reglab/statecodes huggingface dataset:
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter AA - CONSUMER CHOICE HEALTH BENEFIT PLANS › Division 3 - REQUIRED NOTICES › Section 21.3529 - Duty of Agent

Current through Reg. 49, No. 28; July 12, 2024
Each agent marketing, soliciting, receiving an
						application for, or administering a consumer choice health benefit plan
						shall:
(1) provide each prospective
					 and current policyholder or contract holder with all disclosures and offers
					 required by §
											21.3530(a)
					 of this subchapter (relating to Health Carrier Disclosure) and §
											21.3542(a)
					 of this subchapter (relating to Offer of State-Mandated Plan); and
(2) upon request, consult with prospective
					 and current policyholders and contract holders regarding the state-mandated
					 health benefits not included in the consumer choice health benefit
					 plan.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter AA - CONSUMER CHOICE HEALTH BENEFIT PLANS › Division 3 - REQUIRED NOTICES › Section 21.3535 - Retention of Disclosure

Current through Reg. 49, No. 28; July 12, 2024
(a) A health
					 carrier must, for a period of five years after the date a consumer choice
					 health benefit plan terminates:
(1) retain in
					 the health carrier's records the signed disclosure statement required by §
												21.3530
					 of this title (relating to Health Carrier Disclosure); and
(2) on request from the department, provide
					 copies of the retained documents to the department.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter AA - CONSUMER CHOICE HEALTH BENEFIT PLANS › Division 4 - ADDITIONAL REQUIREMENTS › Section 21.3540 - Direct Access to Services

Current through Reg. 49, No. 28; July 12, 2024
Any consumer choice health benefit plan must include
						coverage for direct access to the health care services of an obstetrical or
						gynecological care provider as required by the Insurance Code Chapter 1451,
						Subchapter F.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter AA - CONSUMER CHOICE HEALTH BENEFIT PLANS › Division 4 - ADDITIONAL REQUIREMENTS › Section 21.3541 - Basic Health Care Services

Current through Reg. 49, No. 28; July 12, 2024
An HMO offering a consumer choice health benefit plan
						must provide the basic health care services required by §
											11.508
						and §
											11.509
						of this title (relating to Mandatory Benefit Standards: Group, Individual and
						Conversion Agreements, and Additional Mandatory Benefit Standards: Group
						Agreement Only).
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter AA - CONSUMER CHOICE HEALTH BENEFIT PLANS › Division 4 - ADDITIONAL REQUIREMENTS › Section 21.3542 - Offer of State-Mandated Plan

Current through Reg. 49, No. 28; July 12, 2024
(a) A
					 health carrier that offers the opportunity to apply for one or more consumer
					 choice health benefit plans under this section must also, no later than at the
					 time of application, offer the opportunity to apply for an accident and
					 sickness insurance policy or evidence of coverage in the same category that
					 reasonably approximates the consumer choice health benefit plan offered, that
					 includes state-mandated health benefits, and that is otherwise authorized by
					 the Insurance Code.
(b) With regard
					 to health plans required by subsection (a) of this section, a health carrier
					 must:
(1) use the same sources and methods of
					 distribution to market both consumer choice health benefit plans and health
					 benefit plans required by this subsection, and a health carrier that markets
					 consumer choice health benefit plans through online marketplaces, other than
					 the federal health exchange, must use the same sources and methods of
					 distribution to market both consumer choice health benefit plans and
					 state-mandated health benefit plans required by this subsection;
(2) make the offer of the health plans, the
					 premium cost of the plans, as well as any additional details regarding them,
					 contemporaneously with and in the same manner as the offer and premium cost of,
					 and other details regarding, the consumer choice health benefit plan policy or
					 evidence of coverage; and
(3)
					 provide at least the following information:
(A) a description of how the person or entity
					 may apply for or enroll in each offered policy or evidence of coverage;
					 and
(B) the benefits or services
					 available, or both, and the premium cost under each offered policy or evidence
					 of coverage.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter AA - CONSUMER CHOICE HEALTH BENEFIT PLANS › Division 4 - ADDITIONAL REQUIREMENTS › Section 21.3543 - Required Plan Filings

Current through Reg. 49, No. 28; July 12, 2024
A health carrier must:
(1) file the consumer choice health benefit
					 plan separate from any state-mandated health benefit plan with the department
					 in accordance with:
(A) Insurance Code
					 Chapter 1271 and Chapter 11 of this title (relating to Health Maintenance
					 Organizations) including the filing fee requirements; and
(B) Insurance Code Chapter 1701 and Chapter
					 3, Subchapter A of this title (relating to Requirements for Filing of Policy
					 Forms, Riders, Amendments, Endorsements for Life, Accident, and Health
					 Insurance and Annuities) including the filing fee requirements;
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter AA - CONSUMER CHOICE HEALTH BENEFIT PLANS › Division 4 - ADDITIONAL REQUIREMENTS › Section 21.3544 - Required Annual Reporting

