reglab/statecodes huggingface dataset:
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle H - Health Benefits and Other Coverages for Governmental Employees › Chapter 1551 - Texas Employees Group Benefits Act › Subchapter J. State Consumer-Directed Health Plan › Section 1551.457. Plan Enrollee Contributions

Sec. 1551.457.  PLAN ENROLLEE CONTRIBUTIONS.  (a)  Each plan enrollee, in accordance with Section 1551.305, shall contribute any amount required to cover the selected participation in the high deductible health plan that exceeds the state contribution amount under Section 1551.456.
(b)  A plan enrollee may contribute any amount allowed under federal law to the enrollee's health savings account in addition to the state contribution under Section 1551.456.
(c)  A plan enrollee shall make contributions under this section in the manner prescribed by the board of trustees.
Added by Acts 2015, 84th Leg., R.S., Ch. 1015 (H.B. 966), Sec. 1, eff. September 1, 2015.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle H - Health Benefits and Other Coverages for Governmental Employees › Chapter 1551 - Texas Employees Group Benefits Act › Subchapter J. State Consumer-Directed Health Plan › Section 1551.458. Coordination With Cafeteria Plan

Sec. 1551.458.  COORDINATION WITH CAFETERIA PLAN.  (a)  The board of trustees has exclusive authority to determine the eligibility of a plan enrollee to participate in any flexible spending account that is part of a cafeteria plan offered under this chapter.
(b)  The board of trustees may adopt rules regarding the eligibility of a plan enrollee to participate in any flexible spending account that is part of a cafeteria plan offered under this chapter.
(c)  A plan enrollee may not participate in any flexible spending account that would disqualify the enrollee's health savings account from favorable tax treatment under federal law.
Added by Acts 2015, 84th Leg., R.S., Ch. 1015 (H.B. 966), Sec. 1, eff. September 1, 2015.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle H - Health Benefits and Other Coverages for Governmental Employees › Chapter 1551 - Texas Employees Group Benefits Act › Subchapter J. State Consumer-Directed Health Plan › Section 1551.459. Exemption From Execution; Unassignability

Sec. 1551.459.  EXEMPTION FROM EXECUTION; UNASSIGNABILITY.  A state contribution to a health savings account or a high deductible health plan is exempt from execution and is unassignable in the same manner and to the same extent as an amount described by Section 1551.011.
Added by Acts 2015, 84th Leg., R.S., Ch. 1015 (H.B. 966), Sec. 1, eff. September 1, 2015.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle H - Health Benefits and Other Coverages for Governmental Employees › Chapter 1551 - Texas Employees Group Benefits Act › Subchapter J. State Consumer-Directed Health Plan › Section 1551.460. Single Undivided Risk Pool

Sec. 1551.460.  SINGLE UNDIVIDED RISK POOL.  In implementing and administering the state consumer-directed health plan established under this subchapter, the board of trustees may not divide the self-funded risk pool of the group benefits program provided under this chapter or create a separate self-funded risk pool for that program.
Added by Acts 2015, 84th Leg., R.S., Ch. 1015 (H.B. 966), Sec. 1, eff. September 1, 2015.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle H - Health Benefits and Other Coverages for Governmental Employees › Chapter 1552 - Long-Term Care Insurance for State Employees › Section 1552.001. Definitions

Sec. 1552.001.  DEFINITIONS.  In this chapter, "annuitant," "board of trustees," and "employee" have the meanings assigned by Section 1551.003.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 3, eff. June 1, 2003.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle H - Health Benefits and Other Coverages for Governmental Employees › Chapter 1552 - Long-Term Care Insurance for State Employees › Section 1552.002. Establishment of Program

Sec. 1552.002.  ESTABLISHMENT OF PROGRAM.  (a)  The board of trustees may establish a long-term care insurance program to provide long-term care insurance coverage for:
(1)  an individual eligible to participate in the program provided by Chapter 1551 as an employee or annuitant;
(2)  the spouse, parent, or grandparent of an employee or annuitant; and
(3)  a parent of a spouse described by Subdivision (2).
(b)  The board of trustees may not implement a long-term care insurance program unless any cost or administrative burden associated with the development of, implementation of, or communications about the program is incidental.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 3, eff. June 1, 2003.
Amended by:
Acts 2019, 86th Leg., R.S., Ch. 158 (H.B. 392), Sec. 2, eff. September 1, 2019.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle H - Health Benefits and Other Coverages for Governmental Employees › Chapter 1552 - Long-Term Care Insurance for State Employees › Section 1552.003. Administering Firm

Sec. 1552.003.  ADMINISTERING FIRM.  The board of trustees may select an administering firm to administer the long-term care insurance program under contract with the board.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 3, eff. June 1, 2003.
Amended by:
Acts 2019, 86th Leg., R.S., Ch. 158 (H.B. 392), Sec. 3, eff. September 1, 2019.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle H - Health Benefits and Other Coverages for Governmental Employees › Chapter 1552 - Long-Term Care Insurance for State Employees › Section 1552.005. Program Not Part of Other Group Coverages

