reglab/statecodes huggingface dataset:
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1371 - Coverage for Certain Prosthetic Devices, Orthotic Devices, and Related Services › Section 1371.002. Applicability of Chapter

Sec. 1371.002.  APPLICABILITY OF CHAPTER.  (a)  This chapter applies only to a health benefit plan, including a small employer health benefit plan written under Chapter 1501 or coverage provided by a health group cooperative under Subchapter B of that chapter, 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 Lloyd's plan operating under Chapter 941;
(7)  a health maintenance organization operating under Chapter 843;
(8)  a multiple employer welfare arrangement that holds a certificate of authority under Chapter 846; or
(9)  an approved nonprofit health corporation that holds a certificate of authority under Chapter 844.
(b)  Notwithstanding any provision in Chapter 1551, 1575, 1579, or 1601 or any other law, this chapter applies to:
(1)  a basic coverage plan under Chapter 1551;
(2)  a basic plan under Chapter 1575;
(3)  a primary care coverage plan under Chapter 1579; and
(4)  basic coverage under Chapter 1601.
Added by Acts 2009, 81st Leg., R.S., Ch. 30 (H.B. 806), Sec. 1, eff. September 1, 2009.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1371 - Coverage for Certain Prosthetic Devices, Orthotic Devices, and Related Services › Section 1371.003. Required Coverage for Prosthetic Devices, Orthotic Devices, and Related Services

Sec. 1371.003.  REQUIRED COVERAGE FOR PROSTHETIC DEVICES, ORTHOTIC DEVICES, AND RELATED SERVICES.  (a)  A health benefit plan must provide coverage for prosthetic devices, orthotic devices, and professional services related to the fitting and use of those devices that equals the coverage provided under federal laws for health insurance for the aged and disabled under Sections 1832, 1833, and 1834, Social Security Act (42 U.S.C. Sections 1395k, 1395l, and 1395m), and 42 C.F.R. Sections 410.100, 414.202, 414.210, and 414.228, as applicable.
(b)  Covered benefits under this chapter are limited to the most appropriate model of prosthetic device or orthotic device that adequately meets the medical needs of the enrollee as determined by the  enrollee's treating physician or podiatrist and prosthetist or orthotist, as applicable.
(c)  Subject to applicable copayments and deductibles, the repair and replacement of a prosthetic device or orthotic device is a covered benefit under this chapter unless the repair or replacement is necessitated by misuse or loss by the enrollee.
(d)  Coverage required under this section:
(1)  must be provided in a manner determined to be appropriate in consultation with the treating physician or podiatrist and prosthetist or orthotist, as applicable, and the enrollee;
(2)  may be subject to annual deductibles, copayments, and coinsurance that are consistent with annual deductibles, copayments, and coinsurance required for other coverage under the health benefit plan;  and
(3)  may not be subject to annual dollar limits.
(e)  Covered benefits under this chapter may be provided by a pharmacy that has employees who are qualified under the Medicare system and applicable Medicaid regulations to service and bill for orthotic services.  This chapter does not preclude a pharmacy from being reimbursed by a health benefit plan for the provision of orthotic services.
Added by Acts 2009, 81st Leg., R.S., Ch. 30 (H.B. 806), Sec. 1, eff. September 1, 2009.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1371 - Coverage for Certain Prosthetic Devices, Orthotic Devices, and Related Services › Section 1371.004. Preauthorization

Sec. 1371.004.  PREAUTHORIZATION.  A health benefit plan may require prior authorization for a prosthetic device or an orthotic device in the same manner that the health benefit plan requires prior authorization for any other covered benefit.
Added by Acts 2009, 81st Leg., R.S., Ch. 30 (H.B. 806), Sec. 1, eff. September 1, 2009.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1371 - Coverage for Certain Prosthetic Devices, Orthotic Devices, and Related Services › Section 1371.005. Managed Care Plan

Sec. 1371.005.  MANAGED CARE PLAN.  A health benefit plan provider may require that, if coverage is provided through a managed care plan, the benefits mandated under this chapter are covered benefits only if the prosthetic devices or orthotic devices are provided by a vendor or a provider, and related services are rendered by a provider, that contracts with or is designated by the health benefit plan provider.  If the health benefit plan provider provides in-network and out-of-network services, the coverage for prosthetic devices or orthotic devices provided through out-of-network services must be comparable to that provided through in-network services.
Added by Acts 2009, 81st Leg., R.S., Ch. 30 (H.B. 806), Sec. 1, eff. September 1, 2009.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1372 - Coverage for Biomarker Testing › Section 1372.001. Definitions

