reglab/statecodes huggingface dataset:
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter K - CERTIFICATION OF CREDITABLE COVERAGE › Section 21.1103 - Timing of Issuance of a Written Certificate of Creditable Coverage to an Individual

Current through Reg. 49, No. 28; July 12, 2024
(a) Each issuer of
				  a health benefit plan shall comply with the following:
(1) For an individual who is a qualified
				  beneficiary entitled to elect COBRA continuation coverage, a certificate of
				  creditable coverage shall be provided at the time the individual would lose
				  coverage under the plan in the absence of COBRA continuation coverage or
				  alternative coverage elected, instead of COBRA continuation coverage. The
				  certificate of creditable coverage shall be provided within 30 days of the date
				  the individual would lose coverage under the plan, in the absence of COBRA
				  continuation coverage.
(2) For an
				  individual who is not a qualified beneficiary entitled to elect COBRA
				  continuation coverage, a certificate of creditable coverage shall be provided
				  within 30 days after the date the individual ceases to be covered under the
				  health benefit plan.
(3) For an
				  individual who is a qualified beneficiary and has elected COBRA continuation
				  coverage, a certificate of creditable coverage shall be provided within 30 days
				  after coverage under COBRA ceases or within 30 days after the expiration of any
				  grace period for nonpayment of premium. A certificate of creditable coverage is
				  required to be provided regardless of whether the individual has previously
				  received a certificate of creditable coverage under paragraph (1) of this
				  subsection.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter K - CERTIFICATION OF CREDITABLE COVERAGE › Section 21.1104 - Form and Content of Written Certificate of Creditable Coverage

Current through Reg. 49, No. 28; July 12, 2024
(a) Except as otherwise provided in §
										21.1107
				  of this title (relating to Creditable Coverage Established Through Means Other
				  Than Written Certificate), a certificate of creditable coverage must be
				  provided in writing.
(b) The
				  written certificate of creditable coverage shall include the following:
(1) The date the certificate is
				  issued;
(2) The name of the issuer
				  of the health benefit plan that provided the coverage described in the
				  certificate;
(3) The individual's
				  or dependent's name for which the certificate of creditable coverage is
				  issued;
(4) Any other information
				  necessary for the health benefit plan providing the coverage specified in the
				  certificate to identify the individual, including but not limited to, the
				  individual's identification number under the health benefit plan;
(5) The name, address and telephone number of
				  the third party administrator, plan sponsor, or issuer of the health benefit
				  plan providing the certificate;
(6)
				  A telephone number to call for further information regarding the certificate of
				  creditable coverage, if different than paragraph (5) of this section;
(7) Either one of the following:
(A) the date any waiting period (or
				  affiliation period, if applicable) began and the date creditable coverage
				  began; or
(B) a statement
				  indicating the individual has:
(i) 18 months
				  of creditable coverage for individual coverage; or
(ii) 12 months of creditable coverage for
				  group coverage; and
(8) The date creditable coverage ended, or a
				  statement that creditable coverage is continuing.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter K - CERTIFICATION OF CREDITABLE COVERAGE › Section 21.1105 - Delivery of Certificate of Creditable Coverage

Current through Reg. 49, No. 28; July 12, 2024
(a) A certificate shall be provided to an
				  individual as provided in §
										21.1103(a)
				  of this title (relating to Timing of Issuance of a Written Certificate of
				  Creditable Coverage to an Individual) or an entity requesting the certificate
				  on behalf of the individual by first-class mail. A certificate may also be made
				  available to the intended recipient by fax, or e-mail, if available.
(b) If a certificate or certificates of
				  creditable coverage are provided to the individual at the individual's last
				  known address, then the requirements of this section are satisfied with respect
				  to all individuals residing at that address.
(c) If a spouse or a dependent's last known
				  address is different than other individuals covered under the health benefit
				  plan, a separate certificate is required to be provided to the spouse or the
				  dependent at the spouse's or dependent's last known address.
(d) If separate certificates of creditable
				  coverage are provided by mail to individuals who reside at the same address,
				  separate mailings of each certificate are not required.
(e) An individual entitled to receive the
				  certificate of creditable coverage under §
										21.1103(a)
				  of this title (relating to Timing of Issuance of a Written Certificate of
				  Creditable Coverage to an Individual) may designate another individual or
				  entity to receive the certificate.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter K - CERTIFICATION OF CREDITABLE COVERAGE › Section 21.1106 - Dependent Coverage