Sec. 1552.005.  PROGRAM NOT PART OF OTHER GROUP COVERAGES.  (a)  The long-term care insurance program is not part of the group coverages offered under Chapter 1551.
(b)  The state may not contribute any part of the premiums for coverage offered under this chapter.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 3, eff. June 1, 2003.
Amended by:
Acts 2019, 86th Leg., R.S., Ch. 158 (H.B. 392), Sec. 4, eff. September 1, 2019.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle H - Health Benefits and Other Coverages for Governmental Employees › Chapter 1552 - Long-Term Care Insurance for State Employees › Section 1552.006. Rules

Sec. 1552.006.  RULES.  The board of trustees may adopt rules as necessary to implement this chapter, including rules specifying the coverage to be offered under the long-term care insurance program.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 3, eff. June 1, 2003.
Amended by:
Acts 2019, 86th Leg., R.S., Ch. 158 (H.B. 392), Sec. 5, eff. September 1, 2019.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle H - Health Benefits and Other Coverages for Governmental Employees › Chapter 1560 - Delivery of Prescription Drugs by Mail › Section 1560.001. Definitions

Sec. 1560.001.  DEFINITIONS.  In this chapter:
(1)  "Community retail pharmacy" means a pharmacy that is licensed as a Class A pharmacy under Chapter 560, Occupations Code.
(2)  "Mail order pharmacy" means a pharmacy that is licensed under Chapter 560, Occupations Code, and that primarily delivers prescription drugs to an enrollee through the United States Postal Service or a commercial delivery service.
Added by Acts 2009, 81st Leg., R.S., Ch. 1207 (S.B. 704), Sec. 5, eff. September 1, 2009.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle H - Health Benefits and Other Coverages for Governmental Employees › Chapter 1560 - Delivery of Prescription Drugs by Mail › Section 1560.002. Applicability of Chapter

Sec. 1560.002.  APPLICABILITY OF CHAPTER.  This chapter 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 or administered by:
(1)  the Teacher Retirement System of Texas under Chapter 1575 or 1579; or
(2)  the Employees Retirement System of Texas under Chapter 1551.
Added by Acts 2009, 81st Leg., R.S., Ch. 1207 (S.B. 704), Sec. 5, eff. September 1, 2009.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle H - Health Benefits and Other Coverages for Governmental Employees › Chapter 1560 - Delivery of Prescription Drugs by Mail › Section 1560.003. Multiple-Month Supply of Prescription Drug

Sec. 1560.003.  MULTIPLE-MONTH SUPPLY OF PRESCRIPTION DRUG.  (a)  In this section, "multiple-month supply" means a supply for 60 or more days.
(b)  Notwithstanding any other law, an issuer of a health benefit plan that provides pharmacy benefits to enrollees must allow an enrollee to obtain from a community retail pharmacy a multiple-month supply of any prescription drug under the same terms and conditions applicable when the prescription drug is obtained from a mail order pharmacy, if the community retail pharmacy agrees to accept reimbursement on exactly the same terms and conditions that apply to a mail order pharmacy.
(c)  This section does not require:
(1)  the issuer of a health benefit plan to contract with:
(A)  a retail pharmacy that does not agree to accept reimbursement on exactly the same terms and conditions that apply to a mail order pharmacy; or
(B)  more than one mail order pharmacy; or
(2)  a community retail pharmacy to:
(A)  provide a multiple-month supply of a prescription drug under the same terms and conditions applicable when the prescription drug is obtained from a mail order pharmacy; or
(B)  agree to accept reimbursement on exactly the same terms and conditions that apply to a mail order pharmacy.
Added by Acts 2009, 81st Leg., R.S., Ch. 1207 (S.B. 704), Sec. 5, eff. September 1, 2009.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle H - Health Benefits and Other Coverages for Governmental Employees › Chapter 1560 - Delivery of Prescription Drugs by Mail › Section 1560.004. Prescription Drug Reimbursement Rates

Sec. 1560.004.  PRESCRIPTION DRUG REIMBURSEMENT RATES.  (a)  An issuer of a health benefit plan that provides pharmacy benefits to enrollees shall reimburse pharmacies participating in the health plan using prescription drug reimbursement rates, for both brand name and generic prescription drugs, that are based on a current and nationally recognized benchmark index that includes average wholesale price and maximum allowable cost.
(b)  Regardless of whether a pharmacy is a mail order pharmacy or a community retail pharmacy, an issuer of a health benefit plan shall use the same benchmark index, including the same average wholesale price, maximum allowable cost, and national prescription drug codes, to reimburse all pharmacies participating in the health benefit plan.
Added by Acts 2009, 81st Leg., R.S., Ch. 1207 (S.B. 704), Sec. 5, eff. September 1, 2009.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle H - Health Benefits and Other Coverages for Governmental Employees › Chapter 1575 - Texas Public School Employees Group Benefits Program › Subchapter A. General Provisions › Section 1575.001. Short Title

Sec. 1575.001.  SHORT TITLE.  This chapter may be cited as the Texas Public School Retired Employees Group Benefits Act.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 3, eff. June 1, 2003.  Amended by Acts 2003, 78th Leg., ch. 1276, Sec. 10A.413(a), eff. Sept. 1, 2003.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle H - Health Benefits and Other Coverages for Governmental Employees › Chapter 1575 - Texas Public School Employees Group Benefits Program › Subchapter A. General Provisions › Section 1575.002. General Definitions

