reglab/statecodes huggingface dataset:
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1453 - Disclosure of Reimbursement Guidelines Under Managed Care Plan › Section 1453.001. Definitions

Sec. 1453.001.  DEFINITIONS.  In this chapter:
(1)  "Health care provider" means:
(A)  a hospital, emergency clinic, outpatient clinic, or other facility providing health care services;  or
(B)  an individual who is licensed in this state to provide health care services.
(2)  "Managed care entity" means:
(A)  a health maintenance organization;
(B)  a preferred provider benefit plan issuer;
(C)  an approved nonprofit health corporation that holds a certificate of authority under Chapter 844;  or
(D)  another entity that offers a managed care plan, including:
(i)  an insurance company;
(ii)  a group hospital service corporation operating under Chapter 842;
(iii)  a fraternal benefit society operating under Chapter 885;
(iv)  a stipulated premium company operating under Chapter 884;
(v)  a multiple employer welfare arrangement that holds a certificate of authority under Chapter 846;  and
(vi)  an entity not authorized under this code or another insurance law of this state that contracts directly for health care services on a risk-sharing basis, including a capitation basis.
(3)  "Managed care plan" means a health benefit plan:
(A)  under which health care services are provided through contracts with health care providers to individuals enrolled in or insured under the plan;  and
(B)  that provides financial incentives to individuals enrolled in or insured under the plan to use health care providers participating in the plan and procedures covered by 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 F - Physicians and Health Care Providers › Chapter 1453 - Disclosure of Reimbursement Guidelines Under Managed Care Plan › Section 1453.002. Provision of Information Regarding Reimbursement Guidelines

Sec. 1453.002.  PROVISION OF INFORMATION REGARDING REIMBURSEMENT GUIDELINES.  (a)  On the written request of an out-of-network health care provider, a managed care entity shall furnish to the provider a written description of the factors considered by the entity in determining the amount of reimbursement the provider may receive for goods or services provided to an individual enrolled in or insured under the entity's managed care plan.
(b)  This section does not require a managed care entity to disclose proprietary information that is prohibited from disclosure by a contract between the entity and a vendor that supplies payment or statistical data to the entity.
(c)  A contract between a managed care entity and a vendor that supplies payment or statistical data to the entity may not prohibit the entity from disclosing under this section:
(1)  the name of the vendor;  or
(2)  the methodology and origin of information used to determine the amount of reimbursement.
(d)  A managed care entity that denies a request for information described by Subsection (b) shall send a copy of the request and the information requested to the department for review.
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 F - Physicians and Health Care Providers › Chapter 1453 - Disclosure of Reimbursement Guidelines Under Managed Care Plan › Section 1453.003. Rules

Sec. 1453.003.  RULES.  The commissioner shall adopt rules as necessary to implement this chapter.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1454 - Equal Health Care for Women › Subchapter A. General Provisions › Section 1454.001. Definitions

Sec. 1454.001.  DEFINITIONS.  In this chapter:
(1)  "Health care provider" means a home health aide, hospital, nurse practitioner, nurse midwife, outpatient care center, physician assistant, registered nurse, or surgery center.
(2)  "Physician" has the meaning assigned by Section 151.002, Occupations Code.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1454 - Equal Health Care for Women › Subchapter A. General Provisions › Section 1454.002. Applicability of Chapter

Sec. 1454.002.  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 by:
(1)  an insurance company;
(2)  a group hospital service corporation operating under Chapter 842;
(3)  a fraternal benefit society operating under Chapter 885;
(4)  a stipulated premium company operating under Chapter 884;
(5)  a reciprocal exchange operating under Chapter 942;
(6)  a health maintenance organization operating under Chapter 843;
(7)  a multiple employer welfare arrangement that holds a certificate of authority under Chapter 846;
(8)  an approved nonprofit health corporation that holds a certificate of authority under Chapter 844;  or
(9)  a small employer health benefit plan written under Chapter 1501.
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 F - Physicians and Health Care Providers › Chapter 1454 - Equal Health Care for Women › Subchapter B. Reimbursement for Health Care Services › Section 1454.051. Equal Reimbursement Required

Sec. 1454.051.  EQUAL REIMBURSEMENT REQUIRED.  A health benefit plan issuer that reimburses a physician or health care provider for reproductive health or oncology services provided to women must reimburse the physician or provider in an amount at least equal to the annual average compensation per hour or unit that would be paid in the service area to a physician or provider for the same medical, surgical, hospital, pharmaceutical, nursing, or other similar resources used to provide the services if the resources would be used to provide health services exclusively to men or to the general population.
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 F - Physicians and Health Care Providers › Chapter 1454 - Equal Health Care for Women › Subchapter B. Reimbursement for Health Care Services › Section 1454.052. Reimbursement for Abortion Not Required

