reglab/statecodes huggingface dataset:
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle B - Group Health Coverage › Chapter 1253 - Cancellation of Group Coverage in Certain Circumstances › Subchapter B. Continuation of Group Accident and Health Insurance Policies During Labor Dispute › Section 1253.059. Limitations on Continuation of Coverage

Sec. 1253.059.  LIMITATIONS ON CONTINUATION OF COVERAGE.  This subchapter does not require the continuation of coverage under a policy for any loss of time benefits included in the policy or the continuation of other coverage for a period:
(1)  longer than six months after a work stoppage occurs;
(2)  beyond the time that 75 percent of the covered employees continue the coverage;  or
(3)  as to an individual covered employee, beyond the time that the employee takes a full-time job with another employer.
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 B - Group Health Coverage › Chapter 1253 - Cancellation of Group Coverage in Certain Circumstances › Subchapter B. Continuation of Group Accident and Health Insurance Policies During Labor Dispute › Section 1253.060. Other Provisions; Commissioner Approval Required

Sec. 1253.060.  OTHER PROVISIONS;  COMMISSIONER APPROVAL REQUIRED.  A policy may contain any other provision relating to continuation of policy coverage during a work stoppage that the commissioner approves.
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 B - Group Health Coverage › Chapter 1254 - Notice of Rate Increase for Group Health and Accident Coverage › Section 1254.001. Notice of Rate Increase

Sec. 1254.001.  NOTICE OF RATE INCREASE.  (a)  In this section, "insurer" means:
(1)  a life insurance company;
(2)  a health insurance company;
(3)  an accident insurance company;
(4)  a general casualty company;
(5)  a mutual life insurance company or other mutual insurance company;
(6)  a mutual or natural premium life insurance company;
(7)  a Lloyd's plan;
(8)  a reciprocal or interinsurance exchange;
(9)  a fraternal benefit society;
(10)  a local mutual aid association;  or
(11)  a group hospital service corporation.
(b)  Not less than 60 days before the date on which a premium rate increase takes effect on a group policy of health insurance, accident and health insurance, or life, health, and accident insurance delivered or issued for delivery in this state by an insurer, the insurer shall give written notice to the policyholder of:
(1)  the amount of the increase; and
(2)  the date on which the increase is to take effect.
(c)  A health maintenance organization shall give notice of an increase in subscriber charges and service fees under a group contract or coverage in the same manner as is required of an insurer under Subsection (b).
(d)  An insurer that issues a group policy described by Subsection (b) to a multiple employer trust shall give the notice required by that subsection to the trustee or group policyholder.
(e)  The notice required by this section must be based on coverage in effect on the date of the notice.
(f)  This section may not be construed to prevent an insurer or health maintenance organization, at the request of a policyholder or contract holder, from negotiating a change in benefits or rates after delivery of the notice required by this section.
(g)  An insurer may not require a policyholder or trustee entitled to notice under this section to respond to the insurer to renew the policy or take other action relating to the renewal or extension of the policy before the 45th day after the date the notice described by Subsection (b) is given.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
Amended by:
Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.031(a), eff. September 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle B - Group Health Coverage › Chapter 1255 - Group Family Leave Insurance › Subchapter A. General Provisions › Section 1255.001. Definitions

Sec. 1255.001.  DEFINITIONS.  In this chapter:
(1)  "Continuing supervision by a health care provider" includes a period of incapacity that is permanent or long-term due to a condition for which treatment may not be effective and for which the affected individual is not receiving active treatment by a health care provider.
(2)  "Dependent" means an individual who is under 18 years of age, or 18 years of age or older and incapable of self-care due to a mental or physical disability, and is, in relation to an insured:
(A)  a biological, adopted, or foster child;
(B)  a legal ward;
(C)  a child of the insured's spouse;
(D)  a child with respect to whom the insured is a party to a suit in which the insured seeks to adopt the child; or
(E)  a child of a person to whom the insured stands in loco parentis.
(3)  "Family leave" means leave taken by an employee from work for reasons described by Section 1255.102.
(4)  "Family leave insurance" means an insurance policy issued through an employer related to a benefit program provided to an employee to pay for a portion of the employee's income loss due to family leave taken by the employee.
(5)  "Family member," in relation to an insured, includes a dependent, spouse, or parent or any other person defined as a family member in the family leave insurance policy.
(6)  "Health care provider" means a person licensed, certified, or otherwise authorized by the laws of this state to provide health care services in the ordinary course of business or practice of a profession.
(7)  "Parent" means, in relation to an insured:
(A)  a biological, adoptive, or foster parent;
(B)  a stepparent;
(C)  a legal guardian; or
(D)  a person who stood in loco parentis to the insured when the insured was a child.
(8)  "Serious health condition" means an illness, injury, impairment, or physical or mental condition, including transplantation preparation and recovery from surgery related to organ or tissue donation, that involves:
(A)  inpatient care in a hospital, hospice, or residential health care facility;
(B)  continuing treatment; or
(C)  continuing supervision by a health care provider.
Added by Acts 2023, 88th Leg., R.S., Ch. 703 (H.B. 1996), Sec. 2, eff. September 1, 2023.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle B - Group Health Coverage › Chapter 1255 - Group Family Leave Insurance › Subchapter A. General Provisions › Section 1255.002. Applicability of Chapter