Current through Reg. 49, No. 28; July 12, 2024
(a) An issuer of a
				  health benefit plan is required to use reasonable efforts to determine the
				  information needed for a certificate of creditable coverage relating to
				  dependent coverage.
(b) An issuer
				  of a health benefit plan that cannot provide the names or addresses of
				  dependents for providing a dependent's certificate of creditable coverage may
				  satisfy the requirements of §
										21.1104(b)(3)
				  of this title (relating to Form and Content of Certificate of Creditable
				  Coverage) until June 30, 1998, by providing the name of the individual covered
				  by the issuer of the health benefit plan and specifying that the type of
				  coverage described in the certificate is for dependent coverage (for example:
				  family coverage or employee/spouse coverage).
(c) An issuer of a health benefit plan that
				  issues a written certificate of creditable coverage that does not contain the
				  name of a dependent must furnish a certificate within 21 days after the
				  individual ceases to be covered under the policy.
(d) An issuer of a health benefit plan shall
				  treat an individual as having furnished a certificate of creditable coverage
				  showing the dependent status if the individual attests to the dependent status
				  and the period of such dependency and the individual cooperates with the
				  issuer's efforts to verify the dependent status.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter K - CERTIFICATION OF CREDITABLE COVERAGE › Section 21.1107 - Creditable Coverage Established Through Means Other Than Written Certificate

Current through Reg. 49, No. 28; July 12, 2024
(a) An individual
				  may establish creditable coverage through means other than a written
				  certificate of creditable coverage as provided in §
										21.1103
				  of this title (relating to Timing of Issuance of a Written Certificate of
				  Creditable Coverage) if the accuracy of a written certificate is contested or
				  if a written certificate is unavailable when needed by the individual. For
				  example, the individual may make such a demonstration, including but not
				  limited to, the following circumstances:
(1)
				  an entity has failed to provide a certificate within the required time
				  period;
(2) the coverage is for a
				  period before July 1, 1996;
(3) the
				  individual has an urgent medical condition that necessitates a determination of
				  whether prior creditable coverage existed before the individual can deliver a
				  certificate to the health benefit plan; or
(4) the individual lost a certificate he or
				  she had previously received and is unable to obtain another
				  certificate.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter K - CERTIFICATION OF CREDITABLE COVERAGE › Section 21.1108 - Notification of Creditable Coverage and Preexisting Condition Exclusion