Sec. 1372.001.  DEFINITIONS.  In this chapter:
(1)  "Biomarker" means a characteristic that is objectively measured and evaluated as an indicator of normal biological processes, pathogenic processes, or pharmacologic responses to a specific therapeutic intervention. The term includes:
(A)  gene mutations; and
(B)  protein expression.
(2)  "Biomarker testing" means the analysis of a patient's tissue, blood, or other biospecimen for the presence of a biomarker.  The term includes:
(A)  single-analyte tests;
(B)  multiplex panel tests; and
(C)  whole genome sequencing.
(3)  "Consensus statements" means statements that:
(A)  address specific clinical circumstances based on the best available evidence for the purpose of optimizing clinical care outcomes; and
(B)  are developed by an independent, multidisciplinary panel of experts that uses a transparent methodology and reporting structure and is subject to a conflict of interest policy.
(4)  "Nationally recognized clinical practice guidelines" means evidence-based clinical practice guidelines that:
(A)  establish a standard of care informed by a systematic review of evidence and an assessment of the benefits and costs of alternative care options;
(B)  include recommendations intended to optimize patient care; and
(C)  are developed by an independent organization or medical professional society that uses a transparent methodology and reporting structure and is subject to a conflict of interest policy.
Added by Acts 2023, 88th Leg., R.S., Ch. 279 (S.B. 989), Sec. 1, eff. September 1, 2023.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1372 - Coverage for Biomarker Testing › Section 1372.002. Applicability of Chapter

Sec. 1372.002.  APPLICABILITY OF CHAPTER.  (a)  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 health maintenance organization operating under Chapter 843;
(4)  an approved nonprofit health corporation that holds a certificate of authority under Chapter 844;
(5)  a multiple employer welfare arrangement that holds a certificate of authority under Chapter 846;
(6)  a stipulated premium company operating under Chapter 884;
(7)  a fraternal benefit society operating under Chapter 885;
(8)  a Lloyd's plan operating under Chapter 941; or
(9)  an exchange operating under Chapter 942.
(b)  Notwithstanding any other law, this chapter applies to:
(1)  a small employer health benefit plan subject to Chapter 1501, including coverage provided through a health group cooperative under Subchapter B of that chapter;
(2)  a standard health benefit plan issued under Chapter 1507;
(3)  a basic coverage plan under Chapter 1551;
(4)  a basic plan under Chapter 1575;
(5)  a primary care coverage plan under Chapter 1579;
(6)  a plan providing basic coverage under Chapter 1601;
(7)  the state Medicaid program, including the Medicaid managed care program operated under Chapter 533, Government Code;
(8)  the child health plan program under Chapter 62, Health and Safety Code; and
(9)  a self-funded health benefit plan sponsored by a professional employer organization under Chapter 91, Labor Code.
Added by Acts 2023, 88th Leg., R.S., Ch. 279 (S.B. 989), Sec. 1, eff. September 1, 2023.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1372 - Coverage for Biomarker Testing › Section 1372.003. Coverage Required

Sec. 1372.003.  COVERAGE REQUIRED.  (a)  Subject to Subsection (b), a health benefit plan must provide coverage for biomarker testing for the purpose of diagnosis, treatment, appropriate management, or ongoing monitoring of an enrollee's disease or condition to guide treatment when the test is supported by the following kinds of medical and scientific evidence:
(1)  a labeled indication for a test approved or cleared by the United States Food and Drug Administration;
(2)  an indicated test for a drug approved by the United States Food and Drug Administration;
(3)  a national coverage determination made by the Centers for Medicare and Medicaid Services or a local coverage determination made by a Medicare administrative contractor;
(4)  nationally recognized clinical practice guidelines; or
(5)  consensus statements.
(b)  A health benefit plan issuer must provide coverage under Subsection (a) only when use of biomarker testing provides clinical utility because use of the test for the condition:
(1)  is evidence-based;
(2)  is scientifically valid based on the medical and scientific evidence described by Subsection (a);
(3)  informs a patient's outcome and a provider's clinical decision; and
(4)  predominately addresses the acute or chronic issue for which the test is being ordered, except that a test may include some information that cannot be immediately used in the formulation of a clinical decision.
(c)  A health benefit plan must provide coverage under Subsection (a) in a manner that limits disruptions in care, including limiting the number of biopsies and biospecimen samples.
Added by Acts 2023, 88th Leg., R.S., Ch. 279 (S.B. 989), Sec. 1, eff. September 1, 2023.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1376 - Certain Tests for Early Detection of Cardiovascular Disease › Section 1376.001. Applicability of Chapter

