reglab/statecodes huggingface dataset:
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter V - COORDINATION OF BENEFITS › Section 3.3503 - 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) Allowable
				  expense--Except as otherwise provided in §
										3.3505 of this title (relating to
				  Allowable Expenses), or where a statute requires a different definition, any
				  health care expense, including coinsurance or copayments and without reduction
				  for any applicable deductible, that is covered in full or in part by any of the
				  plans covering the person.
(2)
				  Allowed amount--The amount of a billed charge that a carrier determines to be
				  covered for services provided by a noncontracted health care provider or
				  physician. The allowed amount includes the carrier's payment and any applicable
				  deductible, copayment, or coinsurance amounts for which the insured is
				  responsible.
(3) Birthday--Refers
				  only to the month and day in a calendar year and does not include the year in
				  which the individual is born.
(4)
				  Carrier--An entity authorized under the Insurance Code to provide coverage
				  subject to this subchapter, including an insurer, health maintenance
				  organization, group hospital service corporation, or stipulated premium
				  company.
(5) Certificate holder--An
				  insured or enrollee who is covered other than as a dependent under a group plan
				  or a group-type plan.
(6) Claim--A
				  request that benefits be provided or paid. The benefits claimed may be in the
				  form of:
(A) services, including
				  supplies;
(B) payment for all or a
				  portion of the expenses incurred;
(C) a combination of subparagraphs (A) and
				  (B) of this paragraph; or
(D) an
				  indemnification.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter V - COORDINATION OF BENEFITS › Section 3.3504 - General Prohibition

Current through Reg. 49, No. 28; July 12, 2024
A carrier may not coordinate benefits to reduce the
					 benefits paid under a plan regulated by this subchapter in the absence of a COB
					 provision in the contract that meets the requirements of this subchapter.
					 Despite §
										11.511(1)(B)
					 of this title (relating to Optional Provisions), and subject to the
					 requirements of Insurance Code Chapter 1203 and this subchapter, an HMO group
					 plan may coordinate benefits with an individual or conversion
					 plan.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter V - COORDINATION OF BENEFITS › Section 3.3506 - Use of the Term "Plan" in Contracts

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  Separate parts of a plan for members of a group that are provided through
				  alternative contracts that are intended to be part of a coordinated package of
				  benefits are considered one plan, and there is no COB among the separate parts
				  of the plan.
(b) If a plan
				  coordinates benefits, its contract must state the types of coverage that will
				  be considered in applying the COB provision of that contract. Whether the
				  contract uses the term "plan" or some other term such as "program," the
				  contractual definition may be no broader than the definition of "plan" in this
				  subchapter. The model COB contract provisions provide an example of how to
				  define "plan" in §
										3.3510(d)
				  of this title (relating to Model COB Contract Provisions).
(c) A contract may apply one COB provision to
				  certain benefits, such as dental benefits, coordinating only with like
				  benefits, and may apply other separate COB provisions to coordinate other
				  benefits.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter V - COORDINATION OF BENEFITS › Section 3.3507 - Rules for COB and Order of Benefits

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  Coverage by two or more plans. When a person is covered by two or more plans,
				  the rules for determining the order of benefit payments will be determined as
				  provided in paragraphs (1) - (5) of this subsection.
(1) The primary plan must pay or provide its
				  benefits as if the secondary plan or plans did not exist.
(2) A plan may take into consideration the
				  benefits paid or provided by another plan only when, under this subchapter, it
				  is secondary to that other plan.
(3) If the primary plan is a closed panel
				  plan and the secondary plan is not, the secondary plan must pay or provide
				  benefits as if it were the primary plan when a covered person uses a
				  noncontracted health care provider or physician, except for emergency services
				  or authorized referrals that are paid or provided by the primary
				  plan.
(4) When multiple contracts
				  providing coordinated coverage are treated as a single plan under this
				  subchapter, this section applies only to the plan as a whole, and coordination
				  among the component contracts is governed by the terms of the contracts. If
				  more than one carrier pays or provides benefits under the plan, the carrier
				  designated as primary within the plan must be responsible for the plan's
				  compliance with this subchapter.
(5) If a person is covered by more than one
				  secondary plan, the order of benefit determination rules of this subchapter
				  decide the order in which secondary plans' benefits are determined in relation
				  to each other. Each secondary plan must take into consideration the benefits of
				  the primary plan or plans and the benefits of any other plan, that, under the
				  rules of this subchapter, has its benefits determined before those of that
				  secondary plan.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter V - COORDINATION OF BENEFITS › Section 3.3508 - Procedure to be Followed by Secondary Plan

