reglab/statecodes huggingface dataset:
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter KK - HEALTH CARE REIMBURSEMENT RATE INFORMATION › Section 21.4501 - Purpose

Current through Reg. 49, No. 28; July 12, 2024
The purpose of this subchapter is to:
(1) prescribe the data collection and
				  submission requirements for the submission of data related to health care
				  reimbursement rates by health benefit plan issuers;
(2) specify the definitions necessary to
				  implement Insurance Code Chapter 38, Subchapter H; and
(3) facilitate TDI's publication of aggregate
				  health care reimbursement rate information derived from the data collected
				  under this subchapter.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter KK - HEALTH CARE REIMBURSEMENT RATE INFORMATION › Section 21.4502 - Applicability

Current through Reg. 49, No. 28; July 12, 2024
(a) This subchapter applies to the issuer of
				  an applicable health benefit plan as defined in §
										21.4503 of
				  this title and as provided by Insurance Code §
										38.353(a):
(1) an insurance company;
(2) a group hospital service
				  corporation;
(3) a fraternal
				  benefit society;
(4) a stipulated
				  premium company;
(5) a reciprocal
				  or interinsurance exchange; and
(6)
				  a health maintenance organization (HMO).
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter KK - HEALTH CARE REIMBURSEMENT RATE INFORMATION › Section 21.4504 - Geographic Regions

Current through Reg. 49, No. 28; July 12, 2024
Issuers must report data collected under this subchapter
					 according to the three-digit ZIP code in which the health care service was
					 provided. Publication of health care reimbursement rate information derived
					 from the data collected under this subchapter may be aggregated by TDI across
					 broader geographic regions if necessary to ensure, consistent with Insurance
					 Code §
										38.357,
					 that the published information does not reveal the name of any provider or
					 health benefit plan issuer.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter KK - HEALTH CARE REIMBURSEMENT RATE INFORMATION › Section 21.4505 - Requirement to Collect Data

Current through Reg. 49, No. 28; July 12, 2024
(a) Each
				  applicable health benefit plan issuer and plan specified in §
										21.4502(a) and
				  (b) of this title must annually collect the
				  data specified under §
										21.4507
				  of this title and prepare and file data as provided.
(b) Data elements and health care services
				  specified under §
										21.4507(b) and
				  (c) of this title must be collected with
				  respect to medical billing codes specified by TDI. The current set of medical
				  billing codes will be available to issuers in a Microsoft Excel template on
				  TDI's website at www.tdi.texas.gov/health/reimbursement.html. If there are
				  changes in standard medical practice or medical billing codes that necessitate
				  changing the identified billing codes for the services specified in §
										21.4507(c)
				  of this title, the billing codes on TDI's website will be updated and affected
				  carriers notified, but in no event will these updates occur more often than
				  annually or less than six months before the May 1 reporting deadline.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter KK - HEALTH CARE REIMBURSEMENT RATE INFORMATION › Section 21.4506 - Submission of Report

Current through Reg. 49, No. 28; July 12, 2024
(a) Not later than
				  May 1 of each year, each plan and applicable health benefit plan issuer
				  identified in §
										21.4502(a) and
				  (b) of this title, or the plan or issuer's
				  authorized agent must submit to TDI the data required under §
										21.4507
				  of this title.
(b) The data filed
				  under this section is required to be filed electronically as a Microsoft Excel
				  form and emailed to TDI at ReimbursementRates@tdi.texas.gov, or uploaded by
				  secure File Transfer Protocol (FTP).
(c) Issuers may meet the requirements of this
				  subchapter by submitting data using the Microsoft Excel template available on
				  TDI's website at www.tdi.texas.gov/health/reimbursement.html.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter KK - HEALTH CARE REIMBURSEMENT RATE INFORMATION › Section 21.4507 - Data Required

Current through Reg. 49, No. 28; July 12, 2024
(a) Applicable
				  health benefit plans must include the following information as a cover page to
				  each report:
(1) reporting period;
(2) company or plan name;
(3) NAIC number, issued to the company by the
				  National Association of Insurance Commissioners;
(4) TDI company number;
(5) contact information for the person
				  designated to discuss the report with TDI staff, including name, telephone
				  number, and email address;
(6) an
				  indication of whether the report is for insurance business or HMO business,
				  consistent with subsection (d) of this section, or "NA" for reports limited to
				  self-insured business;
(7) an
				  indication of whether the report includes data on self-insured business,
				  including data for certain governmental plans required to report under
				  Insurance Code Chapter 38, Subchapter H; and
(8) a certification that the information
				  provided is a full and true statement of the data required under this
				  subchapter.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter MM - WELLNESS PROGRAMS › Section 21.4701 - Applicability and Scope