Sec. 1255.002.  APPLICABILITY OF CHAPTER.  (a)  This chapter applies only to a family leave insurance policy, amendment, or rider to a group disability policy delivered or issued for delivery in this state by a life, health, and accident insurance company.
(b)  Notwithstanding Chapter 1701 and except as provided by Section 1255.108, this chapter does not apply to a certificate of family leave insurance delivered to a resident in this state if the group policy was delivered or issued for delivery in another state.
(c)  This chapter applies to an insurance company authorized to write life, health, and accident insurance in this state, including a stipulated premium company operating under Chapter 884.
(d)  This chapter does not apply to:
(1)  a society, company, or other insurer whose activities are exempt by statute from department regulation and that is entitled by statute to a certificate from the department that shows the entity's exempt status;
(2)  a credit accident and health insurance policy issued under Chapter 1153;
(3)  a workers' compensation insurance policy;
(4)  a liability insurance policy, with or without supplementary expense coverage;
(5)  a reinsurance policy or contract;
(6)  a blanket or group insurance policy, except as otherwise provided by this chapter; or
(7)  a life insurance endowment or annuity contract, or a contract supplemental to a life insurance endowment or annuity contract, if the contract or supplemental contract contains only provisions relating to accident and health insurance that:
(A)  provide additional benefits in case of accidental death, accidental dismemberment, or accidental loss of sight; or
(B)  operate to:
(i)  safeguard the contract or supplemental contract against lapse; or
(ii)  give a special surrender value, a special benefit, or an annuity if the insured or annuitant becomes totally and permanently disabled, as defined by the contract or supplemental contract.
Added by Acts 2023, 88th Leg., R.S., Ch. 703 (H.B. 1996), Sec. 2, eff. September 1, 2023.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle B - Group Health Coverage › Chapter 1255 - Group Family Leave Insurance › Subchapter A. General Provisions › Section 1255.003. Consideration as Disability Income Insurance

Sec. 1255.003.  CONSIDERATION AS DISABILITY INCOME INSURANCE.  A family leave insurance policy is considered a type of disability income insurance for all purposes under this code.
Added by Acts 2023, 88th Leg., R.S., Ch. 703 (H.B. 1996), Sec. 2, eff. September 1, 2023.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle B - Group Health Coverage › Chapter 1255 - Group Family Leave Insurance › Subchapter A. General Provisions › Section 1255.004. Application of Other Law; Conflicts

Sec. 1255.004.  APPLICATION OF OTHER LAW; CONFLICTS.  (a)  The provisions of Subchapter B, Chapter 1251, governing eligibility for group accident and health insurance apply to govern the eligibility of a group for purposes of this chapter to the extent those provisions do not conflict with this chapter. This chapter prevails over Subchapter B, Chapter 1251, if there is a conflict.
(b)  Notwithstanding any other law, the law of the state in which the group or master policy providing family leave insurance is delivered or issued for delivery governs disputes between the insurer, group policyholder, and certificate holder.
Added by Acts 2023, 88th Leg., R.S., Ch. 703 (H.B. 1996), Sec. 2, eff. September 1, 2023.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle B - Group Health Coverage › Chapter 1255 - Group Family Leave Insurance › Subchapter A. General Provisions › Section 1255.005. Rulemaking Authority

Sec. 1255.005.  RULEMAKING AUTHORITY.  The commissioner may adopt reasonable rules as necessary to implement this chapter.
Added by Acts 2023, 88th Leg., R.S., Ch. 703 (H.B. 1996), Sec. 2, eff. September 1, 2023.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle B - Group Health Coverage › Chapter 1255 - Group Family Leave Insurance › Subchapter B. Minimum Policy Standards › Section 1255.101. Compliance With Minimum Standards for Benefits

Sec. 1255.101.  COMPLIANCE WITH MINIMUM STANDARDS FOR BENEFITS.  A group family leave insurance policy must meet the minimum standards for benefits as provided by this subchapter.
Added by Acts 2023, 88th Leg., R.S., Ch. 703 (H.B. 1996), Sec. 2, eff. September 1, 2023.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle B - Group Health Coverage › Chapter 1255 - Group Family Leave Insurance › Subchapter B. Minimum Policy Standards › Section 1255.102. Family Leave Benefits

