Diabetes › Subchapter A. Guidelines for Diabetes Care; Minimum Coverage Required › Section 1358.005. Coverage Required

Sec. 1358.005.  COVERAGE REQUIRED.  (a)  A health benefit plan must provide coverage in accordance with the standards adopted under Section 1358.004.
(b)  Coverage required under this section may not be subject to a deductible, coinsurance, or copayment requirement that exceeds the deductible, coinsurance, or copayment requirement applicable to other similar coverage provided under the 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 E - Benefits Payable Under Health Coverages › Chapter 1358 - Diabetes › Subchapter B. Supplies and Services Associated With Diabetes Treatment › Section 1358.051. Definitions

Sec. 1358.051.  DEFINITIONS.  In this subchapter:
(1)  "Diabetes equipment" means:
(A)  blood glucose monitors, including noninvasive glucose monitors and glucose monitors designed to be used by blind individuals;
(B)  insulin pumps and associated appurtenances;
(C)  insulin infusion devices; and
(D)  podiatric appliances for the prevention of complications associated with diabetes.
(2)  "Diabetes supplies" means:
(A)  test strips for blood glucose monitors;
(B)  visual reading and urine test strips;
(C)  lancets and lancet devices;
(D)  insulin and insulin analogs;
(E)  injection aids;
(F)  syringes;
(G)  prescriptive and nonprescriptive oral agents for controlling blood sugar levels;  and
(H)  glucagon emergency kits.
(3)  "Nutrition counseling" has the meaning assigned by Section 701.002, Occupations Code.
(4)  "Qualified enrollee" means an individual eligible for coverage under a health benefit plan who has been diagnosed with:
(A)  insulin dependent or noninsulin dependent diabetes;
(B)  elevated blood glucose levels induced by pregnancy;  or
(C)  another medical condition associated with elevated blood glucose levels.
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. 11.038(a), eff. September 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1358 - Diabetes › Subchapter B. Supplies and Services Associated With Diabetes Treatment › Section 1358.052. Applicability of Subchapter

Sec. 1358.052.  APPLICABILITY OF SUBCHAPTER.  This subchapter applies only to a health benefit plan that:
(1)  provides benefits for medical or surgical expenses incurred as a result of a health condition, accident, or sickness, including:
(A)  an individual, group, blanket, or franchise insurance policy or insurance agreement, a group hospital service contract, or an individual or group evidence of coverage that is offered by:
(i)  an insurance company;
(ii)  a group hospital service corporation operating under Chapter 842;
(iii)  a fraternal benefit society operating under Chapter 885;
(iv)  a stipulated premium company operating under Chapter 884;
(v)  a reciprocal exchange operating under Chapter 942;  or
(vi)  a health maintenance organization operating under Chapter 843;  and
(B)  to the extent permitted by the Employee Retirement Income Security Act of 1974 (29 U.S.C. Section 1001 et seq.), a health benefit plan that is offered by a multiple employer welfare arrangement as defined by Section 3 of that Act;  or
(2)  is offered by an approved nonprofit health corporation that holds a certificate of authority under Chapter 844.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1358 - Diabetes › Subchapter B. Supplies and Services Associated With Diabetes Treatment › Section 1358.053. Exception

Sec. 1358.053.  EXCEPTION.  This subchapter does not apply to:
(1)  a plan that provides coverage:
(A)  only for a specified disease or another limited benefit;
(B)  only for accidental death or dismemberment;
(C)  for wages or payments in lieu of wages for a period during which an employee is absent from work because of sickness or injury;
(D)  as a supplement to a liability insurance policy;
(E)  for credit insurance;
(F)  only for dental or vision care;  or
(G)  only for indemnity for hospital confinement;
(2)  a small employer health benefit plan written under Chapter 1501;
(3)  a Medicare supplemental policy as defined by Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss);
(4)  a workers' compensation insurance policy;
(5)  medical payment insurance coverage provided under a motor vehicle insurance policy;  or
(6)  a long-term care insurance policy, including a nursing home fixed indemnity policy, unless the commissioner determines that the policy provides benefit coverage so comprehensive that the policy is a health benefit plan as described by Section 1358.052.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1358 - Diabetes › Subchapter B. Supplies and Services Associated With Diabetes Treatment › Section 1358.054. Coverage Required

