reglab/statecodes huggingface dataset:
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter A. General Provisions › Section 1301.0052. Exclusive Provider Benefit Plans: Referrals for Medically Necessary Services

Sec. 1301.0052.  EXCLUSIVE PROVIDER BENEFIT PLANS: REFERRALS FOR MEDICALLY NECESSARY SERVICES. (a) If a covered service is medically necessary and is not available through a preferred provider, the issuer of an exclusive provider benefit plan, on the request of a preferred provider, shall:
(1)  approve the referral of an insured to a nonpreferred provider within a reasonable period; and
(2)  fully reimburse the nonpreferred provider at the usual and customary rate or at a rate agreed to by the issuer and the nonpreferred provider.
(b)  An exclusive provider benefit plan must provide for a review by a health care provider with expertise in the same specialty as or a specialty similar to the type of health care provider to whom a referral is requested under Subsection (a) before the issuer of the plan may deny the referral.
Added by Acts 2011, 82nd Leg., R.S., Ch. 288 (H.B. 1772), Sec. 9, eff. September 1, 2011.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter A. General Provisions › Section 1301.0053. Exclusive Provider Benefit Plans: Emergency Care

Sec. 1301.0053.  EXCLUSIVE PROVIDER BENEFIT PLANS:  EMERGENCY CARE.  (a)  If an out-of-network provider provides emergency care as defined by Section 1301.155 or post-emergency stabilization care to an enrollee in an exclusive provider benefit plan, the issuer of the plan shall reimburse the out-of-network provider at the usual and customary rate or at a rate agreed to by the issuer and the out-of-network provider for the provision of the services and any supply related to those services.  The insurer shall make a payment required by this subsection directly to the provider not later than, as applicable:
(1)  the 30th day after the date the insurer receives an electronic clean claim as defined by Section 1301.101 for those services that includes all information necessary for the insurer to pay the claim; or
(2)  the 45th day after the date the insurer receives a nonelectronic clean claim as defined by Section 1301.101 for those services that includes all information necessary for the insurer to pay the claim.
(b)  For emergency care or post-emergency stabilization care subject to this section or a supply related to that care, an out-of-network provider or a person asserting a claim as an agent or assignee of the provider may not bill an insured in, and the insured does not have financial responsibility for, an amount greater than an applicable copayment, coinsurance, and deductible under the insured's exclusive provider benefit plan that:
(1)  is based on:
(A)  the amount initially determined payable by the insurer; or
(B)  if applicable, a modified amount as determined under the insurer's internal appeal process; and
(2)  is not based on any additional amount determined to be owed to the provider under Chapter 1467.
(c)  This section may not be construed to require the imposition of a penalty under Section 1301.137.
(d)  Post-emergency stabilization care that is subject to this section and a supply related to that care are subject to Chapter 1467 in the same manner as if the care and supply are emergency care, as defined by Section 1301.155.
(e)  This section does not apply to claims for post-emergency stabilization care if all of the conditions described by 42 U.S.C. Section 300gg-111(a)(3)(C)(ii)(II) are met.
Added by Acts 2011, 82nd Leg., R.S., Ch. 288 (H.B. 1772), Sec. 9, eff. September 1, 2011.
Amended by:
Acts 2019, 86th Leg., R.S., Ch. 1342 (S.B. 1264), Sec. 1.06, eff. September 1, 2019.
Acts 2023, 88th Leg., R.S., Ch. 740 (H.B. 3359), Sec. 4, eff. September 1, 2023.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter A. General Provisions › Section 1301.00554. Other Maximum Distance Standard Requirements; Commissioner Authority

Sec. 1301.00554.  OTHER MAXIMUM DISTANCE STANDARD REQUIREMENTS; COMMISSIONER AUTHORITY.  (a)  In this section, "maximum distance" has the meaning assigned by Section 1301.00553.
(b)  For a physician specialty not specifically listed in Section 1301.00553, the maximum distance, in any county classification, is 75 miles.
(c)  When necessary due to utilization or supply patterns, the commissioner by rule may decrease the base maximum travel time and distance standards listed in this section or Section 1301.00553 for specific counties.
Added by Acts 2023, 88th Leg., R.S., Ch. 740 (H.B. 3359), Sec. 6, eff. September 1, 2023.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter A. General Provisions › Section 1301.00555. Maximum Appointment Wait Time Standards