Current through Reg. 49, No. 28; July 12, 2024
This subchapter applies to any small employer health
					 benefit plan issuer, any large employer health benefit plan issuer, any insurer
					 issuing an individual or group accident and health insurance policy, or any
					 health maintenance organization evidence of coverage, with respect to a policy
					 or plan that establishes premium discounts, rebates, or reductions in otherwise
					 applicable copayments, coinsurance, or deductibles, or any combination of these
					 incentives, in return for participation in programs designed to promote disease
					 prevention, wellness, and health.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter MM - WELLNESS PROGRAMS › Section 21.4702 - Definitions

Current through Reg. 49, No. 28; July 12, 2024
The following words and terms, when used in this
					 subchapter, have the following meanings, unless the context clearly indicates
					 otherwise.
(1) Health status-related
				  factor--Health status; medical condition, including both physical and mental
				  illnesses; claims experience; receipt of health care; medical history; genetic
				  information; evidence of insurability, including conditions arising out of acts
				  of domestic violence; and disability.
(2) Wellness Program--Any program designed to
				  promote disease prevention, wellness, and health.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter MM - WELLNESS PROGRAMS › Section 21.4703 - Wellness Programs Exception

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  Notwithstanding the provisions of Insurance Code Chapter 1501, §541.056(a)
				  and §544.052, and the provisions of Chapter 26, Subchapter A of this title
				  , an individual or group health benefit plan issuer, an accident and health
				  insurance issuer, or a health maintenance organization may vary the amount of
				  premium or contribution it requires similarly situated individuals to pay, or
				  vary benefits, or both, including cost-sharing mechanisms such as a deductible,
				  copayment, or coinsurance, based on whether an individual has met the standards
				  of a wellness program that satisfies the requirements of §§
										21.4706,
				  21.4707,
				  or 21.4708 of this title .
(b)
				  Notwithstanding the provisions of Insurance Code §
										541.056(a)
				  and §
										544.052, an
				  insurer issuing an accident and health insurance policy may vary the amount of
				  premium or contribution it requires similarly situated individuals or
				  individuals of the same class and of essentially the same hazard to pay, or
				  vary benefits, or both, including cost-sharing mechanisms such as a deductible,
				  copayment, or coinsurance, based on whether an individual has met the standards
				  of a wellness program that satisfies the requirements of §§
										21.4706,
				  21.4707,
				  or 21.4708 of this title .
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter MM - WELLNESS PROGRAMS › Section 21.4704 - Purposes

Current through Reg. 49, No. 28; July 12, 2024
The purposes of this subchapter are to provide for the
					 circumstances under which, and the constraints within which, a group health
					 benefit plan issuer, an accident and health insurance issuer, or health
					 maintenance organization may:
(1) vary
				  benefits, including cost-sharing mechanisms such as a deductible, copayment, or
				  coinsurance, based on whether an individual has met the standards of a wellness
				  program that satisfies the requirements of §§
										21.4706,
				  21.4707,
				  or 21.4708 of this title; or ;
(2)
				  vary the amount of premium or contribution it requires similarly situated
				  individuals to pay based on whether an individual has met the standards of a
				  wellness program that satisfies the requirements of §§
										21.4706,
				  21.4707,
				  or 21.4708 of this title .
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter MM - WELLNESS PROGRAMS › Section 21.4705 - General Provisions Applicable to Wellness Programs

Current through Reg. 49, No. 28; July 12, 2024
(a) Wellness programs as set out in this
				  subchapter are excepted from the general prohibitions against discrimination
				  based on a health status-related factor for plan provisions that vary benefits,
				  including cost-sharing mechanisms, or the premium or contribution for
				  individuals eligible for plan coverage, in connection with participation in
				  such a wellness program.
(b) A
				  wellness program must be reasonably designed to promote disease prevention,
				  wellness, and health. A program satisfies this standard if it:
(1) has a reasonable probability of improving
				  the health of, or preventing disease in, participating individuals;
(2) is not overly burdensome;
(3) is not a subterfuge for otherwise
				  prohibited discrimination based on a health status-related factor;
				  and
(4) is not highly suspect in
				  the method chosen to promote disease prevention, wellness, and
				  health.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter MM - WELLNESS PROGRAMS › Section 21.4706 - Wellness Programs With Participation as Sole Basis for Reward Eligibility

Current through Reg. 49, No. 28; July 12, 2024
(a) A wellness
				  program that contains no condition for obtaining a reward premised on an
				  individual satisfying a standard associated with a health factor does not
				  violate this subchapter so long as the status-related program is made available
				  to all individuals eligible for coverage under the plan.
(b) Wellness programs meeting the description
				  of this section would include the following program types:
(1) a program that reimburses all or part of
				  the cost for membership in a fitness center;
(2) a diagnostic testing program that
				  provides a reward for participation and does not base any part of the reward on
				  testing outcomes;
(3) a program
				  that encourages preventive care through the waiver of the copayment or
				  deductible requirement under a group health plan or individual policy for the
				  costs of a particular preventive care item or items;
(4) a program that reimburses covered
				  individuals for the costs of smoking cessation programs without regard to
				  whether the individual quits smoking; or
(5) a program that provides a reward to
				  covered individuals for attending a monthly health education seminar.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter MM - WELLNESS PROGRAMS › Section 21.4707 - Activity-Only Wellness Programs