Sec. 1255.102.  FAMILY LEAVE BENEFITS.  A group family leave insurance policy may provide benefits for any leave taken by an insured from work to:
(1)  participate in providing care, including physical or psychological care, for a family member of the insured made necessary by a serious health condition of the family member;
(2)  bond with the insured's child during the first 12 months after the child's birth, or the first 12 months after the placement of the child for adoption or foster care with the insured;
(3)  address a qualifying exigency, as interpreted under the Family and Medical Leave Act of 1993 (29 U.S.C. Section 2612(a)(1)(E)) and 29 C.F.R. Sections 825.126(b)(1)-(8), arising from the fact that the spouse, dependent, or parent of the insured is on active duty or has been notified of an impending call or order to active duty in the armed forces of the United States, including the National Guard and armed forces reserves;
(4)  care for a family member described by Subdivision (3) who is injured in the line of duty; or
(5)  take other leave to provide care for a family member or other family leave as specified in the policy.
Added by Acts 2023, 88th Leg., R.S., Ch. 703 (H.B. 1996), Sec. 2, eff. September 1, 2023.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle B - Group Health Coverage › Chapter 1255 - Group Family Leave Insurance › Subchapter B. Minimum Policy Standards › Section 1255.103. Explanation of Covered Family Leave Reasons

Sec. 1255.103.  EXPLANATION OF COVERED FAMILY LEAVE REASONS.  A group family leave insurance policy must provide the details regarding and requirements for each covered family leave reason.
Added by Acts 2023, 88th Leg., R.S., Ch. 703 (H.B. 1996), Sec. 2, eff. September 1, 2023.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle B - Group Health Coverage › Chapter 1255 - Group Family Leave Insurance › Subchapter B. Minimum Policy Standards › Section 1255.104. Benefit Period

Sec. 1255.104.  BENEFIT PERIOD.  (a)  A group family leave insurance policy must establish the length of family leave benefits that are available for each covered family leave reason.
(b)  The length of family leave benefits available for a covered family leave reason may not be less than two weeks during a period of 52 consecutive calendar weeks.
(c)  A group family leave insurance policy may calculate the 52 consecutive calendar weeks by any of the following methods:
(1)  a calendar year;
(2)  a fixed period starting on a particular date, including an effective or anniversary date;
(3)  the period measured forward from the insured's first day of family leave;
(4)  a rolling period measured from the insured's first day of family leave; or
(5)  any other method that is specified in the policy.
Added by Acts 2023, 88th Leg., R.S., Ch. 703 (H.B. 1996), Sec. 2, eff. September 1, 2023.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle B - Group Health Coverage › Chapter 1255 - Group Family Leave Insurance › Subchapter B. Minimum Policy Standards › Section 1255.105. Waiting Period

Sec. 1255.105.  WAITING PERIOD.  (a)  A group family leave insurance policy must specify whether there is an unpaid waiting period.
(b)  If a group family leave insurance policy contains an unpaid waiting period, the terms of the unpaid waiting period may include:
(1)  whether the waiting period runs over a consecutive calendar day period;
(2)  whether the waiting period is counted toward the annual allotment of family leave benefits or is in addition to the annual allotment of family leave benefits;
(3)  whether the waiting period must be met only once per benefit year or must be met for each separate claim for benefits; and
(4)  whether the insured may work or receive paid time off or other compensation by the employer during the waiting period.
Added by Acts 2023, 88th Leg., R.S., Ch. 703 (H.B. 1996), Sec. 2, eff. September 1, 2023.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle B - Group Health Coverage › Chapter 1255 - Group Family Leave Insurance › Subchapter B. Minimum Policy Standards › Section 1255.106. Amount of Family Leave Benefits; Other Income

Sec. 1255.106.  AMOUNT OF FAMILY LEAVE BENEFITS; OTHER INCOME. (a) A group family leave insurance policy must specify:
(1)  the amount of benefits that will be paid for covered family leave reasons;
(2)  the definition of wages or other income on which the amount of family leave benefits is based; and
(3)  the method for calculating those wages or other income.
(b)  If the family leave benefits are subject to offsets for wages or other income received by the insured or for which the insured may be eligible, the group family leave insurance policy must specify:
(1)  which wages or other income may be offset; and
(2)  the circumstances under which the wages or other income may be offset.
Added by Acts 2023, 88th Leg., R.S., Ch. 703 (H.B. 1996), Sec. 2, eff. September 1, 2023.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle B - Group Health Coverage › Chapter 1255 - Group Family Leave Insurance › Subchapter B. Minimum Policy Standards › Section 1255.107. Permissible Limitations, Exclusions, or Reductions