Sec. 1376.001.  APPLICABILITY OF CHAPTER.  (a)  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 Lloyd's plan operating under Chapter 941;
(v)  a stipulated premium company operating under Chapter 884; or
(vi)  a health maintenance organization operating under Chapter 843;
(B)  a health benefit plan that is offered by a multiple employer welfare arrangement that holds a certificate of authority under Chapter 846;
(C)  a small employer health benefit plan written under Chapter 1501; or
(D)  a Medicare supplemental policy as defined by Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss); or
(2)  is offered by an approved nonprofit health corporation operating under Chapter 844.
(b)  Notwithstanding any provision in Chapter 1601 or any other law, this chapter applies to basic coverage under Chapter 1601.
Added by Acts 2009, 81st Leg., R.S., Ch. 1270 (H.B. 1290), Sec. 1, eff. September 1, 2009.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1376 - Certain Tests for Early Detection of Cardiovascular Disease › Section 1376.002. Exceptions

Sec. 1376.002.  EXCEPTIONS.  This chapter does not apply to:
(1)  a plan that provides coverage:
(A)  only for a specified disease or other limited benefit;
(B)  only for accidental death or dismemberment;
(C)  for wages or payments in lieu of wages for a period during which an employee is absent from work because of sickness or injury;
(D)  as a supplement to a liability insurance policy; or
(E)  only for indemnity for hospital confinement;
(2)  a standard health benefit plan issued under Chapter 1507;
(3)  a workers' compensation insurance policy;
(4)  medical payment insurance coverage provided under a motor vehicle insurance policy; or
(5)  a long-term care policy, including a nursing home fixed indemnity policy, unless the commissioner determines that the policy provides benefit coverage so comprehensive that the policy is a health benefit plan as described by Section 1376.001.
Added by Acts 2009, 81st Leg., R.S., Ch. 1270 (H.B. 1290), Sec. 1, eff. September 1, 2009.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1376 - Certain Tests for Early Detection of Cardiovascular Disease › Section 1376.003. Minimum Coverage Required

Sec. 1376.003.  MINIMUM COVERAGE REQUIRED.  (a)  A health benefit plan that provides coverage for screening medical procedures must provide the minimum coverage required by this section to each covered individual:
(1)  who is:
(A)  a male older than 45 years of age and younger than 76 years of age; or
(B)  a female older than 55 years of age and younger than 76 years of age; and
(2)  who:
(A)  is diabetic; or
(B)  has a risk of developing coronary heart disease, based on a score derived using the Framingham Heart Study coronary prediction algorithm, that is intermediate or higher.
(b)  The minimum coverage required to be provided under this section is coverage of up to $200 for one of the following noninvasive screening tests for atherosclerosis and abnormal artery structure and function every five years, performed by a laboratory that is certified by a national organization recognized by the commissioner by rule for the purposes of this section:
(1)  computed tomography (CT) scanning measuring coronary artery calcification; or
(2)  ultrasonography measuring carotid intima-media thickness and plaque.
Added by Acts 2009, 81st Leg., R.S., Ch. 1270 (H.B. 1290), Sec. 1, eff. September 1, 2009.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1377 - Coverage for Certain Amino Acid-Based Elemental Formulas › Subchapter A. General Provisions › Section 1377.001. Definition

Sec. 1377.001.  DEFINITION.  In this chapter, "enrollee" means an individual entitled to coverage under a health benefit plan.
Added by Acts 2009, 81st Leg., R.S., Ch. 1129 (H.B. 2000), Sec. 1, eff. September 1, 2009.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1377 - Coverage for Certain Amino Acid-Based Elemental Formulas › Subchapter A. General Provisions › Section 1377.002. Applicability of Chapter

Sec. 1377.002.  APPLICABILITY OF CHAPTER.  (a)  This chapter applies only to a health benefit plan, including a small employer health benefit plan written under Chapter 1501 or coverage provided by a health group cooperative under Subchapter B of that chapter, 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)  an exchange operating under Chapter 942;
(6)  a Lloyd's plan operating under Chapter 941;
(7)  a health maintenance organization operating under Chapter 843;
(8)  a multiple employer welfare arrangement that holds a certificate of authority under Chapter 846; or
(9)  an approved nonprofit health corporation that holds a certificate of authority under Chapter 844.
(b)  Notwithstanding any provision in Chapter 1551, 1575, 1579, or 1601 or any other law, this chapter applies to:
(1)  a basic coverage plan under Chapter 1551;
(2)  a basic plan under Chapter 1575;
(3)  a primary care coverage plan under Chapter 1579; and
(4)  basic coverage under Chapter 1601.
Added by Acts 2009, 81st Leg., R.S., Ch. 1129 (H.B. 2000), Sec. 1, eff. September 1, 2009.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1377 - Coverage for Certain Amino Acid-Based Elemental Formulas › Subchapter A. General Provisions › Section 1377.003. Exception

