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 1355 - Benefits for Certain Mental Disorders › Subchapter B. Alternative Mental Health Treatment Benefits › Section 1355.055. Determinations for Treatment in a Residential Treatment Center for Children and Adolescents

Sec. 1355.055.  DETERMINATIONS FOR TREATMENT IN A RESIDENTIAL TREATMENT CENTER FOR CHILDREN AND ADOLESCENTS.  (a)  Treatment in a residential treatment center for children and adolescents must be determined as if necessary care and treatment were inpatient care and treatment in a hospital.
(b)  For the purposes of determining policy benefits and benefit maximums, each two days of treatment in a residential treatment center for children and adolescents is the equivalent of one day of treatment of mental or emotional illness or disorder in a hospital or inpatient program.
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 1355 - Benefits for Certain Mental Disorders › Subchapter B. Alternative Mental Health Treatment Benefits › Section 1355.056. Determinations for Treatment by a Crisis Stabilization Unit

Sec. 1355.056.  DETERMINATIONS FOR TREATMENT BY A CRISIS STABILIZATION UNIT.  (a)  Treatment by a crisis stabilization unit must be determined as if necessary care and treatment were inpatient care and treatment in a hospital.
(b)  For the purposes of determining plan benefits and benefit maximums, each two days of treatment in a crisis stabilization unit is the equivalent of one day of treatment of mental or emotional illness or disorder in a hospital or inpatient program.
(c)  Treatment provided to an individual by a crisis stabilization unit licensed or certified by the Health and Human Services Commission shall be reimbursed.
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. 8.04, 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 1355 - Benefits for Certain Mental Disorders › Subchapter B. Alternative Mental Health Treatment Benefits › Section 1355.057. Review and Adjustment of Minimum Ratios of Reimbursement

Sec. 1355.057.  REVIEW AND ADJUSTMENT OF MINIMUM RATIOS OF REIMBURSEMENT.  (a)  The commissioner shall monitor and review the minimum ratios of reimbursement for alternative treatments required by Sections 1355.055 and 1355.056.
(b)  If the commissioner finds that the limits provided by this subchapter are creating an artificial increase in the costs of services, the commissioner by rule may adjust the ratios to the extent necessary to prevent the artificial increase.
(c)  Before the commissioner adjusts a ratio under Subsection (b), the commissioner must give notice and hold a hearing to:
(1)  consider information related to the adjustment;  and
(2)  determine whether the information justifies the adjustment.
(d)  The department shall review the reimbursement ratios at least every two years.
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 1355 - Benefits for Certain Mental Disorders › Subchapter B. Alternative Mental Health Treatment Benefits › Section 1355.058. Health and Human Services Commission Assistance

Sec. 1355.058.  HEALTH AND HUMAN SERVICES COMMISSION ASSISTANCE.  (a)  The Health and Human Services Commission shall assist the department in carrying out the department's responsibilities under this subchapter.
(b)  The department and the Health and Human Services Commission by rule may adopt a memorandum of understanding to carry out 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. 30 (H.B. 446), Sec. 8.05, 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 1355 - Benefits for Certain Mental Disorders › Subchapter C. Psychiatric Day Treatment Facilities › Section 1355.101. Definition

Sec. 1355.101.  DEFINITION.  In this subchapter, "psychiatric day treatment facility" means a mental health facility that:
(1)  provides treatment for individuals suffering from acute mental and nervous disorders in a structured psychiatric program using individualized treatment plans with specific attainable goals and objectives that are appropriate to the patient and the program's treatment modality;  and
(2)  is clinically supervised by a doctor of medicine who is certified in psychiatry by the American Board of Psychiatry and Neurology.
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 1355 - Benefits for Certain Mental Disorders › Subchapter C. Psychiatric Day Treatment Facilities › Section 1355.102. Applicability of Subchapter

Sec. 1355.102.  APPLICABILITY OF SUBCHAPTER.  This subchapter applies to a group policy of accident and health insurance delivered or issued for delivery in this state, including a group policy issued by a group hospital service corporation operating under Chapter 842.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1355 - Benefits for Certain Mental Disorders › Subchapter C. Psychiatric Day Treatment Facilities › Section 1355.103. Applicability of General Provisions of Other Law