Sec. 1454.052.  REIMBURSEMENT FOR ABORTION NOT REQUIRED.  This chapter does not require a health benefit plan issuer to provide reimbursement for an abortion, as defined by the Family Code, or for a service related to an abortion.
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 F - Physicians and Health Care Providers › Chapter 1454 - Equal Health Care for Women › Subchapter C. Enforcement › Section 1454.101. Sanctions Authorized

Sec. 1454.101.  SANCTIONS AUTHORIZED.  The sanctions authorized by Chapter 82 apply to a health benefit plan issuer that violates this chapter.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1454 - Equal Health Care for Women › Subchapter C. Enforcement › Section 1454.102. Cease and Desist Procedures and Restitution for Attorney's Fees Authorized

Sec. 1454.102.  CEASE AND DESIST PROCEDURES AND RESTITUTION FOR ATTORNEY'S FEES AUTHORIZED.  The commissioner may use the cease and desist procedures authorized by Chapter 83 against a health benefit plan issuer that violates this chapter.  In accordance with Chapter 83, the commissioner may order the health benefit plan issuer to make complete restitution for the violation, which may include restitution for the reasonable attorney's fees incurred by a person making a complaint under this chapter.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1454 - Equal Health Care for Women › Subchapter C. Enforcement › Section 1454.103. Administrative Penalties Authorized

Sec. 1454.103.  ADMINISTRATIVE PENALTIES AUTHORIZED.  (a)  In addition to any sanctions authorized by this subchapter, the commissioner may impose an administrative penalty in accordance with Chapter 84 on a health benefit plan issuer that violates this chapter.
(b)  On a finding that a health benefit plan issuer knowingly violated this chapter, the commissioner may impose in addition to the administrative penalty authorized by Section 84.022 an administrative penalty that does not exceed $25,000.
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 F - Physicians and Health Care Providers › Chapter 1454 - Equal Health Care for Women › Subchapter C. Enforcement › Section 1454.104. Amount of Damages

Sec. 1454.104.  AMOUNT OF DAMAGES.  Notwithstanding this subchapter, in imposing a sanction or penalty for a violation of this chapter, the commissioner may order a health benefit plan issuer to pay the greater of complete or economic damages.
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 F - Physicians and Health Care Providers › Chapter 1454 - Equal Health Care for Women › Subchapter C. Enforcement › Section 1454.105. Applicability of Certain Procedural Requirements to Sanctions or Administrative Penalties

Sec. 1454.105.  APPLICABILITY OF CERTAIN PROCEDURAL REQUIREMENTS TO SANCTIONS OR ADMINISTRATIVE PENALTIES.  Subchapter C, Chapter 84, applies to the imposition of a sanction or administrative penalty under this chapter.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1454 - Equal Health Care for Women › Subchapter C. Enforcement › Section 1454.106. Intervention in Proceeding

Sec. 1454.106.  INTERVENTION IN PROCEEDING.  (a)  In a proceeding relating to the imposition by the commissioner of a sanction or administrative penalty under this chapter, a person affected by an order of the commissioner, including a physician or health care provider, may intervene in the proceeding by filing a notice of intervention with the commissioner.  The commissioner shall provide an affected person a reasonable period to intervene.
(b)  At the time the commissioner notifies a health benefit plan issuer of the issuer's opportunity for a hearing regarding an alleged violation, the commissioner shall notify each affected person of all relevant information regarding the hearing.
(c)  A person who intervenes under this section has the rights and powers of a party under Chapter 2001, Government Code.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1454 - Equal Health Care for Women › Subchapter C. Enforcement › Section 1454.107. Time for Commissioner's Determination

Sec. 1454.107.  TIME FOR COMMISSIONER'S DETERMINATION.  Not later than the 120th day after the date a complaint alleging a violation of this chapter is filed with the department, the commissioner shall determine whether the alleged violation occurred and impose appropriate sanctions.
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 F - Physicians and Health Care Providers › Chapter 1454 - Equal Health Care for Women › Subchapter C. Enforcement › Section 1454.108. Failure of Commissioner to Make Determination by Order; Action in District Court

Sec. 1454.108.  FAILURE OF COMMISSIONER TO MAKE DETERMINATION BY ORDER;  ACTION IN DISTRICT COURT.  (a)  If the commissioner fails to determine by order in the time prescribed by Section 1454.107 whether a violation alleged in a complaint filed under this chapter occurred, the person who filed the complaint may bring an action in district court for the violation.
(b)  The action must be commenced not later than the first anniversary of the date by which the commissioner is required to make a determination under Section 1454.107.
(c)  In an action filed under this section, a court may:
(1)  impose the sanctions authorized by this subchapter or similar sanctions;
(2)  assess an additional civil penalty of $25,000 if the trier of fact finds the defendant knowingly violated this chapter;  and
(3)  award a claimant who prevails in an action filed under this section reasonable attorney's fees and court costs, including reasonable and necessary expert witness fees.
(d)  On a finding by the court that an action filed under this section was groundless and brought in bad faith or brought for the purpose of harassment, the court shall award the defendant reasonable and necessary attorney's fees.
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 F - Physicians and Health Care Providers › Chapter 1454 - Equal Health Care for Women › Subchapter C. Enforcement › Section 1454.109. Appeal of Commissioner's Order