Sec. 1377.003.  EXCEPTION.  This chapter does not apply to:
(1)  a plan that provides coverage:
(A)  only for benefits for a specified disease or  for another limited benefit, other than a plan that provides benefits for a disease or disorder listed in Section 1377.051(a);
(B)  only for accidental death or dismemberment;
(C)  for wages or payments in lieu of wages for a period during which an employee is absent from work because of sickness or injury;
(D)  as a supplement to a liability insurance policy;
(E)  only for dental or vision care; or
(F)  only for indemnity for hospital confinement;
(2)  a Medicare supplemental policy as defined by Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss);
(3)  a workers' compensation insurance policy;
(4)  medical payment insurance coverage provided under an automobile insurance policy;
(5)  a credit insurance policy;
(6)  a limited benefit policy that does not provide coverage for physical examinations or wellness exams; or
(7)  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 1377.002.
Added by Acts 2009, 81st Leg., R.S., Ch. 1129 (H.B. 2000), Sec. 1, eff. September 1, 2009.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1377 - Coverage for Certain Amino Acid-Based Elemental Formulas › Subchapter B. Coverage for Certain Amino Acid-Based Elemental Formulas › Section 1377.051. Required Coverage for Certain Amino Acid-Based Elemental Formulas

Sec. 1377.051.  REQUIRED COVERAGE FOR CERTAIN AMINO ACID-BASED ELEMENTAL FORMULAS.  (a)  A health benefit plan must provide coverage as provided by this chapter for amino acid-based elemental formulas, regardless of the formula delivery method, that are used for the diagnosis and treatment of:
(1)  immunoglobulin E and non-immunoglobulin E mediated allergies to multiple food proteins;
(2)  severe food protein-induced enterocolitis syndrome;
(3)  eosinophilic disorders, as evidenced by the results of a biopsy; and
(4)  impaired absorption of nutrients caused by disorders affecting the absorptive surface, functional length, and motility of the gastrointestinal tract.
(b)  Subject to Subsection (c), the coverage required under Subsection (a) is required if the treating physician has issued a written order stating that the amino acid-based elemental formula is medically necessary for the treatment of an enrollee who is diagnosed with a disease or disorder listed in Subsection (a). The coverage must include coverage of any medically necessary services associated with the administration of the formula.
(c)  A health benefit plan must provide the coverage described by Subsection (a) on a basis no less favorable than the basis on which prescription drugs and other medications and related services are covered by the plan, and to the same extent that the plan provides coverage for drugs that are available only on the orders of a physician.
Added by Acts 2009, 81st Leg., R.S., Ch. 1129 (H.B. 2000), Sec. 1, eff. September 1, 2009.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1377 - Coverage for Certain Amino Acid-Based Elemental Formulas › Subchapter B. Coverage for Certain Amino Acid-Based Elemental Formulas › Section 1377.052. Utilization Review

Sec. 1377.052.  UTILIZATION REVIEW.  (a)  A utilization review agent acting on behalf of a health benefit plan issuer may review a treating physician's determination of the medical necessity of the use of an amino acid-based elemental formula for the treatment of an enrollee who is diagnosed with a disease or disorder listed in Section 1377.051(a).
(b)  Utilization review under this section is subject to Chapter 4201.
Added by Acts 2009, 81st Leg., R.S., Ch. 1129 (H.B. 2000), Sec. 1, eff. September 1, 2009.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1379 - Coverage for Routine Patient Care Costs for Enrollees Participating in Certain Clinical Trials › Subchapter A. General Provisions › Section 1379.001. Definitions

Sec. 1379.001.  DEFINITIONS.  In this chapter:
(1)  "Enrollee" means an individual entitled to coverage under a health benefit plan.
(2)  "Life-threatening disease or condition" means a disease or condition from which the likelihood of death is probable unless the course of the disease or condition is interrupted.
(3)  "Research institution" means the institution or other person or entity conducting a phase I, phase II, phase III, or phase IV clinical trial.
Added by Acts 2009, 81st Leg., R.S., Ch. 719 (S.B. 39), Sec. 1, eff. September 1, 2009.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1379 - Coverage for Routine Patient Care Costs for Enrollees Participating in Certain Clinical Trials › Subchapter A. General Provisions › Section 1379.002. Applicability of Chapter