Current through Reg. 49, No. 28; July 12, 2024
(a)
					 Health carriers offering a consumer choice health benefit plan must file
					 annually with the department a data certification, not later than June 1 of
					 each year, on Form CCP 2, Consumer Choice Health Benefit Plans Data
					 Certification. The data certification includes the following, each set out by
					 plan type:
(1) the total number of consumer
					 choice health benefit plans newly issued and renewed covering Texas
					 lives;
(2) the total number of
					 Texas lives (including members/employees, spouses, and dependents) covered
					 under newly issued and renewed consumer choice health benefit plans;
(3) the gross premiums received for newly
					 issued and renewed consumer choice health benefit plans covering Texas lives;
					 and
(4) the average premium rate
					 for consumer choice plans and state-mandated plans.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter BB - DENTAL CARE BENEFITS › Section 21.3601 - Scope

Current through Reg. 49, No. 28; July 12, 2024
This subchapter applies to insurers who issue health
					 insurance policies covering dental care services.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter BB - DENTAL CARE BENEFITS › Section 21.3602 - Definitions

Current through Reg. 49, No. 28; July 12, 2024
The following words and terms, when used in this
					 subchapter, shall have the following meanings unless the context clearly
					 indicates otherwise:
(1) Contracting
				  dentist--A dentist who, as a contracting provider under a health insurance
				  policy, has entered into a written agreement with an insurer to limit charges
				  for dental care services provided to insureds.
(2) Dental care services--Any services
				  furnished to a person for the purpose of preventing, alleviating, curing, or
				  healing human dental illness or injury.
(3) Dentist--Any person who furnishes dental
				  care services and who is licensed as a dentist by the state of Texas.
(4) Health insurance policy--An individual,
				  group, blanket, or franchise insurance policy or certificate or insurance
				  agreement or rider that is delivered, renewed or issued for delivery in this
				  state and that provides benefits for dental care services.
(5) Insurer--An insurance company that is
				  authorized under the Texas Insurance Code to issue, deliver or issue for
				  delivery in this state health insurance policies or certificates.
(6) Non-contracting dentist--A dentist who is
				  not a contracting dentist as defined in this section.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter BB - DENTAL CARE BENEFITS › Section 21.3603 - Right to Choose Dentist

Current through Reg. 49, No. 28; July 12, 2024
A health insurance policy providing benefits for dental
					 care services shall not:
(1) prevent
				  an insured from selecting the dentist of his choice to furnish dental care
				  services offered by the policy or interfere with the selection of any dentist,
				  provided the dental care services are within the scope of the dentist's
				  license; or
(2) authorize any
				  person to regulate, interfere, or intervene in any manner in the diagnosis or
				  treatment rendered by a dentist to a patient for the purpose of providing
				  dental care services, provided the dentist practices within the scope of the
				  dentist's license.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter BB - DENTAL CARE BENEFITS › Section 21.3604 - Payment of Benefits for Dental Care Services

Current through Reg. 49, No. 28; July 12, 2024
(a) A health insurance policy shall not
				  provide a different level of payment of benefits or reimbursement, including
				  deductibles, maximums or other cost-sharing provisions, for covered dental care
				  services based on whether the services are provided by a contracting or
				  non-contracting dentist.
(b) A
				  health insurance policy shall define and explain the standard of payment or
				  reimbursement for dental care services. In defining the standard, a policy may
				  express the level of payment or reimbursement as a percentage of charges for
				  dental care services, provided the insurer uses the same percentage for both
				  contracting and non-contracting dentists.
(c) A health insurance policy may, in the
				  same policy, apply the percentage specified in subsection (b) of this section
				  to a contracted rate and a fee expressed as "usual and customary" or words of
				  similar import.
(d) Notwithstanding
				  subsection (a) of this section, an insurer is not required to make payment to a
				  non-contracting dentist that is greater than the actual fee charged for the
				  dental care service.
(e) A health
				  insurance policy must disclose, if applicable, that the benefit offered is
				  limited to the least costly treatment.
(f) A health insurance policy must provide
				  that an insured may assign the right to benefits to a dentist who provides
				  dental care services, in which case, the insurer shall pay benefits directly to
				  the designated dentist, and such payment shall discharge the insurer's
				  obligation to pay those benefits.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter BB - DENTAL CARE BENEFITS › Section 21.3605 - Applicability

Current through Reg. 49, No. 28; July 12, 2024
This subchapter is applicable to health insurance policies
					 issued or renewed on or after July 1, 2004.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter BB - DENTAL CARE BENEFITS › Section 21.3606 - Severability