Sec. 1575.002.  GENERAL DEFINITIONS.  In this chapter:
(1)  "Active employee" means a contributing member of the Teacher Retirement System of Texas who:
(A)  is employed by a public school;  and
(B)  is not entitled to coverage under a plan provided under Chapter 1551 or 1601.
(2)  "Carrier" means an insurance company or hospital service corporation authorized by the department under this code or another insurance law of this state to provide any of the insurance coverages, benefits, or services provided by this chapter.
(3)  "Fund" means the retired school employees group insurance fund.
(4)  "Group program" means the Texas Public School Employees Group Insurance Program authorized by this chapter.
(5)  "Health benefit plan" means any group arrangement to provide health care benefits or to pay or reimburse expenses for health care services.
(5-a)  "Medicare Advantage plan" means a health benefit plan operated under Part C of the Medicare program.
(5-b)  "Medicare prescription drug plan" means a health benefit plan operated under Part D of the Medicare program.
(6)   "Public school" means:
(A)  a school district;
(B)  another educational district whose employees are members of the Teacher Retirement System of Texas;
(C)  a regional education service center established under Chapter 8, Education Code;  or
(D)  an open-enrollment charter school established under Subchapter D, Chapter 12, Education Code.
(7)  "Trustee" means the Teacher Retirement System of Texas.
(8)  "Usual and customary rate" means the relevant allowable amount as described by the applicable master benefit plan document or policy.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 3, eff. June 1, 2003.  Amended by Acts 2003, 78th Leg., ch. 201, Sec. 47, eff. Sept. 1, 2003;  Acts 2003, 78th Leg., ch. 366, Sec. 3.01, eff. Sept. 1, 2003;  Acts 2003, 78th Leg., ch. 1231, Sec. 1, eff. Sept. 1, 2004;  Acts 2003, 78th Leg., ch. 1276, Sec. 10A.414(a), eff. Sept. 1, 2003.
Amended by:
Acts 2017, 85th Leg., R.S., Ch. 712 (H.B. 3976), Sec. 1, eff. September 1, 2017.
Acts 2019, 86th Leg., R.S., Ch. 1342 (S.B. 1264), Sec. 1.13, eff. September 1, 2019.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle H - Health Benefits and Other Coverages for Governmental Employees › Chapter 1575 - Texas Public School Employees Group Benefits Program › Subchapter A. General Provisions › Section 1575.0025. References to Basic Plan

Sec. 1575.0025.  REFERENCES TO BASIC PLAN.  A reference in this code to a "basic plan" under this chapter means a health benefit plan provided under this chapter other than a Medicare Advantage plan or a Medicare prescription drug plan.
Added by Acts 2017, 85th Leg., R.S., Ch. 712 (H.B. 3976), Sec. 2, eff. September 1, 2017.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle H - Health Benefits and Other Coverages for Governmental Employees › Chapter 1575 - Texas Public School Employees Group Benefits Program › Subchapter A. General Provisions › Section 1575.003. Definition of Dependent and Related Terms

Sec. 1575.003.  DEFINITION OF DEPENDENT AND RELATED TERMS.  In this chapter:
(1)  "Dependent" means:
(A)  the spouse of a retiree;
(B)  a child of a retiree or deceased active member if the child is younger than 26 years of age, including:
(i)  an adopted child or child who is lawfully placed for legal adoption;
(ii)  a foster child, stepchild, or other child who is in a regular parent-child relationship; or
(iii)  a natural child;
(C)  a retiree's natural child, adopted child, foster child, stepchild, or other child who is in a regular parent-child relationship and who lives with or has his or her care provided by the retiree or surviving spouse on a regular basis regardless of the child's age, if the child has a mental disability or is physically incapacitated to an extent that the child is dependent on the retiree or surviving spouse for care or support, as determined by the trustee; or
(D)  a deceased active member's natural child, adopted child, foster child, stepchild, or other child who is in a regular parent-child relationship, without regard to the age of the child, if, while the active member was alive, the child:
(i)  lived with or had the child's care provided by the active member on a regular basis; and
(ii)  had a mental disability or was physically incapacitated to an extent that the child was dependent on the active member or surviving spouse for care or support, as determined by the trustee.
(2)  "Surviving dependent child" means:
(A)  the dependent child of a deceased retiree who has survived the deceased retiree and the deceased retiree's spouse;  or
(B)  the dependent child of a deceased active member who has survived the deceased member and the deceased member's spouse if the deceased member:
(i)  had contributions made to the group program at the last place of employment of the deceased member in public education in this state;
(ii)  had 10 or more years of service credit in the Teacher Retirement System of Texas;  and
(iii)  died on or after September 1, 1986.
(3)  "Surviving spouse" means:
(A)  the surviving spouse of a deceased retiree;  or
(B)  the surviving spouse of a deceased active member:
(i)  for whom contributions have been made to the group program at the last place of employment of the deceased member in public education in this state;
(ii)  who had 10 or more years of service credit in the Teacher Retirement System of Texas;  and
(iii)  who died on or after September 1, 1986.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 3, eff. June 1, 2003.  Amended by Acts 2003, 78th Leg., ch. 1276, Sec. 10A.414(b), (c), eff. Sept. 1, 2003.
Amended by:
Acts 2011, 82nd Leg., R.S., Ch. 455 (S.B. 1667), Sec. 21, eff. September 1, 2011.
Acts 2013, 83rd Leg., R.S., Ch. 1078 (H.B. 3357), Sec. 18, eff. June 14, 2013.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle H - Health Benefits and Other Coverages for Governmental Employees › Chapter 1575 - Texas Public School Employees Group Benefits Program › Subchapter A. General Provisions › Section 1575.005. Issuance of Certificate of Coverage