Current through Reg. 49, No. 28; July 12, 2024
In determining the amount to be paid by the secondary plan
					 on a claim, should the plan wish to coordinate benefits, the secondary plan
					 must calculate the benefits it would have paid on the claim in the absence of
					 other health care coverage and apply that calculated amount to any allowable
					 expense under its plan that is unpaid by the primary plan. The secondary plan
					 may reduce its payment by the amount that, when combined with the amount paid
					 by the primary plan, results in the total benefits paid or provided by all
					 plans for the claim equaling 100 percent of the total allowable expense for
					 that claim. In addition, the secondary plan must credit to its plan deductible
					 any amounts it would have credited to its deductible in the absence of other
					 health care coverage.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter V - COORDINATION OF BENEFITS › Section 3.3509 - Miscellaneous Provisions

Current through Reg. 49, No. 28; July 12, 2024
(a) A secondary
				  plan that provides benefits in the form of services may recover the reasonable
				  cash value of providing the services from the primary plan, to the extent that
				  benefits for the services are covered by the primary plan and have not already
				  been paid or provided by the primary plan. This subsection does not require a
				  plan to reimburse a covered person in cash for the value of services provided
				  by a plan that provides benefits in the form of services.
(b) A plan with order of benefit
				  determination rules that comply with this subchapter may coordinate its
				  benefits with a noncompliant plan that is "excess" or "always secondary" or
				  that uses order of benefit determination rules that are inconsistent with those
				  contained in this subchapter on the following basis:
(1) if the complying plan is the primary
				  plan, it must pay or provide its benefits first;
(2) if the complying plan is the secondary
				  plan, it must pay or provide its benefits first, but the amount of the benefits
				  payable must be determined as if the complying plan were the secondary plan. In
				  such a situation, the payment must be the limit of the complying plan's
				  liability; and
(3) if the
				  noncompliant plan does not provide the information needed by the complying plan
				  to determine its benefits within a reasonable time after it is requested to do
				  so, the complying plan must assume that the benefits of the noncompliant plan
				  are identical to its own, and must pay its benefits accordingly. If, within two
				  years of payment, the complying plan receives information as to the actual
				  benefits of the noncompliant plan, it must adjust payments
				  accordingly.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter V - COORDINATION OF BENEFITS › Section 3.3510 - Model COB Contract Provisions

Current through Reg. 49, No. 28; July 12, 2024
(a) Subsection (d)
				  of this section contains an optional model COB provision form for use in
				  contracts. The use of this model form is subject to the provisions of §
										3.3509 of this title (relating to
				  Miscellaneous Provisions) and the provisions of §
										3.3507 of this title (relating to
				  Rules for COB and Order of Benefits).
(b) Subsection (e) of this section contains
				  an optional model plain language description of the COB process that explains
				  to the covered person how health plans will implement COB. It is not intended
				  to replace or change the provisions that are set forth in the contract. Its
				  purpose is to explain the process by which two or more plans will pay for or
				  provide benefits.
(c) A COB
				  provision or a plain language description does not have to use the words and
				  format shown in the model forms. Changes may be made to fit the language and
				  style of the rest of the contract or to reflect the difference among plans that
				  provide services, pay benefits for expenses incurred, and indemnify. No
				  substantive changes are allowed.
(d) The model COB contract provisions are as
				  follows:
Attached Graphic
(e) The model COB notice
				  publication is as follows:
Attached Graphic
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter W - MISCELLANEOUS RULES FOR GROUP AND INDIVIDUAL ACCIDENT AND HEALTH INSURANCE › Section 3.3601 - Orthodontic Coverages

Current through Reg. 49, No. 28; July 12, 2024
No policy or certificate of insurance may be delivered or
					 issued for delivery in this state on or after January 1, 1987, if the policy or
					 certificate excludes orthodontic coverage on the ground that overbite, overjet,
					 openbite, or arch length discrepancies measure less than four millimeters or
					 any other arbitrary unit of measurement or qualifications which are not
					 reasonably supported by accepted orthodontic practice.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter W - MISCELLANEOUS RULES FOR GROUP AND INDIVIDUAL ACCIDENT AND HEALTH INSURANCE › Section 3.3602 - Requirements for Short-Term Limited-Duration Coverage