Sec. 1355.103.  APPLICABILITY OF GENERAL PROVISIONS OF OTHER LAW.  The provisions of Chapter 1201, including provisions relating to the applicability, purpose, and enforcement of that chapter, construction of policies under that chapter, rulemaking under that chapter, and definitions of terms applicable in that chapter, apply to this subchapter.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1355 - Benefits for Certain Mental Disorders › Subchapter C. Psychiatric Day Treatment Facilities › Section 1355.104. Required Coverage for Treatment in Psychiatric Day Treatment Facility

Sec. 1355.104.  REQUIRED COVERAGE FOR TREATMENT IN PSYCHIATRIC DAY TREATMENT FACILITY.  (a)  A group insurance policy that provides coverage for treatment of mental or emotional illness or disorder when an individual is confined in a hospital must also provide coverage for treatment obtained under the direction and continued medical supervision of a doctor of medicine or doctor of osteopathy in a psychiatric day treatment facility that provides organizational structure and individualized treatment plans separate from an inpatient program.
(b)  The psychiatric day treatment facility coverage required by this section may not be less favorable than the hospital coverage and must be subject to the same durational limits, deductibles, and coinsurance factors.
(c)  A group insurance policy subject to this section may require that:
(1)  the treatment obtained in a psychiatric day treatment facility be provided by a facility that treats a patient for not more than 8 hours in any 24-hour period;
(2)  the attending physician certify that the treatment is in lieu of hospitalization;  and
(3)  the psychiatric day treatment facility be accredited by the Program for Psychiatric Facilities, or its successor, of the Joint Commission on Accreditation of Healthcare Organizations.
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 1355 - Benefits for Certain Mental Disorders › Subchapter C. Psychiatric Day Treatment Facilities › Section 1355.105. Determinations for Treatment in Psychiatric Day Treatment Facility

Sec. 1355.105.  DETERMINATIONS FOR TREATMENT IN PSYCHIATRIC DAY TREATMENT FACILITY.  (a)  Benefits provided under this subchapter shall be determined as if necessary care and treatment in a psychiatric day treatment facility were inpatient care and treatment in a hospital.
(b)  For the purpose of determining policy benefits and benefit maximums, each full day of treatment in a psychiatric day treatment facility is the equivalent of one-half of one day of treatment of mental or emotional illness or disorder in a hospital or inpatient program.
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 1355 - Benefits for Certain Mental Disorders › Subchapter C. Psychiatric Day Treatment Facilities › Section 1355.106. Offer of Coverage Required; Alternative Benefits

Sec. 1355.106.  OFFER OF COVERAGE REQUIRED;  ALTERNATIVE BENEFITS.  (a)  An insurer shall offer, and a policyholder is entitled to reject, coverage under a group insurance policy for treatment of mental or emotional illness or disorder when confined in a hospital or in a psychiatric day treatment facility.
(b)  A policyholder may select an alternative level of benefits under the group insurance policy if the alternative level is offered by or negotiated with the insurer.
(c)  The alternative level of benefits must provide policy benefits and benefit maximums for treatment in a psychiatric day treatment facility equal to at least one-half of that provided for treatment in a hospital, except that benefits for treatment in a psychiatric day treatment facility may not exceed the usual and customary charges of the facility.
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 1355 - Benefits for Certain Mental Disorders › Subchapter D. Certain Coverages Provided by Local Governments › Section 1355.151. Prohibition on Exclusion or Limitation of Certain Coverages

Sec. 1355.151.  PROHIBITION ON EXCLUSION OR LIMITATION OF CERTAIN COVERAGES.  (a)  In this section, "serious mental illness" has the meaning assigned by Section 1355.001.
(b)  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 is less extensive for serious mental illness than the coverage provided for any other physical 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 1355 - Benefits for Certain Mental Disorders › Subchapter E. Benefits for Treatment by Tax-Supported Institution › Section 1355.201. Applicability of General Provisions of Other Law