Sec. 1575.005.  ISSUANCE OF CERTIFICATE OF COVERAGE.  At the time and in the circumstances specified by the trustee, a carrier shall issue to each retiree, surviving spouse, or surviving dependent child covered under this chapter a certificate of coverage that:
(1)  states the benefits to which the person is entitled;
(2)  states to whom the benefits are payable;
(3)  states to whom a claim must be submitted;  and
(4)  summarizes the provisions of the coverage principally affecting the person.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 3, eff. June 1, 2003.  Amended by Acts 2003, 78th Leg., ch. 1276, Sec. 10A.416(a), eff. Sept. 1, 2003.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle H - Health Benefits and Other Coverages for Governmental Employees › Chapter 1575 - Texas Public School Employees Group Benefits Program › Subchapter A. General Provisions › Section 1575.006. Exemption From Process

Sec. 1575.006.  EXEMPTION FROM PROCESS.  (a)  The following are exempt from execution, attachment, garnishment, or any other process:
(1)  benefit payments, active employee and state contributions, and retiree, surviving spouse, and surviving dependent child contributions;
(2)  any rights, benefits, or payments accruing to any person under this chapter; and
(3)  any money in the fund.
(b)  The items listed in Subsection (a) may not be assigned except for direct payment to benefit providers as authorized by the trustee by contract, rule, or otherwise.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 3, eff. June 1, 2003.  Amended by Acts 2003, 78th Leg., ch. 1276, Sec. 10A.417, eff. Sept. 1, 2003.
Amended by:
Acts 2017, 85th Leg., R.S., Ch. 712 (H.B. 3976), Sec. 3, eff. September 1, 2017.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle H - Health Benefits and Other Coverages for Governmental Employees › Chapter 1575 - Texas Public School Employees Group Benefits Program › Subchapter A. General Provisions › Section 1575.007. Exemption From State Taxes and Fees

Sec. 1575.007.  EXEMPTION FROM STATE TAXES AND FEES.  A premium or contribution on a policy, insurance contract, or agreement authorized by this chapter is not subject to any state tax, regulatory fee, or surcharge, including a premium or maintenance tax or fee.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 3, eff. June 1, 2003.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle H - Health Benefits and Other Coverages for Governmental Employees › Chapter 1575 - Texas Public School Employees Group Benefits Program › Subchapter A. General Provisions › Section 1575.008. Coverage Exempt From Insurance Law

Sec. 1575.008.  COVERAGE EXEMPT FROM INSURANCE LAW.  A coverage plan provided under this chapter is exempt from any other insurance law, including common law, that does not expressly apply to the plan or this chapter.
Added by Acts 2005, 79th Leg., Ch. 1359 (S.B. 1691), Sec. 39, eff. September 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle H - Health Benefits and Other Coverages for Governmental Employees › Chapter 1575 - Texas Public School Employees Group Benefits Program › Subchapter A. General Provisions › Section 1575.009. Balance Billing Prohibition Notice

Text of section effective until September 01, 2025
Sec. 1575.009.  BALANCE BILLING PROHIBITION NOTICE.  (a)  The administrator of a managed care plan provided under the group program shall provide written notice in accordance with this section in an explanation of benefits provided to the enrollee and the physician or health care provider in connection with a health care or medical service or supply or transport provided by an out-of-network provider.  The notice must include:
(1)  a statement of the billing prohibition under Section 1575.171, 1575.172, 1575.173, or 1575.174, as applicable;
(2)  the total amount the physician or provider may bill the enrollee under the enrollee's managed care plan and an itemization of copayments, coinsurance, deductibles, and other amounts included in that total; and
(3)  for an explanation of benefits provided to the physician or provider, information required by commissioner rule advising the physician or provider of the availability of mediation or arbitration, as applicable, under Chapter 1467.
(b)  The administrator shall provide the explanation of benefits with the notice required by this section to a physician or health care provider not later than the date the administrator makes a payment under Section 1575.171, 1575.172, 1575.173, or 1575.174, as applicable.
Added by Acts 2019, 86th Leg., R.S., Ch. 1342 (S.B. 1264), Sec. 1.14, eff. September 1, 2019.
Amended by:
Acts 2023, 88th Leg., R.S., Ch. 981 (S.B. 2476), Sec. 11(a), eff. September 1, 2023.
Acts 2023, 88th Leg., R.S., Ch. 981 (S.B. 2476), Sec. 11(b), eff. September 1, 2025.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle H - Health Benefits and Other Coverages for Governmental Employees › Chapter 1575 - Texas Public School Employees Group Benefits Program › Subchapter A. General Provisions › Section 1575.009. Balance Billing Prohibition Notice