Sec. 1454.109.  APPEAL OF COMMISSIONER'S ORDER.  (a)  A person affected by an order of the commissioner regarding a violation of this chapter, including a person who intervenes under Section 1454.106, may file an appeal in district court.
(b)  The standard of review for an appeal filed under this section is substantial evidence.
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 F - Physicians and Health Care Providers › Chapter 1455 - Telemedicine, Teledentistry, and Telehealth › Section 1455.001. Definitions

Sec. 1455.001.  DEFINITIONS.  In this chapter:
(1)  "Dentist" means a person licensed to practice dentistry in this state under Subtitle D, Title 3, Occupations Code.
(1-a)  "Health professional" means:
(A)  a physician;
(B)  an individual who is:
(i)  licensed or certified in this state to perform health care services; and
(ii)  authorized to assist:
(a)  a physician in providing telemedicine medical services that are delegated and supervised by the physician; or
(b)  a dentist in providing teledentistry dental services that are delegated and supervised by the dentist;
(C)  a licensed or certified health professional acting within the scope of the license or certification who does not perform a telemedicine medical service or a teledentistry dental service; or
(D)  a dentist.
(2)  "Physician" means a person licensed to practice medicine in this state under Subtitle B, Title 3, Occupations Code.
(2-a) "Platform" means the technology, system, software, application, modality, or other method through which a health professional remotely interfaces with a patient when providing a health care service or procedure as a telemedicine medical service or telehealth service.
(3)  "Teledentistry dental service," "telehealth service," and "telemedicine medical service" have the meanings assigned by Section 111.001, Occupations Code.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
Amended by:
Acts 2017, 85th Leg., R.S., Ch. 205 (S.B. 1107), Sec. 5, eff. January 1, 2018.
Acts 2019, 86th Leg., R.S., Ch. 1174 (H.B. 3345), Sec. 1, eff. September 1, 2019.
Acts 2021, 87th Leg., R.S., Ch. 811 (H.B. 2056), Sec. 26, eff. September 1, 2021.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1455 - Telemedicine, Teledentistry, and Telehealth › Section 1455.002. Applicability of Chapter

Sec. 1455.002.  APPLICABILITY OF CHAPTER.  This chapter applies only to a health benefit plan that:
(1)  provides benefits for medical or surgical expenses incurred as a result of a health condition, accident, or sickness, including:
(A)  an individual, group, blanket, or franchise insurance policy or insurance agreement, a group hospital service contract, or an individual or group evidence of coverage that is offered by:
(i)  an insurance company;
(ii)  a group hospital service corporation operating under Chapter 842;
(iii)  a fraternal benefit society operating under Chapter 885;
(iv)  a stipulated premium company operating under Chapter 884;  or
(v)  a health maintenance organization operating under Chapter 843;  and
(B)  to the extent permitted by the Employee Retirement Income Security Act of 1974 (29 U.S.C. Section 1001 et seq.), a health benefit plan that is offered by:
(i)  a multiple employer welfare arrangement as defined by Section 3 of that Act;  or
(ii)  another analogous benefit arrangement;  or
(2)  is offered by an approved nonprofit health corporation that holds a certificate of authority under Chapter 844.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1455 - Telemedicine, Teledentistry, and Telehealth › Section 1455.003. Exception

Sec. 1455.003.  EXCEPTION.  This chapter does not apply to:
(1)  a plan that provides coverage:
(A)  only for a specified disease;
(B)  only for accidental death or dismemberment;
(C)  for wages or payments in lieu of wages for a period during which an employee is absent from work because of sickness or injury;  or
(D)  as a supplement to a liability insurance policy;
(2)  a small employer health benefit plan written under Chapter 1501;
(3)  a Medicare supplemental policy as defined by Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss);
(4)  a workers' compensation insurance policy;
(5)  medical payment insurance coverage provided under a motor vehicle insurance policy;  or
(6)  a long-term care insurance policy, including a nursing home fixed indemnity policy, unless the commissioner determines that the policy provides benefit coverage so comprehensive that the policy is a health benefit plan as described by Section 1455.002.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1455 - Telemedicine, Teledentistry, and Telehealth › Section 1455.005. Rules