Current through Reg. 49, No. 28; July 12, 2024
(a) A
				  health-contingent wellness program that requires an individual to perform or
				  complete an activity related to a health factor in order to obtain a reward but
				  does not require the individual to attain or maintain a specific health outcome
				  is an activity-only wellness program.
(b) An activity-only wellness program does
				  not violate this subchapter so long as the requirements of this section are
				  met.
(1) Size of reward. The reward for the
				  activity-only wellness program, coupled with the reward for other
				  health-contingent wellness programs offered under the same plan , must not
				  exceed in total value 30 percent of the cost of employee-only or member-only
				  coverage under the plan; or 50 percent of the cost of employee-only or
				  member-only coverage under the plan if the program includes a program designed
				  to prevent or reduce tobacco use, except that no more than 20 percent of the
				  reward may be attributable to the tobacco use program. However, if, in addition
				  to employees or members, any class of dependents--such as spouses or spouses
				  and dependent children--may participate in the activity-only wellness program,
				  the reward must not exceed 30 percent of the cost of the coverage in which an
				  employee or member, and any dependents, are enrolled; or 50 percent of the cost
				  of the coverage in which an employee or member, and any dependents, are
				  enrolled, to the extent that the additional 20 percent is in connection with a
				  program designed to prevent or reduce tobacco use.
(A) For purposes of this section, the cost of
				  coverage is determined based on the total amount of employer and employee
				  contributions toward the cost of coverage, or member contributions toward the
				  cost of coverage, for the benefit package under which the employee or member
				  is, or the employee or member and any dependents are, receiving
				  coverage.
(B) A reward can be in
				  the form of a discount or rebate of a premium or contribution; a waiver of all
				  or part of a cost-sharing mechanism such as deductibles, copayments, or
				  coinsurance; the absence of a surcharge; or the value of a benefit that would
				  otherwise not be provided under the plan.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter MM - WELLNESS PROGRAMS › Section 21.4708 - Outcome-Based Wellness Programs

Current through Reg. 49, No. 28; July 12, 2024
(a) A
				  health-contingent wellness program that requires an individual to attain or
				  maintain a specific health outcome in order to obtain a reward is an
				  outcome-based wellness program.
(b)
				  An outcome-based wellness program does not violate this subchapter so long as
				  the requirements of this section are met.
(1)
				  Size of reward. The reward for the outcome-based wellness program, coupled with
				  the reward for other health-contingent wellness programs with respect to the
				  plan, must not exceed in total value 30 percent of the cost of employee-only or
				  member-only coverage under the plan; or 50 percent of the cost of employee-only
				  or member-only coverage under the plan, to the extent that the additional 20
				  percent is in connection with a program designed to prevent or reduce tobacco
				  use. However, if, in addition to employees or members, any class of
				  dependents--such as spouses or spouses and dependent children--may participate
				  in the outcome-based wellness program, the reward must not exceed 30 percent of
				  the cost of the coverage in which an employee or member and any dependents are
				  enrolled; or 50 percent of the cost of the coverage in which an employee or
				  member and any dependents are enrolled, to the extent that the additional 20
				  percent is in connection with a program designed to prevent or reduce tobacco
				  use.
(A) For purposes of this section, the
				  cost of coverage is determined based on the total amount of employer and
				  employee contributions toward the cost of coverage, or member contributions
				  toward the cost of coverage, for the benefit package under which the employee
				  or member is, or the employee or member and any dependents are, receiving
				  coverage.
(B) A reward can be in
				  the form of a discount or rebate of a premium or contribution; a waiver of all
				  or part of a cost-sharing mechanism such as deductibles, copayments, or
				  coinsurance; the absence of a surcharge; or the value of a benefit that would
				  otherwise not be provided under the plan.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter NN - NONINSURANCE BENEFITS AND FEATURES › Section 21.4801 - Applicability and Scope

Current through Reg. 49, No. 28; July 12, 2024
In accordance with the Insurance Code §
										1701.061,
					 this subchapter applies to any insurer that provides or discloses a
					 noninsurance benefit as part of a life insurance policy or certificate, annuity
					 contract or certificate, or an accident or health insurance policy, contract or
					 certificate.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter NN - NONINSURANCE BENEFITS AND FEATURES › Section 21.4802 - Definition of Noninsurance Benefit