Sec. 1358.054.  COVERAGE REQUIRED.  (a)  A health benefit plan that provides coverage for the treatment of diabetes and conditions associated with diabetes must provide to each qualified enrollee coverage for:
(1)  diabetes equipment;
(2)  diabetes supplies;  and
(3)  diabetes self-management training in accordance with the requirements of Section 1358.055.
(a-1)  A health benefit plan described by Subsection (a) must provide to each qualified enrollee coverage for emergency refills of diabetes equipment or diabetes supplies dispensed to the enrollee in accordance with Section 562.0541, Occupations Code, in the same manner as for a nonemergency refill of diabetes equipment or diabetes supplies.
(b)  A health benefit plan may require a deductible, copayment, or coinsurance for coverage provided under this section.  The amount of the deductible, copayment, or coinsurance may not exceed the amount of the deductible, copayment, or coinsurance required for treatment of other analogous chronic medical conditions.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
Amended by:
Acts 2021, 87th Leg., R.S., Ch. 679 (H.B. 1935), Sec. 2, eff. September 1, 2021.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1358 - Diabetes › Subchapter B. Supplies and Services Associated With Diabetes Treatment › Section 1358.056. Coverage for New or Improved Equipment and Supplies

Sec. 1358.056.  COVERAGE FOR NEW OR IMPROVED EQUIPMENT AND SUPPLIES.  A health benefit plan must provide coverage for new or improved diabetes equipment or supplies, including improved insulin or another prescription drug, approved by the United States Food and Drug Administration if the equipment or supplies are determined by a physician or other health care practitioner to be medically necessary and appropriate.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1358 - Diabetes › Subchapter B. Supplies and Services Associated With Diabetes Treatment › Section 1358.057. Rules

Sec. 1358.057.  RULES.  (a)  The commissioner shall adopt rules necessary to implement this subchapter.
(b)  In adopting rules under this section, the commissioner may consult with the commissioner of public health and other appropriate entities.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1358 - Diabetes › Subchapter C. Cost-Sharing Limit › Section 1358.101. Applicability of Subchapter

Sec. 1358.101.  APPLICABILITY OF SUBCHAPTER.  (a)  This subchapter applies only to a health benefit plan that provides benefits for medical or surgical expenses incurred as a result of a health condition, accident, or sickness, including an individual, group, blanket, or franchise insurance policy or insurance agreement, a group hospital service contract, or a small or large employer group contract or similar coverage document that is offered by:
(1)  an insurance company;
(2)  a group hospital service corporation operating under Chapter 842;
(3)  a fraternal benefit society operating under Chapter 885;
(4)  a stipulated premium company operating under Chapter 884;
(5)  a reciprocal exchange operating under Chapter 942;
(6)  a health maintenance organization operating under Chapter 843;
(7)  a multiple employer welfare arrangement that holds a certificate of authority under Chapter 846; or
(8)  an approved nonprofit health corporation that holds a certificate of authority under Chapter 844.
(b)  This subchapter applies to group health coverage made available by a school district in accordance with Section 22.004, Education Code.
(c)  Notwithstanding any provision in Chapter 1551, 1575, 1579, or 1601 or any other law, this subchapter applies to:
(1)  a basic coverage plan under Chapter 1551;
(2)  a basic plan under Chapter 1575;
(3)  a primary care coverage plan under Chapter 1579; and
(4)  basic coverage under Chapter 1601.
(d)  Notwithstanding any other law, this subchapter applies to coverage under:
(1)  the child health plan program under Chapter 62, Health and Safety Code, or the health benefits plan for children under Chapter 63, Health and Safety Code; and
(2)  the medical assistance program under Chapter 32, Human Resources Code.
Added by Acts 2021, 87th Leg., R.S., Ch. 589 (S.B. 827), Sec. 1, eff. September 1, 2021.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1358 - Diabetes › Subchapter C. Cost-Sharing Limit › Section 1358.102. Exception

Sec. 1358.102.  EXCEPTION.  This subchapter does not apply to:
(1)  a health benefit plan that provides coverage:
(A)  only for a specified disease or for another single benefit;
(B)  only for accidental death or dismemberment;
(C)  for wages or payments in lieu of wages for a period during which an employee is absent from work because of sickness or injury;
(D)  as a supplement to a liability insurance policy;
(E)  for credit insurance;
(F)  only for dental or vision care;
(G)  only for hospital expenses; or
(H)  only for indemnity for hospital confinement;
(2)  a Medicare supplemental policy as defined by Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss);
(3)  medical payment insurance coverage provided under a motor vehicle insurance policy;
(4)  a long-term care insurance policy, including a nursing home fixed indemnity policy, unless the commissioner determines that the policy provides benefit coverage so comprehensive that the policy is a health benefit plan as described by Section 1358.101;
(5)  health and accident coverage provided by a risk pool created under Chapter 172, Local Government Code; or
(6)  a workers' compensation insurance policy.
Added by Acts 2021, 87th Leg., R.S., Ch. 589 (S.B. 827), Sec. 1, eff. September 1, 2021.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1358 - Diabetes › Subchapter C. Cost-Sharing Limit › Section 1358.103. Limit on Cost-Sharing Requirement