Current through Reg. 49, No. 28; July 12, 2024
If any provision of this subchapter or the application
					 thereof to any person or circumstances is for any reason held invalid, the
					 invalidity shall not affect the other provisions or any application of this
					 subchapter that can be given effect without the invalid provisions or
					 application. To this end all provisions of this subchapter are declared
					 severable.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter CC - ELECTRONIC HEALTH CARE TRANSACTIONS › Section 21.3701 - Electronic Claims Filing Requirements

Current through Reg. 49, No. 28; July 12, 2024
(a) The purpose of this section is to
				  implement Insurance Code Chapter 1213. This section applies to a contract
				  between an issuer of a health benefit plan and a health care professional or
				  health care facility (hereinafter referred to as "physicians or
				  providers").
(b) Consistent with
				  Insurance Code Chapter 1213 and this section, the issuer of a health benefit
				  plan may, by contract, require physicians and providers to electronically
				  submit the following:
(1) health care claims
				  or equivalent encounter information;
(2) referral certifications; and/or
(3) any authorization or eligibility
				  transactions.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter DD - ELIGIBILITY STATEMENTS › Section 21.3801 - Scope and Applicability

Current through Reg. 49, No. 28; July 12, 2024
This subchapter applies to a health benefit plan issuer
					 that enters into or renews a contract with a participating provider on or after
					 January 31, 2006. The provisions of Insurance Code §
										1274.002
					 and this subchapter are not applicable to Medicaid and Children's Health
					 Insurance Program (CHIP) plans provided by a health benefit plan issuer to
					 persons enrolled in the medical assistance program established under Chapter
					 32, Human Resources Code, or the child health plan established under Chapter
					 62, Health and Safety Code.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter DD - ELIGIBILITY STATEMENTS › Section 21.3802 - 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) Enrollee--An individual
				  who is eligible for coverage under a health benefit plan, including a covered
				  dependent.
(2) 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 or disability income
				  insurance coverage or a combination of accident-only and disability income
				  insurance coverage;
(B) credit-only
				  insurance coverage;
(C) disability
				  insurance coverage;
(D) coverage
				  only for a specified disease or illness;
(E) Medicare services under a federal
				  contract;
(F) Medicare supplement,
				  Medicare Select, Medicare Advantage, or any successor policies regulated in
				  accordance with federal law;
(G)
				  long-term care coverage or benefits, nursing home care coverage or benefits,
				  home health care coverage or benefits, community-based care coverage or
				  benefits, or any combination of those coverages or benefits;
(H) coverage that provides only dental or
				  vision benefits;
(I) coverage
				  provided by a single service health maintenance organization;
(J) coverage issued as a supplement to
				  liability insurance;
(K) workers'
				  compensation insurance coverage or similar insurance coverage;
(L) automobile medical payment insurance
				  coverage;
(M) a jointly managed
				  trust authorized under
				  29
				  U.S.C. Section 141 et seq. that contains 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
				  U.S.C. Section 157;
(N) hospital indemnity or other fixed
				  indemnity insurance coverage;
(O)
				  reinsurance contracts issued on a stop-loss, quota-share, or similar
				  basis;
(P) liability insurance
				  coverage, including general liability insurance and automobile liability
				  insurance coverage; or
(Q) coverage
				  that provides other limited benefits specified by federal
				  regulations.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter DD - ELIGIBILITY STATEMENTS › Section 21.3803 - Method for Requesting Eligibility Statements

Current through Reg. 49, No. 28; July 12, 2024
(a) Beginning January 31, 2006, a health
				  benefit plan issuer shall, in writing, communicate to each participating
				  provider that enters into or renews a contract with the health benefit plan
				  issuer, the method or methods by which the provider may request an eligibility
				  statement. The health benefit plan issuer may communicate the method or methods
				  a provider may use to request an eligibility statement in existing materials,
				  such as a provider manual, so long as the information is clearly identified and
				  properly captioned with an underlined, bold-faced, or otherwise conspicuous
				  heading.
(b) A health benefit plan
				  issuer may accept a request for an eligibility statement by:
(1) telephone;
(2) Internet website portal; or
(3) other electronic means.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter DD - ELIGIBILITY STATEMENTS › Section 21.3804 - Requests for Eligibility Statements

Current through Reg. 49, No. 28; July 12, 2024
(a) A
				  participating provider may, prior to providing services to an enrollee, request
				  an eligibility statement using a method designated by the health benefit plan
				  issuer.
(b) A request under
				  subsection (a) of this section must include:
(1) the enrollee's full name;
(2) the enrollee's relationship to the
				  primary enrollee; and
(3) the
				  enrollee's birth date.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter DD - ELIGIBILITY STATEMENTS › Section 21.3805 - Requirement to Provide Eligibility Statements