Sec. 1355.201.  APPLICABILITY OF GENERAL PROVISIONS OF OTHER LAW.  The provisions of Chapter 1201, including provisions relating to the applicability, purpose, and enforcement of that chapter, construction of policies under that chapter, rulemaking under that chapter, and definitions of terms applicable in that chapter, apply to this subchapter.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1355 - Benefits for Certain Mental Disorders › Subchapter E. Benefits for Treatment by Tax-Supported Institution › Section 1355.202. Prohibition of Exclusion of Mental Health or Intellectual Disability Benefits for Treatment by Tax-Supported Institution

Sec. 1355.202.  PROHIBITION OF EXCLUSION OF MENTAL HEALTH OR INTELLECTUAL DISABILITY BENEFITS FOR TREATMENT BY TAX-SUPPORTED INSTITUTION.  (a)  An individual or group accident and health insurance policy delivered or issued for delivery to a person in this state that provides coverage for mental illness or intellectual disability may not exclude benefits under that coverage for support, maintenance, and treatment provided by a tax-supported institution of this state, or by a community center for mental health services or intellectual disability services, that regularly and customarily charges patients who are not indigent for those services.
(b)  In determining whether a patient is not indigent, as provided by Subchapter B, Chapter 552, Health and Safety Code, a tax-supported institution of this state or a community center for mental health services or intellectual disability services shall consider any insurance policy or policies that provide coverage to the patient for mental illness or 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. 8.06, 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 1355 - Benefits for Certain Mental Disorders › Subchapter F. Coverage for Mental Health Conditions and Substance Use Disorders › Section 1355.251. Definitions

Sec. 1355.251.  DEFINITIONS.  In this subchapter:
(1)  "Mental health benefit" means a benefit relating to an item or service for a mental health condition, as defined under the terms of a health benefit plan and in accordance with applicable federal and state law.
(2)  "Nonquantitative treatment limitation" means a limit on the scope or duration of treatment that is not expressed numerically.  The term includes:
(A)  a medical management standard limiting or excluding benefits based on medical necessity or medical appropriateness or based on whether a treatment is experimental or investigational;
(B)  formulary design for prescription drugs;
(C)  network tier design;
(D)  a standard for provider participation in a network, including reimbursement rates;
(E)  a method used by a health benefit plan to determine usual, customary, and reasonable charges;
(F)  a step therapy protocol;
(G)  an exclusion based on failure to complete a course of treatment; and
(H)  a restriction based on geographic location, facility type, provider specialty, and other criteria that limit the scope or duration of a benefit.
(3)  "Quantitative treatment limitation" means a treatment limitation that determines whether, or to what extent, benefits are provided based on an accumulated amount such as an annual or lifetime limit on days of coverage or number of visits.  The term includes a deductible, a copayment, coinsurance, or another out-of-pocket expense or annual or lifetime limit, or another financial requirement.
(4)  "Substance use disorder benefit" means a benefit relating to an item or service for a substance use disorder, as defined under the terms of a health benefit plan and in accordance with applicable federal and state law.
Added by Acts 2017, 85th Leg., R.S., Ch. 769 (H.B. 10), Sec. 2, eff. September 1, 2017.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1355 - Benefits for Certain Mental Disorders › Subchapter F. Coverage for Mental Health Conditions and Substance Use Disorders › Section 1355.252. Applicability of Subchapter

Sec. 1355.252.  APPLICABILITY OF SUBCHAPTER.  (a)  This subchapter applies only to a health benefit plan that provides benefits or coverage for medical or surgical expenses incurred as a result of a health condition, accident, or sickness and for treatment expenses incurred as a result of a mental health condition or substance use disorder, including an individual, group, blanket, or franchise insurance policy or insurance agreement, a group hospital service contract, an individual or group evidence of coverage, or a 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 health maintenance organization operating under Chapter 843;
(6)  a reciprocal exchange operating under Chapter 942;
(7)  a Lloyd's plan operating under Chapter 941;
(8)  an approved nonprofit health corporation that holds a certificate of authority under Chapter 844; or
(9)  a multiple employer welfare arrangement that holds a certificate of authority under Chapter 846.
(b)  Notwithstanding Section 1501.251 or any other law, this subchapter applies to coverage under a small employer health benefit plan subject to Chapter 1501.
(c)  This subchapter applies to a standard health benefit plan issued under Chapter 1507.
Added by Acts 2017, 85th Leg., R.S., Ch. 769 (H.B. 10), Sec. 2, eff. September 1, 2017.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1355 - Benefits for Certain Mental Disorders › Subchapter F. Coverage for Mental Health Conditions and Substance Use Disorders › Section 1355.253. Exceptions