Sec. 1379.002.  APPLICABILITY OF CHAPTER.  (a)  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)  an exchange operating under Chapter 942;
(6)  a health maintenance organization operating under Chapter 843;
(7)  a multiple employer welfare arrangement that holds a certificate of authority under Chapter 846; or
(8)  an approved nonprofit health corporation that holds a certificate of authority under Chapter 844.
(b)  This chapter applies to group health coverage made available by a school district in accordance with Section 22.004, Education Code.
(c)  Notwithstanding any provision in Chapter 1551, 1575, 1579, or 1601 or any other law, this chapter applies to:
(1)  a basic coverage plan under Chapter 1551;
(2)  a basic plan under Chapter 1575;
(3)  a primary care coverage plan under Chapter 1579; and
(4)  basic coverage under Chapter 1601.
(d)  Notwithstanding Section 1501.251 or any other law, this chapter applies to coverage under a small employer health benefit plan subject to Chapter 1501.
Added by Acts 2009, 81st Leg., R.S., Ch. 719 (S.B. 39), Sec. 1, eff. September 1, 2009.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1379 - Coverage for Routine Patient Care Costs for Enrollees Participating in Certain Clinical Trials › Subchapter A. General Provisions › Section 1379.003. Applicability to Certain Government Programs

Sec. 1379.003.  APPLICABILITY TO CERTAIN GOVERNMENT PROGRAMS.  To the extent allowed by federal law, the state Medicaid program, and a managed care organization that contracts with the Health and Human Services Commission to provide health care services to Medicaid recipients through a managed care plan, shall provide the benefits required under this chapter to a Medicaid recipient.
Added by Acts 2009, 81st Leg., R.S., Ch. 719 (S.B. 39), Sec. 1, eff. September 1, 2009.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1379 - Coverage for Routine Patient Care Costs for Enrollees Participating in Certain Clinical Trials › Subchapter A. General Provisions › Section 1379.004. Exception

Sec. 1379.004.  EXCEPTION.  This chapter does not apply to:
(1)  a plan that provides coverage:
(A)  for wages or payments in lieu of wages for a period during which an employee is absent from work because of sickness or injury;
(B)  as a supplement to a liability insurance policy;
(C)  for credit insurance;
(D)  for a specified disease or diseases;
(E)  only for dental or vision care;
(F)  only for hospital expenses; or
(G)  only for indemnity for hospital confinement;
(2)  a Medicare supplemental policy as defined by Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss);
(3)  a workers' compensation insurance policy;
(4)  medical payment insurance coverage provided under a motor vehicle insurance policy; or
(5)  a long-term care policy, including a nursing home fixed indemnity policy, unless the commissioner determines that the policy provides benefit coverage so comprehensive that the policy is a health benefit plan as described by Section 1379.002.
Added by Acts 2009, 81st Leg., R.S., Ch. 719 (S.B. 39), Sec. 1, eff. September 1, 2009.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1379 - Coverage for Routine Patient Care Costs for Enrollees Participating in Certain Clinical Trials › Subchapter A. General Provisions › Section 1379.005. Rules

Sec. 1379.005.  RULES.  The commissioner, in accordance with Subchapter A, Chapter 36, may adopt rules to implement this chapter.
Added by Acts 2009, 81st Leg., R.S., Ch. 719 (S.B. 39), Sec. 1, eff. September 1, 2009.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1379 - Coverage for Routine Patient Care Costs for Enrollees Participating in Certain Clinical Trials › Subchapter B. Coverage for Routine Patient Care Costs › Section 1379.051. Routine Patient Care Costs

Sec. 1379.051.  ROUTINE PATIENT CARE COSTS.  For purposes of this chapter, routine patient care costs means the costs of any medically necessary health care service for which benefits are provided under a health benefit plan, without regard to whether the enrollee is participating in a clinical trial.  Routine patient care costs do not include:
(1)  the cost of an investigational new drug or device that is not approved for any indication by the United States Food and Drug Administration, including a drug or device that is the subject of the clinical trial;
(2)  the cost of a service that is not a health care service, regardless of whether the service is required in connection with participation in a clinical trial;
(3)  the cost of a service that is clearly inconsistent with widely accepted and established standards of care for a particular diagnosis;
(4)  a cost associated with managing a clinical trial; or
(5)  the cost of a health care service that is specifically excluded from coverage under a health benefit plan.
Added by Acts 2009, 81st Leg., R.S., Ch. 719 (S.B. 39), Sec. 1, eff. September 1, 2009.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1379 - Coverage for Routine Patient Care Costs for Enrollees Participating in Certain Clinical Trials › Subchapter B. Coverage for Routine Patient Care Costs › Section 1379.052. Coverage Required