Sec. 1358.103.  LIMIT ON COST-SHARING REQUIREMENT.  (a)  In this section, "insulin" means a prescription drug that contains insulin and is used to treat diabetes.  The term does not include an insulin drug that is administered to a patient intravenously.
(b)  A health benefit plan may not impose a cost-sharing provision for insulin that is included in the health benefit plan's formulary if the total amount the enrollee is required to pay exceeds $25 per prescription for a 30-day supply, regardless of the amount or type of insulin needed to fill the enrollee's prescription.
Added by Acts 2021, 87th Leg., R.S., Ch. 589 (S.B. 827), Sec. 1, eff. September 1, 2021.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1358 - Diabetes › Subchapter C. Cost-Sharing Limit › Section 1358.104. Formulary Requirement

Sec. 1358.104.  FORMULARY REQUIREMENT.  A health benefit plan must include at least one insulin from each therapeutic class in the plan's formulary.
Added by Acts 2021, 87th Leg., R.S., Ch. 589 (S.B. 827), Sec. 1, eff. September 1, 2021.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1359 - Formulas for Individuals With Phenylketonuria or Other Heritable Diseases › Section 1359.001. Definitions

Sec. 1359.001.  DEFINITIONS.  In this chapter:
(1)  "Heritable disease" means an inherited disease that may result in a physical or intellectual disability or death.
(2)  "Phenylketonuria" means an inherited condition that, if not treated, may cause a severe intellectual disability.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
Amended by:
Acts 2023, 88th Leg., R.S., Ch. 30 (H.B. 446), Sec. 8.07, eff. September 1, 2023.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1359 - Formulas for Individuals With Phenylketonuria or Other Heritable Diseases › Section 1359.002. Applicability of Chapter

Sec. 1359.002.  APPLICABILITY OF CHAPTER.  This chapter applies only to a group health benefit plan that is a group policy, contract, or certificate of health insurance or an evidence of coverage delivered, issued for delivery, or renewed in this state by:
(1)  an insurance company;
(2)  a group hospital service corporation operating under Chapter 842;  or
(3)  a health maintenance organization operating under Chapter 843.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1359 - Formulas for Individuals With Phenylketonuria or Other Heritable Diseases › Section 1359.003. Coverage Required

Sec. 1359.003.  COVERAGE REQUIRED.  (a)  A group health benefit plan must provide coverage for formulas necessary to treat phenylketonuria or a heritable disease.
(b)  The group health benefit plan must provide the coverage to the same extent that the plan provides coverage for drugs that are available only on the orders of a physician.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1360 - Diagnosis and Treatment Affecting Temporomandibular Joint › Section 1360.001. Definition

Sec. 1360.001.  DEFINITION.  In this chapter, "temporomandibular joint" includes the jaw and the craniomandibular joint.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1360 - Diagnosis and Treatment Affecting Temporomandibular Joint › Section 1360.002. Applicability of Chapter

Sec. 1360.002.  APPLICABILITY OF CHAPTER.  This chapter applies only to a group health benefit plan delivered or issued for delivery in this state that:
(1)  provides benefits for dental, medical, or surgical expenses incurred as a result of a health condition, accident, or sickness, including:
(A)  a group, blanket, or franchise insurance policy or insurance agreement, a group hospital service contract, or a group evidence of coverage that is offered by:
(i)  an insurance company;
(ii)  a group hospital service corporation operating under Chapter 842;
(iii)  a fraternal benefit society operating under Chapter 885;
(iv)  a stipulated premium company operating under Chapter 884;  or
(v)  a health maintenance organization operating under Chapter 843;  and
(B)  to the extent permitted by the Employee Retirement Income Security Act of 1974 (29 U.S.C. Section 1001 et seq.), a health benefit plan that is offered by:
(i)  a multiple employer welfare arrangement as defined by Section 3 of that Act;
(ii)  an entity not authorized under this code or another insurance law of this state that contracts directly for health care services on a risk-sharing basis, including a capitation basis;  or
(iii)  another analogous benefit arrangement;  or
(2)  is offered by an approved nonprofit health corporation that holds a certificate of authority under Chapter 844.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1360 - Diagnosis and Treatment Affecting Temporomandibular Joint › Section 1360.003. Exception