Sec. 1301.00555.  MAXIMUM APPOINTMENT WAIT TIME STANDARDS.  An insurer must ensure that:
(1)  routine care is available and accessible from preferred providers:
(A)  within three weeks for medical conditions; and
(B)  within two weeks for behavioral health conditions; and
(2)  preventive health care services are available and accessible from preferred providers:
(A)  within two months for a child, or earlier if necessary for compliance with recommendations for specific preventive health care services; and
(B)  within three months for an adult.
Added by Acts 2023, 88th Leg., R.S., Ch. 740 (H.B. 3359), Sec. 6, eff. September 1, 2023.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter A. General Provisions › Section 1301.00566. Effect of Network Adequacy Standards Waiver on Balance Billing Prohibitions

Sec. 1301.00566.  EFFECT OF NETWORK ADEQUACY STANDARDS WAIVER ON BALANCE BILLING PROHIBITIONS.  After a network adequacy standards waiver is granted by the commissioner, an insurer may refer to the provisions prohibiting balance billing under Sections 1301.0053, 1301.155, 1301.164, or 1301.165, as applicable, in an access plan submitted to the department for the sole purpose of explaining how the insurer will coordinate care to limit the likelihood of a balance bill for services subject to those provisions and not to justify a departure from network adequacy standards.
Added by Acts 2023, 88th Leg., R.S., Ch. 740 (H.B. 3359), Sec. 8, eff. September 1, 2023.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter A. General Provisions › Section 1301.0057. Access to Out-of-Network Providers

Sec. 1301.0057.  ACCESS TO OUT-OF-NETWORK PROVIDERS.  An insurer may not terminate, or threaten to terminate, an insured's participation in a preferred provider benefit plan solely because the insured uses an out-of-network provider.
Added by Acts 2015, 84th Leg., R.S., Ch. 275 (H.B. 574), Sec. 5, eff. September 1, 2015.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter A. General Provisions › Section 1301.0058. Protected Communications by Preferred Providers

Sec. 1301.0058.  PROTECTED COMMUNICATIONS BY PREFERRED PROVIDERS.  (a)  An insurer may not in any manner prohibit, attempt to prohibit, penalize, terminate, or otherwise restrict a preferred provider from communicating with an insured about the availability of out-of-network providers for the provision of the insured's medical or health care services.
(b)  An insurer may not terminate the contract of or otherwise penalize a preferred provider solely because the provider's patients use out-of-network providers for medical or health care services.
(c)  An insurer's contract with a preferred provider may require that, except in a case of a medical emergency as determined by the preferred provider, before the provider may make an out-of-network referral for an insured, the preferred provider inform the insured:
(1)  that:
(A)  the insured may choose a preferred provider or an out-of-network provider; and
(B)  if the insured chooses the out-of-network provider the insured may incur higher out-of-pocket expenses; and
(2)  whether the preferred provider has a financial interest in the out-of-network provider.
Added by Acts 2015, 84th Leg., R.S., Ch. 275 (H.B. 574), Sec. 5, eff. September 1, 2015.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter A. General Provisions › Section 1301.006. Availability of and Accessibility to Health Care Services

Sec. 1301.006.  AVAILABILITY OF AND ACCESSIBILITY TO HEALTH CARE SERVICES.  (a)  An insurer that markets a preferred provider benefit plan shall contract with physicians and health care providers to ensure that all medical and health care services and items contained in the package of benefits for which coverage is provided, including treatment of illnesses and injuries, will be provided under the health insurance policy in a manner ensuring availability of and accessibility to adequate personnel, specialty care, and facilities.
(b)  A contract between an insurer that markets a plan regulated under this chapter and an institutional provider may not, as a condition of staff membership or privileges, require a physician or other practitioner to enter into a preferred provider contract.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
Amended by:
Acts 2011, 82nd Leg., 1st C.S., Ch. 7 (S.B. 7), Sec. 10.01, eff. September 28, 2011.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter A. General Provisions › Section 1301.0061. Terms of Enrollee Eligibility