Current through Reg. 49, No. 28; July 12, 2024
(a) After receipt of a written certification
				  of creditable coverage as provided under §
										21.1103
				  of this title (relating to Timing of Issuance of a Written Certificate of
				  Creditable Coverage to an Individual) or other means as provided under §
										21.1107
				  of this title (relating to Creditable Coverage Established Through Means Other
				  Than Written Certificate), an issuer of a health benefit plan shall as soon as
				  reasonably possible, not to exceed 30 days after receipt of the information
				  regarding creditable coverage, make a determination regarding the individual's
				  period of creditable coverage and notify the individual to whom a preexisting
				  condition exclusion period is to apply of its determination in accordance with
				  subsection (b) of this section.
(b)
				  An issuer of a health benefit plan seeking to impose a preexisting condition
				  exclusion shall disclose to the individual, in writing, its determination of
				  any preexisting condition exclusion period that applies to the individual as
				  soon as reasonably possible, not to exceed 30 days after receipt of the
				  information regarding creditable coverage. The issuer of a health benefit plan
				  shall disclose the basis for such determination, including the source and
				  substance of any information on which the issuer relied. The issuer of a health
				  benefit plan shall establish a grievance procedure in accordance with
				  applicable law and shall notify the individual in writing of such grievance
				  procedure. The issuer of a health benefit plan shall provide an individual with
				  a reasonable opportunity to submit additional evidence of creditable
				  coverage.
(c) An issuer of a health
				  benefit plan may modify an initial determination of creditable coverage if the
				  issuer determines the individual did not have the claimed creditable coverage,
				  provided that:
(1) a notice of the
				  reconsideration is provided to the individual; and
(2) until the final determination is made,
				  the issuer of the health benefit plan, for purposes of approving access to
				  medical services, acts in a manner consistent with the initial
				  determination.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter K - CERTIFICATION OF CREDITABLE COVERAGE › Section 21.1109 - 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 to be invalid,
					 the remainder of this subchapter and the application of its provisions to any
					 persons under other circumstances shall not be affected
					 thereby.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter K - CERTIFICATION OF CREDITABLE COVERAGE › Section 21.1110 - Form CCC

Current through Reg. 49, No. 28; July 12, 2024
(a) Form CCC
				  relating to Insurance Code §
										1205.002
				  and §
										1357.056 for
				  certification and disclosure of coverage under a health benefit plan is
				  included in subsection (b) of this section in its entirety and has been filed
				  with the Office of the Secretary of State.
(b) Form CCC referenced in this subchapter is
				  as follows.
Attached
					 Graphic
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter L - MEDICAL CHILD SUPPORT, UNFAIR PRACTICES › Section 21.2001 - 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) Actuarial
				  assumptions--The value of a parameter, or other choice, having an impact on an
				  estimate of a future cost or other actuarial item under evaluation.
(2) Actuarially equivalent--Producing equal
				  actuarial present value, determined as of a given date with each value based on
				  the same set of actuarial assumptions.
(3) Actuarial present value--The value of an
				  amount or series of amounts payable or receivable at various times, determined
				  as of a given date by the application of a particular set of actuarial
				  assumptions.
(4) Child--
(A) a person under 18 years of age who is not
				  and has not been married or who has not had the disabilities of minority
				  removed for general purposes; or
(B) in the context of child support, "child"
				  includes a person over 18 years of age for whom a person may be obligated to
				  pay child support.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter L - MEDICAL CHILD SUPPORT, UNFAIR PRACTICES › Section 21.2002 - Prohibition Against Denial of Enrollment

Current through Reg. 49, No. 28; July 12, 2024
(a) An insurer shall not deny enrollment of a
				  child who is the subject of a medical support order under the health coverage
				  of the child's parent on the ground that the child:
(1) has a preexisting condition;
(2) was born out of wedlock;
(3) is not claimed as a dependent on the
				  parent's federal income tax return;
(4) does not reside with the parent or in the
				  insurer's service area; or
(5) is
				  or has been an applicant for or recipient of medical assistance.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter L - MEDICAL CHILD SUPPORT, UNFAIR PRACTICES › Section 21.2004 - Enrollment of Child Who Is the Subject of a Medical Support Order