Sec. 1455.005.  RULES.  Subject to Section 111.004, Occupations Code, the commissioner may adopt rules necessary to implement this chapter.
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. 23.002(10), eff. September 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1455 - Telemedicine, Teledentistry, and Telehealth › Section 1455.006. Telemedicine Medical Services, Teledentistry Dental Services, and Telehealth Services Statement

Sec. 1455.006.  TELEMEDICINE MEDICAL SERVICES, TELEDENTISTRY DENTAL SERVICES, AND TELEHEALTH SERVICES STATEMENT.  (a)  Each issuer of a health benefit plan shall adopt and display in a conspicuous manner on the health benefit plan issuer's Internet website the issuer's policies and payment practices for telemedicine medical services, teledentistry dental services, and telehealth services.
(b)  This section does not require an issuer of a health benefit plan to display negotiated contract payment rates for health professionals who contract with the issuer to provide telemedicine medical services, teledentistry dental services, or telehealth services.
Added by Acts 2017, 85th Leg., R.S., Ch. 205 (S.B. 1107), Sec. 7, eff. January 1, 2018.
Amended by:
Acts 2021, 87th Leg., R.S., Ch. 811 (H.B. 2056), Sec. 28, eff. January 1, 2022.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1456 - Disclosure of Provider Status › Section 1456.001. Definitions

Sec. 1456.001.  DEFINITIONS.  In this chapter:
(1)  "Balance billing" means the practice of charging an enrollee in a health benefit plan that uses a provider network to recover from the enrollee the balance of a non-network health care provider's fee for service received by the enrollee from the health care provider that is not fully reimbursed by the enrollee's health benefit plan.
(2)  "Enrollee" means an individual who is eligible to receive health care services through a health benefit plan.
(3)  "Facility-based physician" means a radiologist, an anesthesiologist, a pathologist, an emergency department physician, a neonatologist, or an assistant surgeon:
(A)  to whom the facility has granted clinical privileges; and
(B)  who provides services to patients of the facility under those clinical privileges.
(4)  "Health care facility" means a hospital, emergency clinic, outpatient clinic, birthing center, ambulatory surgical center, or other facility providing health care services.
(5)  "Health care practitioner" means an individual who is licensed to provide and provides health care services.
(6)  "Provider network" means a health benefit plan under which health care services are provided to enrollees through contracts with health care providers and that requires those enrollees to use health care providers participating in the plan and procedures covered by the plan.  The term includes a network operated by:
(A)  a health maintenance organization;
(B)  a preferred provider benefit plan issuer; or
(C)  another entity that issues a health benefit plan, including an insurance company.
Added by Acts 2007, 80th Leg., R.S., Ch. 997 (S.B. 1731), Sec. 11, eff. September 1, 2007.
Amended by:
Acts 2015, 84th Leg., R.S., Ch. 467 (S.B. 481), Sec. 2, eff. September 1, 2015.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1456 - Disclosure of Provider Status › Section 1456.002. Applicability of Chapter

Sec. 1456.002.  APPLICABILITY OF CHAPTER.  (a)  This chapter applies to any health benefit plan that:
(1)  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 that is offered by:
(A)  an insurance company;
(B)  a group hospital service corporation operating under Chapter 842;
(C)  a fraternal benefit society operating under Chapter 885;
(D)  a stipulated premium company operating under Chapter 884;
(E)  a health maintenance organization operating under Chapter 843;
(F)  a multiple employer welfare arrangement that holds a certificate of authority under Chapter 846;
(G)  an approved nonprofit health corporation that holds a certificate of authority under Chapter 844; or
(H)  an entity not authorized under this code or another insurance law of this state that contracts directly for health care services on a risk-sharing basis, including a capitation basis; or
(2)  provides health and accident coverage through a risk pool created under Chapter 172, Local Government Code, notwithstanding Section 172.014, Local Government Code, or any other law.
(b)  This chapter applies to a person to whom a health benefit plan contracts to:
(1)  process or pay claims;
(2)  obtain the services of physicians or other providers to provide health care services to enrollees; or
(3)  issue verifications or preauthorizations.
Text of subsection effective until April 01, 2025
(c)  This chapter does not apply to:
(1)  Medicaid managed care programs operated under Chapter 533, Government Code;
(2)  Medicaid programs operated under Chapter 32, Human Resources Code; or
(3)  the state child health plan operated under Chapter 62 or 63, Health and Safety Code.
Text of subsection effective on April 01, 2025
(c)  This chapter does not apply to:
(1)  Medicaid managed care programs operated under Chapter 540 or 540A, Government Code, as applicable;
(2)  Medicaid programs operated under Chapter 32, Human Resources Code; or
(3)  the state child health plan operated under Chapter 62 or 63, Health and Safety Code.
Added by Acts 2007, 80th Leg., R.S., Ch. 997 (S.B. 1731), Sec. 11, eff. September 1, 2007.
Amended by:
Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 2.134, eff. April 1, 2025.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1456 - Disclosure of Provider Status › Section 1456.003. Required Disclosure: Health Benefit Plan