Sec. 1360.003.  EXCEPTION.  This chapter does not apply to:
(1)  a plan that provides coverage:
(A)  only for a specified disease or another limited benefit;
(B)  only for accidental death or dismemberment;
(C)  for wages or payments in lieu of wages for a period during which an employee is absent from work because of sickness or injury;
(D)  as a supplement to a liability insurance policy;
(E)  for credit insurance;
(F)  only for vision care;  or
(G)  only for indemnity for hospital confinement;
(2)  a Medicare supplemental policy as defined by Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss);
(3)  a workers' compensation insurance policy;
(4)  a small employer health benefit plan written under Chapter 1501;
(5)  medical payment insurance coverage provided under a motor vehicle insurance policy;  or
(6)  a long-term care insurance policy, including a nursing home fixed indemnity policy, unless the commissioner determines that the policy provides benefit coverage so comprehensive that the policy is a health benefit plan as described by Section 1360.002.
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 E - Benefits Payable Under Health Coverages › Chapter 1360 - Diagnosis and Treatment Affecting Temporomandibular Joint › Section 1360.004. Coverage Required

Sec. 1360.004.  COVERAGE REQUIRED.  (a)  A health benefit plan that provides coverage for medically necessary diagnostic or surgical treatment of conditions affecting skeletal joints must provide comparable coverage for diagnostic or surgical treatment of conditions affecting the temporomandibular joint if the treatment is medically necessary as a result of:
(1)  an accident;
(2)  a trauma;
(3)  a congenital defect;
(4)  a developmental defect;  or
(5)  a pathology.
(b)  Coverage required under this section may be subject to any provision in the health benefit plan that is generally applicable to surgical treatment, including a requirement for precertification of 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 E - Benefits Payable Under Health Coverages › Chapter 1360 - Diagnosis and Treatment Affecting Temporomandibular Joint › Section 1360.005. Dental Services Coverage Not Required

Sec. 1360.005.  DENTAL SERVICES COVERAGE NOT REQUIRED.  (a)  This chapter does not require a health benefit plan to provide coverage for dental services if dental services are not otherwise scheduled or provided as part of the coverage provided under the plan.
(b)  A health benefit plan may not exclude from coverage under the plan an individual who is unable to undergo dental treatment in an office setting or under local anesthesia due to a documented physical, mental, or medical reason as determined by the individual's physician or by the dentist providing the dental 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 E - Benefits Payable Under Health Coverages › Chapter 1361 - Detection and Prevention of Osteoporosis › Section 1361.001. Definition

Sec. 1361.001.  DEFINITION.  In this chapter, "qualified enrollee" means an individual entitled to coverage under a group health benefit plan who is:
(1)  a postmenopausal woman who is not receiving estrogen replacement therapy;
(2)  an individual with:
(A)  vertebral abnormalities;
(B)  primary hyperparathyroidism;  or
(C)  a history of bone fractures;  or
(3)  an individual who is:
(A)  receiving long-term glucocorticoid therapy;  or
(B)  being monitored to assess the response to or efficacy of an approved osteoporosis drug therapy.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1361 - Detection and Prevention of Osteoporosis › Section 1361.002. Applicability of Chapter

Sec. 1361.002.  APPLICABILITY OF CHAPTER.  This chapter applies only to a group health benefit plan delivered, issued for delivery, or renewed in this state that provides coverage for medical or surgical expenses incurred as a result of accident or sickness, including:
(1)  a group insurance policy;
(2)  a group contract issued by a group hospital service corporation operating under Chapter 842;  and
(3)  a group contract issued by a health maintenance organization operating under Chapter 843.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1361 - Detection and Prevention of Osteoporosis › Section 1361.003. Coverage Required

Sec. 1361.003.  COVERAGE REQUIRED.  A group health benefit plan must provide to a qualified enrollee coverage for medically accepted bone mass measurement to detect low bone mass and to determine the enrollee's risk of osteoporosis and fractures associated with osteoporosis.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1362 - Certain Tests for Detection of Prostate Cancer › Section 1362.001. Applicability of Chapter