Current through Reg. 49, No. 28; July 12, 2024
(a) The purpose of this section is to define
				  short-term limited-duration insurance and address requirements for short-term
				  limited-duration coverage. This section applies to any individual or group
				  accident and health insurance policy or certificate issued under Insurance Code
				  Chapters 1201 or 1251.
(b) For the
				  purposes of Chapters 3, 21, and 26 of this title, "short-term limited-duration
				  insurance" has the meaning given in Insurance Code §
										1509.001.
(c) An individual policy or group certificate
				  of short-term limited-duration insurance must provide benefits consistent with
				  the minimum standards for the type of coverage offered.
(d) Short-term limited-duration coverage,
				  including individual policies and group certificates:
(1) may not be marketed as guaranteed
				  renewable;
(2) must be marketed
				  either as nonrenewable, or renewable (without new underwriting) at the option
				  of the policyholder or enrollee, if the enrollee contributes to the
				  premium;
(3) must clearly state the
				  duration of the initial term and the total maximum duration including any
				  renewal options;
(4) may not be
				  modified after the date of issue, except by signed acceptance of the
				  policyholder or the enrollee, if the enrollee contributes to the premium;
				  and
(5) if coverage is renewable, a
				  short-term limited-duration individual policy or group certificate must:
(A) include a statement that the enrollee has
				  a right to continue the coverage in force by timely payment of premiums for the
				  number of terms listed;
(B) include
				  a statement that the issuer will not increase premium rates or make changes in
				  provisions in the policy, or certificate, on renewal based on individual health
				  status;
(C) if applicable, include
				  a statement that the issuer retains the right, at the time of policy renewal,
				  to make changes to premium rates by class; and
(D) include a statement that the issuer, at
				  the time of renewal, may not deny renewal based on individual health
				  status.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter W - MISCELLANEOUS RULES FOR GROUP AND INDIVIDUAL ACCIDENT AND HEALTH INSURANCE › Section 3.3604 - Notice for Policies That Provide Benefits for Expenses Incurred for an Accidental Injury Only

Current through Reg. 49, No. 28; July 12, 2024
The notice in this section is for policies that provide
					 benefits for expenses incurred for an accidental injury only, and shall follow
					 the content and format of one of the two statements (but not both
					 simultaneously) set out in this section, as follows:
(1) Original disclosure statement:
Attached
				  Graphic
(2) Alternative
				  disclosure statement:
Attached
				  Graphic
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter W - MISCELLANEOUS RULES FOR GROUP AND INDIVIDUAL ACCIDENT AND HEALTH INSURANCE › Section 3.3605 - Policies That Provide Benefits for Specified Limited Services

Current through Reg. 49, No. 28; July 12, 2024
The notice in this section is for policies that provide
					 benefits for specified limited services, and shall follow the content and
					 format of one of the two statements (but not both simultaneously) set out in
					 this section, as follows:
(1) Original
				  disclosure statement:
Attached
				  Graphic
(2) Alternative
				  disclosure statement:
Attached
				  Graphic
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter W - MISCELLANEOUS RULES FOR GROUP AND INDIVIDUAL ACCIDENT AND HEALTH INSURANCE › Section 3.3606 - Policies That Reimburse Expenses Incurred for Specified Diseases or Impairments

Current through Reg. 49, No. 28; July 12, 2024
The notice in this section is for policies that reimburse
					 expenses incurred for specified diseases or other specified impairments
					 (including expense-incurred cancer, specified disease and other types of health
					 insurance policies that limit reimbursement to named medical conditions), and
					 shall follow the content and format of one of the two statements (but not both
					 simultaneously) of this section as follows:
(1) Original disclosure statement:
Attached
				  Graphic
(2) Alternative
				  disclosure statement:
Attached
				  Graphic
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter W - MISCELLANEOUS RULES FOR GROUP AND INDIVIDUAL ACCIDENT AND HEALTH INSURANCE › Section 3.3607 - Policies That Pay Fixed Dollar Amounts for Specified Diseases or Impairments

Current through Reg. 49, No. 28; July 12, 2024
The notice in this section is for policies that pay fixed
					 dollar amounts for specified diseases or other specified impairments (including
					 cancer, specified disease, and other health insurance policies that pay a
					 scheduled benefit or specific payment based on diagnosis of the conditions
					 named in the policy), and shall follow the content and format of one of the two
					 statements (but not both simultaneously) set out in this section, as
					 follows:
(1) Original disclosure
				  statement:
Attached
				  Graphic
(2) Alternative
				  disclosure statement:
Attached
				  Graphic
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter W - MISCELLANEOUS RULES FOR GROUP AND INDIVIDUAL ACCIDENT AND HEALTH INSURANCE › Section 3.3608 - Indemnity or Other Policies That Pay a Fixed Dollar Amount Per Day

Current through Reg. 49, No. 28; July 12, 2024
The notice in this section is for indemnity policies and
					 other policies that pay a fixed dollar amount per day, excluding long-term care
					 policies, and shall follow the content and format of one of the two statements
					 (but not both simultaneously) set out in this section, as follows:
(1) Original disclosure statement:
Attached
				  Graphic
(2) Alternative
				  disclosure statement:
Attached
				  Graphic
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter W - MISCELLANEOUS RULES FOR GROUP AND INDIVIDUAL ACCIDENT AND HEALTH INSURANCE › Section 3.3609 - Policies That Provide Benefits upon Both an Expense-Incurred and Fixed Indemnity Basis