Sec. 1301.0061.  TERMS OF ENROLLEE ELIGIBILITY.  (a)  A contract between an insurer and a group policyholder under a preferred provider benefit plan must provide that:
(1)  in addition to any other premiums for which the group policyholder is liable, the group policyholder is liable for an individual insured's premiums from the time the individual is no longer part of the group eligible for coverage under the policy until the end of the month in which the policyholder notifies the insurer that the individual is no longer part of the group eligible for coverage under the policy; and
(2)  the individual remains covered under the policy until the end of that period.
(b)  Each insurer that enters into a contract described by Subsection (a) shall notify the group policyholder periodically as provided by this section that the policyholder is liable for premiums on an individual who is no longer part of the group eligible for coverage until the insurer receives notification of termination of the individual's eligibility for coverage.
(c)  If the insurer charges the group policyholder on a monthly basis for the premiums, the insurer shall include the notice required by Subsection (b) in each monthly statement sent to the group policyholder.  If the insurer charges the group policyholder on other than a monthly basis for the premiums, the insurer shall notify the group policyholder periodically in the manner prescribed by the commissioner by rule.
(d)  The notice required by Subsection (b) must include a description of methods preferred by the insurer for notification by a group policyholder of an individual's termination from coverage eligibility.
Added by Acts 2005, 79th Leg., Ch. 669 (S.B. 51), Sec. 1, eff. September 1, 2005.
Amended by:
Acts 2009, 81st Leg., R.S., Ch. 1217 (S.B. 1143), Sec. 2, eff. September 1, 2009.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter A. General Provisions › Section 1301.007. Rules

Sec. 1301.007.  RULES.  The commissioner shall adopt rules as necessary to:
(1)  implement this chapter; and
(2)  ensure reasonable accessibility and availability of preferred provider services to residents of this state.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
Amended by:
Acts 2005, 79th Leg., Ch. 1221 (H.B. 1030), Sec. 2, eff. September 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter A. General Provisions › Section 1301.008. Conflict With Other Law

Sec. 1301.008.  CONFLICT WITH OTHER LAW.  To the extent of any conflict between this chapter and Subchapter C, Chapter 1204, this chapter controls.
Added by Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.037(c), eff. September 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter A. General Provisions › Section 1301.009. Annual Report

Sec. 1301.009.  ANNUAL REPORT.  (a)  Not later than March 1 of each year, an insurer shall file with the commissioner a report relating to the preferred provider benefit plan offered under this chapter and covering the preceding calendar year.
(b)  The report shall:
(1)  be verified by at least two principal officers;
(2)  be in a form prescribed by the commissioner; and
(3)  include:
(A)  a financial statement of the insurer, including its balance sheet and receipts and disbursements for the preceding calendar year, certified by an independent public accountant;
(B)  the number of individuals enrolled during the preceding calendar year, the number of enrollees as of the end of  that year, and the number of enrollments terminated during that year; and
(C)  a statement of:
(i)  an evaluation of enrollee satisfaction;
(ii)  an evaluation of quality of care;
(iii)  coverage areas;
(iv)  accreditation status;
(v)  premium costs;
(vi)  plan costs;
(vii)  premium increases;
(viii)  the range of benefits provided;
(ix)  copayments and deductibles;
(x)  the accuracy and speed of claims payment by the insurer for the plan;
(xi)  the credentials of physicians who are preferred providers;
(xii)  the number of preferred providers;
(xiii)  any waiver requests made and waivers of  network adequacy standards granted under Section 1301.00565;
(xiv)  any material deviation from network adequacy standards reported to the department under Section 1301.0055; and
(xv)  any corrective actions, sanctions, or penalties assessed against the insurer by the department for deficiencies related to the preferred provider benefit plan.
(c)  The annual report filed by the insurer shall be made publicly available on the department's website in a user-friendly format that allows consumers to make direct comparisons of the financial and other data reported by insurers under this section.
(d)  An insurer providing group coverage of $10 million or less in premiums or individual coverage of $2 million or less in premiums is not required to report the data required under Subsection (b)(3)(C).
Added by Acts 2007, 80th Leg., R.S., Ch. 997 (S.B. 1731), Sec. 10, eff. September 1, 2007.
Amended by:
Acts 2023, 88th Leg., R.S., Ch. 740 (H.B. 3359), Sec. 9, eff. September 1, 2023.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter A. General Provisions › Section 1301.010. Balance Billing Prohibition Notice

Text of section effective until September 01, 2025
Sec. 1301.010.  BALANCE BILLING PROHIBITION NOTICE.  (a)  An insurer shall provide written notice in accordance with this section in an explanation of benefits provided to the insured and the physician or health care provider in connection with a medical care or health care service or supply or transport provided by an out-of-network provider.  The notice must include:
(1)  a statement of the billing prohibition under Section 1301.0053, 1301.155, 1301.164, 1301.165, or 1301.166, as applicable;
(2)  the total amount the physician or provider may bill the insured under the insured's preferred provider benefit plan and an itemization of copayments, coinsurance, deductibles, and other amounts included in that total; and
(3)  for an explanation of benefits provided to the physician or provider, information required by commissioner rule advising the physician or provider of the availability of mediation or arbitration, as applicable, under Chapter 1467.
(b)  An insurer shall provide the explanation of benefits with the notice required by this section to a physician or health care provider not later than the date the insurer makes a payment under Section 1301.0053, 1301.155, 1301.164, 1301.165, or 1301.166, as applicable.
Added by Acts 2019, 86th Leg., R.S., Ch. 1342 (S.B. 1264), Sec. 1.07, eff. September 1, 2019.
Amended by:
Acts 2023, 88th Leg., R.S., Ch. 981 (S.B. 2476), Sec. 7(a), eff. September 1, 2023.
Acts 2023, 88th Leg., R.S., Ch. 981 (S.B. 2476), Sec. 7(b), eff. September 1, 2025.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter A. General Provisions › Section 1301.010. Balance Billing Prohibition Notice