Sec. 1362.001.  APPLICABILITY OF CHAPTER.  This chapter applies only to a health benefit plan that:
(1)  provides benefits for medical or surgical expenses incurred as a result of a health condition, accident, or sickness, including:
(A)  an individual, group, blanket, or franchise insurance policy or insurance agreement, a group hospital service contract, or an individual or group evidence of coverage that is offered by:
(i)  an insurance company;
(ii)  a group hospital service corporation operating under Chapter 842;
(iii)  a fraternal benefit society operating under Chapter 885;
(iv)  a stipulated premium company operating under Chapter 884;  or
(v)  a health maintenance organization operating under Chapter 843;  and
(B)  to the extent permitted by the Employee Retirement Income Security Act of 1974 (29 U.S.C. Section 1001 et seq.), a health benefit plan that is offered by:
(i)  a multiple employer welfare arrangement as defined by Section 3 of that Act;  or
(ii)  another analogous benefit arrangement;
(2)  is offered by:
(A)  an approved nonprofit health corporation that holds a certificate of authority under Chapter 844;  or
(B)  an entity not authorized under this code or another insurance law of this state that contracts directly for health care services on a risk-sharing basis, including a capitation basis;  or
(3)  provides health and accident coverage through a risk pool created under Chapter 172, Local Government Code, notwithstanding Section 172.014, Local Government Code, or any other law.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1362 - Certain Tests for Detection of Prostate Cancer › Section 1362.002. Exception

Sec. 1362.002.  EXCEPTION.  This chapter does not apply to:
(1)  a health benefit plan that provides coverage:
(A)  only for a specified disease or for another limited benefit;
(B)  only for accidental death or dismemberment;
(C)  for wages or payments in lieu of wages for a period during which an employee is absent from work because of sickness or injury;
(D)  as a supplement to a liability insurance policy;  or
(E)  only for indemnity for hospital confinement;
(2)  a small employer health benefit plan written under Chapter 1501;
(3)  a Medicare supplemental policy as defined by Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss);
(4)  a workers' compensation insurance policy;
(5)  medical payment insurance coverage provided under a motor vehicle insurance policy;  or
(6)  a long-term care insurance policy, including a nursing home fixed indemnity policy, unless the commissioner determines that the policy provides benefit coverage so comprehensive that the policy is a health benefit plan as described by Section 1362.001.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1362 - Certain Tests for Detection of Prostate Cancer › Section 1362.003. Coverage Required

Sec. 1362.003.  COVERAGE REQUIRED.  (a)  A health benefit plan that provides coverage for diagnostic medical procedures must provide to each male enrolled in the plan coverage for expenses for an annual medically recognized diagnostic examination for the detection of prostate cancer.
(b)  Coverage required under this section includes at a minimum:
(1)  a physical examination for the detection of prostate cancer;  and
(2)  a prostate-specific antigen test used for the detection of prostate cancer for each male who:
(A)  is at least 50 years of age and is asymptomatic;  or
(B)  is at least 40 years of age and has a family history of prostate cancer or another prostate cancer risk factor.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1362 - Certain Tests for Detection of Prostate Cancer › Section 1362.004. Notice of Coverage

Sec. 1362.004.  NOTICE OF COVERAGE.  (a)  A health benefit plan issuer shall provide to each individual enrolled in the plan written notice of the coverage required under this chapter.
(b)  The notice must be provided in accordance with rules adopted by the commissioner.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1362 - Certain Tests for Detection of Prostate Cancer › Section 1362.005. Rules

Sec. 1362.005.  RULES.  The commissioner shall adopt rules necessary to administer 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 E - Benefits Payable Under Health Coverages › Chapter 1363 - Certain Tests for Detection of Colorectal Cancer › Section 1363.001. Applicability of Chapter