Sec. 1255.107.  PERMISSIBLE LIMITATIONS, EXCLUSIONS, OR REDUCTIONS.  (a)  A group family leave insurance policy that limits, excludes, or reduces eligibility for family leave benefits under this chapter must state the limit, exclusion, or reduction in the policy.
(b)  Permissible limitations, exclusions, or reductions in the policy include a limitation, exclusion, or reduction for:
(1)  a period of family leave for which the required notice and medical certification have not been provided as prescribed by the policy;
(2)  family leave related to a serious health condition or other harm to a family member brought about by the wilful intention of the insured;
(3)  a period of family leave during which the insured performed work for compensation or profit;
(4)  a period of family leave for which the insured is eligible to receive money from the insured's employer or from a fund to which the employer has contributed;
(5)  a period of family leave in which the insured is eligible to receive benefits under another statutory program or employer-sponsored program, including unemployment insurance benefits, workers' compensation benefits, statutory disability benefits, statutory paid leave benefits, or paid time off from the employer's paid leave policy;
(6)  a period of family leave beginning before the insured becomes eligible for family leave benefits under the policy; or
(7)  periods of family leave during which more than one person covered under the policy seeks family leave for the same family member.
Added by Acts 2023, 88th Leg., R.S., Ch. 703 (H.B. 1996), Sec. 2, eff. September 1, 2023.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle B - Group Health Coverage › Chapter 1255 - Group Family Leave Insurance › Subchapter B. Minimum Policy Standards › Section 1255.108. Certificate of Insurance

Sec. 1255.108.  CERTIFICATE OF INSURANCE.  (a)  An insurer providing family leave insurance shall issue a certificate of insurance to each employee or member of the insured group.
(b)  The certificate of insurance must include:
(1)  a summary of the essential features of the paid family leave insurance coverage and benefits available to the insured;
(2)  the limitations, exclusions, or reductions;
(3)  the annual and lifetime policy limits; and
(4)  the person to whom the benefits are payable.
(c)  An insurer may file a certificate issued to an insured in this state for a group policy providing family leave insurance that was delivered or issued for delivery in another state with the department for informational purposes.
(d)  An insurer is not required to file or receive approval under Chapter 1701 for a certificate for a foreign group.
Added by Acts 2023, 88th Leg., R.S., Ch. 703 (H.B. 1996), Sec. 2, eff. September 1, 2023.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle C - Managed Care › Chapter 1271 - Benefits Provided by Health Maintenance Organizations; Evidence of Coverage; Charges › Subchapter A. General Provisions › Section 1271.001. Applicability of Definitions

Sec. 1271.001.  APPLICABILITY OF DEFINITIONS.  In this chapter, terms defined by Section 843.002 have 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 C - Managed Care › Chapter 1271 - Benefits Provided by Health Maintenance Organizations; Evidence of Coverage; Charges › Subchapter A. General Provisions › Section 1271.002. Right to Evidence of Coverage; Issuance

Sec. 1271.002.  RIGHT TO EVIDENCE OF COVERAGE;  ISSUANCE.  (a)  Each enrollee residing in this state is entitled to evidence of coverage under a health care plan.
(b)  The health maintenance organization shall issue the evidence of coverage, except as provided by Subsection (c).
(c)  If the enrollee obtains coverage under a health care plan through an insurance policy or a contract issued by a group hospital service corporation, whether by option or otherwise, the insurer or the group hospital service corporation shall issue the evidence of coverage.
(d)  By agreement between the health maintenance organization, insurer, or group hospital service corporation and the subscriber or person entitled to receive the evidence of coverage, policy, or contract, the evidence of coverage required by this section may be delivered electronically.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
Amended by:
Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.032(a), eff. September 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle C - Managed Care › Chapter 1271 - Benefits Provided by Health Maintenance Organizations; Evidence of Coverage; Charges › Subchapter A. General Provisions › Section 1271.003. Evidence of Coverage Not Health Insurance Policy

Sec. 1271.003.  EVIDENCE OF COVERAGE NOT HEALTH INSURANCE POLICY.  An evidence of coverage is not a health insurance policy as that term is defined by this 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 C - Managed Care › Chapter 1271 - Benefits Provided by Health Maintenance Organizations; Evidence of Coverage; Charges › Subchapter A. General Provisions › Section 1271.004. Individual Health Care Plan

Sec. 1271.004.  INDIVIDUAL HEALTH CARE PLAN.  (a)  In this section, "individual health care plan" means a health care plan:
(1)  that provides health care services for individuals and their dependents;
(2)  under which an enrollee:
(A)  pays the premium;  and
(B)  is not covered under the contract in accordance with a continuation of services or continuation of benefits requirement applicable under federal or state law;  and
(3)  in which the evidence of coverage meets the requirements of the definition of "basic health care services" provided by Section 843.002.
(b)  A health maintenance organization may provide an individual health care plan in accordance with this section and Section 1271.307.
(c)  A health maintenance organization may limit enrollment in an individual health care plan to individuals who reside or work within the service area for the plan's network.
(d)  The commissioner may adopt rules necessary to implement this section and to meet the minimum requirements of federal law, including regulations.
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 C - Managed Care › Chapter 1271 - Benefits Provided by Health Maintenance Organizations; Evidence of Coverage; Charges › Subchapter A. General Provisions › Section 1271.005. Applicability of Other Law