Text of section effective on September 01, 2025
Sec. 1301.010.  BALANCE BILLING PROHIBITION NOTICE.  (a)  An insurer shall provide written notice in accordance with this section in an explanation of benefits provided to the insured and the physician or health care provider in connection with a medical care or health care service or supply provided by an out-of-network provider.  The notice must include:
(1)  a statement of the billing prohibition under Section 1301.0053, 1301.155, 1301.164, or 1301.165, as applicable;
(2)  the total amount the physician or provider may bill the insured under the insured's preferred provider benefit plan and an itemization of copayments, coinsurance, deductibles, and other amounts included in that total; and
(3)  for an explanation of benefits provided to the physician or provider, information required by commissioner rule advising the physician or provider of the availability of mediation or arbitration, as applicable, under Chapter 1467.
(b)  An insurer shall provide the explanation of benefits with the notice required by this section to a physician or health care provider not later than the date the insurer makes a payment under Section 1301.0053, 1301.155, 1301.164, or 1301.165, as applicable.
Added by Acts 2019, 86th Leg., R.S., Ch. 1342 (S.B. 1264), Sec. 1.07, eff. September 1, 2019.
Amended by:
Acts 2023, 88th Leg., R.S., Ch. 981 (S.B. 2476), Sec. 7(a), eff. September 1, 2023.
Acts 2023, 88th Leg., R.S., Ch. 981 (S.B. 2476), Sec. 7(b), eff. September 1, 2025.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter B. Relations With Physicians or Health Care Providers › Section 1301.051. Designation as Preferred Provider

Sec. 1301.051.  DESIGNATION AS PREFERRED PROVIDER.  (a)  An insurer shall afford a fair, reasonable, and equivalent opportunity to apply to be and to be designated as a preferred provider to practitioners and institutional providers and to health care providers other than practitioners and institutional providers, if those other health care providers are included by the insurer as preferred providers, provided that the practitioners, institutional providers, or health care providers:
(1)  are licensed to treat injuries or illnesses or to provide services covered by a health insurance policy;  and
(2)  comply with the terms established by the insurer for designation as preferred providers.
(b)  An insurer may not unreasonably withhold a designation as a preferred provider.
(c)  An insurer shall give a physician or health care provider who, on the person's initial application, is not designated as a preferred provider written reasons for denial of the designation.
(d)  Unless otherwise limited by this code, this section does not prohibit an insurer from rejecting a physician's or health care provider's application for designation based on a determination that the preferred provider benefit plan has sufficient qualified providers.
(e)  An insurer may not withhold a designation to:
(1)  a podiatrist described by Section 1301.0521; or
(2)  an optometrist, therapeutic optometrist, or ophthalmologist described by Section 1301.0522.
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. 11.034(a), eff. September 1, 2005.
Acts 2015, 84th Leg., R.S., Ch. 1271 (S.B. 684), Sec. 1, eff. September 1, 2015.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter B. Relations With Physicians or Health Care Providers › Section 1301.0515. Acupuncturist Services

Sec. 1301.0515.  ACUPUNCTURIST SERVICES.  (a)  An insurer offering a preferred provider benefit plan that includes acupuncture in the services covered by the plan may not refuse to provide reimbursement for the performance of a covered acupuncture service solely because the service is provided by an acupuncturist.
(b)  This section does not require an insurer to offer acupuncture as a covered service.
Added by Acts 2005, 79th Leg., Ch. 622 (H.B. 2371), Sec. 2, eff. September 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter B. Relations With Physicians or Health Care Providers › Section 1301.0516. Chiropractic Services