Sec. 1355.253.  EXCEPTIONS.  (a)  This subchapter does not apply to:
(1)  a plan that provides coverage:
(A)  for wages or payments in lieu of wages for a period during which an employee is absent from work because of sickness or injury;
(B)  as a supplement to a liability insurance policy;
(C)  for credit insurance;
(D)  only for dental or vision care;
(E)  only for hospital expenses;
(F)  only for indemnity for hospital confinement; or
(G)  only for accidents;
(2)  a Medicare supplemental policy as defined by Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss(g)(1));
(3)  a workers' compensation insurance policy;
(4)  medical payment insurance coverage provided under a motor vehicle insurance policy; or
(5)  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 1355.252.
(b)  To the extent that this section would otherwise require this state to make a payment under 42 U.S.C. Section 18031(d)(3)(B)(ii), a qualified health plan, as defined by 45 C.F.R. Section 155.20, is not required to provide a benefit under this subchapter that exceeds the specified essential health benefits required under 42 U.S.C. Section 18022(b).
Added by Acts 2017, 85th Leg., R.S., Ch. 769 (H.B. 10), Sec. 2, eff. September 1, 2017.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1355 - Benefits for Certain Mental Disorders › Subchapter F. Coverage for Mental Health Conditions and Substance Use Disorders › Section 1355.254. Coverage for Mental Health Conditions and Substance Use Disorders

Sec. 1355.254.  COVERAGE FOR MENTAL HEALTH CONDITIONS AND SUBSTANCE USE DISORDERS.  (a)  A health benefit plan must provide benefits and coverage for mental health conditions and substance use disorders under the same terms and conditions applicable to the plan's medical and surgical benefits and coverage.
(b)  Coverage under Subsection (a) may not impose quantitative or nonquantitative treatment limitations on benefits for a mental health condition or substance use disorder that are generally more restrictive than quantitative or nonquantitative treatment limitations imposed on coverage of benefits for medical or surgical expenses.
Added by Acts 2017, 85th Leg., R.S., Ch. 769 (H.B. 10), Sec. 2, eff. September 1, 2017.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1355 - Benefits for Certain Mental Disorders › Subchapter F. Coverage for Mental Health Conditions and Substance Use Disorders › Section 1355.255. Compliance

Sec. 1355.255.  COMPLIANCE.  The commissioner shall enforce compliance with Section 1355.254 by evaluating the benefits and coverage offered by a health benefit plan for quantitative and nonquantitative treatment limitations in the following categories:
(1)  in-network and out-of-network inpatient care;
(2)  in-network and out-of-network outpatient care;
(3)  emergency care; and
(4)  prescription drugs.
Added by Acts 2017, 85th Leg., R.S., Ch. 769 (H.B. 10), Sec. 2, eff. September 1, 2017.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1355 - Benefits for Certain Mental Disorders › Subchapter F. Coverage for Mental Health Conditions and Substance Use Disorders › Section 1355.256. Definitions Under Plan

Sec. 1355.256.  DEFINITIONS UNDER PLAN.  (a)  A health benefit plan must define a condition to be a mental health condition or not a mental health condition in a manner consistent with generally recognized independent standards of medical practice.
(b)  A health benefit plan must define a condition to be a substance use disorder or not a substance use disorder in a manner consistent with generally recognized independent standards of medical practice.
Added by Acts 2017, 85th Leg., R.S., Ch. 769 (H.B. 10), Sec. 2, eff. September 1, 2017.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1355 - Benefits for Certain Mental Disorders › Subchapter F. Coverage for Mental Health Conditions and Substance Use Disorders › Section 1355.257. Coordination With Other Law; Intent of Legislature