Current through Reg. 49, No. 28; July 12, 2024
For purposes of this subchapter, the term "noninsurance
					 benefit" has the same meaning as provided in the Insurance Code §
										1701.061(a).
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter NN - NONINSURANCE BENEFITS AND FEATURES › Section 21.4803 - Purpose

Current through Reg. 49, No. 28; July 12, 2024
The purpose of this subchapter is to provide the essential
					 standards to be met in satisfaction of requirements applicable to noninsurance
					 benefits intended to be offered as part of a policy, contract or certificate of
					 insurance under the Insurance Code §
										1701.061.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter NN - NONINSURANCE BENEFITS AND FEATURES › Section 21.4804 - Reasonable Relation to Policy, Contract or Certificate

Current through Reg. 49, No. 28; July 12, 2024
(a) In accordance with the Insurance Code
				  §
										1701.061(a),
				  any noninsurance benefit provided or disclosed as part of an insurance policy,
				  contract or certificate of insurance must be reasonably related to the type of
				  insurance policy, contract or certificate being issued.
(b) For purposes of this subchapter, the
				  standard of "reasonable relation" takes into account the nature, character,
				  purpose and scope of the insurance policy, contract or certificate with which
				  the noninsurance benefit or feature is associated and to be offered. An example
				  representing the existence of "reasonable relation" is a noninsurance benefit
				  which, in form and application, is specifically related to the purpose and
				  function of the underlying insurance policy, contract or certificate.
				  Determination of "reasonable relation" will include examination of the degree
				  to which the noninsurance benefit is related in its nature, character and
				  purpose to that of the insurance policy, contract or certificate, including, as
				  appropriate, the type and amount of benefit provided.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter NN - NONINSURANCE BENEFITS AND FEATURES › Section 21.4805 - Disclosure Requirements for Form Filings that Include Noninsurance Benefits

Current through Reg. 49, No. 28; July 12, 2024
A policy, contract or certificate form filing that includes
					 a noninsurance benefit shall also include the items set out in paragraphs (1) -
					 (3) of this section:
(1) A description
				  of the noninsurance benefit must be provided. The description must be
				  sufficiently specific to provide information about the nature, character,
				  purpose and scope of the benefit.
(2) A notice fully disclosing the
				  noninsurance benefit to the policyholder, contract holder or certificate holder
				  must be provided. Full disclosure includes the following:
(A) an explanation of how the noninsurance
				  benefit may be obtained;
(B) a
				  statement disclosing:
(i) whether acceptance
				  or declination of the noninsurance benefit is optional to the policyholder,
				  contract holder, certificate holder or, as applicable, other individual covered
				  person;
(ii) the identifiable
				  charge and amount, if any, for a noninsurance benefit that an individual
				  covered person has the option to accept or decline;
(iii) the means by which the policyholder,
				  contract holder, certificate holder or other person entitled to the benefit may
				  obtain the benefit in the event the provider of the benefit, if other than the
				  insurer, fails to provide or to continue to provide the benefit as set out in
				  the policy, contract or certificate; and
(C) a statement providing information about
				  the nature, character and purpose of the benefit, as well as any limitations
				  associated with or applicable to the benefit.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter NN - NONINSURANCE BENEFITS AND FEATURES › Section 21.4806 - Additional Provisions Applicable to Noninsurance Benefits

Current through Reg. 49, No. 28; July 12, 2024
(a) A noninsurance benefit provided or
				  disclosed as part of a policy, contract or certificate as set out in the
				  Insurance Code §
										1701.061
				  may not contain any provision that is unfairly deceptive.
(b) A noninsurance benefit provided or
				  disclosed as part of a policy, contract or certificate as set out in the
				  Insurance Code §
										1701.061 is
				  subject to the Insurance Code, Chapters 82 - 84.
(c) If a noninsurance benefit is to be
				  available to in-force business, commitment documentation setting out such
				  availability must be submitted with the form filing, specifically identifying
				  all existing in-force business to which the noninsurance benefit is intended to
				  be made available.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter NN - NONINSURANCE BENEFITS AND FEATURES › Section 21.4807 - Noninsurance Benefits Composed of Certain Discount Programs