Text of section effective on September 01, 2025
Sec. 1575.009.  BALANCE BILLING PROHIBITION NOTICE.  (a)  The administrator of a managed care plan provided under the group program shall provide written notice in accordance with this section in an explanation of benefits provided to the enrollee and the physician or health care provider in connection with a health care or medical service or supply provided by an out-of-network provider.  The notice must include:
(1)  a statement of the billing prohibition under Section 1575.171, 1575.172, or 1575.173, as applicable;
(2)  the total amount the physician or provider may bill the enrollee under the enrollee's managed care plan and an itemization of copayments, coinsurance, deductibles, and other amounts included in that total; and
(3)  for an explanation of benefits provided to the physician or provider, information required by commissioner rule advising the physician or provider of the availability of mediation or arbitration, as applicable, under Chapter 1467.
(b)  The administrator shall provide the explanation of benefits with the notice required by this section to a physician or health care provider not later than the date the administrator makes a payment under Section 1575.171, 1575.172, or 1575.173, as applicable.
Added by Acts 2019, 86th Leg., R.S., Ch. 1342 (S.B. 1264), Sec. 1.14, eff. September 1, 2019.
Amended by:
Acts 2023, 88th Leg., R.S., Ch. 981 (S.B. 2476), Sec. 11(a), eff. September 1, 2023.
Acts 2023, 88th Leg., R.S., Ch. 981 (S.B. 2476), Sec. 11(b), eff. September 1, 2025.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle H - Health Benefits and Other Coverages for Governmental Employees › Chapter 1575 - Texas Public School Employees Group Benefits Program › Subchapter A. General Provisions › Section 1575.010. Information Regarding Appeals

Sec. 1575.010.  INFORMATION REGARDING APPEALS.  The trustee shall develop and distribute informational materials to individuals enrolled in a health benefit plan offered under the group program regarding:
(1)  the enrollee's right to appeal denial of an adverse determination, as defined by Section 4201.002, to an independent review organization;
(2)  the procedures for appealing to an independent review organization; and
(3)  the assistance available from the trustee in navigating the procedures for appeal.
Added by Acts 2021, 87th Leg., R.S., Ch. 141 (H.B. 1585), Sec. 16, eff. May 26, 2021.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle H - Health Benefits and Other Coverages for Governmental Employees › Chapter 1575 - Texas Public School Employees Group Benefits Program › Subchapter B. Administration › Section 1575.051. Administration of Group Program

Sec. 1575.051.  ADMINISTRATION OF GROUP PROGRAM.  The trustee shall take the actions it considers necessary to devise, implement, and administer the group program.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 3, eff. June 1, 2003.  Amended by Acts 2003, 78th Leg., ch. 1276, Sec. 10A.419, eff. Sept. 1, 2003.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle H - Health Benefits and Other Coverages for Governmental Employees › Chapter 1575 - Texas Public School Employees Group Benefits Program › Subchapter B. Administration › Section 1575.052. Authority to Adopt Rules and Procedures; Other Authority

Sec. 1575.052.  AUTHORITY TO ADOPT RULES AND PROCEDURES;  OTHER AUTHORITY.  (a)  The trustee may adopt rules, plans, procedures, and orders reasonably necessary to implement this chapter, including:
(1)  minimum benefit and financing standards for group coverage for retirees, dependents, surviving spouses, and surviving dependent children;
(2)  group coverage for retirees, dependents, surviving spouses, and surviving dependent children;
(3)  procedures for contributions and deductions;
(4)  periods for enrollment and selection of coverage and procedures for enrolling and exercising options under the group program;
(5)  procedures for claims administration;
(6)  procedures to administer the fund; and
(7)  a timetable for:
(A)  developing minimum benefit and financial standards for group coverage;
(B)  establishing health benefit plans offered under the group program; and
(C)  taking bids and awarding contracts for health benefit plans offered under the group program.
(b)  The trustee may:
(1)  study the operation of all group coverage provided under this chapter; and
(2)  contract for advice and counsel in implementing and administering the group program with independent and experienced group insurance consultants and actuaries.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 3, eff. June 1, 2003.  Amended by Acts 2003, 78th Leg., ch. 1276, Sec. 10A.420(a), eff. Sept. 1, 2003.
Amended by:
Acts 2005, 79th Leg., Ch. 1359 (S.B. 1691), Sec. 40, eff. September 1, 2005.
Acts 2017, 85th Leg., R.S., Ch. 712 (H.B. 3976), Sec. 4, eff. September 1, 2017.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle H - Health Benefits and Other Coverages for Governmental Employees › Chapter 1575 - Texas Public School Employees Group Benefits Program › Subchapter B. Administration › Section 1575.053. Personnel

Sec. 1575.053.  PERSONNEL.  (a)  The trustee may employ persons to assist the trustee in implementing this chapter.
(b)  The trustee shall prescribe the duties and compensation of each employee.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 3, eff. June 1, 2003.  Amended by Acts 2003, 78th Leg., ch. 1276, Sec. 10A.421, eff. Sept. 1, 2003.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle H - Health Benefits and Other Coverages for Governmental Employees › Chapter 1575 - Texas Public School Employees Group Benefits Program › Subchapter B. Administration › Section 1575.054. Budget