Current through Reg. 49, No. 28; July 12, 2024
(a) A health benefit plan issuer shall
				  maintain a system to enable it to provide eligibility statements to
				  participating providers using the information provided under §
										21.3804(b) and
				  (c) of this subchapter (relating to Requests
				  for Eligibility Statements). On receipt of a request for an eligibility
				  statement that complies with §
										21.3804
				  of this subchapter, a health benefit plan issuer must provide an eligibility
				  statement to the participating provider allowing the provider access to the
				  information at the time of the enrollee's visit.
(b) If the health benefit plan issuer is
				  unable to provide an eligibility statement, the health benefit plan issuer
				  shall notify the participating provider such that the provider receives the
				  response at the time of the patient's visit and may contemporaneously request
				  additional information to assist the health benefit plan issuer in providing an
				  eligibility statement. A health benefit plan issuer may not use a request for
				  additional information to satisfy the requirement that the issuer maintain a
				  system to provide eligibility statements using the information described in
				  §
										21.3804(b) and
				  (c) of this subchapter.
(c) An eligibility statement provided under
				  this section shall include information that will enable the participating
				  provider to determine at the time of the request:
(1) the enrollee's identification and
				  eligibility under the health benefit plan, including:
(A) the enrollee's identification number
				  assigned by the health benefit plan issuer;
(B) the name of the enrollee and, if
				  necessary to obtain payment for services to be provided to the patient, the
				  names of any affected covered dependents;
(C) the birth date of the enrollee and, if
				  necessary to obtain payment for services to be provided to the patient, the
				  birth dates of any affected covered dependents;
(D) the gender of the enrollee and, if
				  necessary to obtain payment for services to be provided to the patient, the
				  gender of any affected covered dependent; and
(E) the current enrollment and eligibility
				  status of the enrollee under the health benefit plan;
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter DD - ELIGIBILITY STATEMENTS › Section 21.3806 - Privacy Issues

Current through Reg. 49, No. 28; July 12, 2024
A health benefit plan issuer may refuse to provide all or
					 part of an eligibility statement if applicable state or federal law prevents
					 the disclosure of an enrollee's or dependent's personally identifiable
					 information to the requesting participating provider. A health benefit plan
					 issuer that refuses to provide all or part of an eligibility statement shall
					 provide a response to the request for an eligibility statement indicating the
					 reason(s) for refusing to provide the information. Within three days of
					 refusing to provide an eligibility statement under this section, a health
					 benefit plan issuer shall provide a written response indicating the reason(s)
					 for refusing to provide the information and describing the particular state or
					 federal law provision(s) that prevent the disclosure.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter DD - ELIGIBILITY STATEMENTS › Section 21.3807 - Effect of Eligibility Statement

Current through Reg. 49, No. 28; July 12, 2024
An eligibility statement provided under this subchapter is
					 not a verification under § 19.1724 of this title (relating to
					 Verification).
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter DD - ELIGIBILITY STATEMENTS › Section 21.3808 - Severability

Current through Reg. 49, No. 28; July 12, 2024
If a court of competent jurisdiction holds that any
					 provision of this subchapter is inconsistent with any statutes of this state,
					 is unconstitutional, or is invalid for any reason, the remaining provisions of
					 this subchapter shall remain in full effect.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter EE - HIGH DEDUCTIBLE HEALTH PLANS › Section 21.3901 - Purpose

Current through Reg. 49, No. 28; July 12, 2024
The purpose of this subchapter is to implement Texas
					 Insurance Code Chapter 1653 which prohibits construing state statutes to
					 prevent a health carrier from applying deductible or copayment requirements to
					 benefits, including state-mandated health benefits, in order to qualify health
					 benefit plans as high deductible health plans.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter EE - HIGH DEDUCTIBLE HEALTH PLANS › Section 21.3902 - Definitions

Current through Reg. 49, No. 28; July 12, 2024
The following words and terms, when used in this
					 subchapter, shall have the following meanings, unless the context clearly
					 indicates otherwise.
(1) Accident and
				  health insurance policy--Any policy or contract that provides insurance against
				  loss resulting from:
(A) accidental bodily
				  injury;
(B) accidental death;
				  or
(C) sickness.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter EE - HIGH DEDUCTIBLE HEALTH PLANS › Section 21.3903 - Applicability of State Mandates to High Deductible Health Plans