Current through Reg. 49, No. 28; July 12, 2024
The notice in this section is for policies that provide
					 benefits upon both an expense-incurred and fixed indemnity basis, and shall
					 follow the content and format of one of the two statements (but not both
					 simultaneously) set out in this section, as follows:
(1) Original disclosure statement:
Attached
				  Graphic
(2) Alternative
				  disclosure statement:
Attached
				  Graphic
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter W - MISCELLANEOUS RULES FOR GROUP AND INDIVIDUAL ACCIDENT AND HEALTH INSURANCE › Section 3.3613 - Other Health Insurance Policies

Current through Reg. 49, No. 28; July 12, 2024
The notice in this section is for other health insurance
					 policies not specifically identified in §§
										3.3604-3.3609
					 of this title (relating to Required Disclosure Statements for Policies that
					 Duplicate Medicare), and shall follow the content and format of one of the two
					 statements (but not both simultaneously) set out in this section, as
					 follows:
(1) Original disclosure
				  statement:
Attached
				  Graphic
(2) Alternative
				  disclosure statement:
Attached
				  Graphic
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter W - MISCELLANEOUS RULES FOR GROUP AND INDIVIDUAL ACCIDENT AND HEALTH INSURANCE › Section 3.3614 - Notice Regarding Policies or Certificates Which Are Not Medicare Supplement Policies

Current through Reg. 49, No. 28; July 12, 2024
Any accident and sickness insurance policy, subscriber
					 contract, or evidence of coverage other than a Medicare supplement policy,
					 disability income policy, or a policy issued pursuant to a contract under
					 Section 1876 of the Federal Social Security Act (42
					 USC §§1395ss, et seq) issued for
					 delivery in this state to persons eligible for Medicare shall be accompanied by
					 a notice to the insureds under the policy, subscriber contract, or evidence of
					 coverage that the policy, subscriber contract, or evidence of coverage is not a
					 Medicare supplement policy or certificate. The notice shall either be printed
					 on or attached to the first page of the outline of coverage delivered to
					 insureds under the policy or subscriber contract, or if no outline of coverage
					 is delivered, to the first page of the policy, certificate, subscriber
					 contract, or evidence of coverage delivered to insureds. The notice shall be in
					 no less than 12-point type and shall contain the following language: "THIS
					 (POLICY, CERTIFICATE, SUBSCRIBER CONTRACT, OR EVIDENCE OF COVERAGE) IS NOT A
					 MEDICARE SUPPLEMENT (POLICY OR CERTIFICATE). If you are eligible for Medicare,
					 review the Guide to Health Insurance for People with Medicare available from
					 the company."
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter X - PREFERRED AND EXCLUSIVE PROVIDER PLANS › Division 1 - GENERAL REQUIREMENTS › Section 3.3701 - Applicability and Scope

Current through Reg. 49, No. 28; July 12, 2024
(a) Except as
					 otherwise specified in this subchapter, this subchapter applies to any
					 preferred provider benefit plan or exclusive provider benefit plan as specified
					 in this subsection.
(1) This subchapter
					 applies to any preferred or exclusive provider benefit plan policy that is
					 offered, delivered, issued for delivery, or renewed on or after 150 days from
					 the effective date of this section. Any preferred or exclusive provider benefit
					 plan policy delivered, issued for delivery, or renewed prior to this
					 applicability date is subject to the statutes and provisions of this subchapter
					 in effect at the time the policy was delivered, issued for delivery, or
					 renewed.
(2) This subchapter does
					 not apply to:
(A) provisions for dental care
					 benefits in any health insurance policy; or
(B) an exclusive provider benefit plan
					 regulated under Subchapter KK of this chapter (relating to Exclusive Provider
					 Benefit Plan) written by an insurer pursuant to a contract with the Texas
					 Health and Human Services Commission to provide services under the Texas
					 Children's Health Insurance Program, Medicaid, or with the Statewide Rural
					 Health Care System.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter X - PREFERRED AND EXCLUSIVE PROVIDER PLANS › Division 1 - GENERAL REQUIREMENTS › Section 3.3706 - Designation as a Preferred Provider, Decision to Withhold Designation, Termination of a Preferred Provider, Review of Process