Sec. 1271.005.  APPLICABILITY OF OTHER LAW.  (a)  Chapters 1368 and 1652 apply to a health maintenance organization other than a health maintenance organization that offers only a single health care service plan.
(b)  Subchapter B, Chapter 1355, applies to a health maintenance organization providing benefits for mental health treatment in a residential treatment center for children and adolescents or crisis stabilization unit to the extent that:
(1)  Subchapter B, Chapter 1355, does not conflict with this chapter, Chapter 843, Subchapter A, Chapter 1452, or Subchapter B, Chapter 1507; and
(2)  the residential treatment center for children and adolescents or crisis stabilization unit is located within the service area of the health maintenance organization and is subject to inspection and review as required by this chapter, Chapter 843, Subchapter A, Chapter 1452, or Subchapter B, Chapter 1507, or rules adopted under this chapter, Chapter 843, Subchapter A, Chapter 1452, or Subchapter B, Chapter 1507.
(c)  A health maintenance organization shall comply with Subchapter B, Chapter 542, with respect to prompt payment to an enrollee.
(d)  Notwithstanding any other law, Subchapter C, Chapter 1355, applies to a group contract issued by a health maintenance organization.
(e)  Notwithstanding any other law, Section 1201.062 applies to an evidence of coverage issued by a health maintenance organization.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
Amended by:
Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.074(b), eff. September 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle C - Managed Care › Chapter 1271 - Benefits Provided by Health Maintenance Organizations; Evidence of Coverage; Charges › Subchapter A. General Provisions › Section 1271.006. Benefits to Dependent Child and Grandchild

Sec. 1271.006.  BENEFITS TO DEPENDENT CHILD AND GRANDCHILD.  (a)  If children are eligible for coverage under the terms of an evidence of coverage, any limiting age applicable to an unmarried child of an enrollee, including an unmarried grandchild of an enrollee, is 25 years of age.  The limiting age applicable to a child must be stated in the evidence of coverage.
(b)  A health maintenance organization may provide benefits under a health care plan to an enrollee's dependent grandchild who is living with and in the household of the enrollee.
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 C - Managed Care › Chapter 1271 - Benefits Provided by Health Maintenance Organizations; Evidence of Coverage; Charges › Subchapter A. General Provisions › Section 1271.007. Religious Convictions

Sec. 1271.007.  RELIGIOUS CONVICTIONS.  (a)  This chapter, Chapters 843, 1272, and 1367, Subchapter A, Chapter 1452, and Subchapter B, Chapter 1507, do not require a health maintenance organization, physician, or provider to recommend, offer advice concerning, pay for, provide, assist in, perform, arrange, or participate in providing or performing any health care service that violates the religious convictions of the health maintenance organization, physician, or provider.
(b)  A health maintenance organization that limits or denies health care services under this section shall state the limitations in the evidence of coverage as required by Section 1271.052.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
Amended by:
Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.074(c), eff. September 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle C - Managed Care › Chapter 1271 - Benefits Provided by Health Maintenance Organizations; Evidence of Coverage; Charges › Subchapter A. General Provisions › Section 1271.008. Balance Billing Prohibition Notice

Text of section effective until September 01, 2025
Sec. 1271.008.  BALANCE BILLING PROHIBITION NOTICE.  (a)  A health maintenance organization shall provide written notice in accordance with this section in an explanation of benefits provided to the enrollee and the physician or provider in connection with a health care service or supply or transport provided by a non-network physician or provider.  The notice must include:
(1)  a statement of the billing prohibition under Section 1271.155, 1271.157, 1271.158, or 1271.159, as applicable;
(2)  the total amount the physician or provider may bill the enrollee under the enrollee's health benefit plan and an itemization of copayments, coinsurance, deductibles, and other amounts included in that total; and
(3)  for an explanation of benefits provided to the physician or provider, information required by commissioner rule advising the physician or provider of the availability of mediation or arbitration, as applicable, under Chapter 1467.
(b)  A health maintenance organization shall provide the explanation of benefits with the notice required by this section to a physician or health care provider not later than the date the health maintenance organization makes a payment under Section 1271.155, 1271.157, 1271.158, or 1271.159, as applicable.
Added by Acts 2019, 86th Leg., R.S., Ch. 1342 (S.B. 1264), Sec. 1.02, eff. September 1, 2019.
Amended by:
Acts 2023, 88th Leg., R.S., Ch. 981 (S.B. 2476), Sec. 2(a), eff. September 1, 2023.
Acts 2023, 88th Leg., R.S., Ch. 981 (S.B. 2476), Sec. 2(b), eff. September 1, 2025.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle C - Managed Care › Chapter 1271 - Benefits Provided by Health Maintenance Organizations; Evidence of Coverage; Charges › Subchapter A. General Provisions › Section 1271.008. Balance Billing Prohibition Notice