Current through Reg. 49, No. 28; July 12, 2024
Subject to §
										21.3904(a)
					 of this subchapter (relating to Exemption from State Mandates for High
					 Deductible Health Plans), a high deductible health plan is subject to any law
					 mandating a minimum health insurance benefit or
					 reimbursement.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter EE - HIGH DEDUCTIBLE HEALTH PLANS › Section 21.3904 - Exemption from State Mandates for High Deductible Health Plans

Current through Reg. 49, No. 28; July 12, 2024
(a) No provision of the Insurance Code may be
				  construed to prevent a health carrier or other entity issuing a health benefit
				  plan from applying deductible or copayment requirements to benefits and
				  services, including state-mandated health benefits and services, in order to
				  qualify the health benefit plan as a high deductible health plan.
(b) Subsection (a) of this section does not
				  apply to a preventive care benefit or service. Example: Insurance Code
				  §§
										1367.053 and
				  1367.054
				  require a health benefit plan to cover certain childhood immunizations without
				  making them subject to a deductible, copayment, or coinsurance requirement.
				  While compliance with this Texas statute would ostensibly prevent a health
				  benefit plan from qualifying as a high deductible health plan, since IRS
				  Bulletin 2004-15 classifies the benefit as preventive care, the safe harbor of
				  29 U.S.C. §228 allows a high-deductible health plan to cover it on a
				  first-dollar basis. Accordingly, compliance with §§1367.053 and
				  1367.054 does not prevent a health benefit plan from qualifying as a high
				  deductible health plan, and Insurance Code §
										1653.002
				  thus would not except a health carrier issuing a high deductible health plan
				  from compliance with the state mandate.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter EE - HIGH DEDUCTIBLE HEALTH PLANS › Section 21.3905 - Applicability

Current through Reg. 49, No. 28; July 12, 2024
This subchapter applies to coverage under a health benefit
					 plan issued, amended to be effective, renewed, or issued for delivery on or
					 after January 1, 2006.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter FF - OBLIGATION TO CONTINUE PREMIUM PAYMENT AND COVERAGE AFTER NOTICE OF LOST GROUP ELIGIBILITY › Section 21.4001 - Purpose and Scope

Current through Reg. 49, No. 28; July 12, 2024
This subchapter applies to group preferred provider benefit
					 plans and evidences of coverage issued pursuant to Insurance Code Chapters 843
					 and 1301. The subchapter outlines a group policyholder's or group contract
					 holder's liability for premium payment, and a health carrier's obligation to
					 provide coverage, from the time an individual insured or enrollee loses
					 eligibility for coverage as part of a particular group until the end of the
					 month in which the group policyholder or group contract holder notifies the
					 health carrier that the individual is no longer part of the group eligible for
					 coverage. The subchapter does not impose requirements on a group policyholder,
					 a group contract holder, or a health carrier when an entire group ends coverage
					 under a health benefit plan or when an individual terminates coverage while
					 remaining part of the group eligible for coverage.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter FF - OBLIGATION TO CONTINUE PREMIUM PAYMENT AND COVERAGE AFTER NOTICE OF LOST GROUP ELIGIBILITY › Section 21.4002 - Definitions

Current through Reg. 49, No. 28; July 12, 2024
The following words and terms, when used in this
					 subchapter, shall have the following meanings unless the context clearly
					 indicates otherwise.
(1) Evidence of
				  coverage--Any certificate, agreement, or contract, including a blended
				  contract, that:
(A) is issued to an enrollee;
				  and
(B) states the coverage to
				  which the enrollee is entitled.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter FF - OBLIGATION TO CONTINUE PREMIUM PAYMENT AND COVERAGE AFTER NOTICE OF LOST GROUP ELIGIBILITY › Section 21.4003 - Group Policyholder, Group Contract Holder, and Carrier Premium Payment and Coverage Obligations

Current through Reg. 49, No. 28; July 12, 2024
(a) Liability for
				  Premiums for Individuals Who Are No Longer Part of the Covered Group.
(1) A contract between a health carrier and a
				  group policyholder or group contract holder under a health benefit plan
				  contract must provide that:
(A) the group
				  policyholder or group contract holder, as described in the Insurance Code
				  Chapter 1251, is liable for an individual insured's or enrollee's premiums from
				  the time the individual is no longer part of the group eligible for coverage
				  under the plan until the end of the month in which the group policyholder or
				  group contract holder notifies the health carrier that the individual is no
				  longer part of the group eligible for coverage under the plan; and
(B) the individual remains covered under the
				  plan until the end of the period specified in subparagraph (A) of this
				  paragraph.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter GG - HEALTH CARE QUALITY ASSURANCE PRESUMED COMPLIANCE › Section 21.4101 - Purpose and Scope