Sec. 1355.257.  COORDINATION WITH OTHER LAW; INTENT OF LEGISLATURE.  This subchapter supplements Subchapters A and B of this chapter and Chapter 1368 and the department rules adopted under those statutes.  It is the intent of the legislature that Subchapter A or B of this chapter or Chapter 1368 or a department rule adopted under those statutes controls in any circumstance in which that other law requires:
(1)  a benefit that is not required by this subchapter; or
(2)  a more extensive benefit than is required by this subchapter.
Added by Acts 2017, 85th Leg., R.S., Ch. 769 (H.B. 10), Sec. 2, eff. September 1, 2017.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1355 - Benefits for Certain Mental Disorders › Subchapter F. Coverage for Mental Health Conditions and Substance Use Disorders › Section 1355.2571. Parity Complaint Portal

Sec. 1355.2571.  PARITY COMPLAINT PORTAL.  (a) The commissioner shall develop and maintain a parity complaint portal that is an integrated system that allows for the enrollee of a health benefit plan to submit complaints of suspected violations of the provisions of this subchapter. The parity complaint portal must:
(1)  allow for an enrollee to submit a complaint through multiple ways;
(2)  provide updates on the status of an enrollee's complaint;
(3)  ensure timely, effective, and equitable resolution for submitted complaints;
(4)  include educational materials regarding:
(A)  benefits for mental health conditions and substance use disorders required under this subchapter;
(B)  an enrollee's rights and responsibilities under a health benefit plan concerning coverage under this subchapter;
(C)  circumstances under which a claim may be denied; and
(D)  the processes for reviewing a complaint submitted through the portal;
(5)  adhere to national best practices as determined by the commissioner; and
(6)  include the findings of the report required by Section 1355.2572(b).
(b)  In developing the parity complaint portal under Subsection (a), the commissioner:
(1)  shall conduct an assessment of complaint portals and similar systems used by other relevant public or private entities;
(2)  shall develop best practice standards for complaint submissions and tracking consistent with the findings of the assessment conducted under Subdivision (1); and
(3)  may develop a new complaint portal or modify an existing complaint portal.
(c)  The Health and Human Services Commission shall appoint a liaison to the department to receive reports of concerns, complaints, and potential violations submitted through the parity complaint portal established under Subsection (a).
Added by Acts 2021, 87th Leg., R.S., Ch. 703 (H.B. 2595), 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 1355 - Benefits for Certain Mental Disorders › Subchapter F. Coverage for Mental Health Conditions and Substance Use Disorders › Section 1355.2572. Educational Materials and Parity Law Training; Report

Sec. 1355.2572.  EDUCATIONAL MATERIALS AND PARITY LAW TRAINING; REPORT.  (a) The commissioner, in collaboration with the Health and Human Services Commission's ombudsman for behavioral health, shall develop educational materials and parity law training sessions regarding the coverage for mental health conditions and substance use disorders required under this subchapter. The commissioner shall ensure that the materials and training sessions:
(1)  are available to health benefit plan issuers and enrollees;
(2)  include online, print, and in-person formats;
(3)  are made available through the parity complaint portal established under Section 1355.2571 and at relevant locations and settings, including:
(A)  any relevant agency offices;
(B)  health benefit plan provider service locations; and
(C)  relevant professional conferences and trade association meetings;  and
(4)  include a list of relevant third-party organization educational and parity law awareness materials that provide additional information regarding mental health conditions and substance use disorder parity and, if provided in an online format, provide the links needed to access those materials online.
(b)  Not later than September 1 of each year, the commissioner, in collaboration with the Health and Human Services Commission's ombudsman for behavioral health, shall:
(1)  prepare and submit a report to the appropriate committees of the legislature and the appropriate state agencies on the status of:
(A)  rights and responsibilities for mental health condition and substance use disorder benefits; and
(B)  resolved and unresolved complaints submitted through the parity complaint portal established under Section 1355.2571(a); and
(2)  publish the findings of the report under Subdivision (1) to the parity complaint portal established under Section 1355.2571(a).
Added by Acts 2021, 87th Leg., R.S., Ch. 703 (H.B. 2595), 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 1355 - Benefits for Certain Mental Disorders › Subchapter F. Coverage for Mental Health Conditions and Substance Use Disorders › Section 1355.258. Rules