Sec. 1363.001.  APPLICABILITY OF CHAPTER.  This chapter applies only to a health benefit plan, including a small employer health benefit plan written under Chapter 1501 or coverage that is provided by a health group cooperative under Subchapter B of that chapter, that:
(1)  provides benefits for medical or surgical expenses incurred as a result of a health condition, accident, or sickness, including:
(A)  an individual, group, blanket, or franchise insurance policy or insurance agreement, a group hospital service contract, or an individual or group evidence of coverage that is offered by:
(i)  an insurance company;
(ii)  a group hospital service corporation operating under Chapter 842;
(iii)  a fraternal benefit society operating under Chapter 885;
(iv)  a Lloyd's plan operating under Chapter 941;
(v)  a stipulated premium company operating under Chapter 884;
(vi)  a health maintenance organization operating under Chapter 843; or
(vii)  a reciprocal or interinsurance exchange operating under Chapter 942; and
(B)  to the extent permitted by the Employee Retirement Income Security Act of 1974 (29 U.S.C. Section 1001 et seq.), a health benefit plan that is offered by:
(i)  a multiple employer welfare arrangement as defined by Section 3 of that Act; or
(ii)  another analogous benefit arrangement;
(2)  is offered by an approved nonprofit health corporation operating under Chapter 844; or
(3)  provides health and accident coverage through a risk pool created under Chapter 172, Local Government Code, notwithstanding Section 172.014, Local Government Code, or any other law.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
Amended by:
Acts 2021, 87th Leg., R.S., Ch. 308 (S.B. 1028), Sec. 1, eff. September 1, 2021.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1363 - Certain Tests for Detection of Colorectal Cancer › Section 1363.002. Exception

Sec. 1363.002.  EXCEPTION.  This chapter does not apply to:
(1)  a plan that provides coverage:
(A)  only for a specified disease or other limited benefit;
(B)  only for accidental death or dismemberment;
(C)  for wages or payments in lieu of wages for a period during which an employee is absent from work because of sickness or injury;
(D)  as a supplement to a liability insurance policy;
(E)  only for indemnity for hospital confinement; or
(F)  only for dental or vision care;
(2)  a Medicare supplemental policy as defined by Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss), as amended;
(3)  a credit-only insurance policy;
(4)  a workers' compensation insurance policy;
(5)  medical payment insurance coverage provided under a motor vehicle insurance policy;
(6)  a limited benefit policy that does not provide coverage for physical examinations or wellness exams;
(7)  a multiple employer welfare arrangement that holds a certificate of authority under Chapter 846; or
(8)  a long-term care policy, including a nursing home fixed indemnity policy, unless the commissioner determines that the policy provides benefit coverage so comprehensive that the policy is a health benefit plan as described by Section 1363.001.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
Amended by:
Acts 2021, 87th Leg., R.S., Ch. 308 (S.B. 1028), Sec. 2, eff. September 1, 2021.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1363 - Certain Tests for Detection of Colorectal Cancer › Section 1363.003. Minimum Coverage Required

Sec. 1363.003.  MINIMUM COVERAGE REQUIRED.  (a)  A health benefit plan that provides coverage for screening medical procedures must provide to each individual enrolled in the plan who is 45 years of age or older and at normal risk for developing colon cancer coverage for expenses incurred in conducting a medically recognized screening examination for the detection of colorectal cancer.
(b)  The minimum coverage required under this section must include:
(1)  all colorectal cancer examinations, preventive services, and laboratory tests assigned a grade of "A" or "B" by the United States Preventive Services Task Force for average-risk individuals, including the services that may be assigned a grade of "A" or "B" in the future; and
(2)  an initial colonoscopy or other medical test or procedure for colorectal cancer screening and a follow-up colonoscopy if the results of the initial colonoscopy, test, or procedure are abnormal.
(c)  For an enrollee in a managed care plan as defined by Section 1451.151, the plan may impose a cost-sharing requirement for coverage described by this section only if the enrollee obtains the covered benefit or service outside the plan's network.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
Amended by:
Acts 2021, 87th Leg., R.S., Ch. 308 (S.B. 1028), Sec. 3, eff. September 1, 2021.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1363 - Certain Tests for Detection of Colorectal Cancer › Section 1363.004. Notice of Coverage

Sec. 1363.004.  NOTICE OF COVERAGE.  (a)  A health benefit plan issuer shall provide to each individual enrolled in the plan written notice of the coverage required under this chapter.
(b)  The notice must be provided in accordance with rules adopted by the commissioner.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1363 - Certain Tests for Detection of Colorectal Cancer › Section 1363.005. Rules

Sec. 1363.005.  RULES.  The commissioner shall adopt rules as necessary to administer 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 E - Benefits Payable Under Health Coverages › Chapter 1364 - Coverage Provisions Relating to Hiv, Aids, or HIV-Related Illnesses › Subchapter A. Exclusion From or Denial of Coverage Prohibited › Section 1364.001. Applicability of Subchapter

Sec. 1364.001.  APPLICABILITY OF SUBCHAPTER.  This subchapter applies only to a group health benefit plan that is delivered, issued for delivery, or renewed and that is:
(1)  a group accident and health insurance policy;
(2)  a group contract issued by a group hospital service corporation operating under Chapter 842;  or
(3)  a group evidence of coverage issued by a health maintenance organization operating under Chapter 843.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1364 - Coverage Provisions Relating to Hiv, Aids, or HIV-Related Illnesses › Subchapter A. Exclusion From or Denial of Coverage Prohibited › Section 1364.002. Exception