Sec. 1301.0516.  CHIROPRACTIC SERVICES.  (a)  An insurer offering a preferred provider benefit plan that covers a service that is within the scope of a chiropractor's license may not refuse to provide reimbursement for the performance of the covered service solely because the service is provided by a chiropractor.
(b)  This section does not require an insurer to cover a particular medical or health care service.
(c)  This section does not affect the right of an insurer to determine whether a medical or health care service is medically necessary.
(d)  An insurer that violates this section is subject to an administrative penalty as provided by Chapter 84 of not more than $1,000 for each claim that remains unpaid in violation of this section.  Each day a violation continues constitutes a separate violation.
Added by Acts 2019, 86th Leg., R.S., Ch. 116 (S.B. 1739), Sec. 2, eff. September 1, 2019.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter B. Relations With Physicians or Health Care Providers › Section 1301.052. Designation of Advanced Practice Nurse or Physician Assistant as Preferred Provider

Sec. 1301.052.  DESIGNATION OF ADVANCED PRACTICE NURSE OR PHYSICIAN ASSISTANT AS PREFERRED PROVIDER.  An insurer offering a preferred provider benefit plan may not refuse a request made by a physician participating as a preferred provider under the plan and an advanced practice nurse or physician assistant to have the advanced practice nurse or physician assistant included as a preferred provider under the plan if:
(1)  the advanced practice nurse or physician assistant is authorized by the physician to provide care under Subchapter B, Chapter 157, Occupations Code;  and
(2)  the advanced practice nurse or physician assistant meets the quality of care standards previously established by the insurer for participation in the plan by advanced practice nurses and physician assistants.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter B. Relations With Physicians or Health Care Providers › Section 1301.0521. Designation of Certain Podiatrists as Preferred Providers

Sec. 1301.0521.  DESIGNATION OF CERTAIN PODIATRISTS AS PREFERRED PROVIDERS.  (a)  Notwithstanding Section 1301.051, an insurer may not withhold the designation of preferred provider to a podiatrist licensed by the Texas Department of Licensing and Regulation who:
(1)  joins the professional practice of a contracted preferred provider;
(2)  applies to the insurer for designation as a preferred provider; and
(3)  complies with the terms and conditions of eligibility to be a preferred provider.
(b)  A podiatrist designated as a preferred provider under this section must comply with the terms of the preferred provider contract used by the insurer or the insurer's network provider.
Added by Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.035(a), eff. September 1, 2005.
Amended by:
Acts 2019, 86th Leg., R.S., Ch. 467 (H.B. 4170), Sec. 19.013, eff. September 1, 2019.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter B. Relations With Physicians or Health Care Providers › Section 1301.0522. Designation of Certain Optometrists, Therapeutic Optometrists, and Ophthalmologists as Preferred Providers

Sec. 1301.0522.  DESIGNATION OF CERTAIN OPTOMETRISTS, THERAPEUTIC OPTOMETRISTS, AND OPHTHALMOLOGISTS AS PREFERRED PROVIDERS.  (a)  Notwithstanding Section 1301.051, an insurer may not withhold the designation of preferred provider to an optometrist or therapeutic optometrist licensed by the Texas Optometry Board or an ophthalmologist licensed by the Texas Medical Board who:
(1)  joins the professional practice of a contracted preferred provider;
(2)  applies to the insurer for designation as a preferred provider; and
(3)  complies with the terms and conditions of eligibility to be a preferred provider.
(b)  An optometrist, therapeutic optometrist, or ophthalmologist designated as a preferred provider under this section must comply with the terms of the preferred provider contract used by the insurer or the insurer's network provider.
Added by Acts 2015, 84th Leg., R.S., Ch. 1271 (S.B. 684), Sec. 2, eff. September 1, 2015.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter B. Relations With Physicians or Health Care Providers › Section 1301.053. Appeal Relating to Designation as Preferred Provider

Sec. 1301.053.  APPEAL RELATING TO DESIGNATION AS PREFERRED PROVIDER.  (a)  An insurer that does not designate a practitioner as a preferred provider shall provide a reasonable mechanism for reviewing that action.  The review mechanism must incorporate, in an advisory role only, a review panel.
(b)  A review panel must be composed of at least three individuals selected by the insurer from a list of participating practitioners and must include one member who is a practitioner in the same or similar specialty as the affected practitioner, if available.  The practitioners contracting with the insurer in the applicable service area shall provide the list of practitioners to the insurer.
(c)  On request, the insurer shall provide to the affected practitioner:
(1)  the panel's recommendation, if any;  and
(2)  a written explanation of the insurer's determination, if that determination is contrary to the panel's recommendation.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter B. Relations With Physicians or Health Care Providers › Section 1301.054. Notice to Practitioners of Preferred Provider Benefit Plan