Sec. 1456.003.  REQUIRED DISCLOSURE:  HEALTH BENEFIT PLAN.  (a)  Each health benefit plan that provides health care through a provider network shall provide notice to its enrollees that:
(1)  a facility-based physician or other health care practitioner may not be included in the health benefit plan's provider network; and
(2)  a health care practitioner described by Subdivision (1) may balance bill the enrollee for amounts not paid by the health benefit plan unless the health care or medical service or supply provided to the enrollee is subject to a law prohibiting balance billing.
(b)  The health benefit plan shall provide the disclosure in writing to each enrollee:
(1)  in any materials sent to the enrollee in conjunction with issuance or renewal of the plan's insurance policy or evidence of coverage;
(2)  in an explanation of payment summary provided to the enrollee or in any other analogous document that describes the enrollee's benefits under the plan; and
(3)  conspicuously displayed, on any health benefit plan website that an enrollee is reasonably expected to access.
(c)  A health benefit plan must clearly identify any health care facilities within the provider network in which facility-based physicians do not participate in the health benefit plan's provider network.  Health care facilities identified under this subsection must be identified in a separate and conspicuous manner in any provider network directory or website directory.
(d)  Along with any explanation of benefits sent to an enrollee that contains a remark code indicating a payment made to a non-network physician has been paid at the health benefit plan's allowable or usual and customary amount, a health benefit plan must also include the number for the department's consumer protection division for complaints regarding payment.
Added by Acts 2007, 80th Leg., R.S., Ch. 997 (S.B. 1731), Sec. 11, eff. September 1, 2007.
Amended by:
Acts 2019, 86th Leg., R.S., Ch. 1342 (S.B. 1264), Sec. 3.01, eff. September 1, 2019.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1456 - Disclosure of Provider Status › Section 1456.004. Required Disclosure: Facility-Based Physicians

Sec. 1456.004.  REQUIRED DISCLOSURE:  FACILITY-BASED PHYSICIANS.  (a)  If a facility-based physician bills a patient who is covered by a health benefit plan described in Section 1456.002 that does not have a contract with the facility-based physician, the facility-based physician shall send a billing statement that:
(1)  contains an itemized listing of the services and supplies provided along with the dates the services and supplies were provided;
(2)  contains a conspicuous, plain-language explanation that:
(A)  the facility-based physician is not within the health plan provider network; and
(B)  the health benefit plan has paid a rate, as determined by the health benefit plan, which is below the facility-based physician billed amount;
(3)  contains a telephone number to call to discuss the statement, provide an explanation of any acronyms, abbreviations, and numbers used on the statement, or discuss any payment issues;
(4)  contains a statement that the patient may call to discuss alternative payment arrangements;
(5)  contains a notice that the patient may file complaints with the Texas Medical Board and includes the Texas Medical Board mailing address and complaint telephone number; and
(6)  for billing statements that total an amount greater than $200, over any applicable copayments or deductibles, states, in plain language, that if the patient finalizes a payment plan agreement within 45 days of receiving the first billing statement and substantially complies with the agreement, the facility-based physician may not furnish adverse information to a consumer reporting agency regarding an amount owed by the patient for the receipt of medical treatment.
(b)  A patient may be considered by the facility-based physician to be out of substantial compliance with the payment plan agreement if payments are not made in compliance with the agreement for a period of 90 days.
(c)  Repealed by Acts 2019, 86th Leg., R.S., Ch. 1342 (S.B. 1264), Sec. 3.03(1), eff. September 1, 2019.
Added by Acts 2007, 80th Leg., R.S., Ch. 997 (S.B. 1731), Sec. 11, eff. September 1, 2007.
Amended by:
Acts 2009, 81st Leg., R.S., Ch. 1290 (H.B. 2256), Sec. 3, eff. June 19, 2009.
Acts 2015, 84th Leg., R.S., Ch. 467 (S.B. 481), Sec. 3, eff. September 1, 2015.
Acts 2019, 86th Leg., R.S., Ch. 1342 (S.B. 1264), Sec. 3.03(1), eff. September 1, 2019.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1456 - Disclosure of Provider Status › Section 1456.005. Disciplinary Action and Administrative Penalty