Sec. 1355.258.  RULES.  The commissioner shall adopt rules necessary to implement this subchapter.
Added by Acts 2017, 85th Leg., R.S., Ch. 769 (H.B. 10), Sec. 2, eff. September 1, 2017.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1356 - Mammography and Other Breast Imaging › Section 1356.001. Definitions

Sec. 1356.001.  DEFINITIONS.  In this chapter:
(1)  "Breast tomosynthesis" means a radiologic mammography procedure that involves the acquisition of projection images over a stationary breast to produce cross-sectional digital three-dimensional images of the breast from which applicable breast cancer screening diagnoses may be determined.
(1-a)  "Diagnostic imaging" means an imaging examination using mammography, ultrasound imaging, or magnetic resonance imaging that is designed to evaluate:
(A)  a subjective or objective abnormality detected by a physician or patient in a breast;
(B)  an abnormality seen by a physician on a screening mammogram;
(C)  an abnormality previously identified by a physician as probably benign in a breast for which follow-up imaging is recommended by a physician; or
(D)  an individual with a personal history of breast cancer or dense breast tissue.
(2)  "Low-dose mammography" means:
(A)  the x-ray examination of the breast using equipment dedicated specifically for mammography, including an x-ray tube, filter, compression device, and screens, with an average radiation exposure delivery of less than one rad mid-breast and with two views for each breast;
(B)  digital mammography; or
(C)  breast tomosynthesis.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
Amended by:
Acts 2017, 85th Leg., R.S., Ch. 816 (H.B. 1036), Sec. 2, eff. September 1, 2017.
Acts 2019, 86th Leg., R.S., Ch. 1356 (H.B. 170), Sec. 1, eff. September 1, 2019.
Acts 2021, 87th Leg., R.S., Ch. 867 (S.B. 1065), 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 1356 - Mammography and Other Breast Imaging › Section 1356.003. Applicability of General Provisions of Other Law

Sec. 1356.003.  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 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 1356 - Mammography and Other Breast Imaging › Section 1356.004. Exception

Sec. 1356.004.  EXCEPTION.  This chapter does not apply to a plan that provides coverage only for a specified disease or for another limited benefit.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1356 - Mammography and Other Breast Imaging › Section 1356.005. Coverage Required

Sec. 1356.005.  COVERAGE REQUIRED.  (a)  A health benefit plan that provides coverage to a female who is 35 years of age or older must include coverage for an annual screening by all forms of low-dose mammography for the presence of occult breast cancer.
(a-1)  A health benefit plan that provides coverage for a screening mammogram must provide coverage for diagnostic imaging that is no less favorable than the coverage for a screening mammogram.
(b)  Coverage required by this section:
(1)  may not be less favorable than coverage for other radiological examinations under the plan;  and
(2)  must be subject to the same dollar limits, deductibles, and coinsurance factors as coverage for other radiological examinations under the plan.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
Amended by:
Acts 2017, 85th Leg., R.S., Ch. 816 (H.B. 1036), Sec. 4, eff. September 1, 2017.
Acts 2019, 86th Leg., R.S., Ch. 1356 (H.B. 170), Sec. 3, eff. September 1, 2019.
Acts 2021, 87th Leg., R.S., Ch. 867 (S.B. 1065), 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 1357 - Mastectomy › Subchapter A. Reconstructive Surgery Following Mastectomy › Section 1357.001. Definitions

Sec. 1357.001.  DEFINITIONS.  In this subchapter:
(1)  "Breast reconstruction" means reconstruction of a breast incident to mastectomy to restore or achieve breast symmetry.  The term includes surgical reconstruction of a breast on which mastectomy has been performed and surgical reconstruction of a breast on which mastectomy has not been performed.
(2)  "Enrollee" means an individual entitled to coverage under a 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 1357 - Mastectomy › Subchapter A. Reconstructive Surgery Following Mastectomy › Section 1357.002. Applicability of Subchapter