Sec. 1301.054.  NOTICE TO PRACTITIONERS OF PREFERRED PROVIDER BENEFIT PLAN.  (a)  When sponsoring a preferred provider benefit plan, an insurer shall immediately notify each practitioner in the plan's service area of the insurer's intent to offer the plan and of the opportunity to participate.  The notification must be made by publication or in writing to each practitioner.
(b)  After establishing a preferred provider benefit plan, an insurer shall annually provide notice of and an opportunity to participate in the plan to practitioners in the plan's service area who do not participate in the plan.
(c)  On request, an insurer shall provide to any physician or health care provider information concerning the application process and qualification requirements for participation as a preferred provider in 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 D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter B. Relations With Physicians or Health Care Providers › Section 1301.055. Complaint Resolution

Sec. 1301.055.  COMPLAINT RESOLUTION.  (a)  Each contract under a preferred provider benefit plan between an insurer and a physician or other practitioner or a physicians' group must have a mechanism for resolving complaints initiated by an insured, a physician or other practitioner, or a physicians' group.
(b)  A complaint resolution mechanism must provide for reasonable due process that includes, in an advisory role only, a review panel selected in the manner described by Section 1301.053(b).
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter B. Relations With Physicians or Health Care Providers › Section 1301.056. Restrictions on Payment and Reimbursement

Sec. 1301.056.  RESTRICTIONS ON PAYMENT AND REIMBURSEMENT.  (a)  An insurer or third-party administrator may not reimburse a physician or other practitioner, institutional provider, or organization of physicians and health care providers on a discounted fee basis for covered services that are provided to an insured unless:
(1)  the insurer or third-party administrator has contracted with either:
(A)  the physician or other practitioner, institutional provider, or organization of physicians and health care providers;  or
(B)  a preferred provider organization that has a network of preferred providers and that has contracted with the physician or other practitioner, institutional provider, or organization of physicians and health care providers;
(2)  the physician or other practitioner, institutional provider, or organization of physicians and health care providers has agreed to the contract and has agreed to provide health care services under the terms of the contract;  and
(3)  the insurer or third-party administrator has agreed to provide coverage for those health care services under the health insurance policy.
(b)  A party to a preferred provider contract, including a contract with a preferred provider organization, may not sell, lease, or otherwise transfer information regarding the payment or reimbursement terms of the contract without the express authority of and prior adequate notification to the other contracting parties.  This subsection does not affect the authority of the commissioner of insurance or the commissioner of workers' compensation under this code or Title 5, Labor Code, to request and obtain information.
(c)  An insurer or third-party administrator who violates this section:
(1)  commits an unfair claim settlement practice in violation of Subchapter A, Chapter 542;  and
(2)  is subject to administrative penalties under Chapters 82 and 84.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
Amended by:
Acts 2005, 79th Leg., Ch. 265 (H.B. 7), Sec. 6.061, eff. September 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter B. Relations With Physicians or Health Care Providers › Section 1301.057. Termination of Participation; Expedited Review Process

Sec. 1301.057.  TERMINATION OF PARTICIPATION;  EXPEDITED REVIEW PROCESS.  (a)  Before terminating a contract with a preferred provider, an insurer shall:
(1)  provide written reasons for the termination;  and
(2)  if the affected provider is a practitioner, provide, on request, a reasonable review mechanism, except in a case involving:
(A)  imminent harm to a patient's health;
(B)  an action by a state medical or other physician licensing board or other government agency that effectively impairs the practitioner's ability to practice medicine;  or
(C)  fraud or malfeasance.
(b)  The review mechanism described by Subsection (a)(2) must incorporate, in an advisory role only, a review panel selected in the manner described by Section 1301.053(b) and must be completed within a period not to exceed 60 days.
(c)  The insurer shall provide to the affected practitioner:
(1)  the panel's recommendation, if any;  and
(2)  on request, a written explanation of the insurer's determination, if that determination is contrary to the panel's recommendation.
(d)  On request, an insurer shall provide to a practitioner whose participation in a preferred provider benefit plan is being terminated:
(1)  an expedited review conducted in accordance with a process that complies with rules established by the commissioner; and
(2)  all information on which the insurer wholly or partly based the termination, including the economic profile of the preferred provider, the standards by which the provider is measured, and the statistics underlying the profile and standards.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
Amended by:
Acts 2015, 84th Leg., R.S., Ch. 275 (H.B. 574), Sec. 6, eff. September 1, 2015.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter B. Relations With Physicians or Health Care Providers › Section 1301.058. Economic Profiling