Current through Reg. 49, No. 28; July 12, 2024
(a) General
				  purpose. This subchapter implements provisions of the Health Care Quality
				  Assurance Act (Act), codified as the Insurance Code Chapter 847. The general
				  purpose of the Act and this subchapter is to provide standards for the
				  appropriate recognition of accreditation of health benefit plan issuers by
				  nationally recognized accreditation organizations. These standards will
				  facilitate increased affordability of health benefit plan coverage for
				  consumers and eliminate the duplication of effort by both health benefit plan
				  issuers and state agencies.
(b)
				  Applicability. This subchapter applies to an entity that:
(1) issues a health benefit plan as defined
				  in the Insurance Code §
											847.003(2);
(2) holds a license or certificate of
				  authority issued by the commissioner; and
(3) provides benefits for medical or surgical
				  expenses incurred as a result of a health condition, accident, or sickness,
				  including those entities listed in the Insurance Code §
											847.004.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter GG - HEALTH CARE QUALITY ASSURANCE PRESUMED COMPLIANCE › Section 21.4102 - Definitions

Current through Reg. 49, No. 28; July 12, 2024
The following words and terms, when used in this
					 subchapter, shall have the following meanings unless the context clearly
					 indicates otherwise.
(1) Accreditation
				  report--The final report a national accreditation organization issues that
				  contains a detailed analysis of the accreditation survey results including the
				  scores of the health benefit plan issuer and the extent to which the health
				  benefit plan issuer meets or exceeds, or fails to meet, the required
				  accreditation standards.
(2)
				  Delegated entity--Has the meaning assigned by the Insurance Code §
										1272.001(a)(1).
(3) Delegated third party--Has the meaning
				  assigned by the Insurance Code §
										1272.001(a)(3).
(4) Health benefit plan--Has the meaning
				  assigned by the Insurance Code §
										847.003(2).
(5) National accreditation organization--Has
				  the meaning assigned by the Insurance Code §
										847.003(3).
(6) Nonconditional accreditation--Final
				  accreditation survey results that a national accreditation organization issues
				  stating an outcome that meets or exceeds the requirements of the national
				  accreditation organization in a particular category and that is not conditional
				  or contingent upon the health benefit plan issuer correcting any
				  deficiencies.
(7) Summary
				  results--A synopsis of the final accreditation survey results, excluding
				  numeric scores and percentages that a national accreditation organization
				  issues that provides the accreditation outcome results of the health benefit
				  plan issuer, such as in report card format, but that is not a complete and
				  detailed report of the accreditation survey results.
(8) Utilization review agent--Has the meaning
				  assigned by the Insurance Code §
										4201.002(14).
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter GG - HEALTH CARE QUALITY ASSURANCE PRESUMED COMPLIANCE › Section 21.4103 - Presumed Compliance

Current through Reg. 49, No. 28; July 12, 2024
(a) Health benefit
				  plan issuer presumed compliance. Pursuant to the Insurance Code §
										847.005(a),
				  a health benefit plan issuer shall be presumed to be in compliance with state
				  statutory and regulatory requirements if:
(1)
				  a national accreditation organization has issued the health benefit plan issuer
				  nonconditional accreditation applicable to its operations within the state of
				  Texas; and
(2) the national
				  accreditation organization's accreditation requirements are the same,
				  substantially similar to, or more stringent than the department's statutory and
				  regulatory requirements.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter GG - HEALTH CARE QUALITY ASSURANCE PRESUMED COMPLIANCE › Section 21.4104 - Health Benefit Plan Issuers Contracting with Delegated Entities, Delegated Third Parties, and Utilization Review Agents

Current through Reg. 49, No. 28; July 12, 2024
(a) Delegations by health benefit plan
				  issuers with nonconditional accreditation. If a health benefit plan issuer with
				  nonconditional accreditation has delegated one or more functions to a delegated
				  entity, delegated third party, or utilization review agent, those delegated
				  functions shall be presumed in compliance with state statutory and regulatory
				  requirements if:
(1) the delegation was in
				  place at the time of the national accreditation organization's review of the
				  health benefit plan issuer; or
(2)
				  the delegated entity, delegated third party, or utilization review agent has
				  received nonconditional accreditation or certification by a national
				  accreditation organization.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter GG - HEALTH CARE QUALITY ASSURANCE PRESUMED COMPLIANCE › Section 21.4105 - Department Monitoring and Analysis of National Accreditation Organization Standards