Sec. 1456.005.  DISCIPLINARY ACTION AND ADMINISTRATIVE PENALTY.  (a)  The commissioner may take disciplinary action against a licensee that violates this chapter, in accordance with Chapter 84.
(b)  A violation of this chapter by a facility-based physician is grounds for disciplinary action and imposition of an administrative penalty by the Texas Medical Board.
(c)  The Texas Medical Board shall:
(1)  notify a facility-based physician of a finding by the Texas Medical Board that the facility-based physician is violating or has violated this chapter or a rule adopted under this chapter; and
(2)  provide the facility-based physician with an opportunity to correct the violation without penalty or reprimand.
Added by Acts 2007, 80th Leg., R.S., Ch. 997 (S.B. 1731), Sec. 11, eff. September 1, 2007.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1456 - Disclosure of Provider Status › Section 1456.006. Commissioner Rules; Form of Disclosure

Sec. 1456.006.  COMMISSIONER RULES; FORM OF DISCLOSURE.  The commissioner by rule may prescribe specific requirements for the disclosure required under Section 1456.003.  The form of the disclosure must be substantially as follows:
NOTICE: "ALTHOUGH HEALTH CARE SERVICES MAY BE OR HAVE BEEN PROVIDED TO YOU AT A HEALTH CARE FACILITY THAT IS A MEMBER OF THE PROVIDER NETWORK USED BY YOUR HEALTH BENEFIT PLAN, OTHER PROFESSIONAL SERVICES MAY BE OR HAVE BEEN PROVIDED AT OR THROUGH THE FACILITY BY PHYSICIANS AND OTHER HEALTH CARE PRACTITIONERS WHO ARE NOT MEMBERS OF THAT NETWORK. YOU MAY BE RESPONSIBLE FOR PAYMENT OF ALL OR PART OF THE FEES FOR THOSE PROFESSIONAL SERVICES THAT ARE NOT PAID OR COVERED BY YOUR HEALTH BENEFIT PLAN UNLESS BALANCE BILLING FOR THOSE SERVICES IS PROHIBITED."
Added by Acts 2007, 80th Leg., R.S., Ch. 997 (S.B. 1731), Sec. 11, eff. September 1, 2007.
Amended by:
Acts 2019, 86th Leg., R.S., Ch. 1342 (S.B. 1264), Sec. 3.02, eff. September 1, 2019.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1456 - Disclosure of Provider Status › Section 1456.007. Health Benefit Plan Estimate of Charges

Sec. 1456.007.  HEALTH BENEFIT PLAN ESTIMATE OF CHARGES.  A health benefit plan that must comply with this chapter under Section 1456.002 shall, on the request of an enrollee, provide an estimate of payments that will be made for any health care service or supply and shall also specify any deductibles, copayments, coinsurance, or other amounts for which the enrollee is responsible.  The estimate must be provided not later than the 10th business day after the date on which the estimate was requested.  A health benefit plan must advise the enrollee that:
(1)  the actual payment and charges for the services or supplies will vary based upon the enrollee's actual medical condition and other factors associated with performance of medical services; and
(2)  the enrollee may be personally liable for the payment of services or supplies based upon the enrollee's health benefit plan coverage.
Added by Acts 2007, 80th Leg., R.S., Ch. 997 (S.B. 1731), Sec. 11, eff. September 1, 2007.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1457 - Provisional Credentialing Status › Section 1457.001. Definitions

Sec. 1457.001.  DEFINITIONS.  In this chapter:
(1)  "Enrollee" means an individual who is eligible to receive health care services through a health benefit plan.
(2)  "Physician" means an individual licensed to practice medicine in this state under the authority of Subtitle B, Title 3, Occupations Code.
(3)  "Provider network" means a health benefit plan under which health care services are provided to enrollees through contracts with physicians and that requires those enrollees to use physicians participating in the plan and procedures covered by the plan.  The term includes a network operated by:
(A)  a health maintenance organization;
(B)  a preferred provider organization; or
(C)  another entity that issues a health benefit plan, including an insurance company.
Added by Acts 2005, 79th Leg., Ch. 789 (S.B. 155), Sec. 2, eff. June 17, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1457 - Provisional Credentialing Status › Section 1457.002. Provisional Credentialing Status

Sec. 1457.002.  PROVISIONAL CREDENTIALING STATUS.  (a)  A health benefit plan shall have a process for provisional credentialing status in compliance with the requirements of the National Committee for Quality Assurance.
(b)  A health benefit plan may grant provisional credentialing status to a physician who:
(1)  submits a completed standard credentialing application to the health benefit plan;
(2)  meets the health plan's requirements for provisional credentialing; and
(3)  joins as a partner, shareholder, or employee of another physician who is contracted with a health benefit plan to provide medical or health care services to enrollees.
(c)  A health benefit plan must complete the credentialing process within 60 calendar days of the date a physician is granted provisional status.  In the event the physician does not meet the health plan's credentialing standards, the physician must be provided the same appeal process as any other physician applying for participation with the health benefit plan.
Added by Acts 2005, 79th Leg., Ch. 789 (S.B. 155), Sec. 2, eff. June 17, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1458 - Provider Network Contract Arrangements › Subchapter A. General Provisions › Section 1458.002. Definition of Health Benefit Plan