Sec. 1357.002.  APPLICABILITY OF SUBCHAPTER.  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 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.
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 1357 - Mastectomy › Subchapter A. Reconstructive Surgery Following Mastectomy › Section 1357.003. Exception

Sec. 1357.003.  EXCEPTION.  This subchapter does not apply to:
(1)  a plan that provides coverage:
(A)  only for a specified disease or another limited benefit, other than benefits for cancer;
(B)  only for accidental death or dismemberment;
(C)  only for wages or payments in lieu of wages for a period during which an employee is absent from work because of sickness or injury;
(D)  only for credit insurance;
(E)  only for dental or vision care;
(F)  only for indemnity for hospital confinement;  or
(G)  as a supplement to a liability insurance policy;
(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 workers' compensation insurance policy;
(4)  medical payment insurance coverage provided under a motor vehicle insurance policy;  or
(5)  a long-term care insurance policy, including a nursing home fixed indemnity policy, unless the commissioner determines that the policy provides benefit coverage so comprehensive that the policy is a health benefit plan as described by Section 1357.002.
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 1357 - Mastectomy › Subchapter A. Reconstructive Surgery Following Mastectomy › Section 1357.004. Coverage Required

Sec. 1357.004.  COVERAGE REQUIRED.  (a)  A health benefit plan that provides coverage for mastectomy must provide coverage for:
(1)  reconstruction of the breast on which the mastectomy has been performed;
(2)  surgery and reconstruction of the other breast to achieve a symmetrical appearance;  and
(3)  prostheses and treatment of physical complications, including lymphedemas, at all stages of mastectomy.
(b)  Coverage required under this section:
(1)  shall be provided in a manner determined to be appropriate in consultation with the attending physician and the enrollee;
(2)  may be subject to annual deductibles, copayments, and coinsurance that are consistent with annual deductibles, copayments, and coinsurance required for other coverage under the health benefit plan;  and
(3)  may not be subject to dollar limits other than the lifetime maximum benefits 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 1357 - Mastectomy › Subchapter A. Reconstructive Surgery Following Mastectomy › Section 1357.005. Prohibited Conduct

Sec. 1357.005.  PROHIBITED CONDUCT.  (a)  An issuer of a health benefit plan may not:
(1)  offer a financial incentive for an enrollee to not receive breast reconstruction or to waive the coverage required under this subchapter;
(2)  condition, limit, or deny the eligibility of a person to enroll in the plan or to renew coverage under the terms of the plan solely to avoid the requirements of this subchapter;  or
(3)  reduce or limit the reimbursement or amount paid to, or otherwise penalize, an attending physician or provider or provide a financial incentive or other benefit to an attending physician or provider to induce the physician or provider to provide care to an enrollee in a manner that is inconsistent with this subchapter.
(b)  This section does not prevent an issuer of a health benefit plan from negotiating with a physician or provider the level and type of reimbursement that the physician or provider will receive for care provided in accordance with this subchapter.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1357 - Mastectomy › Subchapter A. Reconstructive Surgery Following Mastectomy › Section 1357.006. Notice of Coverage

Sec. 1357.006.  NOTICE OF COVERAGE.  (a)  An issuer of a health benefit plan that provides coverage under this subchapter shall provide to each enrollee notice of the availability of the coverage.
(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 1357 - Mastectomy › Subchapter A. Reconstructive Surgery Following Mastectomy › Section 1357.007. Rules

Sec. 1357.007.  RULES.  The commissioner may adopt rules to implement this subchapter and to meet the minimum requirements of federal 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 1357 - Mastectomy › Subchapter B. Hospital Stay Following Mastectomy and Certain Related Procedures › Section 1357.051. Definition

Sec. 1357.051.  DEFINITION.  In this subchapter, "enrollee" means an individual entitled to coverage under a 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 1357 - Mastectomy › Subchapter B. Hospital Stay Following Mastectomy and Certain Related Procedures › Section 1357.052. Applicability of Subchapter