Current through Reg. 49, No. 28; July 12, 2024
(a) Access to designation as a preferred
					 provider. Physicians, practitioners, institutional providers, and health care
					 providers other than physicians, practitioners, and institutional providers, if
					 other health care providers are included by an insurer as preferred providers,
					 that are licensed to treat injuries or illnesses or to provide services covered
					 by the preferred provider benefit plan and that comply with the terms and
					 conditions established by the insurer for designation as preferred providers,
					 are eligible to apply for and must be afforded a fair, reasonable, and
					 equitable opportunity to become preferred providers, subject to subsection (b)
					 of this section.
(1) An insurer initially
					 sponsoring a preferred provider benefit plan is required to notify all
					 physicians and practitioners in the service area covered by the plan of its
					 intent to offer the plan and of the opportunity to apply to
					 participate.
(2) Subsequently, an
					 insurer is required to annually notify all non-contracting physicians and
					 practitioners in the service area covered by the plan of the existence of the
					 plan and the opportunity to apply to participate in the plan.
(3) An insurer is required, upon request, to
					 make available to any physician or provider information concerning the
					 application process and qualification requirements, including the use of
					 economic profiling by the insurer, used by the insurer to admit a provider to
					 the plan.
(4) All notifications
					 required to be made by an insurer pursuant to this subsection are required to
					 be made by publication or distributed in writing to each physician and
					 practitioner in the same manner.
(5) Selection standards used by the insurer
					 in choosing participating preferred providers must not directly or indirectly:
(A) avoid high risk populations by excluding
					 physicians or providers because the physicians or providers are located in
					 geographic areas that contain populations presenting a risk of higher than
					 average claims, losses or health services utilization; or
(B) exclude a physician or provider because
					 the physician or provider treats or specializes in treating populations
					 presenting a risk of higher than average claims, losses or health services
					 utilization.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter X - PREFERRED AND EXCLUSIVE PROVIDER PLANS › Division 1 - GENERAL REQUIREMENTS › Section 3.3708 - Payment of Certain Out-of-Network Claims

Current through Reg. 49, No. 28; July 12, 2024
(a) For an
					 out-of-network claim for which the insured is protected from balance billing
					 under Insurance Code Chapter 1301, concerning Preferred Provider Benefit Plans,
					 or when no preferred provider is reasonably available, an insurer must pay the
					 claim at the preferred level of coverage, including with respect to any
					 applicable copay, coinsurance, deductible, or maximum out-of-pocket amount. The
					 insurer must pay the claim according to the following payment standards:
(1) for emergency care and post-emergency
					 stabilization care, the applicable payment standards are under §1301.0053,
					 concerning Exclusive Provider Benefit Plans: Emergency Care; and
					 §1301.155, concerning Emergency Care;
(2) for certain care provided in a health
					 care facility, the applicable payment standards are under §1301.164,
					 concerning Out-of-Network Facility-Based Providers;
(3) for certain diagnostic imaging or
					 laboratory services performed in connection with care provided by a preferred
					 provider, the applicable payment standards are under §1301.165, concerning
					 Out-of-Network Diagnostic Imaging Provider or Laboratory Service
					 Provider;
(4) until August 31,
					 2025, for certain services and transports provided by an emergency medical
					 services provider, other than air ambulance, the applicable payment standards
					 are under §1301.166, concerning Out-of-Network Emergency Medical Services
					 Provider; and
(5) for services
					 provided by a nonpreferred provider when a preferred provider is not available
					 within the network adequacy standards established in §
												3.3704(f) of this
					 title (relating to Freedom of Choice; Availability of Preferred Providers), the
					 applicable payment standards are under Insurance Code §
												1301.005, concerning
					 Availability of Preferred Providers; Service Area Limitations, and Insurance
					 Code §
												1301.0052, concerning
					 Exclusive Provider Benefit Plans: Referrals for Medically Necessary
					 Services.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter X - PREFERRED AND EXCLUSIVE PROVIDER PLANS › Division 1 - GENERAL REQUIREMENTS › Section 3.3709 - Annual Network Adequacy Report

Current through Reg. 49, No. 28; July 12, 2024
(a) Network
					 adequacy report required. On or before April 1 of each year and prior to
					 marketing any plan in a new service area, an insurer must submit a network
					 adequacy report for each network to be used with a preferred or exclusive
					 provider benefit plan. The network adequacy report must be submitted to the
					 department using SERFF or another electronic method that is acceptable to the
					 department.
(b) General content of
					 report. The report required in subsection (a) of this section must specify:
(1) the insurer's name, National Association
					 of Insurance Commissioners number, network name, and network ID;
(2) the network configuration information
					 specified in §3.3712 of this title (relating to Network Configuration
					 Filings);
(3) whether the preferred
					 provider service delivery network supporting each plan is adequate under the
					 standards in §
												3.3704 of this title (relating to
					 Freedom of Choice; Availability of Preferred Providers); and
(4) if applicable, the waiver request and
					 access plan information as specified in §
												3.3707 of this title (relating to
					 Waiver Due to Failure to Contract in Local Markets).
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter X - PREFERRED AND EXCLUSIVE PROVIDER PLANS › Division 1 - GENERAL REQUIREMENTS › Section 3.3710 - Failure to Provide an Adequate Network