Current through Reg. 49, No. 28; July 12, 2024
(a) If the insurer offers coverage of
				  dependent children under the policy, enrollment of a child who is the subject
				  of a medical support order in the health coverage shall be automatic for the
				  first 31 days after receipt of a medical support order or notice of a medical
				  support order by the employer, or the insurer if there is no employer and the
				  insurer provides health coverage to the parent ordered to provide medical
				  support. The insurer shall enroll the child without regard to any enrollment
				  period restriction that might otherwise be applicable to the parent or the
				  child. Receipt of a medical support order or notice of a medical support order
				  requiring that health coverage be provided for a child shall be considered a
				  change in the family circumstances of the employee or member, for health
				  coverage purposes, equivalent to the birth or adoption of a child. For purposes
				  of this section, the change of family circumstances shall not be construed to
				  require coverage of any person other than the child subject to the court order
				  and, if not already covered, the parent ordered to provide medical
				  support.
(b) Within 31 days after
				  receipt of a medical support order or notice of a medical support order by the
				  employer or the insurer as specified in subsection (a) of this section, the
				  insurer shall complete all necessary forms and procedures to enroll the child
				  in health coverage on a permanent basis:
(1)
				  on application of a parent of the child, a custodial parent of the child, a
				  child support agency having a duty to collect or enforce support for the child,
				  or the child over 18 years of age; and
(2) if the required premium is paid within 31
				  days of the receipt of the medical support order or notice of the medical
				  support order by the employer, or the insurer if there is no employer except
				  that the insurer shall not terminate coverage of a child that is the subject of
				  a medical support order if such insurer's billing cycle does not coincide with
				  this 31 day premium payment requirement, until the next billing cycle has
				  occurred and there has been nonpayment of the additional required premium,
				  within 30 days of the due date of such premium.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter L - MEDICAL CHILD SUPPORT, UNFAIR PRACTICES › Section 21.2005 - Prohibition on Cancellation or Nonrenewal

Current through Reg. 49, No. 28; July 12, 2024
(a) An insurer shall not cancel or refuse to
				  renew coverage of a child entitled to enrollment or enrolled under this
				  subchapter unless satisfactory written evidence is filed with the insurer by
				  the parent or the employer demonstrating that:
(1) the court order or administrative order
				  that required the coverage is no longer in effect; or
(2) the child is enrolled in comparable
				  health coverage or will be enrolled in comparable coverage that will take
				  effect not later than the effective date of the cancellation or
				  nonrenewal.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter L - MEDICAL CHILD SUPPORT, UNFAIR PRACTICES › Section 21.2006 - Notice of Availability of Continuation or Conversion Coverage

Current through Reg. 49, No. 28; July 12, 2024
(a) For the purpose of providing notification
				  to the custodial parent under Insurance Code § 1504.054 and §
										21.2008
				  of this title (relating to Information Provided by an Insurer), the custodial
				  parent must notify the insurer of any change of address. If no such change of
				  address is submitted by the custodial parent to the insurer, then the insurer
				  must comply with the provisions of Insurance Code § 1504.054 and §
										21.2008
				  of this title (relating to Information Provided by an Insurer) regarding
				  notification to the custodial parent if such notice is sent to the last known
				  address of the custodial parent.
(b) The insurer must enroll or continue
				  enrollment of the child on application of a parent of the child, a child
				  support agency, or the child over 18 years of age.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter L - MEDICAL CHILD SUPPORT, UNFAIR PRACTICES › Section 21.2007 - Assignment of Medical Support Rights to State Agency

Current through Reg. 49, No. 28; July 12, 2024
An insurer shall not impose requirements on a state agency
					 that has been assigned the rights of an individual eligible for medical
					 assistance and covered for health benefits by that insurer which are different
					 from the requirements applicable to an agent or assignee of any other covered
					 individual.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter L - MEDICAL CHILD SUPPORT, UNFAIR PRACTICES › Section 21.2008 - Information Provided by an Insurer

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  Upon request, an insurer shall provide to a state agency providing medical
				  assistance, or to a child support agency enforcing medical support, information
				  necessary to facilitate reimbursement of medical services provided to or paid
				  on behalf of a child.
(b) An
				  insurer providing coverage to a child through a parent of the child shall
				  provide information and documents within 31 days after coverage has been made
				  permanent or upon written request, whichever occurs first, to each custodial
				  parent or a child over 18 years of age as may be necessary for the child to
				  obtain benefits through that coverage, including:
(1) the name of the insurer;
(2) the number of the policy;
(3) a copy of the policy and schedule of
				  benefits;
(4) a health insurance
				  membership card;
(5) claim forms;
				  and
(6) any other information or
				  document necessary to submit a claim in accordance with the insurer's policies
				  and procedures.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter L - MEDICAL CHILD SUPPORT, UNFAIR PRACTICES › Section 21.2009 - Submission and Payment of Claims