Current through Reg. 49, No. 28; July 12, 2024
(a) A noninsurance benefit may consist in
				  whole or in part of discount cards for health care programs, vision care
				  programs, dental care programs, prescriptions, physical fitness programs or
				  facilities, or other similar programs.
(b) Noninsurance benefits which include, in
				  whole or in part, discount health care programs and discount health care
				  program operators are subject to the provisions in paragraphs (1) and (2) of
				  this subsection.
(1) Noninsurance benefits
				  offered or provided prior to April 1, 2010, which include, in whole or in part,
				  discount health programs and discount health care program operators as defined
				  in the Health and Safety Code § 76.001, are subject to the provisions of
				  the Health and Safety Code Chapter 76, any administrative rules adopted by the
				  Texas Department of Licensing and Regulation implementing that chapter, and any
				  orders entered by the Executive Director or Commission to administer and
				  enforce the chapter.
(2)
				  Noninsurance benefits offered or provided on or after April 1, 2010, which
				  include, in whole or in part, discount health programs and discount health care
				  program operators as defined in the Insurance Code §
											562.002 and §
											7001.001, are subject
				  to the provisions of the Insurance Code Chapters 562 and 7001, any
				  administrative rules adopted by the Commissioner of Insurance, and any orders
				  entered by the commissioner to administer and enforce the chapters.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter OO - DISCLOSURES BY OUT-OF-NETWORK PROVIDERS › Section 21.4901 - Purpose and Applicability

Current through Reg. 49, No. 28; July 12, 2024
(a) The
				  purpose of this subchapter is to interpret and implement Insurance Code
				  §§1271.157,
				  1271.158,
				  1275.052, 1275.053,
				  1301.164,
				  1301.165,
				  1551.229,
				  1551.230,
				  1575.172,
				  1575.173,
				  1579.110,
				  and
				  1579.111;
				  and Insurance Code Chapter 1467.
(b)
				  Section 21.4903 of this title is only applicable to a covered nonemergency
				  health care or medical service or supply provided by:
(1) a facility-based provider that is not a
				  participating provider for a health benefit plan, if the service or supply is
				  provided at a health care facility that is a participating provider;
				  or
(2) a diagnostic imaging
				  provider or laboratory service provider that is not a participating provider
				  for a health benefit plan, if the service or supply is provided in connection
				  with a health care or medical service or supply provided by a participating
				  provider.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter OO - DISCLOSURES BY OUT-OF-NETWORK PROVIDERS › Section 21.4902 - Definitions

Current through Reg. 49, No. 28; July 12, 2024
Words and terms defined in Insurance Code Chapter 1467,
					 concerning Out-of-Network Claim Dispute Resolution, have the same meaning when
					 used in this subchapter unless the context clearly indicates otherwise, and the
					 following words and terms have the following meanings when used in this
					 subchapter unless the context clearly indicates otherwise.
(1) Administrator--Has the meaning assigned
				  by Insurance Code §
										1467.001, concerning
				  Definitions. The term also includes an administrator of a nonprofit
				  agricultural organization under Insurance Code Chapter 1682, concerning Health
				  Benefits Provided by Certain Nonprofit Agricultural Organizations, and an
				  administrator of a self-insured or self-funded ERISA plan under Insurance Code
				  Chapter 1275, concerning Balance Billing Prohibitions and Out-of-Network Claim
				  Dispute Resolution for Certain Plans, offering a health benefit plan.
(2) ERISA--The Employee Retirement Income
				  Security Act of 1974 (29 USC
				  §
											1001 et seq.).
(3) Health benefit plan--A plan that provides
				  coverage under:
(A) a health benefit plan
				  offered by an HMO operating under Insurance Code Chapter 843, concerning Health
				  Maintenance Organizations;
(B) a
				  preferred provider benefit plan, including an exclusive provider benefit plan,
				  offered by an insurer under Insurance Code Chapter 1301, concerning Preferred
				  Provider Benefit Plans;
(C) a plan,
				  other than an HMO plan, under Insurance Code Chapters 1551, concerning Texas
				  Employees Group Benefits Act; 1575, concerning Texas Public School Employees
				  Group Benefits Program; 1579, concerning Texas School Employees Uniform Group
				  Health Coverage; or 1682; or
(D) a
				  self-insured or self-funded plan established by an employer under ERISA
				  (29 USC §
												1001 et seq.) for which the plan sponsor has
				  elected to apply Insurance Code Chapter 1275 to the plan for the relevant plan
				  year.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter OO - DISCLOSURES BY OUT-OF-NETWORK PROVIDERS › Section 21.4903 - Out-of-Network Notice and Disclosure Requirements