Current through Reg. 49, No. 28; July 12, 2024
(a) If the
					 commissioner determines, after notice and opportunity for hearing, that the
					 insurer's network and any access plan supporting the network are inadequate to
					 ensure that preferred provider benefits are reasonably available to all
					 insureds or are inadequate to ensure that all medical and health care services
					 and items covered under the health insurance policy are provided in a manner
					 ensuring availability of and accessibility to adequate personnel, specialty
					 care, and facilities, the commissioner may order one or more sanctions under
					 the authority of the commissioner in Insurance Code Chapters 82, concerning
					 Sanctions, and 83, concerning Emergency Cease and Desist Orders, including:
(1) reduction of a service area;
(2) cessation of marketing in parts of the
					 state; and
(3) cessation of
					 marketing entirely and withdrawal from the preferred provider benefit plan
					 market.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter X - PREFERRED AND EXCLUSIVE PROVIDER PLANS › Division 1 - GENERAL REQUIREMENTS › Section 3.3711 - Geographic Regions

Current through Reg. 49, No. 28; July 12, 2024
For the purposes of this subchapter, the 11 Texas
						geographic regions that an insurer is required to use for reporting data under
						§
											3.3709 of this title (relating to
						Annual Network Adequacy Report) are defined based on the public health regions
						designated under Health and Safety Code §
											121.007,
						concerning Public Health Regions, and listed in the annual network adequacy
						report form.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter X - PREFERRED AND EXCLUSIVE PROVIDER PLANS › Division 1 - GENERAL REQUIREMENTS › Section 3.3712 - Network Configuration Filings

Current through Reg. 49, No. 28; July 12, 2024
(a) An insurer must
					 submit network configuration information as specified in this section in
					 connection with a request for a waiver under §
											3.3707 of this title (relating to
					 Waiver Due to Failure to Contract in Local Markets), an annual network adequacy
					 report required under §
											3.3709 of this title (relating to
					 Annual Network Adequacy Report), or an application for a network modification
					 under §
											3.3722 of this title (relating to
					 Application for Preferred and Exclusive Provider Benefit Plan Approval;
					 Qualifying Examination; Network Modifications).
(b) A network configuration filing must be
					 submitted to the department using SERFF or another electronic method that is
					 acceptable to the department.
(c) A
					 network configuration filing must contain the following items.
(1) Provider listing data. The insurer must
					 use the provider listings form available at
www.tdi.texas.gov
to provide a comprehensive
					 searchable and sortable listing of physicians and health care providers in the
					 plan's network that includes:
(A) information
					 about the insurer, including the insurer's name, National Association of
					 Insurance Commissioners number, network name, and network ID;
(B) information about each preferred
					 provider, including:
(i) the preferred
					 provider's name, address of practice location, county, and telephone
					 number;
(ii) the preferred
					 provider's national provider identifier (NPI) number and Texas license
					 number;
(iii) the preferred
					 provider's specialty type, license, or facility type, as applicable, using the
					 categories specified in the form; and
(iv) whether the preferred provider offers
					 telemedicine or telehealth; and
(C) information about a preferred provider
					 that is not a facility, including information on the preferred provider's
					 facility privileges.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter X - PREFERRED AND EXCLUSIVE PROVIDER PLANS › Division 2 - APPLICATION, EXAMINATION, AND PLAN REQUIREMENTS › Section 3.3720 - Preferred and Exclusive Provider Benefit Plan Requirements

Current through Reg. 49, No. 28; July 12, 2024
Sections
						3.3721 of this title (relating to
						Preferred and Exclusive Provider Benefit Plan Network Approval Required),
						3.3722 of this title (relating to Application for Preferred and Exclusive
						Provider Benefit Plan Approval; Qualifying Examination; Network Modifications),
						and 3.3723 of this title (relating to Examinations) apply to preferred and
						exclusive provider benefit plans offered pursuant to Insurance Code Chapter
						1301, concerning Preferred Provider Benefit Plans, in commercial markets.
						Section 3.3724 of this title (relating to
						Quality Improvement Program) applies only to exclusive provider benefit plans
						offered under Insurance Code Chapter 1301 in commercial
						markets.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter X - PREFERRED AND EXCLUSIVE PROVIDER PLANS › Division 2 - APPLICATION, EXAMINATION, AND PLAN REQUIREMENTS › Section 3.3721 - Preferred and Exclusive Provider Benefit Plan Network Approval Required