Sec. 1301.058.  ECONOMIC PROFILING.  An insurer that conducts, uses, or relies on economic profiling to admit or terminate the participation of physicians or health care providers in a preferred provider benefit plan shall make available to a physician or health care provider on request the economic profile of that physician or health care provider, including the written criteria by which the physician or health care provider's performance is to be measured.  An economic profile must be adjusted to recognize the characteristics of a physician's or health care provider's practice that may account for variations from expected costs.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter B. Relations With Physicians or Health Care Providers › Section 1301.059. Quality Assessment

Sec. 1301.059.  QUALITY ASSESSMENT.  (a)  In this section, "quality assessment" means a mechanism used by an insurer to evaluate, monitor, or improve the quality and effectiveness of the medical care delivered by physicians or health care providers to persons covered by a health insurance policy to ensure that the care delivered is consistent with the care delivered by an ordinary, reasonable, and prudent physician or health care provider under the same or similar circumstances.
(b)  An insurer may not engage in quality assessment except through a panel of at least three physicians selected by the insurer from among a list of physicians contracting with the insurer.  The physicians contracting with the insurer in the applicable service area shall provide the list of physicians to the insurer.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter B. Relations With Physicians or Health Care Providers › Section 1301.060. Compensation on Discounted Fee Basis

Sec. 1301.060.  COMPENSATION ON DISCOUNTED FEE BASIS.  A preferred provider contract must include a provision by which the physician or health care provider agrees that if the preferred provider is compensated on a discounted fee basis, the insured may be billed only on the discounted fee and not the full charge.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter B. Relations With Physicians or Health Care Providers › Section 1301.061. Preferred Provider Networks

Sec. 1301.061.  PREFERRED PROVIDER NETWORKS.  (a)  An insurer may enter into an agreement with a preferred provider organization for the purposes of offering a network of preferred providers.  The agreement may provide that either the insurer or the preferred provider organization on the insurer's behalf will comply with the notice requirements and other requirements imposed on the insurer by this subchapter.
(b)  An insurer that enters into an agreement with a preferred provider organization under this section shall meet the requirements of this chapter or ensure that those requirements are met.
(c)   Each preferred provider benefit plan offered in this state must comply with this chapter.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
Amended by:
Acts 2007, 80th Leg., R.S., Ch. 730 (H.B. 2636), Sec. 3B.0271(a), eff. September 1, 2007.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter B. Relations With Physicians or Health Care Providers › Section 1301.062. Preferred Provider Contracts Between Insurers and Podiatrists

Sec. 1301.062.  PREFERRED PROVIDER CONTRACTS BETWEEN INSURERS AND PODIATRISTS.  A preferred provider contract between an insurer and a podiatrist licensed by the Texas Department of Licensing and Regulation must provide that:
(1)  the podiatrist may request a copy of the coding guidelines and payment schedules applicable to the compensation that the podiatrist will receive under the contract for services;
(2)  the insurer shall provide a copy of the coding guidelines and payment schedules not later than the 30th day after the date of the podiatrist's request;
(3)  the insurer may not unilaterally make material retroactive revisions to the coding guidelines and payment schedules; and
(4)  the podiatrist may, practicing within the scope of the law regulating podiatry, furnish x-rays and nonprefabricated orthotics covered by the health insurance policy.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
Amended by:
Acts 2019, 86th Leg., R.S., Ch. 467 (H.B. 4170), Sec. 19.014, eff. September 1, 2019.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter B. Relations With Physicians or Health Care Providers › Section 1301.0625. Health Care Collaboratives

Sec. 1301.0625.  HEALTH CARE COLLABORATIVES.  (a)  Subject to the requirements of this chapter, a health care collaborative may be designated as a preferred provider under a preferred provider benefit plan and may offer enhanced benefits for care provided by the health care collaborative.
(b)  A preferred provider contract between an insurer and a health care collaborative may use a payment methodology other than a fee-for-service or discounted fee methodology.  A reimbursement methodology used in a contract under this subsection is not subject to Chapter 843.
(c)  A contract authorized by Subsection (b) must specify that the health care collaborative and the physicians or providers providing health care services on behalf of the collaborative will hold an insured harmless for payment of the cost of covered health care services if the insurer or the health care collaborative do not pay the physician or health care provider for the services.
(d)  An insurer issuing an exclusive provider benefit plan authorized by another law of this state may limit access to only preferred providers participating in a health care collaborative if the limitation is consistent with all requirements applicable to exclusive provider benefit plans.
Added by Acts 2011, 82nd Leg., 1st C.S., Ch. 7 (S.B. 7), Sec. 4.03, eff. September 28, 2011.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter B. Relations With Physicians or Health Care Providers › Section 1301.063. Contract Provisions Relating to Use of Hospitalist