Current through Reg. 49, No. 28; July 12, 2024
(a) For purposes of this section a "balance
				  bill" is a bill for an amount greater than an applicable copayment,
				  coinsurance, and deductible under an enrollee's health benefit plan, as
				  specified in Insurance Code §§
										1271.157(c),
				  1271.158(c),
				  1275.052(c), 1275.053(c),
				  1301.164(c),
				  1301.165(c),
				  1551.229(c),
				  1551.230(c),
				  1575.172(c),
				  1575.173(c),
				  1579.110(c),
				  or
				  1579.111(c).
(b) An out-of-network provider may not
				  balance bill an enrollee receiving a non-emergency health care or medical
				  service or supply, and the enrollee does not have financial responsibility for
				  a balance bill, unless the enrollee elects to obtain the service or supply from
				  the out-of-network provider knowing that the provider is out-of-network and the
				  enrollee may be financially responsible for a balance bill. For purposes of
				  this subsection, an enrollee elects to obtain a service or supply only if:
(1) the enrollee has a meaningful choice
				  between a participating provider for a health benefit plan issuer or
				  administrator and an out-of-network provider. No meaningful choice exists if an
				  out-of-network provider was selected for or assigned to an enrollee by another
				  provider or health benefit plan issuer or administrator;
(2) the enrollee is not coerced by a provider
				  or health benefit plan issuer or administrator when making the election. A
				  provider engages in coercion if the provider charges or attempts to charge a
				  nonrefundable fee, deposit, or cancellation fee for the service or supply prior
				  to the enrollee's election; and
(3)
				  the out-of-network provider or the agent or assignee of the provider provides
				  written notice and disclosure to the enrollee and obtains the enrollee's
				  written consent, as specified in subsection (c) of this section.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter OO - DISCLOSURES BY OUT-OF-NETWORK PROVIDERS › Section 21.4904 - Health Benefit Plan Issuer and Administrator Responsibility

Current through Reg. 49, No. 28; July 12, 2024
Consistent with Insurance Code §1661.002, a health
					 benefit plan issuer or administrator must assist an enrollee with evaluating
					 the enrollee's financial responsibility for a health care or medical service or
					 supply based on the information in the notice and disclosure statement provided
					 to the enrollee under §21.4903 of this title.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter PP - OUT-OF-NETWORK CLAIM DISPUTE RESOLUTION › Division 1 - GENERAL PROVISIONS › Section 21.5001 - Purpose

Current through Reg. 49, No. 28; July 12, 2024
The purpose of this subchapter is to:
(1) prescribe the process for requesting,
					 initiating, and conducting mandatory mediation and mandatory binding
					 arbitration of claims as authorized in Insurance Code Chapter 1467, concerning
					 Out-of-Network Claim Dispute Resolution;
(2) facilitate the process for the
					 investigation and review of a complaint filed with the department that relates
					 to the settlement of an out-of-network claim under Insurance Code Chapter
					 1467;
(3) prescribe the contents of
					 the explanation of benefits as required by Insurance Code §
											1271.008, concerning
					 Balance Billing Prohibition Notice; §1275.003, concerning Balance Billing
					 Prohibition Notice; §1301.010, concerning Balance Billing Prohibition
					 Notice; §1551.015, concerning Balance Billing Prohibition Notice;
					 §1575.009, concerning Balance Billing Prohibition Notice; and
					 §1579.009, concerning Balance Billing Prohibition Notice; and
(4) facilitate the collection of data as
					 authorized in Insurance Code §
											1467.006, concerning
					 Benchmarking Database.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter PP - OUT-OF-NETWORK CLAIM DISPUTE RESOLUTION › Division 1 - GENERAL PROVISIONS › Section 21.5002 - Scope

Current through Reg. 49, No. 28; July 12, 2024
(a) This subchapter applies to a qualified
					 mediation claim or qualified arbitration claim filed under health benefit plan
					 coverage:
(1) issued by an insurer as a
					 preferred provider benefit plan under Insurance Code Chapter 1301, concerning
					 Preferred Provider Benefit Plans, including an exclusive provider benefit
					 plan;
(2) administered by an
					 administrator of a health benefit plan, other than a health maintenance
					 organization (HMO) plan, under Insurance Code Chapters 1551, concerning Texas
					 Employees Group Benefits Act; 1575, concerning Texas Public School Employees
					 Group Benefits Program; 1579, concerning Texas School Employees Uniform Group
					 Health Coverage; or 1682, concerning Health Benefits Provided by Certain
					 Nonprofit Agricultural Organizations;
(3) offered by an HMO operating under
					 Insurance Code Chapter 843, concerning Health Maintenance Organizations;
					 or
(4) offered by a self-insured or
					 self-funded plan established by an employer under ERISA if the plan sponsor
					 submitted election according to §
												21.5060 of this title (relating to
					 Election Submission Requirements).
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter PP - OUT-OF-NETWORK CLAIM DISPUTE RESOLUTION › Division 1 - GENERAL PROVISIONS › Section 21.5003 - Definitions