Sec. 1458.002.  DEFINITION OF HEALTH BENEFIT PLAN.  (a)  In this chapter, "health benefit plan" means:
(1)  a hospital and medical expense incurred policy;
(2)  a nonprofit health care service plan contract;
(3)  a health maintenance organization subscriber contract; or
(4)  any other health care plan or arrangement that pays for or furnishes medical or health care services.
(b)  "Health benefit plan" does not include one or more or any combination of the following:
(1)  coverage only for accident or disability income insurance or any combination of those coverages;
(2)  credit-only insurance;
(3)  coverage issued as a supplement to liability insurance;
(4)  liability insurance, including general liability insurance and automobile liability insurance;
(5)  workers' compensation or similar insurance;
(6)  a discount health care program, as defined by Section 7001.001;
(7)  coverage for on-site medical clinics;
(8)  automobile medical payment insurance;
(9)  a multiple employer welfare arrangement that holds a certificate of authority under Chapter 846; or
(10)  other similar insurance coverage, as specified by federal regulations issued under the Health Insurance Portability and Accountability Act of 1996 (Pub. L. No. 104-191), under which benefits for medical care are secondary or incidental to other insurance benefits.
(c)  "Health benefit plan" does not include the following benefits if they are provided under a separate policy, certificate, or contract of insurance, or are otherwise not an integral part of the coverage:
(1)  dental or vision benefits;
(2)  benefits for long-term care, nursing home care, home health care, community-based care, or any combination of these benefits;
(3)  other similar, limited benefits, including benefits specified by federal regulations issued under the Health Insurance Portability and Accountability Act of 1996 (Pub. L. No. 104-191); or
(4)  a Medicare supplement benefit plan described by Section 1652.002.
(d)  "Health benefit plan" does not include coverage limited to a specified disease or illness or hospital indemnity coverage or other fixed indemnity insurance coverage if:
(1)  the coverage is provided under a separate policy, certificate, or contract of insurance;
(2)  there is no coordination between the provision of the coverage and any exclusion of benefits under any group health benefit plan maintained by the same plan sponsor; and
(3)  the coverage is paid with respect to an event without regard to whether benefits are provided with respect to such an event under any group health benefit plan maintained by the same plan sponsor.
Added by Acts 2013, 83rd Leg., R.S., Ch. 197 (S.B. 822), Sec. 1, eff. September 1, 2013.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1458 - Provider Network Contract Arrangements › Subchapter A. General Provisions › Section 1458.003. Exemptions

Sec. 1458.003.  EXEMPTIONS.  This chapter does not apply:
(1)  under circumstances in which access to the provider network is granted to an entity that operates under the same brand licensee program as the contracting entity; or
(2)  to a contract between a contracting entity and a discount health care program operator, as defined by Section 7001.001.
Added by Acts 2013, 83rd Leg., R.S., Ch. 197 (S.B. 822), Sec. 1, eff. September 1, 2013.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1458 - Provider Network Contract Arrangements › Subchapter A. General Provisions › Section 1458.004. Rulemaking Authority

Sec. 1458.004.  RULEMAKING AUTHORITY.  The commissioner may adopt rules to implement this chapter.
Added by Acts 2013, 83rd Leg., R.S., Ch. 197 (S.B. 822), Sec. 1, eff. September 1, 2013.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1458 - Provider Network Contract Arrangements › Subchapter B. Registration Requirements › Section 1458.051. Registration Required

Sec. 1458.051.  REGISTRATION REQUIRED.  (a)  Unless the person holds a certificate of authority issued by the department to engage in the business of insurance in this state or operates a health maintenance organization under Chapter 843, a person must register with the department not later than the 30th day after the date on which the person begins acting as a contracting entity in this state.
(b)  Notwithstanding Subsection (a), under Section 1458.055 a contracting entity that holds a certificate of authority issued by the department to engage in the business of insurance in this state or is a health maintenance organization shall file with the commissioner an application for exemption from registration under which the affiliates may access the contracting entity's network.
(c)  An application for an exemption filed under Subsection (b) must be accompanied by a list of the contracting entity's affiliates.  The contracting entity shall update the list with the commissioner on an annual basis.
(d)  A list of affiliates filed with the commissioner under Subsection (c) is public information and is not exempt from disclosure under Chapter 552, Government Code.
Added by Acts 2013, 83rd Leg., R.S., Ch. 197 (S.B. 822), Sec. 1, eff. September 1, 2013.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1458 - Provider Network Contract Arrangements › Subchapter B. Registration Requirements › Section 1458.052. Disclosure of Information