Text of section effective on September 01, 2025
Sec. 1271.008.  BALANCE BILLING PROHIBITION NOTICE.  (a)  A health maintenance organization shall provide written notice in accordance with this section in an explanation of benefits provided to the enrollee and the physician or provider in connection with a health care service or supply provided by a non-network physician or provider.  The notice must include:
(1)  a statement of the billing prohibition under Section 1271.155, 1271.157, or 1271.158, as applicable;
(2)  the total amount the physician or provider may bill the enrollee under the enrollee's health benefit plan and an itemization of copayments, coinsurance, deductibles, and other amounts included in that total; and
(3)  for an explanation of benefits provided to the physician or provider, information required by commissioner rule advising the physician or provider of the availability of mediation or arbitration, as applicable, under Chapter 1467.
(b)  A health maintenance organization shall provide the explanation of benefits with the notice required by this section to a physician or health care provider not later than the date the health maintenance organization makes a payment under Section 1271.155, 1271.157, or 1271.158, as applicable.
Added by Acts 2019, 86th Leg., R.S., Ch. 1342 (S.B. 1264), Sec. 1.02, eff. September 1, 2019.
Amended by:
Acts 2023, 88th Leg., R.S., Ch. 981 (S.B. 2476), Sec. 2(a), eff. September 1, 2023.
Acts 2023, 88th Leg., R.S., Ch. 981 (S.B. 2476), Sec. 2(b), eff. September 1, 2025.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle C - Managed Care › Chapter 1271 - Benefits Provided by Health Maintenance Organizations; Evidence of Coverage; Charges › Subchapter B. Contents of Evidence of Coverage › Section 1271.051. Evidence of Coverage: Contract and Certificate Requirements

Sec. 1271.051.  EVIDENCE OF COVERAGE:  CONTRACT AND CERTIFICATE REQUIREMENTS.  (a)  An evidence of coverage that is a contract must contain a clear and complete statement of the information required by Sections 1271.052, 1271.053, and 1271.054.
(b)  An evidence of coverage that is a certificate must contain a reasonably complete facsimile of the information required by Sections 1271.052, 1271.053, and 1271.054.
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 C - Managed Care › Chapter 1271 - Benefits Provided by Health Maintenance Organizations; Evidence of Coverage; Charges › Subchapter B. Contents of Evidence of Coverage › Section 1271.052. Information About Benefits and Limitations

Sec. 1271.052.  INFORMATION ABOUT BENEFITS AND LIMITATIONS.  An evidence of coverage must state:
(1)  the health care services, limited health care services, or single health care service to which the enrollee is entitled under the health care plan, limited health care service plan, or single health care service plan;
(2)  the issuance of other benefits, if any, to which the enrollee is entitled under the health care plan, limited health care service plan, or single health care service plan;  and
(3)  any limitation on the services, kinds of services, benefits, or kinds of benefits to be provided, including any deductible or copayment feature.
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 C - Managed Care › Chapter 1271 - Benefits Provided by Health Maintenance Organizations; Evidence of Coverage; Charges › Subchapter B. Contents of Evidence of Coverage › Section 1271.053. Information About Obtaining Services

Sec. 1271.053.  INFORMATION ABOUT OBTAINING SERVICES.  An evidence of coverage must indicate where and in what manner information is available about how to obtain services.
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 C - Managed Care › Chapter 1271 - Benefits Provided by Health Maintenance Organizations; Evidence of Coverage; Charges › Subchapter B. Contents of Evidence of Coverage › Section 1271.054. Information About Complaints and Appeals

Sec. 1271.054.  INFORMATION ABOUT COMPLAINTS AND APPEALS.  (a)  An evidence of coverage must contain a clear and understandable description of the health maintenance organization's methods for resolving enrollee complaints, including:
(1)  the enrollee's right to appeal denial of an adverse determination to an independent review organization;  and
(2)  the procedures for appealing to an independent review organization.
(b)  A health maintenance organization may indicate a subsequent change to the methods for resolving enrollee complaints in a separate document issued to the enrollee.
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 C - Managed Care › Chapter 1271 - Benefits Provided by Health Maintenance Organizations; Evidence of Coverage; Charges › Subchapter B. Contents of Evidence of Coverage › Section 1271.055. Out-of-Network Services