Current through Reg. 49, No. 28; July 12, 2024
(a) Analysis of
				  standards. The department will compare statutory and regulatory requirements of
				  the department for health benefit plan issuers with the standards of national
				  accreditation organizations. The standards of national accreditation
				  organizations that are the same as, substantially similar to, or more stringent
				  than the department's statutory and regulatory requirements will be identified
				  and used to determine the presumption of compliance of health benefit plan
				  issuers.
(b) Monitoring schedule.
				  The department will, at least annually, monitor and analyze updates and
				  amendments made to accreditation standards by national accreditation
				  organizations to ensure that those standards remain the same as, substantially
				  similar to, or more stringent than the statutory and regulatory requirements of
				  the department.
(c) Posting of
				  standards. The department will post a table on its website that contains a
				  summary of its comparison of national accreditation organization standards with
				  the statutory and regulatory requirements of the department and indicates which
				  portions of the examination process the department will presume compliance for
				  accredited entities. The presumed compliance table listing the summary of the
				  comparison of national accreditation standards and department statutory and
				  regulatory requirements may be obtained from:
(1) the department's website at
www.tdi.texas.gov
; or
(2) the Financial Regulation Division,
				  MC-FRD, Texas Department of Insurance, P.O. Box 12030, Austin, Texas
				  78711-2030.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter GG - HEALTH CARE QUALITY ASSURANCE PRESUMED COMPLIANCE › Section 21.4106 - Confidentiality

Current through Reg. 49, No. 28; July 12, 2024
(a) Accreditation reports. Pursuant to the
				  Insurance Code §
										847.006(b),
				  accreditation reports submitted to the department are proprietary and
				  confidential under the Government Code Chapter 552 and are not subject to
				  subpoena.
(b) Summary results.
				  Pursuant to the Insurance Code §
										847.006(c)
				  the summary results of a national accreditation organization are not
				  proprietary information and are subject to public disclosure under the
				  Government Code Chapter 552.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter HH - MILITARY SALES PRACTICES › Section 21.4201 - Purpose

Current through Reg. 49, No. 28; July 12, 2024
The purpose of this subchapter is to set forth standards to
					 protect active duty service members of the United States Armed Forces from
					 dishonest and predatory insurance sales practices by declaring certain
					 identified insurance sales practices to be false, misleading, deceptive or
					 unfair.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter HH - MILITARY SALES PRACTICES › Section 21.4202 - Scope

Current through Reg. 49, No. 28; July 12, 2024
(a) This subchapter shall apply only to the
				  solicitation or sale of any life insurance or annuity product by an insurer or
				  insurance agent to an active duty service member of the United States Armed
				  Forces.
(b) This subchapter shall
				  apply only to acts or practices committed on or after the effective date of
				  this subchapter.
(c) This
				  subchapter shall apply in addition to all other statutes and Texas Department
				  of Insurance rules concerning the marketing and solicitation of insurance
				  products, as well as statutes and Texas Department of Insurance rules
				  concerning unfair or deceptive trade practices, and shall not be interpreted to
				  limit those statutes and rules in any manner. The commissioner may discipline
				  or enforce an action against an insurer or insurance agent under this
				  subchapter in addition to any other statute or Texas Department of Insurance
				  rule authorizing disciplinary or enforcement action.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter HH - MILITARY SALES PRACTICES › Section 21.4203 - Exemptions

Current through Reg. 49, No. 28; July 12, 2024
(a) This subchapter shall not apply to
				  solicitations or sales involving:
(1) credit
				  insurance;
(2) group life insurance
				  or group annuities where there is no in-person, face-to-face solicitation of
				  individuals by an insurance agent or where the contract or certificate does not
				  include a side fund;
(3) an
				  application to the existing insurer that issued the existing policy or contract
				  when a contractual change or a conversion privilege is being exercised; or,
				  when the existing policy or contract is being replaced by the same insurer
				  pursuant to a program filed with and approved by the commissioner; or, when a
				  term conversion privilege is exercised among corporate affiliates;
(4) individual stand-alone health policies,
				  including disability income policies;
(5) contracts offered by Servicemembers'
				  Group Life Insurance (SGLI) or Veterans' Group Life Insurance (VGLI), as
				  authorized by
				  38
				  U.S.C. Section 1965 et seq.;
(6) life insurance contracts offered through
				  or by a non-profit military association, qualifying under Section 501(c)(23) of
				  the Internal Revenue Code (IRC), and which are not underwritten by an insurer;
				  or
(7) contracts used to fund:
(A) an employee pension or welfare benefit
				  plan that is covered by the Employee Retirement and Income Security Act
				  (ERISA);
(B) a plan described by
				  Sections 401(a), 401(k), 403(b), 408(k) or 408(p) of the IRC, as amended, if
				  established or maintained by an employer;
(C) a government or church plan defined in
				  Section 414 of the IRC, a government or church welfare benefit plan, or a
				  deferred compensation plan of a state or local government or tax exempt
				  organization under Section 457 of the IRC;
(D) a nonqualified deferred compensation
				  arrangement established or maintained by an employer or plan sponsor;
(E) settlements of or assumptions of
				  liabilities associated with personal injury litigation or any dispute or claim
				  resolution process; or
(F)
				  prearranged funeral contracts.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter HH - MILITARY SALES PRACTICES › Section 21.4204 - Definitions