Current through Reg. 49, No. 28; July 12, 2024
The following words and terms have the following meanings
						when used in this subchapter unless the context clearly indicates
						otherwise.
(1) Administrator--Has the
					 meaning assigned by Insurance Code §
											1467.001, concerning
					 Definitions. The term also includes an administrator of a nonprofit
					 agricultural organization under Insurance Code Chapter 1682, concerning Health
					 Benefits Provided by Certain Nonprofit Agricultural Organizations, and an
					 administrator of a self-insured or self-funded ERISA plan under Insurance Code
					 Chapter 1275, concerning Balance Billing Prohibitions and Out-of-Network Claim
					 Dispute Resolution for Certain Plans, offering a health benefit plan.
(2) Arbitration--Has the meaning assigned by
					 Insurance Code §
											1467.001.
(3) Claim--A request to a health benefit plan
					 for payment for health benefits under the terms of the health benefit plan's
					 coverage, including emergency care, or a health care or medical service or
					 supply, or any combination of emergency care and health care or medical
					 services and supplies, provided that the care, services, or supplies:
(A) are furnished for a single date of
					 service; or
(B) if furnished for
					 more than one date of service, are provided as a continuing or related course
					 of treatment over a period of time for a specific medical problem or condition,
					 or in response to the same initial patient complaint.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter PP - OUT-OF-NETWORK CLAIM DISPUTE RESOLUTION › Division 2 - MEDIATION PROCESS › Section 21.5010 - Qualified Mediation Claim Criteria

Current through Reg. 49, No. 28; July 12, 2024
(a)
					 Required criteria. An out-of-network provider that is a facility or a health
					 benefit plan issuer or administrator may request mandatory mediation of an
					 out-of-network claim under §
											21.5011 of this title (relating to
					 Mediation Request Procedure) if the claim complies with the criteria specified
					 in this subsection. An out-of-network claim that complies with those criteria
					 is referred to as a "qualified mediation claim" in this subchapter.
(1) The out-of-network health benefit claim
					 must be for:
(A) emergency care;
(B) an out-of-network laboratory service
					 provided in connection with a health care or medical service or supply provided
					 by a participating provider; or
(C)
					 an out-of-network diagnostic imaging service provided in connection with a
					 health care or medical service or supply provided by a participating
					 provider.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter PP - OUT-OF-NETWORK CLAIM DISPUTE RESOLUTION › Division 2 - MEDIATION PROCESS › Section 21.5011 - Mediation Request Procedure

Current through Reg. 49, No. 28; July 12, 2024
(a)
					 Mediation request and notice.
(1) An
					 out-of-network provider that is a facility or a health benefit plan issuer or
					 administrator may request mediation. To be eligible for mediation, the party
					 requesting mediation must complete the mediation request information required
					 on the department's website at
www.tdi.texas.gov
, as specified in subsection
					 (b) of this section.
(2) The party
					 who requests the mediation must provide written notice to each other party on
					 the date the mediation is requested. The notification must contain the
					 information as specified on the department's website, including the necessary
					 claim information and contact information of the parties. A health benefit plan
					 issuer or administrator requesting mediation must send the mediation
					 notification to the mailing address or email address specified in the claim
					 submitted by the provider. If a provider does not specify an address to receive
					 notice requesting mediation in the claim, a health benefit plan issuer or
					 administrator may provide notice to the provider at the provider's last known
					 address the issuer or administrator has on file for the provider. A provider
					 requesting mediation must send the mediation notification to the email address
					 specified in the explanation of benefits by the health benefit plan issuer or
					 administrator.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter PP - OUT-OF-NETWORK CLAIM DISPUTE RESOLUTION › Division 2 - MEDIATION PROCESS › Section 21.5012 - Informal Settlement Teleconference

Current through Reg. 49, No. 28; July 12, 2024
All parties subject to mandatory mediation requested by
						an out-of-network provider that is a facility or a health benefit plan issuer
						or administrator under this subchapter must use best efforts to coordinate the
						informal settlement teleconference required by Insurance Code §
											1467.054
						(concerning Request and Preliminary Procedures for Mandatory Mediation). The
						parties or representatives of the parties must arrange a date and time when the
						parties or representatives of the parties can participate in the informal
						settlement teleconference, which must occur not later than the 30th day after
						the date on which the party submitted a request for mediation, unless the
						parties agree to extend the deadline.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter PP - OUT-OF-NETWORK CLAIM DISPUTE RESOLUTION › Division 2 - MEDIATION PROCESS › Section 21.5013 - Mediation Participation

Current through Reg. 49, No. 28; July 12, 2024
Under Insurance Code §
											1467.101 (concerning
						Bad Faith), conduct that constitutes bad faith mediation includes failing
						to:
(1) participate in the
					 mediation;
(2) provide information
					 that the mediator believes is necessary to facilitate an agreement;
					 or
(3) designate a representative
					 participating in the mediation with full authority to enter into any mediated
					 agreement.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter PP - OUT-OF-NETWORK CLAIM DISPUTE RESOLUTION › Division 3 - ARBITRATION PROCESS › Section 21.5020 - Qualified Arbitration Claim Criteria