Sec. 1575.054.  BUDGET.  Expenses incurred in developing and administering the group program shall be paid as provided by a budget adopted by the trustee.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 3, eff. June 1, 2003.  Amended by Acts 2003, 78th Leg., ch. 1276, Sec. 10A.421, eff. Sept. 1, 2003.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle H - Health Benefits and Other Coverages for Governmental Employees › Chapter 1575 - Texas Public School Employees Group Benefits Program › Subchapter B. Administration › Section 1575.055. Department Assistance

Sec. 1575.055.  DEPARTMENT ASSISTANCE.  The department shall, as requested by the trustee, assist the trustee in implementing and administering this chapter.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 3, eff. June 1, 2003.  Amended by Acts 2003, 78th Leg., ch. 1276, Sec. 10A.421, eff. Sept. 1, 2003.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle H - Health Benefits and Other Coverages for Governmental Employees › Chapter 1575 - Texas Public School Employees Group Benefits Program › Subchapter B. Administration › Section 1575.056. Transfer of Records Relating to Active Employee Program

Sec. 1575.056.  TRANSFER OF RECORDS RELATING TO ACTIVE EMPLOYEE PROGRAM.  The trustee shall transfer from the program all records relating to active employees participating in the program established under Chapter 1579 not later than the date on which the program established under Chapter 1579 is implemented.
Added by Acts 2003, 78th Leg., ch. 1276, Sec. 10A.422(a), eff. Sept. 1, 2003.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle H - Health Benefits and Other Coverages for Governmental Employees › Chapter 1575 - Texas Public School Employees Group Benefits Program › Subchapter C. Provision of Benefits › Section 1575.101. System as Group Plan Holder

Sec. 1575.101.  SYSTEM AS GROUP PLAN HOLDER.  The Teacher Retirement System of Texas is the group plan holder of a plan established under this chapter.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 3, eff. June 1, 2003.  Amended by Acts 2003, 78th Leg., ch. 1276, Sec. 10A.423, eff. Sept. 1, 2003.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle H - Health Benefits and Other Coverages for Governmental Employees › Chapter 1575 - Texas Public School Employees Group Benefits Program › Subchapter C. Provision of Benefits › Section 1575.102. Self-Insured Plans

Sec. 1575.102.  SELF-INSURED PLANS.  The trustee may self-insure any plan established under this chapter.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 3, eff. June 1, 2003.  Amended by Acts 2003, 78th Leg., ch. 1276, Sec. 10A.423, eff. Sept. 1, 2003.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle H - Health Benefits and Other Coverages for Governmental Employees › Chapter 1575 - Texas Public School Employees Group Benefits Program › Subchapter C. Provision of Benefits › Section 1575.104. Terms of Contract

Sec. 1575.104.  TERMS OF CONTRACT.  A contract for group coverage awarded by the trustee must meet the minimum benefit and financial standards adopted by the trustee.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 3, eff. June 1, 2003.  Amended by Acts 2003, 78th Leg., ch. 1276, Sec. 10A.423, eff. Sept. 1, 2003.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle H - Health Benefits and Other Coverages for Governmental Employees › Chapter 1575 - Texas Public School Employees Group Benefits Program › Subchapter C. Provision of Benefits › Section 1575.105. Plan Coverage Secondary to Certain Other Coverage

Sec. 1575.105.  PLAN COVERAGE SECONDARY TO CERTAIN OTHER COVERAGE.  The coverage provided by a plan established under this chapter:
(1)  is secondary to Medicare hospital and medical insurance to the extent permitted by federal law if the retiree, dependent, surviving spouse, or surviving dependent child is entitled to receive Medicare hospital insurance benefits without charge;  and
(2)  may be made secondary to other coverage to which the retiree, dependent, surviving spouse, or surviving dependent child is entitled.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 3, eff. June 1, 2003.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle H - Health Benefits and Other Coverages for Governmental Employees › Chapter 1575 - Texas Public School Employees Group Benefits Program › Subchapter C. Provision of Benefits › Section 1575.106. Competitive Bidding Requirements; Rule

Sec. 1575.106.  COMPETITIVE BIDDING REQUIREMENTS;  RULE.  (a)  A contract to provide group benefits under this chapter may be awarded only through competitive bidding under rules adopted by the trustee.
(b)  The trustee shall submit for competitive bidding at least every six years each contract for coverage under this chapter.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 3, eff. June 1, 2003.  Amended by Acts 2003, 78th Leg., ch. 1276, Sec. 10A.424(a), eff. Sept. 1, 2003.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle H - Health Benefits and Other Coverages for Governmental Employees › Chapter 1575 - Texas Public School Employees Group Benefits Program › Subchapter C. Provision of Benefits › Section 1575.107. Contract Award; Considerations