Sec. 1301.063.  CONTRACT PROVISIONS RELATING TO USE OF HOSPITALIST.  (a)  In this section, "hospitalist" means a physician who:
(1)  serves as physician of record at a hospital for a hospitalized patient of another physician;  and
(2)  returns the care of the patient to that other physician at the end of the patient's hospitalization.
(b)  A preferred provider contract between an insurer and a physician may not require the physician to use a hospitalist for a hospitalized patient.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter B. Relations With Physicians or Health Care Providers › Section 1301.064. Contract Provisions Relating to Payment of Claims

Sec. 1301.064.  CONTRACT PROVISIONS RELATING TO PAYMENT OF CLAIMS.  Subject to Subchapter C, a preferred provider contract must provide for payment to a physician or health care provider for health care services and benefits provided to an insured under the contract and to which the insured is entitled under the terms of the contract not later than:
(1)  the 45th day after the date on which a claim for payment is received with the documentation reasonably necessary to process the claim;  or
(2)  if applicable, within the number of calendar days specified by written agreement between the physician or health care provider and the insurer.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter B. Relations With Physicians or Health Care Providers › Section 1301.0641. Contract Provisions Prohibiting Rejection of Batched Claims

Sec. 1301.0641.  CONTRACT PROVISIONS PROHIBITING REJECTION OF BATCHED CLAIMS.  (a)  If requested by a preferred provider, an insurer shall include a provision in the preferred provider's contract providing that the insurer or the insurer's clearinghouse may not refuse to process or pay an electronically submitted clean claim, as defined by Subchapter C, because the claim is submitted together with or in a batch submission with a claim that is not a clean claim.
(b)  In accordance with Chapters 82 and 84, the commissioner may issue a cease and desist order against or impose sanctions on an insurer that violates this section or a contract provision adopted under this section.
Added by Acts 2005, 79th Leg., Ch. 668 (S.B. 50), Sec. 2, eff. September 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter B. Relations With Physicians or Health Care Providers › Section 1301.065. Shifting of Insurer's Tort Liability Prohibited

Sec. 1301.065.  SHIFTING OF INSURER'S TORT LIABILITY PROHIBITED.  A preferred provider contract may not require any physician, health care provider, or physicians' group to execute a hold harmless clause to shift the insurer's tort liability resulting from the insurer's acts or omissions to the preferred provider.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter B. Relations With Physicians or Health Care Providers › Section 1301.066. Retaliation Against Preferred Provider Prohibited

Sec. 1301.066.  RETALIATION AGAINST PREFERRED PROVIDER PROHIBITED.  An insurer may not engage in any retaliatory action against a physician or health care provider, including terminating the physician's or provider's participation in the preferred provider benefit plan or refusing to renew the physician's or provider's contract, because the physician or provider has:
(1)  on behalf of an insured, reasonably filed a complaint against the insurer;  or
(2)  appealed a decision of the insurer.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter B. Relations With Physicians or Health Care Providers › Section 1301.067. Interference With Relationship Between Patient and Physician or Health Care Provider Prohibited

Sec. 1301.067.  INTERFERENCE WITH RELATIONSHIP BETWEEN PATIENT AND PHYSICIAN OR HEALTH CARE PROVIDER PROHIBITED.  (a)  An insurer may not, as a condition of a preferred provider contract with a physician or health care provider or in any other manner, prohibit, attempt to prohibit, or discourage a physician or provider from discussing with or communicating to a current, prospective, or former patient, or a person designated by a patient, information or an opinion:
(1)  regarding the patient's health care, including the patient's medical condition or treatment options;  or
(2)  in good faith regarding the provisions, terms, requirements, or services of the health insurance policy as they relate to the patient's medical needs.
(a-1)  An insurer may not, as a condition of payment with a physician or health care provider or in any other manner, require a physician or health care provider to provide a notification form stating that the physician or health care provider is an out-of-network provider to a current, prospective, or former patient, or a person designated by the patient, if the form contains additional information that is intended, or is otherwise required to be presented in a manner that is intended, to intimidate the patient.
(b)  An insurer may not in any way penalize, terminate the participation of, or refuse to compensate for covered services a physician or health care provider for discussing or communicating with a current, prospective, or former patient, or a person designated by a patient, pursuant to this section.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
Amended by:
Acts 2015, 84th Leg., R.S., Ch. 275 (H.B. 574), Sec. 7, eff. September 1, 2015.