Sec. 1271.055.  OUT-OF-NETWORK SERVICES.  (a)  An evidence of coverage must contain a provision regarding non-network physicians and providers in accordance with the requirements of this section.
(b)  If medically necessary covered services are not available through network physicians or providers, the health maintenance organization, on the request of a network physician or provider and within a reasonable period, shall:
(1)  allow referral to a non-network physician or provider;  and
(2)  fully reimburse the non-network physician or provider at the usual and customary rate or at an agreed rate.
(c)  Before denying a request for a referral to a non-network physician or provider, a health maintenance organization must provide for a review conducted by a specialist of the same or similar type of specialty as the physician or provider to whom the referral is requested.
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 C - Managed Care › Chapter 1271 - Benefits Provided by Health Maintenance Organizations; Evidence of Coverage; Charges › Subchapter B. Contents of Evidence of Coverage › Section 1271.056. Unfair or Deceptive Provisions and Statements Prohibited

Sec. 1271.056.  UNFAIR OR DECEPTIVE PROVISIONS AND STATEMENTS PROHIBITED.  An evidence of coverage may not contain a provision or statement that:
(1)  is unjust, unfair, inequitable, misleading, or deceptive;
(2)  encourages misrepresentation;  or
(3)  is untrue, misleading, or deceptive within the meaning of Section 843.204.
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 C - Managed Care › Chapter 1271 - Benefits Provided by Health Maintenance Organizations; Evidence of Coverage; Charges › Subchapter B. Contents of Evidence of Coverage › Section 1271.057. Discretionary Clauses Prohibited

Sec. 1271.057.  DISCRETIONARY CLAUSES PROHIBITED.  (a) An evidence of coverage may not contain a discretionary clause provision.
(b)  A discretionary clause provision includes a provision that:
(1)  purports or acts to bind the enrollee to, or grant deference in subsequent proceedings to, adverse eligibility or benefit decisions or interpretations of the evidence of coverage by the health maintenance organization; or
(2)  specifies:
(A)  that an enrollee or other claimant may not contest or appeal a denial of a benefit;
(B)  that the health maintenance organization's interpretation of the terms of an evidence of coverage or other form or its decision to deny coverage or the amount of benefits is binding on an enrollee or other claimant;
(C)  that in an appeal, the health maintenance organization's decision-making power as to the interpretation of the terms of an evidence of coverage or other form, or as to coverage, is binding; or
(D)  a standard of review in any appeal process that gives deference to the original benefit decision or provides standards of interpretation or review that are inconsistent with the laws of this state, including the common law.
Added by Acts 2011, 82nd Leg., R.S., Ch. 560 (H.B. 3017), Sec. 1, eff. June 17, 2011.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle C - Managed Care › Chapter 1271 - Benefits Provided by Health Maintenance Organizations; Evidence of Coverage; Charges › Subchapter C. Commissioner Approval › Section 1271.101. Approval of Form of Evidence of Coverage or Group Contract

Sec. 1271.101.  APPROVAL OF FORM OF EVIDENCE OF COVERAGE OR GROUP CONTRACT.  (a)  An evidence of coverage or an amendment of an evidence of coverage may not be issued or delivered to a person in this state until the form of the evidence of coverage or amendment has been filed with and approved by the commissioner.
(b)  Except as provided by Subsection (c), the form of an evidence of coverage or group contract to be used in this state or an amendment to one of those forms is subject to the filing and approval requirements of Section 1271.102.
(c)  If the form of an evidence of coverage or group contract or of an amendment to one of those forms is subject to the jurisdiction of the commissioner under laws governing health insurance or group hospital service corporations, the filing and approval provisions of those laws apply to that form.  However, Subchapters B and E apply to that form to the extent that laws governing health insurance or group hospital service corporations do not apply to the requirements of Subchapters B and E.
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 C - Managed Care › Chapter 1271 - Benefits Provided by Health Maintenance Organizations; Evidence of Coverage; Charges › Subchapter C. Commissioner Approval › Section 1271.102. Procedures for Approval of Form of Evidence of Coverage or Group Contract; Withdrawal of Approval

Sec. 1271.102.  PROCEDURES FOR APPROVAL OF FORM OF EVIDENCE OF COVERAGE OR GROUP CONTRACT;  WITHDRAWAL OF APPROVAL.  (a)  The commissioner shall, within a reasonable period, approve the form of an evidence of coverage or group contract or an amendment to one of those forms if the form meets the requirements of this chapter.
(b)  If the commissioner does not disapprove a form before the 31st day after the date the form is filed, the form is considered approved.  The commissioner may, by written notice, extend the period for approval or disapproval as necessary for proper consideration of the filing for not more than an additional 30 days.
(c)  If the commissioner disapproves a form, the commissioner shall notify the person who filed the form of the reason for the disapproval.
(d)  A hearing on the disapproval of a form shall be granted not later than the 30th day after the date the person filing the form makes a written request for a hearing.
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 C - Managed Care › Chapter 1271 - Benefits Provided by Health Maintenance Organizations; Evidence of Coverage; Charges › Subchapter C. Commissioner Approval › Section 1271.103. Withdrawal of Approval of Form