Sec. 1379.052.  COVERAGE REQUIRED.  A health benefit plan issuer shall provide benefits for routine patient care costs to an enrollee in connection with a phase I, phase II, phase III, or phase IV clinical trial if the clinical trial is conducted in relation to the prevention, detection, or treatment of a life-threatening disease or condition and is approved by:
(1)  the Centers for Disease Control and Prevention of the United States Department of Health and Human Services;
(2)  the National Institutes of Health;
(3)  the United States Food and Drug Administration;
(4)  the United States Department of Defense;
(5)  the United States Department of Veterans Affairs; or
(6)  an institutional review board of an institution in this state that has an agreement with the Office for Human Research Protections of the United States Department of Health and Human Services.
Added by Acts 2009, 81st Leg., R.S., Ch. 719 (S.B. 39), Sec. 1, eff. September 1, 2009.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1379 - Coverage for Routine Patient Care Costs for Enrollees Participating in Certain Clinical Trials › Subchapter B. Coverage for Routine Patient Care Costs › Section 1379.053. Research Institution

Sec. 1379.053.  RESEARCH INSTITUTION.  (a)  A health benefit plan issuer is not required to reimburse the research institution conducting the clinical trial for the cost of routine patient care provided through the research institution unless the research institution, and each health care professional providing routine patient care through the research institution, agrees to accept reimbursement under the health benefit plan, at the rates that are established under the plan, as payment in full for the routine patient care provided in connection with the clinical trial.
(b)  A health benefit plan issuer is not required to provide benefits under this section for services that are a part of the subject matter of the clinical trial and that are customarily paid for by the research institution conducting the clinical trial.
Added by Acts 2009, 81st Leg., R.S., Ch. 719 (S.B. 39), Sec. 1, eff. September 1, 2009.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1379 - Coverage for Routine Patient Care Costs for Enrollees Participating in Certain Clinical Trials › Subchapter B. Coverage for Routine Patient Care Costs › Section 1379.054. Limitations on Coverage

Sec. 1379.054.  LIMITATIONS ON COVERAGE.  (a)  Notwithstanding Section 1379.053, this chapter does not require a health benefit plan issuer to provide benefits for routine patient care services provided outside of the plan's health care provider network unless out-of-network benefits are otherwise provided under the plan.
(b)  This chapter does not require a health benefit plan issuer to provide benefits for health care services provided outside this state unless the health benefit plan otherwise provides benefits for health care services provided outside this state.
Added by Acts 2009, 81st Leg., R.S., Ch. 719 (S.B. 39), Sec. 1, eff. September 1, 2009.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1379 - Coverage for Routine Patient Care Costs for Enrollees Participating in Certain Clinical Trials › Subchapter B. Coverage for Routine Patient Care Costs › Section 1379.055. Deductible, Coinsurance, and Copayment Requirements

Sec. 1379.055.  DEDUCTIBLE, COINSURANCE, AND COPAYMENT REQUIREMENTS.  The benefits required under this chapter may be made subject to a deductible, coinsurance, or copayment requirement comparable to other deductible, coinsurance, or copayment requirements applicable under the health benefit plan.
Added by Acts 2009, 81st Leg., R.S., Ch. 719 (S.B. 39), Sec. 1, eff. September 1, 2009.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1379 - Coverage for Routine Patient Care Costs for Enrollees Participating in Certain Clinical Trials › Subchapter B. Coverage for Routine Patient Care Costs › Section 1379.056. Cancellation or Nonrenewal Prohibited

Sec. 1379.056.  CANCELLATION OR NONRENEWAL PROHIBITED.  The issuer of a health benefit plan may not cancel or refuse to renew coverage under a plan solely because an enrollee in the plan participates in a clinical trial described by Section 1379.052.
Added by Acts 2009, 81st Leg., R.S., Ch. 719 (S.B. 39), Sec. 1, eff. September 1, 2009.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1380 - Human Organ Transplant › Section 1380.001. Definition

Sec. 1380.001.  DEFINITION.  In this chapter, "forced organ harvesting" means the removal of one or more organs from a living person by means of coercion, abduction, deception, fraud, or abuse of power or a position of vulnerability.
Added by Acts 2023, 88th Leg., R.S., Ch. 1155 (S.B. 1040), Sec. 1, eff. September 1, 2023.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1380 - Human Organ Transplant › Section 1380.002. Applicability of Chapter