Current through Reg. 49, No. 28; July 12, 2024
(a) An
				  insurer shall not require the approval of the insured or enrollee parent for
				  the submission of claims for covered services or for the appeal of a denial of
				  any benefit by a custodial parent, a health care provider, a child over 18
				  years of age, or a state agency that has been assigned medical support
				  rights.
(b) An insurer shall not
				  refuse or fail to make payments on covered claims directly to the custodial
				  parent, health care provider, child over 18 years of age, or state agency
				  submitting the claim, in accordance with the terms of the policy. Nothing in
				  this section shall require an insurer to make duplicate payments on covered
				  claims.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter L - MEDICAL CHILD SUPPORT, UNFAIR PRACTICES › Section 21.2010 - Prohibition on Service Area Restrictions

Current through Reg. 49, No. 28; July 12, 2024
(a) With respect to a child who lives outside
				  the insurer's service area but inside the United States whose coverage under
				  the policy is required by a medical support order, an insurer must either:
(1) cover the child under coverage for which
				  the parent who has been ordered to provide the coverage is eligible and not
				  enforce otherwise applicable policy provisions that would deny, limit, or
				  reduce payment for claims for such child; or
(2) provide coverage through the use of
				  alternative delivery systems, such as reciprocal agreements with indemnity
				  insurers or HMOs.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter L - MEDICAL CHILD SUPPORT, UNFAIR PRACTICES › Section 21.2011 - Unfair or Deceptive Practices

Current through Reg. 49, No. 28; July 12, 2024
(a) A
				  violation of §
										21.2002
				  of this title (relating to Prohibition Against Denial of Enrollment), §
				  21.2003 of this title (relating to Requirements Concerning Adopted Children or
				  Children Placed for Adoption), §
										21.2004
				  of this title (relating to Enrollment of Child Who Is the Subject of a Medical
				  Support Order), §
										21.2005
				  of this title (relating to Prohibition on Cancellation or Nonrenewal), §
										21.2009
				  of this title (relating to Submission and Payment of Claims), and §
										21.2010
				  of this title (relating to Prohibition on Service Area Restrictions) is
				  considered an unfair or deceptive practice and will subject the insurer to the
				  penalties provided in Insurance Code Chapter 541 and other applicable
				  provisions of the Insurance Code.
(b) A violation of §
										21.2006
				  of this title (relating to Notice of Availability of Continuation of Conversion
				  Coverage), §
										21.2007
				  of this title (relating to Assignment of Medical Support Rights to State
				  Agency), and §
										21.2008
				  of this title (relating to Information Provided by an Insurer) subjects the
				  insurer to the penalties provided in Insurance Code Chapter 82 and other
				  applicable provisions of the Insurance Code.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter M - MANDATORY BENEFIT NOTICE REQUIREMENTS › Section 21.2101 - Scope

Current through Reg. 49, No. 28; July 12, 2024
The purpose of this subchapter is:
(1) to require notice to enrollees in a
				  health benefit plan of coverage or benefits for:
(A) prostate cancer examinations;
(B) minimum inpatient stays for maternity and
				  childbirth;
(C) minimum inpatient
				  stays for mastectomy or lymph node dissection;
(D) reconstructive surgery after
				  mastectomy;
(E) certain diagnostic
				  screening tests for early detection of human papillomavirus, ovarian cancer,
				  and cervical cancer; and
(F)
				  certain tests for the detection of colorectal cancer; and
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter M - MANDATORY BENEFIT NOTICE REQUIREMENTS › Section 21.2102 - 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) Another limited
				  benefit--A plan that provides coverage, singularly or in combination, for
				  benefits for a specifically named disease, accident, or combination of diseases
				  or accidents, including, but not limited to:
(A) heart attack;
(B) stroke;
(C) AIDS; or
(D) travel, farm, or occupational
				  accident.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter M - MANDATORY BENEFIT NOTICE REQUIREMENTS › Section 21.2103 - Mandatory Benefit Notices