Sec. 1271.103.  WITHDRAWAL OF APPROVAL OF FORM.  (a)  After notice and opportunity for hearing, the commissioner may withdraw approval of the form of an evidence of coverage or group contract or an amendment to one of those forms if the commissioner determines that the form violates this chapter, Chapter 843, 1272, or 1367, Subchapter A, Chapter 1452, or Subchapter B, Chapter 1507, or a rule adopted by the commissioner.
(b)  If the commissioner withdraws approval of a form under this section, the form may not be issued until it is approved.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
Amended by:
Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.074(d), eff. September 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle C - Managed Care › Chapter 1271 - Benefits Provided by Health Maintenance Organizations; Evidence of Coverage; Charges › Subchapter C. Commissioner Approval › Section 1271.104. Information Required by Commissioner

Sec. 1271.104.  INFORMATION REQUIRED BY COMMISSIONER.  The commissioner may require the submission of any relevant information the commissioner considers necessary in determining whether to approve or disapprove a filing under 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 C - Managed Care › Chapter 1271 - Benefits Provided by Health Maintenance Organizations; Evidence of Coverage; Charges › Subchapter D. Certain Benefits Required › Section 1271.151. Provision of Basic Health Care Services

Sec. 1271.151.  PROVISION OF BASIC HEALTH CARE SERVICES.  A health maintenance organization that offers a basic health care plan shall provide or arrange for basic health care services to its enrollees as needed and without limitation as to time and cost other than any limitation prescribed by rule of the commissioner.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle C - Managed Care › Chapter 1271 - Benefits Provided by Health Maintenance Organizations; Evidence of Coverage; Charges › Subchapter D. Certain Benefits Required › Section 1271.152. Standards for Basic Health Care Services

Sec. 1271.152.  STANDARDS FOR BASIC HEALTH CARE SERVICES.  The commissioner may adopt minimum standards relating to basic health care services.
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 C - Managed Care › Chapter 1271 - Benefits Provided by Health Maintenance Organizations; Evidence of Coverage; Charges › Subchapter D. Certain Benefits Required › Section 1271.153. Periodic Health Evaluations

Sec. 1271.153.  PERIODIC HEALTH EVALUATIONS.  (a)  The basic health care services provided under an evidence of coverage must include periodic health evaluations for each adult enrollee.
(b)  The services provided under this section must include a health risk assessment at least once every three years and, for a female enrollee, an annual well-woman examination provided in accordance with Subchapter F, Chapter 1451.
(c)  This section does not apply to an evidence of coverage for a limited health care service plan or a single health care service 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 C - Managed Care › Chapter 1271 - Benefits Provided by Health Maintenance Organizations; Evidence of Coverage; Charges › Subchapter D. Certain Benefits Required › Section 1271.154. Well-Child Care From Birth

Sec. 1271.154.  WELL-CHILD CARE FROM BIRTH.  (a)  In this section, "well-child care from birth" has the meaning used under Section 1302, Public Health Service Act (42 U.S.C. Section 300e-1), and its subsequent amendments.  The term includes administration of newborn screening required by the Department of State Health Services and the cost of the newborn screening test kit described by Section 33.019, Health and Safety Code.
(b)  A health maintenance organization shall ensure that each health care plan provided by the health maintenance organization includes well-child care from birth that complies with:
(1)  federal requirements adopted under Chapter XI, Public Health Service Act (42 U.S.C. Section 300e et seq.), and its subsequent amendments; and
(2)  the rules adopted by the executive commissioner of the Health and Human Services Commission to implement those requirements, including rules on the cost of the newborn screening test kit described by Section 33.019, Health and Safety Code.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
Amended by:
Acts 2019, 86th Leg., R.S., Ch. 599 (S.B. 747), Sec. 4, eff. September 1, 2019.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle C - Managed Care › Chapter 1271 - Benefits Provided by Health Maintenance Organizations; Evidence of Coverage; Charges › Subchapter D. Certain Benefits Required › Section 1271.156. Benefits for Rehabilitation Services and Therapies

Sec. 1271.156.  BENEFITS FOR REHABILITATION SERVICES AND THERAPIES.  (a)  If benefits are provided for rehabilitation services and therapies under an evidence of coverage, the provision of a rehabilitation service or therapy that, in the opinion of a physician, is medically necessary may not be denied, limited, or terminated if the service or therapy meets or exceeds treatment goals for the enrollee.
(b)  For an enrollee with a physical disability, treatment goals may include maintenance of functioning or prevention of or slowing of further deterioration.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.