Sec. 1380.002.  APPLICABILITY OF CHAPTER.  (a)  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 health maintenance organization operating under Chapter 843;
(4)  an approved nonprofit health corporation that holds a certificate of authority under Chapter 844;
(5)  a multiple employer welfare arrangement that holds a certificate of authority under Chapter 846;
(6)  a stipulated premium company operating under Chapter 884;
(7)  a fraternal benefit society operating under Chapter 885;
(8)  a Lloyd's plan operating under Chapter 941; or
(9)  an exchange operating under Chapter 942.
(b)  Notwithstanding any other law, this chapter applies to:
(1)  a small employer health benefit plan subject to Chapter 1501, including coverage provided through a health group cooperative under Subchapter B of that chapter;
(2)  a standard health benefit plan issued under Chapter 1507;
(3)  a basic coverage plan under Chapter 1551;
(4)  a basic plan under Chapter 1575;
(5)  a primary care coverage plan under Chapter 1579;
(6)  a plan providing basic coverage under Chapter 1601;
(7)  health benefits provided by or through a church benefits board under Subchapter I, Chapter 22, Business Organizations Code;
(8)  the state Medicaid program, including the Medicaid managed care program operated under Chapter 533, Government Code;
(9)  the child health plan program under Chapter 62, Health and Safety Code;
(10)  a regional or local health care program operated under Section 75.104, Health and Safety Code;
(11)  a self-funded health benefit plan sponsored by a professional employer organization under Chapter 91, Labor Code;
(12)  county employee group health benefits provided under Chapter 157, Local Government Code; and
(13)  health and accident coverage provided by a risk pool created under Chapter 172, Local Government Code.
Added by Acts 2023, 88th Leg., R.S., Ch. 1155 (S.B. 1040), Sec. 1, eff. September 1, 2023.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1380 - Human Organ Transplant › Section 1380.003. Coverage Prohibited

Sec. 1380.003.  COVERAGE PROHIBITED.  (a)  A health benefit plan issuer may not cover a human organ transplant or post-transplant care if:
(1)  the transplant operation is performed in China or another country known to have participated in forced organ harvesting, as designated by the commissioner of state health services; or
(2)  the human organ to be transplanted was procured by a sale or donation originating in China or another country known to have participated in forced organ harvesting, as designated by the commissioner of state health services.
(b)  The commissioner of state health services may designate additional countries with governments that fund, sponsor, or otherwise facilitate forced organ harvesting and shall provide written notice to the commissioner, Teacher Retirement System of Texas, Employees Retirement System of Texas, and executive commissioner of the Health and Human Services Commission when the commissioner of state health services designates an additional country.
Added by Acts 2023, 88th Leg., R.S., Ch. 1155 (S.B. 1040), Sec. 1, eff. September 1, 2023.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1425 - Application of Subtitle to Certain Coverage › Subchapter A. Excepted Benefits › Section 1425.001. Exemption From Application of Subtitle

Sec. 1425.001.  EXEMPTION FROM APPLICATION OF SUBTITLE.  (a)  Except as provided by Section 1425.002, a provision of this subtitle that becomes effective on or after January 2, 2010, does not apply to:
(1)  a plan that provides coverage only:
(A)  for a specified disease or diseases or under an individual limited benefit policy;
(B)  for accidental death or dismemberment;
(C)  as a supplement to a liability insurance policy; or
(D)  for dental or vision care;
(2)  disability income insurance coverage or a combination of accident-only and disability income insurance coverage;
(3)  credit insurance coverage;
(4)  a hospital confinement indemnity policy;
(5)  a Medicare supplemental policy as defined by Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss);
(6)  a workers' compensation insurance policy;
(7)  medical payment insurance coverage provided under a motor vehicle insurance policy;
(8)  a long-term care insurance policy, including a nursing home fixed indemnity policy, except as provided by Subsection (b); or
(9)  an occupational accident policy.
(b)  A long-term care insurance policy, including a nursing home fixed indemnity policy, is subject to this subtitle if the commissioner determines that the policy provides benefits so comprehensive that it is a health benefit plan and should not be subject to the exemption provided under this section.
Added by Acts 2009, 81st Leg., R.S., Ch. 228 (S.B. 1479), Sec. 1, eff. May 27, 2009.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1425 - Application of Subtitle to Certain Coverage › Subchapter A. Excepted Benefits › Section 1425.002. Specific Language Controls