Sec. 1364.002.  EXCEPTION.  This subchapter does not apply to:
(1)  a credit accident and health insurance policy subject to Chapter 1153;
(2)  any group specifically provided for or authorized by law in existence and covered under a policy filed with the State Board of Insurance before April 1, 1975;
(3)  accident or health coverage that is incidental to any form of a group automobile, casualty, property, workers' compensation, or employers' liability policy approved by the department;  or
(4)  any policy or contract of insurance with a state agency, department, or board providing health services:
(A)  to eligible individuals under Chapter 32, Human Resources Code;  or
(B)  under a state plan adopted in accordance with 42 U.S.C. Sections 1396-1396g, as amended, or 42 U.S.C. Section 1397aa et seq., as amended.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1364 - Coverage Provisions Relating to Hiv, Aids, or HIV-Related Illnesses › Subchapter A. Exclusion From or Denial of Coverage Prohibited › Section 1364.003. Prohibition

Sec. 1364.003.  PROHIBITION.  A group health benefit plan may not exclude or deny coverage for:
(1)  human immunodeficiency virus (HIV);
(2)  acquired immune deficiency syndrome (AIDS);  or
(3)  an HIV-related illness.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1364 - Coverage Provisions Relating to Hiv, Aids, or HIV-Related Illnesses › Subchapter A. Exclusion From or Denial of Coverage Prohibited › Section 1364.004. Rules

Sec. 1364.004.  RULES.  The commissioner may adopt rules necessary to administer this subchapter.  A rule adopted under this section is subject to notice and hearing as provided by Section 1201.007 for a rule adopted under Chapter 1201.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1364 - Coverage Provisions Relating to Hiv, Aids, or HIV-Related Illnesses › Subchapter B. Cancellation of Group Coverage Prohibited › Section 1364.051. Definitions

Sec. 1364.051.  DEFINITIONS.  In this subchapter, "AIDS" and "HIV" have the meanings assigned by Section 81.101, Health and Safety 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 E - Benefits Payable Under Health Coverages › Chapter 1364 - Coverage Provisions Relating to Hiv, Aids, or HIV-Related Illnesses › Subchapter B. Cancellation of Group Coverage Prohibited › Section 1364.052. Applicability of Subchapter

Sec. 1364.052.  APPLICABILITY OF SUBCHAPTER.  This subchapter applies to an insurer that delivers or issues for delivery a group health insurance policy or contract in this state, including a group hospital service corporation operating under Chapter 842.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1364 - Coverage Provisions Relating to Hiv, Aids, or HIV-Related Illnesses › Subchapter B. Cancellation of Group Coverage Prohibited › Section 1364.053. Prohibition

Sec. 1364.053.  PROHIBITION.  (a)  Except as provided by Subsection (b), an insurer may not cancel during the term of a group health insurance policy or contract an individual's coverage provided by the policy or contract because the individual:
(1)  has been diagnosed as having AIDS or HIV;
(2)  has been treated for AIDS or HIV;  or
(3)  is being treated for AIDS or HIV.
(b)  The insurer may cancel the coverage provided by the policy or contract for fraud or misrepresentation in the obtaining of coverage by failure to disclose a diagnosis of AIDS or an HIV-related condition.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1364 - Coverage Provisions Relating to Hiv, Aids, or HIV-Related Illnesses › Subchapter C. Certain Coverages Provided by Local Governments › Section 1364.101. Prohibition on Exclusion or Limitation of Coverages

Sec. 1364.101.  PROHIBITION ON EXCLUSION OR LIMITATION OF COVERAGES.  A political subdivision that provides group health insurance coverage, health maintenance organization coverage, or self-insured health care coverage to the political subdivision's officers or employees may not contract for or provide coverage that excludes or limits coverage or services for:
(1)  acquired immune deficiency syndrome, as defined by the Centers for Disease Control and Prevention of the United States Public Health Service;  or
(2)  human immunodeficiency virus infection.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1365 - Loss or Impairment of Speech or Hearing › Subchapter A. General Provisions › Section 1365.001. Applicability of Subchapter