Sec. 1458.052.  DISCLOSURE OF INFORMATION.  (a)  A person required to register under Section 1458.051 must disclose:
(1)  all names used by the contracting entity, including any name under which the contracting entity intends to engage or has engaged in business in this state;
(2)  the mailing address and main telephone number of the contracting entity's headquarters;
(3)  the name and telephone number of the contracting entity's primary contact for the department; and
(4)  any other information required by the commissioner by rule.
(b)  The disclosure made under Subsection (a) must include a description or a copy of the applicant's basic organizational structure documents and a copy of organizational charts and lists that show:
(1)  the relationships between the contracting entity and any affiliates of the contracting entity, including subsidiary networks or other networks; and
(2)  the internal organizational structure of the contracting entity's management.
Added by Acts 2013, 83rd Leg., R.S., Ch. 197 (S.B. 822), Sec. 1, eff. September 1, 2013.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1458 - Provider Network Contract Arrangements › Subchapter B. Registration Requirements › Section 1458.053. Submission of Information

Sec. 1458.053.  SUBMISSION OF INFORMATION.  Information required under this subchapter must be submitted in a written or electronic format adopted by the commissioner by rule.
Added by Acts 2013, 83rd Leg., R.S., Ch. 197 (S.B. 822), Sec. 1, eff. September 1, 2013.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1458 - Provider Network Contract Arrangements › Subchapter B. Registration Requirements › Section 1458.054. Fees

Sec. 1458.054.  FEES.  The department may collect a reasonable fee set by the commissioner as necessary to administer the registration process.  Fees collected under this chapter shall be deposited in the Texas Department of Insurance operating fund.
Added by Acts 2013, 83rd Leg., R.S., Ch. 197 (S.B. 822), Sec. 1, eff. September 1, 2013.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1458 - Provider Network Contract Arrangements › Subchapter B. Registration Requirements › Section 1458.055. Exemption for Affiliates

Sec. 1458.055.  EXEMPTION FOR AFFILIATES.  (a)  The commissioner shall grant an exemption for affiliates of a contracting entity if the contracting entity holds a certificate of authority issued by the department to engage in the business of insurance in this state or is a health maintenance organization if the commissioner determines that:
(1)  the affiliate is not subject to a disclaimer of affiliation under Chapter 823; and
(2)  the relationships between the person who holds a certificate of authority and all affiliates of the person, including subsidiary networks or other networks, are disclosed and clearly defined.
(b)  An exemption granted under this section applies only to registration.  An entity granted an exemption is otherwise subject to this chapter.
Added by Acts 2013, 83rd Leg., R.S., Ch. 197 (S.B. 822), Sec. 1, eff. September 1, 2013.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1458 - Provider Network Contract Arrangements › Subchapter C. Rights and Responsibilities of a Contracting Entity › Section 1458.102. Contract Access

Sec. 1458.102.  CONTRACT ACCESS.  (a)  A contracting entity may not provide a person access to health care services or contractual discounts under a provider network contract unless the provider network contract specifically states that the person must comply with all applicable terms, limitations, and conditions of the provider network contract.
(b)  For the purposes of this section, a contracting entity shall permit reasonable access, including electronic access, during business hours for the review of the provider network contract.  The information may be used or disclosed only for the purposes of complying with the terms of the contract or state law.
Added by Acts 2013, 83rd Leg., R.S., Ch. 197 (S.B. 822), Sec. 1, eff. September 1, 2013.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1458 - Provider Network Contract Arrangements › Subchapter C. Rights and Responsibilities of a Contracting Entity › Section 1458.103. Enforcement

Sec. 1458.103.  ENFORCEMENT.  The commissioner may impose a sanction under Chapter 82 or assess an administrative penalty under Chapter 84 on a contracting entity that violates this chapter or a rule adopted to implement this chapter.
Added by Acts 2013, 83rd Leg., R.S., Ch. 197 (S.B. 822), Sec. 1, eff. September 1, 2013.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1460 - Standards Required Regarding Certain Physician Rankings by Health Benefit Plans › Section 1460.001. Definitions

Sec. 1460.001.  DEFINITIONS.  In this chapter:
(1)  "Health benefit plan issuer" means an entity authorized under this code or another insurance law of this state that provides health insurance or health benefits in this state, including:
(A)  an insurance company;
(B)  a group hospital service corporation operating under Chapter 842;
(C)  a health maintenance organization operating under Chapter 843; and
(D)  a stipulated premium company operating under Chapter 884.
(2)  "Physician" means an individual licensed to practice medicine in this state or another state of the United States.
Added by Acts 2009, 81st Leg., R.S., Ch. 652 (H.B. 1888), Sec. 1, eff. September 1, 2009.