Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter W - MISCELLANEOUS RULES FOR GROUP AND INDIVIDUAL ACCIDENT AND HEALTH INSURANCE › Section 3.3603 - Purpose and Scope

Current through Reg. 49, No. 28; July 12, 2024
(a) The purpose and
				  scope of these sections is to codify the notice requirements for the content
				  and format of seven disclosure statements which must be provided to inform
				  prospective buyers of health insurance policies about the extent to which
				  benefits under such policies duplicate Medicare benefits. The disclosure
				  statements in these sections have been developed by the National Association of
				  Insurance Commissioners and approved by the U.S. Secretary of Health and Human
				  Services. Health insurance policy issuers subject to the requirements to
				  provide such disclosure must comply with such requirements on and after August
				  11, 1995. These sections in no way impact the effective date on which issuers
				  must provide affirmative disclosure of Medicare duplication to prospective
				  insureds.
(b) On and after the
				  effective date set out by federal requirements, issuers of the policies that
				  duplicate Medicare benefits must display the applicable statement in a
				  prominent manner as part of, or together with, the application for the
				  policy.
(c) Each of the statements
				  applies to one of seven different types of health insurance policy identified
				  as needing a disclosure based on its potential to duplicate Medicare benefits,
				  even if only incidentally.
(d)
				  Issuers who fail to provide the duplication notice are in violation of both
				  federal and state law, and subject to both federal and state
				  penalties.
(e) The seven separate
				  types of health insurance policies which must be accompanied by an
				  individualized statement of the extent to which the policy duplicates Medicare
				  are listed in paragraphs (1)-(7) of this subsection. Each of these listed
				  policy types must contain the disclosure statement, which may not vary from the
				  statements set out in sections
				  3.3604-3.3309
				  and
				  3.3613
				  of this title (relating to Required Disclosure Statements for Policies That
				  Duplicate Medicare) in terms of language or format, including type size,
				  spacing, boldfacing, line spacing, and use of boxes to surround text. The
				  specific policy types are:
(1) policies that
				  provide benefits for expenses incurred for an accidental injury only;
(2) policies that provide benefits for
				  specified limited services;
(3)
				  policies that reimburse expenses incurred for specified disease or other
				  specified impairments (including cancer policies, specified disease policies
				  and other policies that limit reimbursement to named medical
				  conditions);
(4) policies that pay
				  fixed dollar amounts for specified disease or other specified impairments
				  (including cancer, specified disease policies and other policies that pay a
				  scheduled benefit or specified payment based on diagnosis of the conditions
				  named in the policy);
(5) indemnity
				  policies and other policies that pay a fixed dollar amount per day, excluding
				  long-term care policies;
(6)
				  policies that provide benefits for both expenses incurred and fixed
				  indemnity;
(7) other health
				  insurance policies not specifically identified in paragraphs (1)-(6) of this
				  subsection.