Current through Reg. 49, No. 28; July 12, 2024
An insurer may not offer, deliver, or issue for delivery
						a preferred or exclusive provider benefit plan in this state unless the
						commissioner has completed a qualifying examination to determine compliance
						with Insurance Code Chapter 1301 and this subchapter and has approved the
						insurer's provider network in the service area.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter X - PREFERRED AND EXCLUSIVE PROVIDER PLANS › Division 2 - APPLICATION, EXAMINATION, AND PLAN REQUIREMENTS › Section 3.3722 - Application for Preferred and Exclusive Provider Benefit Plan Approval; Qualifying Examination; Network Modifications

Current through Reg. 49, No. 28; July 12, 2024
(a) Where to file
					 application. An insurer that seeks to offer a preferred or exclusive provider
					 benefit plan must file an application for approval with the Texas Department of
					 Insurance as specified on the department's website and use the form titled
					 Application for Approval of Provider Benefit Plan, which is available at
www.tdi.texas.gov/forms
.
(b) Filing requirements.
(1) An applicant must provide the department
					 with a complete application that includes the elements in the order set forth
					 in subsection (c) of this section.
(2) All pages must be clearly legible and
					 numbered.
(3) If the application is
					 revised or supplemented during the review process, the applicant must submit a
					 transmittal letter describing the revision or supplement plus the specified
					 revision or supplement.
(4) If a
					 page is to be revised, the applicant must submit a complete new page with the
					 changed item or information clearly marked.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter X - PREFERRED AND EXCLUSIVE PROVIDER PLANS › Division 2 - APPLICATION, EXAMINATION, AND PLAN REQUIREMENTS › Section 3.3725

Current through Reg. 49, No. 28; July 12, 2024
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter Y - STANDARDS FOR LONG-TERM CARE INSURANCE, NON-PARTNERSHIP AND PARTNERSHIP LONG-TERM CARE INSURANCE COVERAGE UNDER INDIVIDUAL AND GROUP POLICIES AND ANNUITY CONTRACTS, AND LIFE INSURANCE POLICIES THAT PROVIDE LONG-TERM CARE BENEFITS WITHIN THE POLICY › Division 1 - GENERAL PROVISIONS › Section 3.3801 - Authority

Current through Reg. 49, No. 28; July 12, 2024
This subchapter of rules of the Texas Department of
						Insurance is promulgated and adopted pursuant to the authority vested in the
						commissioner under the Insurance Code Chapter 1651 and
						§36.001.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter Y - STANDARDS FOR LONG-TERM CARE INSURANCE, NON-PARTNERSHIP AND PARTNERSHIP LONG-TERM CARE INSURANCE COVERAGE UNDER INDIVIDUAL AND GROUP POLICIES AND ANNUITY CONTRACTS, AND LIFE INSURANCE POLICIES THAT PROVIDE LONG-TERM CARE BENEFITS WITHIN THE POLICY › Division 1 - GENERAL PROVISIONS › Section 3.3802 - Purpose

Current through Reg. 49, No. 28; July 12, 2024
The purpose of this subchapter is to implement the
						Insurance Code Chapter 1651:
(1) to
					 promote the public interest;
(2) to
					 promote the availability of long-term care insurance coverage;
(3) to protect applicants for long-term care
					 insurance, as defined, from unfair or deceptive sales or enrollment
					 practices;
(4) to facilitate public
					 understanding and comparison of long-term care insurance coverages;
(5) to facilitate flexibility and innovation
					 in the development of long-term care insurance;
(6) to allow the sale of long-term care
					 insurance contracts which will qualify insureds, under certain conditions, for
					 favorable tax treatment under federal law; and
(7) to adopt, in consultation with the Texas
					 Health and Human Services Commission, minimum standards for a long-term care
					 benefit plan that may qualify as an approved plan under the long-term care
					 partnership program.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter Y - STANDARDS FOR LONG-TERM CARE INSURANCE, NON-PARTNERSHIP AND PARTNERSHIP LONG-TERM CARE INSURANCE COVERAGE UNDER INDIVIDUAL AND GROUP POLICIES AND ANNUITY CONTRACTS, AND LIFE INSURANCE POLICIES THAT PROVIDE LONG-TERM CARE BENEFITS WITHIN THE POLICY › Division 1 - GENERAL PROVISIONS › Section 3.3803 - Applicability and Severability