Sec. 1425.002.  SPECIFIC LANGUAGE CONTROLS.  A provision of this subtitle that becomes effective on or after January 2, 2010, and that requires coverage or the offer of coverage of a health care service or benefit applies to a plan or policy described by Section 1425.001(a) only to the extent expressly and specifically provided by law.
Added by Acts 2009, 81st Leg., R.S., Ch. 228 (S.B. 1479), Sec. 1, eff. May 27, 2009.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1425 - Application of Subtitle to Certain Coverage › Subchapter B. Benefits Requiring Defrayal › Section 1425.051. Definition

Sec. 1425.051.  DEFINITION.  In this subchapter, "qualified health plan" has the meaning assigned by 45 C.F.R. Section 155.20.
Added by Acts 2021, 87th Leg., R.S., Ch. 890 (S.B. 2016), Sec. 3, eff. June 16, 2021.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1425 - Application of Subtitle to Certain Coverage › Subchapter B. Benefits Requiring Defrayal › Section 1425.052. Exemption From Subtitle for Benefits Requiring Defrayal

Sec. 1425.052.  EXEMPTION FROM SUBTITLE FOR BENEFITS REQUIRING DEFRAYAL.  (a)  A provision of this subtitle that is enacted on or after January 1, 2012, does not apply to a qualified health plan if a determination is made under 45 C.F.R. Section 155.170 that:
(1)  the provision requires the qualified health plan to offer benefits in addition to the essential health benefits required under 42 U.S.C. Section 18022(b); and
(2)  this state must make payments to defray the cost of the additional benefits mandated by the provision.
(b)  If a determination described by Subsection (a) is made as to a qualified health plan, the provision to which the determination relates does not apply to a non-qualified health plan if the non-qualified health plan is offered in the same market as the qualified health plan.
Added by Acts 2021, 87th Leg., R.S., Ch. 890 (S.B. 2016), Sec. 3, eff. June 16, 2021.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1451 - Access to Certain Practitioners and Facilities › Subchapter B. Designation of Practitioners Under Accident and Health Insurance Policy › Section 1451.051. Applicability of Subchapter

Sec. 1451.051.  APPLICABILITY OF SUBCHAPTER.  (a)  This subchapter applies to an accident and health insurance policy, including an individual, blanket, or group policy.
(b)  This subchapter applies to an accident and health insurance policy issued by a stipulated premium company subject to Chapter 884.
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 1451 - Access to Certain Practitioners and Facilities › Subchapter B. Designation of Practitioners Under Accident and Health Insurance Policy › Section 1451.052. Applicability of General Provisions of Other Law

Sec. 1451.052.  APPLICABILITY OF GENERAL PROVISIONS OF OTHER LAW.  The provisions of Chapter 1201, including provisions relating to the applicability, purpose, and enforcement of that chapter, the construction of policies under that chapter, rulemaking under that chapter, and definitions of terms applicable in that chapter, apply to this subchapter.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1451 - Access to Certain Practitioners and Facilities › Subchapter B. Designation of Practitioners Under Accident and Health Insurance Policy › Section 1451.053. Practitioner Designation

Sec. 1451.053.  PRACTITIONER DESIGNATION.  (a)  An accident and health insurance policy may not make a benefit contingent on treatment or examination by one or more particular health care practitioners listed in Section 1451.001 unless the policy contains a provision that designates the practitioners whom the insurer will and will not recognize.
(b)  The insurer may include the provision anywhere in the policy or in an endorsement attached to the policy.
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 1451 - Access to Certain Practitioners and Facilities › Subchapter B. Designation of Practitioners Under Accident and Health Insurance Policy › Section 1451.054. Terms Used to Designate Health Care Practitioners

Sec. 1451.054.  TERMS USED TO DESIGNATE HEALTH CARE PRACTITIONERS.  A provision of an accident and health insurance policy that designates the health care practitioners whom the insurer will and will not recognize must use the terms defined by Section 1451.001 with the meanings assigned by that section.
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 1451 - Access to Certain Practitioners and Facilities › Subchapter C. Selection of Practitioners › Section 1451.101. Definitions

Sec. 1451.101.  DEFINITIONS.  In this subchapter:
(1)  "Health insurance policy" means a policy, contract, or agreement described by Section 1451.102.
(2)  "Insured" means an individual who is issued, is a party to, or is a beneficiary under a health insurance policy.
(3)  "Insurer" means an insurer, association, or organization described by Section 1451.102.
(4)  "Nurse first assistant" has the meaning assigned by Section 301.1525, Occupations Code.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.