Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter G - PLAIN LANGUAGE REQUIREMENTS FOR HEALTH BENEFIT POLICIES › Section 3.601 - Purpose and Scope, Applicability, and Definitions Used in This Subchapter

Current through Reg. 49, No. 28; July 12, 2024
(a) Purpose and scope. The sections contained
				  in this subchapter are intended to implement Insurance Code §
										1501.260
				  and to establish plain language requirements for health benefit plans or forms
				  that will be approved by the department and issued by health carriers in this
				  state. This subchapter establishes the plain language requirements and minimum
				  score for readability for such health benefit plans or forms, in accordance
				  with Insurance Code §
										1501.260.
				  This subchapter also establishes procedures that health carriers must follow to
				  demonstrate and assure compliance with the new requirements.
(b) Applicability. This subchapter applies to
				  all health benefit plans, including policies, certificates, evidences of
				  coverage, riders, endorsements, amendments, and/or applications, approved by
				  the commissioner on or after January 1, 1994, and issued in the State of Texas
				  after such date. This subchapter does not apply to a health benefit plan group
				  master policy or to a health benefit plan group master policy application or to
				  an enrollment form for a health benefit plan group master policy when the
				  enrollment form is used solely to enroll individuals in the plan. This
				  subchapter also does not apply to any health benefit plan forms approved by the
				  commissioner under department rules before January 1, 1994.
(c) Definitions.
(1) Commissioner--The commissioner of
				  insurance of the State of Texas.
(2) Form--Any health benefit plan
				  certificate, policy, evidence of coverage, endorsement, amendment, application,
				  or rider.
(3) Franchise insurance
				  policy--An individual health benefit plan under which a number of individual
				  policies are offered to a selected group. The rates for such a policy may
				  differ from the rate applicable to individually solicited policies of the same
				  type and may differ from the rate applicable to individuals of essentially the
				  same class.
(4) Health benefit
				  plan--A group, blanket, or franchise insurance policy, a certificate issued
				  under a group policy, a group hospital service contract, or a group subscriber
				  contract or evidence of coverage issued by a health maintenance organization
				  that provides benefits for health care services. The term does not include:
(A) accident-only insurance
				  coverage;
(B) credit insurance
				  coverage;
(C) disability insurance
				  coverage;
(D) specified disease
				  coverage or other limited benefit policies;
(E) coverage of Medicare services under a
				  federal contract;
(F) Medicare
				  supplement and Medicare Select policies regulated in accordance with federal
				  law;
(G) long-term care insurance
				  coverage;
(H) coverage limited to
				  dental care;
(I) coverage limited
				  to care of vision;
(J) coverage
				  provided by a single-service health maintenance organization;
(K) insurance coverage issued as a supplement
				  to liability insurance;
(L)
				  insurance coverage arising out of a workers' compensation system or similar
				  statutory system;
(M) automobile
				  medical payment insurance coverage;
(N) jointly managed trusts authorized under
				  29
				  United States Code §141 et seq. that
				  contain a plan of benefits for employees that is negotiated in a collective
				  bargaining agreement governing wages, hours, and working conditions of the
				  employees that is authorized under
				  29
				  United States Code §157;
(O) hospital confinement indemnity coverage;
				  or
(P) reinsurance contracts issued
				  on a stop-loss, quota-share, or similar basis.
(5) Health carrier--Any entity authorized
				  under the Insurance Code to provide health insurance or health benefits in this
				  state, including an insurance company, a group hospital service corporation
				  under Insurance Code Chapter 842, a health maintenance organization under
				  Insurance Code Chapter 843, and a stipulated premium company under Insurance
				  Code Chapter 884.
(6) Limited
				  benefit policy--A policy that meets the requirements of "limited benefit
				  policy," as defined in §
											26.4 of
				  this title (relating to Definitions).