Sec. 1575.107.  CONTRACT AWARD;  CONSIDERATIONS.  (a)  In awarding a contract to provide group benefits under this chapter, the trustee is not required to select the lowest bid and may consider any relevant criteria, including the bidder's:
(1)  ability to service contracts;
(2)  past experiences;  and
(3)  financial stability.
(b)  If the trustee awards a contract to a bidder whose bid deviates from that advertised, the trustee shall record the deviation and fully justify the reason for the deviation in the minutes of the next meeting of the trustee.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 3, eff. June 1, 2003.  Amended by Acts 2003, 78th Leg., ch. 1276, Sec. 10A.424(b), eff. Sept. 1, 2003.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle H - Health Benefits and Other Coverages for Governmental Employees › Chapter 1575 - Texas Public School Employees Group Benefits Program › Subchapter C. Provision of Benefits › Section 1575.108. Use of Private Entities

Sec. 1575.108.  USE OF PRIVATE ENTITIES.  The trustee may engage a private entity to collect contributions from or to settle claims in connection with a plan established by the trustee under this chapter.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 3, eff. June 1, 2003.  Amended by Acts 2003, 78th Leg., ch. 1276, Sec. 10A.425, eff. Sept. 1, 2003.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle H - Health Benefits and Other Coverages for Governmental Employees › Chapter 1575 - Texas Public School Employees Group Benefits Program › Subchapter C. Provision of Benefits › Section 1575.109. Use of Health Care Provider

Sec. 1575.109.  USE OF HEALTH CARE PROVIDER.  To provide benefits to participants in the group program, the trustee may contract directly with a health care provider, including a health maintenance organization, a preferred provider organization, a carrier, an administrator, and any other qualified vendor.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 3, eff. June 1, 2003.  Amended by Acts 2003, 78th Leg., ch. 1276, Sec. 10A.425, eff. Sept. 1, 2003.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle H - Health Benefits and Other Coverages for Governmental Employees › Chapter 1575 - Texas Public School Employees Group Benefits Program › Subchapter C. Provision of Benefits › Section 1575.110. Pharmacy Benefit Manager Contracts

Sec. 1575.110.  PHARMACY BENEFIT MANAGER CONTRACTS.  (a)  In awarding a contract to provide pharmacy benefit manager services under this chapter, the trustee is not required to select the lowest bid but must select a contract that meets the criteria established by this section.
(b)  The contract must state that:
(1)  the trustee is entitled to audit the pharmacy benefit manager to verify costs and discounts associated with drug claims, pharmacy benefit manager compliance with contract requirements, and services provided by subcontractors;
(2)  the audit must be conducted by an independent auditor in accordance with established auditing standards; and
(3)  to conduct the audit, the trustee and the independent auditor are entitled access to information related to the services and the costs associated with the services performed under the contract, including access to the pharmacy benefit manager's facilities, records, contracts, medical records, and agreements with subcontractors.
(c)  The contract must define the information that the pharmacy benefit manager is required to provide to the trustee concerning the audit of the retail, independent, and mail order pharmacies performing services under the contract and describe how the results of these audits must be reported to the trustee, including how often the results must be reported.  The contract must state whether the pharmacy benefit manager is required to return recovered overpayments to the trustee.
(d)  The contract must state that any audit of a mail order pharmacy owned by the pharmacy benefit manager must be conducted by an independent auditor selected by the trustee in accordance with established auditing standards.
Added by Acts 2009, 81st Leg., R.S., Ch. 1207 (S.B. 704), Sec. 6, eff. September 1, 2009.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle H - Health Benefits and Other Coverages for Governmental Employees › Chapter 1575 - Texas Public School Employees Group Benefits Program › Subchapter D. Coverages and Participation › Section 1575.151. Types of Coverages

Sec. 1575.151.  TYPES OF COVERAGES.  The trustee may include in a plan any coverage it considers advisable, including:
(1)  life insurance;
(2)  accidental death and dismemberment coverage;
(3)  coverage for:
(A)  hospital care and benefits;
(B)  surgical care and treatment;
(C)  medical care and treatment;
(D)  dental care;
(E)  eye care;
(F)  obstetrical benefits;
(G)  long-term care;
(H)  prescribed drugs, medicines, and prosthetic devices;  and
(I)  supplemental benefits, supplies, and services in accordance with this chapter;  and
(4)  protection against loss of salary.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 3, eff. June 1, 2003.  Amended by Acts 2003, 78th Leg., ch. 1276, Sec. 10A.425, eff. Sept. 1, 2003.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle H - Health Benefits and Other Coverages for Governmental Employees › Chapter 1575 - Texas Public School Employees Group Benefits Program › Subchapter D. Coverages and Participation › Section 1575.152. Health Benefit Plan Must Cover Preexisting Conditions

Sec. 1575.152.  HEALTH BENEFIT PLAN MUST COVER PREEXISTING CONDITIONS.  A health benefit plan offered under the group program, other than a Medicare Advantage plan or a Medicare prescription drug plan, must cover preexisting conditions.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 3, eff. June 1, 2003.
Amended by:
Acts 2017, 85th Leg., R.S., Ch. 712 (H.B. 3976), Sec. 5, eff. September 1, 2017.
For expiration of Subsections (d) and (e), see Subsection (e).
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle H - Health Benefits and Other Coverages for Governmental Employees › Chapter 1575 - Texas Public School Employees Group Benefits Program › Subchapter D. Coverages and Participation › Section 1575.153. Health Benefit Plan Coverage for Retirees