Sec. 1365.001.  APPLICABILITY OF SUBCHAPTER. This subchapter applies only to a group health benefit plan that provides hospital and medical coverage on an expense-incurred, service, or prepaid basis, including a group policy, contract, or plan that is offered in this state by:
(1)  an insurer;
(2)  a group hospital service corporation operating under Chapter 842; or
(3)  a health maintenance organization operating under Chapter 843.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
Amended by:
Acts 2023, 88th Leg., R.S., Ch. 8 (H.B. 109), Sec. 2, eff. September 1, 2023.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1365 - Loss or Impairment of Speech or Hearing › Subchapter A. General Provisions › Section 1365.002. Applicability of General Provisions of Other Law

Sec. 1365.002.  APPLICABILITY OF GENERAL PROVISIONS OF OTHER LAW.  The provisions of Chapter 1201, including provisions relating to the applicability, purpose, and enforcement of that chapter, construction of policies under that chapter, rulemaking under that chapter, and definitions of terms applicable in that chapter, apply to this subchapter.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
Amended by:
Acts 2023, 88th Leg., R.S., Ch. 8 (H.B. 109), Sec. 2, eff. September 1, 2023.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1365 - Loss or Impairment of Speech or Hearing › Subchapter A. General Provisions › Section 1365.003. Offer of Coverage Required

Sec. 1365.003.  OFFER OF COVERAGE REQUIRED.  (a)  A group health benefit plan issuer shall offer and make available under the plan coverage for the necessary care and treatment of loss or impairment of speech or hearing.
(b)  Coverage required under this section:
(1)  may not be less favorable than coverage for physical illness generally under the plan;  and
(2)  must be subject to the same durational limits, dollar limits, deductibles, and coinsurance factors as coverage for physical illness generally under the plan.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1365 - Loss or Impairment of Speech or Hearing › Subchapter A. General Provisions › Section 1365.004. Right to Reject Coverage or Select Alternative Benefits

Sec. 1365.004.  RIGHT TO REJECT COVERAGE OR SELECT ALTERNATIVE BENEFITS.  An offer of coverage required under Section 1365.003 is subject to the right of the group contract holder to reject the coverage or to select an alternative level of benefits that is offered by or negotiated with the group health benefit plan issuer.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
Amended by:
Acts 2007, 80th Leg., R.S., Ch. 730 (H.B. 2636), Sec. 3B.028, eff. September 1, 2007.
Acts 2007, 80th Leg., R.S., Ch. 921 (H.B. 3167), Sec. 9.028, eff. September 1, 2007.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1365 - Loss or Impairment of Speech or Hearing › Subchapter B. Hearing Aid Coverage › Section 1365.051. Applicability

Sec. 1365.051.  APPLICABILITY.  (a)  This subchapter applies only to a health benefit plan that provides benefits for medical or surgical expenses incurred as a result of a health condition, accident, or sickness, including an individual, group, blanket, or franchise insurance policy or insurance agreement, a group hospital service contract, or an individual or group evidence of coverage or similar coverage document that is offered by:
(1)  an insurance company;
(2)  a group hospital service corporation operating under Chapter 842;
(3)  a health maintenance organization operating under Chapter 843;
(4)  an approved nonprofit health corporation that holds a certificate of authority under Chapter 844;
(5)  a multiple employer welfare arrangement that holds a certificate of authority under Chapter 846;
(6)  a stipulated premium company operating under Chapter 884;
(7)  a fraternal benefit society operating under Chapter 885;
(8)  a Lloyd's plan operating under Chapter 941; or
(9)  an exchange operating under Chapter 942.
(b)  This subchapter applies to coverage under a group health benefit plan described by Subsection (a) provided to a resident of this state, regardless of whether the group policy, agreement, or contract is delivered, issued for delivery, or renewed within or outside this state.
(c)  Notwithstanding any other law, this subchapter applies to:
(1)  a small employer health benefit plan subject to Chapter 1501, including coverage provided through a health group cooperative under Subchapter B of that chapter;
(2)  a standard health benefit plan issued under Chapter 1507;
(3)  a basic coverage plan under Chapter 1551;
(4)  a basic plan under Chapter 1575;
(5)  a primary care coverage plan under Chapter 1579;
(6)  a plan providing basic coverage under Chapter 1601;
(7)  a regional or local health care program operated under Section 75.104, Health and Safety Code; and
(8)  a self-funded health benefit plan sponsored by a professional employer organization under Chapter 91, Labor Code.
Added by Acts 2023, 88th Leg., R.S., Ch. 8 (H.B. 109), Sec. 3, eff. September 1, 2023.