Sec. 1357.052.  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;  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 an approved nonprofit health corporation that holds a certificate of authority under Chapter 844;  or
(3)  provides coverage only for a specific disease or condition or for hospitalization.
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 1357 - Mastectomy › Subchapter B. Hospital Stay Following Mastectomy and Certain Related Procedures › Section 1357.053. Exception

Sec. 1357.053.  EXCEPTION.  This subchapter does not apply to:
(1)  a plan that provides coverage:
(A)  only for accidental death or dismemberment;
(B)  for wages or payments in lieu of wages for a period during which an employee is absent from work because of sickness or injury;  or
(C)  as a supplement to a liability insurance policy;
(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 1357.052.
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 1357 - Mastectomy › Subchapter B. Hospital Stay Following Mastectomy and Certain Related Procedures › Section 1357.054. Coverage Required

Sec. 1357.054.  COVERAGE REQUIRED.  (a)  A health benefit plan that provides coverage for the treatment of breast cancer must provide to each enrollee coverage for inpatient care for a minimum of:
(1)  48 hours following a mastectomy;  and
(2)  24 hours following a lymph node dissection for the treatment of breast cancer.
(b)  A health benefit plan is not required to provide the minimum hours of coverage of inpatient care required under Subsection (a) if the enrollee and the enrollee's attending physician determine that a shorter period of inpatient care is 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 1357 - Mastectomy › Subchapter B. Hospital Stay Following Mastectomy and Certain Related Procedures › Section 1357.055. Prohibited Conduct

Sec. 1357.055.  PROHIBITED CONDUCT.  An issuer of a health benefit plan may not:
(1)  deny the eligibility or continued eligibility of an individual to enroll in the plan or renew coverage under the plan solely to avoid the requirements of this subchapter;
(2)  provide money payments or rebates to an enrollee to encourage the enrollee to accept less than the minimum coverage required under this subchapter;
(3)  reduce or limit the amount paid to an attending physician, or otherwise penalize the physician, because the physician provided care to an enrollee in accordance with this subchapter;  or
(4)  provide financial or other incentives to an attending physician to encourage the physician to provide care to an enrollee in a manner inconsistent with this subchapter.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1357 - Mastectomy › Subchapter B. Hospital Stay Following Mastectomy and Certain Related Procedures › Section 1357.056. Notice of Coverage

Sec. 1357.056.  NOTICE OF COVERAGE.  (a)  An issuer of a health benefit plan shall provide to each enrollee written notice of the coverage required under this subchapter.
(b)  The notice must be provided in accordance with rules adopted by the commissioner.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1357 - Mastectomy › Subchapter B. Hospital Stay Following Mastectomy and Certain Related Procedures › Section 1357.057. Rules

Sec. 1357.057.  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 E - Benefits Payable Under Health Coverages › Chapter 1358 - Diabetes › Subchapter A. Guidelines for Diabetes Care; Minimum Coverage Required › Section 1358.001. Definition

Sec. 1358.001.  DEFINITION.  In this subchapter, "enrollee" means an individual entitled to coverage under a 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 A. Guidelines for Diabetes Care; Minimum Coverage Required › Section 1358.002. Applicability of Subchapter

Sec. 1358.002.  APPLICABILITY OF SUBCHAPTER.  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:
(1)  an individual, group, blanket, or franchise insurance policy or insurance agreement, a group hospital service contract, or an individual or group evidence of coverage that is offered by:
(A)  an insurance company;
(B)  a group hospital service corporation operating under Chapter 842;
(C)  a fraternal benefit society operating under Chapter 885;
(D)  a stipulated premium company operating under Chapter 884;  or
(E)  a health maintenance organization operating under Chapter 843;
(2)  to the extent permitted by the Employee Retirement Income Security Act of 1974 (29 U.S.C. Section 1001 et seq.), a health benefit plan that is offered by:
(A)  a multiple employer welfare arrangement as defined by Section 3 of that Act;  or
(B)  another analogous benefit arrangement;  and
(3)  health and accident coverage provided by 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.