Current through Reg. 49, No. 28; July 12, 2024
(a)
					 Applicability.
(1) In accordance with the
					 Insurance Code Chapter 1651, §§
												3.3801-
					 3.3804 of
					 this subchapter (relating to General Provisions) apply to all long-term care
					 insurance coverage that is regulated under this subchapter.
(2) In accordance with the Insurance Code
					 Chapter 1651, §§3.3805 - 3.3807, 3.3810, 3.3812, 3.3815, and 3.3818 -
					 3.3849 of this subchapter (relating to Non-Partnership and Partnership
					 Long-Term Care Insurance) apply to all non-partnership and partnership
					 long-term care benefit plans as that term is defined in the Insurance Code
					 §
												1651.003
					 and § 3.3804 of this subchapter (relating to Definitions), and long-term
					 care riders attached to life insurance policies or certificates or annuity
					 contracts or certificates delivered or issued for delivery in this state except
					 as specified in paragraph (5) of this subsection.
(3) In accordance with the Insurance Code
					 Chapter 1651 Subchapter C (relating to Partnership for Long-Term Care Program),
					 §
												3.3860
					 of this subchapter (relating to Policy Summary Requirements for Non-Partnership
					 Life Insurance Policies and Annuity Contracts that Provide Long-Term Care
					 Benefits) applies only to non-partnership life insurance policies and annuity
					 contracts that provide long-term care benefits by rider except as specified in
					 paragraph (5) of this subsection.
(4) In accordance with the Insurance Code
					 Chapter 1651 Subchapter C, §§
												3.3870-
					 3.3874
					 of this subchapter (relating to Partnership Long-Term Care Insurance Only)
					 apply only to long-term care partnership benefit plans as that term is defined
					 in the Insurance Code §
												1651.101 and §
												1651.104
					 delivered or issued for delivery in this state except as specified in paragraph
					 (5) of this subsection.
(5) In
					 accordance with the Insurance Code §
												1651.002, this
					 subchapter does not apply to:
(A)
					 certificates delivered or issued for delivery in this state under a single
					 employer or labor union group policy that is delivered or issued for delivery
					 outside this state; or
(B) a policy
					 or certificate that is not designed, advertised, marketed, or offered as
					 long-term care or nursing home insurance.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter Y - STANDARDS FOR LONG-TERM CARE INSURANCE, NON-PARTNERSHIP AND PARTNERSHIP LONG-TERM CARE INSURANCE COVERAGE UNDER INDIVIDUAL AND GROUP POLICIES AND ANNUITY CONTRACTS, AND LIFE INSURANCE POLICIES THAT PROVIDE LONG-TERM CARE BENEFITS WITHIN THE POLICY › Division 2 - NON-PARTNERSHIP AND PARTNERSHIP LONG-TERM CARE INSURANCE › Section 3.3805 - Standards in Policies

Current through Reg. 49, No. 28; July 12, 2024
(a) Except as
					 otherwise provided by law or this subchapter, no long-term care insurance
					 policy or certificate or group hospital service corporation subscriber
					 contract, delivered or issued for delivery in this state, may contain
					 provisions respecting the matters set forth in §§3.3812 (relating to
					 Policy Standards for Provider), 3.3815 (relating to Standards for Home Health
					 and Adult Day Care Benefits), and 3.3818 (relating to Standards for Eligibility
					 for Benefits) of this title.
(b) A
					 life insurance policy or certificate or annuity contract or certificate to
					 which a long-term care rider is attached is subject to all statutes and
					 regulations applicable to such life policy or certificate or annuity contract
					 or certificate; however, a long-term care rider attached to such policy,
					 certificate or contract is subject to this subchapter.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter Y - STANDARDS FOR LONG-TERM CARE INSURANCE, NON-PARTNERSHIP AND PARTNERSHIP LONG-TERM CARE INSURANCE COVERAGE UNDER INDIVIDUAL AND GROUP POLICIES AND ANNUITY CONTRACTS, AND LIFE INSURANCE POLICIES THAT PROVIDE LONG-TERM CARE BENEFITS WITHIN THE POLICY › Division 2 - NON-PARTNERSHIP AND PARTNERSHIP LONG-TERM CARE INSURANCE › Section 3.3806 - Initial and Subsequent Conditions of Eligibility

Current through Reg. 49, No. 28; July 12, 2024
A long-term care insurance policy and/or certificate
						shall contain a provision which sets forth the individuals eligible to be
						covered under the policy and/or certificate and which specifies the conditions
						applicable to an individual who may become covered under the policy and/or
						certificate by subsequent addition.
(1) Eligible individuals may include:
(A) for group coverage:
(i) the prospective certificate holder (the
					 individual whose employment or other membership status, except for family
					 dependency, is the basis for eligibility for enrollment under the group
					 policy);
(ii) the certificate
					 holder's spouse;
(iii) the
					 certificate holder's children;
(iv)
					 the certificate holder's spouse's children;
(v) the certificate holder's
					 parents;
(vi) the certificate
					 holder's spouse's parents; and
(vii) any other individual included as an
					 eligible individual under a long-term care policy.