Sec. 1575.153.  HEALTH BENEFIT PLAN COVERAGE FOR RETIREES.  (a) A retiree who applies for coverage during an enrollment period may not be denied coverage in a health benefit plan provided under this chapter for which the retiree is eligible unless the trustee finds under Subchapter K that the retiree defrauded or attempted to defraud the group program.
(b)  A retiree who has coverage under a health benefit plan offered under the group program shall pay a monthly contribution, as determined by the trustee.
(c)  As a condition of electing coverage under a health benefit plan, the retiree must, in writing, authorize the trustee to deduct the amount of the contribution from the retiree's monthly annuity payment.  The trustee shall deduct the contribution in the manner and form determined by the trustee.
(d)  Notwithstanding Subsection (b), a retiree is not required to pay a monthly contribution under this section until the 2022 plan year if the retiree:
(1)  has taken a disability retirement under the Teacher Retirement System of Texas on or before January 1, 2017;
(2)  is receiving disability retirement benefits from the Teacher Retirement System of Texas; and
(3)  is not eligible to enroll in Medicare.
(e)  This subsection and Subsection (d) expire at the end of the 2021 plan year on December 31, 2021.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 3, eff. June 1, 2003.  Amended by Acts 2003, 78th Leg., ch. 201, Sec. 49(a), eff. Sept. 1, 2003;  Acts 2003, 78th Leg., ch. 1231, Sec. 3(a), eff. Sept. 1, 2004;  Acts 2003, 78th Leg., ch. 1276, Sec. 10A.426(a), eff. Sept. 1, 2003.
Amended by:
Acts 2017, 85th Leg., R.S., Ch. 712 (H.B. 3976), Sec. 6, eff. September 1, 2017.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle H - Health Benefits and Other Coverages for Governmental Employees › Chapter 1575 - Texas Public School Employees Group Benefits Program › Subchapter D. Coverages and Participation › Section 1575.155. Coverage for Dependents of Retiree

Sec. 1575.155.  COVERAGE FOR DEPENDENTS OF RETIREE.  (a)  A retiree participating in the group program is entitled to secure for the retiree's dependents group coverage under this chapter for which the dependents are eligible under this chapter or any other law, including requirements established by the trustee.
(b)  The additional contribution payments for the dependent coverage shall be deducted from the annuity payments to the retiree in the manner and form determined by the trustee.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 3, eff. June 1, 2003.  Amended by Acts 2003, 78th Leg., ch. 1276, Sec. 10A.427, eff. Sept. 1, 2003.
Amended by:
Acts 2017, 85th Leg., R.S., Ch. 712 (H.B. 3976), Sec. 7, eff. September 1, 2017.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle H - Health Benefits and Other Coverages for Governmental Employees › Chapter 1575 - Texas Public School Employees Group Benefits Program › Subchapter D. Coverages and Participation › Section 1575.156. Coverage for Surviving Spouse or Dependents of Surviving Spouse

Sec. 1575.156.  COVERAGE FOR SURVIVING SPOUSE OR DEPENDENTS OF SURVIVING SPOUSE.  (a)  A surviving spouse who is entitled to group coverage under this chapter may elect to retain or obtain coverage for which the surviving spouse or dependents of the surviving spouse are eligible.
(b)  Repealed by Acts 2017, 85th Leg., R.S., Ch. 712 (H.B. 3976), Sec. 24(2), eff. September 1, 2017.
(c)  A surviving spouse who elects under this section to retain or obtain coverage under a health benefit plan offered under the group program for the surviving spouse or dependents of the surviving spouse shall pay a monthly contribution, as determined by the trustee.
(d)  As a condition of electing coverage under a health benefit plan, the surviving spouse must, in writing, authorize the trustee to deduct the amount of the contribution from the surviving spouse's monthly annuity payment.  The trustee shall deduct the contribution in the manner and form determined by the trustee.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 3, eff. June 1, 2003.  Amended by Acts 2003, 78th Leg., ch. 1276, Sec. 10A.428, eff. Sept. 1, 2003.
Amended by:
Acts 2017, 85th Leg., R.S., Ch. 712 (H.B. 3976), Sec. 8, eff. September 1, 2017.
Acts 2017, 85th Leg., R.S., Ch. 712 (H.B. 3976), Sec. 24(2), eff. September 1, 2017.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle H - Health Benefits and Other Coverages for Governmental Employees › Chapter 1575 - Texas Public School Employees Group Benefits Program › Subchapter D. Coverages and Participation › Section 1575.157. Coverage for Surviving Dependent Child

Sec. 1575.157.  COVERAGE FOR SURVIVING DEPENDENT CHILD.  (a)  A surviving dependent child, the guardian of the child's estate, or the person having custody of the child may elect to retain or obtain group coverage for which the surviving dependent child is eligible at the applicable rate for a dependent.
(b)  A surviving dependent child who has coverage under a health benefit plan offered under the group program shall pay a monthly contribution, as determined by the trustee.  The applicable contributions must be provided by the surviving dependent child in the manner established by the trustee.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 3, eff. June 1, 2003.  Amended by Acts 2003, 78th Leg., ch. 1276, Sec. 10A.429, eff. Sept. 1, 2003.
Amended by:
Acts 2017, 85th Leg., R.S., Ch. 712 (H.B. 3976), Sec. 9, eff. September 1, 2017.