Current through Reg. 49, No. 28; July 12, 2024
(a) Required criteria. An out-of-network
					 provider that is not a facility or a health benefit plan issuer or
					 administrator may request mandatory binding arbitration of an out-of-network
					 claim under §
											21.5021 of this title (relating to
					 Arbitration Request Procedure) if the claim complies with the criteria
					 specified in this section. An out-of-network claim that complies with those
					 criteria is referred to as a "qualified arbitration claim" in this subchapter.
(1) The health benefit claim must be for:
(A) emergency care;
(B) a health care or medical service or
					 supply provided by a facility-based provider in a facility that is a
					 participating provider;
(C) an
					 out-of-network laboratory service provided in connection with a health care or
					 medical service or supply provided by a participating provider; or
(D) an out-of-network diagnostic imaging
					 service provided in connection with a health care or medical service or supply
					 provided by a participating provider; and
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter PP - OUT-OF-NETWORK CLAIM DISPUTE RESOLUTION › Division 3 - ARBITRATION PROCESS › Section 21.5021 - Arbitration Request Procedure

Current through Reg. 49, No. 28; July 12, 2024
(a)
					 Arbitration request and notice.
(1) An
					 out-of-network provider or a health benefit plan issuer or administrator may
					 request arbitration. To be eligible for arbitration, the party requesting
					 arbitration must complete the arbitration request information required on the
					 department's website at
www.tdi.texas.gov
, as specified in subsection
					 (b) of this section.
(2) The party
					 who requests the arbitration must provide written notice to each other party on
					 the date the arbitration is requested. The notification must contain the
					 information as specified on the department's website, including the necessary
					 claim information and contact information of the parties. A health benefit plan
					 issuer or administrator requesting arbitration must send the arbitration
					 notification to the mailing address or email address specified in the claim
					 submitted by the provider. If a provider does not specify an address to receive
					 notice requesting arbitration in the claim, the health benefit plan issuer or
					 administrator may provide notice to the provider at the provider's last known
					 address the issuer or administrator has on file for the provider. A provider
					 requesting arbitration must send the arbitration notification to the email
					 address specified in the explanation of benefits by the health benefit plan
					 issuer or administrator.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter PP - OUT-OF-NETWORK CLAIM DISPUTE RESOLUTION › Division 3 - ARBITRATION PROCESS › Section 21.5022 - Informal Settlement Teleconference

Current through Reg. 49, No. 28; July 12, 2024
A party subject to mandatory arbitration requested by an
						out-of-network provider or a health benefit plan issuer or administrator under
						this division must use best efforts to coordinate an informal settlement
						teleconference, as required by Insurance Code §
											1467.084
						(concerning Availability of Mandatory Arbitration). The health benefit plan
						issuer or administrator must make a reasonable effort to arrange the
						teleconference at a date and time when the parties or representatives of the
						parties can participate in the informal settlement teleconference. The informal
						settlement teleconference must occur no later than the 30th day after
						arbitration is requested, unless the parties agree to extend the
						deadline.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter PP - OUT-OF-NETWORK CLAIM DISPUTE RESOLUTION › Division 3 - ARBITRATION PROCESS › Section 21.5023 - Arbitration Participation

Current through Reg. 49, No. 28; July 12, 2024
Under Insurance Code §
											1467.101 (concerning
						Bad Faith), conduct that constitutes bad faith arbitration includes failing to:
(1) participate in the informal
					 settlement teleconference under §1467.084(d) or an arbitration;
(2) provide information that the arbitrator
					 believes is necessary to facilitate a decision; or
(3) designate a representative participating
					 in the arbitration with full authority to enter into any agreement.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter PP - OUT-OF-NETWORK CLAIM DISPUTE RESOLUTION › Division 4 - COMPLAINT RESOLUTION AND OUTREACH › Section 21.5030 - Complaint Resolution

Current through Reg. 49, No. 28; July 12, 2024
(a) Written
					 complaint.
A party may submit a written complaint on the
						department's website regarding the settlement of an out-of-network health
						benefit claim that is subject to Insurance Code Chapter 1467.
(b) Complaint information. The recommended
					 information for filing a complaint under subsection (a) of this section,
					 includes:
(1) whether the complaint is within
					 the scope of Insurance Code Chapter 1467 (concerning Out-of-Network Claim
					 Dispute Resolution);
(2) whether
					 emergency care, health care, or a medical service have been delayed or have not
					 been given;
(3) whether the health
					 care, medical service, or supply, or a combination of health care, medical
					 service, or supply, that is the subject of the complaint was for emergency
					 care; and
(4) specific information
					 about the qualified mediation claim or qualified arbitration claim, including:
(A) the name, type, and specialty of the
					 provider;
(B) the type of service
					 performed or supplies provided;
(C)
					 the city and county where the service or supply was performed; and
(D) the dollar amount of the disputed
					 claim.