Current through Reg. 49, No. 28; July 12, 2024
The following words and terms, when used in this
					 subchapter, shall have the following meanings unless the context clearly
					 indicates otherwise.
(1) Active
				  duty--Full-time duty in the active military service of the United States and
				  includes members of the reserve component (National Guard and Reserve) while
				  serving under published orders for active duty or full-time training. The term
				  does not include members of the reserve component who are performing active
				  duty or active duty for training under military calls or orders specifying
				  periods of less than 31 calendar days.
(2) Department of Defense (DoD)
				  Personnel--All active duty service members and all civilian employees,
				  including nonappropriated fund employees and special government employees, of
				  the U.S. Department of Defense.
(3)
				  Door to door--A solicitation or sales method whereby an insurance agent
				  proceeds randomly or selectively from household to household without prior
				  specific appointment.
(4) General
				  advertisement--An advertisement having as its sole purpose the promotion of the
				  reader's or viewer's interest in the concept of insurance, or the promotion of
				  the insurer or the insurance agent.
(5) Insurer--An insurance company required to
				  be licensed under the laws of this state to provide life insurance products,
				  including annuities.
(6) Insurance
				  agent--A person required to be licensed under Chapter 4054, Insurance Code, and
				  includes a person required to be licensed in accordance with
				  §4054.051(7).
(7) Known or
				  knowingly--Depending on its use in this subchapter, the insurance agent or
				  insurer had actual awareness, or in the exercise of ordinary care should have
				  known, at the time of the act or practice complained of, that the person
				  solicited:
(A) is a service member;
				  or
(B) is a service member with a
				  pay grade of E-4 or below.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter HH - MILITARY SALES PRACTICES › Section 21.4205 - Practices Declared False, Misleading, Deceptive or Unfair on a Military Installation

Current through Reg. 49, No. 28; July 12, 2024
(a) The
				  following acts or practices when committed on a military installation by an
				  insurer or insurance agent with respect to the in-person, face-to-face
				  solicitation of life insurance are declared to be false, misleading, deceptive
				  or unfair:
(1) knowingly soliciting the
				  purchase of any life insurance product "door to door" or without first
				  establishing a specific appointment for each meeting with the prospective
				  purchaser;
(2) soliciting service
				  members in a group or mass audience or in a captive audience where attendance
				  is not voluntary;
(3) knowingly
				  making appointments with or soliciting service members during their normally
				  scheduled duty hours;
(4) making
				  appointments with or soliciting service members in barracks, day rooms, unit
				  areas, or transient personnel housing or other areas where the installation
				  commander has prohibited solicitation;
(5) soliciting the sale of life insurance
				  without first obtaining permission from the installation commander or the
				  commander's designee;
(6) posting
				  unauthorized bulletins, notices or advertisements;
(7) failing to present DD Form 2885, Personal
				  Commercial Solicitation Evaluation, to service members solicited or encouraging
				  service members solicited not to complete or submit a DD Form 2885;
				  or
(8) knowingly accepting an
				  application for life insurance or issuing a policy of life insurance on the
				  life of an enlisted member of the United States Armed Forces without first
				  obtaining for the insurer's files a completed copy of any required form which
				  confirms that the applicant has received counseling or fulfilled any other
				  similar requirement for the sale of life insurance established by regulations,
				  directives or rules of the DoD or any branch of the Armed Forces.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter HH - MILITARY SALES PRACTICES › Section 21.4207 - Severability

Current through Reg. 49, No. 28; July 12, 2024
If a court of competent jurisdiction holds that any
					 provision of this subchapter is inconsistent with any statutes of this state,
					 is unconstitutional, or is invalid for any reason, the remaining provisions of
					 this subchapter shall remain in effect.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter II - RECOGNITION OF NATIONAL CERTIFYING ORGANIZATIONS FOR NONINVASIVE SCREENING OF CARDIOVASCULAR DISEASE › Section 21.4301 - Recognition

Current through Reg. 49, No. 28; July 12, 2024
The Commissioner recognizes the following organizations
					 pursuant to Insurance Code §
										1376.003(b),
					 which requires the Commissioner to recognize national organizations that
					 certify laboratories to perform the screening tests for atherosclerosis and
					 abnormal artery structure and function that are set forth in the Insurance Code
					 §
										1376.003(b)(1) and
					 (2):
(1) the American College of
				  Radiology;
(2) the Intersocietal
				  Accreditation Commission; or
(3) a
				  certifying organization recognized by the Centers for Medicare and Medicaid
				  Services.