Current through Reg. 49, No. 28; July 12, 2024
(a) Prescribed
				  mandatory benefit notices consist of the following:
(1) For a health benefit plan that provides
				  coverage or benefits for the treatment of breast cancer, a carrier must issue a
				  notice that includes the language provided in Figure 1 of §
											21.2106(b)
				  of this title (relating to Forms).
(2) For a health benefit plan that provides
				  coverage or benefits for a mastectomy, a carrier must issue:
(A) an enrollment notice that includes the
				  language provided in Figure 2 of §
												21.2106(b)
				  of this title; and
(B) an annual
				  notice that includes either:
(i) the language
				  provided in Figure 3 §
													21.2106(b)
				  of this title; or
(ii) the language
				  provided in Figure 2 §
													21.2106(b)
				  of this title.
(3) For a health benefit plan that provides
				  coverage or benefits for diagnostic medical procedures, a carrier must issue a
				  notice that includes the language provided in Figure 4 §
											21.2106(b)
				  of this title.
(4) For a health
				  benefit plan that provides coverage or benefits for maternity, including
				  benefits for childbirth, a carrier must issue a notice that includes the
				  language provided in Figure 5 §
											21.2106(b)
				  of this title.
(5) If the health
				  benefit plan described in paragraph (4) of this subsection includes benefits or
				  coverage for in-home postdelivery care, the following language, or
				  substantially similar language, must be inserted immediately before the
				  "Prohibitions" portion of the notice language in Figure 5 §
											21.2106(b)
				  of this title: "Since we provide in-home postdelivery care, we are not required
				  to provide the minimum number of hours outlined above unless (a) the mother's
				  or child's physician determines the inpatient care is medically necessary, or
				  (b) the mother requests the inpatient stay."
(6) For a health benefit plan that provides
				  coverage or benefits for medical screening procedures, a carrier must issue a
				  notice that includes the language provided in Figure 6 §
											21.2106(b)
				  of this title.
(7) For a health
				  benefit plan that provides coverage or benefits for medical screening
				  procedures, a carrier must issue a notice that includes the language provided
				  in Figure 7 §
											21.2106(b)
				  of this title. If a plan is not required to provide a benefit for ovarian
				  cancer screening due to the exception in Insurance Code §
											1370.002(b)
				  (concerning Exceptions), the notice may be modified to omit the references to
				  ovarian cancer and the CA 125 blood test.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter M - MANDATORY BENEFIT NOTICE REQUIREMENTS › Section 21.2105 - Delivery of Mandatory Benefit Notices

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  The notices required by §
										21.2103(a)(1),
				  (3), and (4) of this title (relating to Mandatory Benefit Notices) must be
				  issued to enrollees of a health benefit plan within 60 days of the plan's
				  issuance or renewal.
(1) Except as specified
				  in paragraph (5) of this subsection, a carrier must deliver the notices to
				  enrollees through the U.S. Postal Service or, as permitted by state law,
				  electronically.
(2) The notice may
				  be delivered with other health benefit plan documents within 60 days of the
				  plan's issuance or renewal. For example, the notice may be delivered with the
				  policy, certificate, evidence of coverage, or the enrollment or insurance
				  card.
(3) If the notices are
				  provided to the primary enrollee's last known address, the requirements of this
				  section are satisfied with respect to all enrollees residing at that
				  address.
(4) If a covered spouse or
				  dependent's last known address is different than the primary enrollee, separate
				  notices are required to be provided to the spouse or the dependent at the
				  spouse's or dependent's last known address.
(5) For group health benefit plans, the
				  notice may be provided to the group master contract holder for distribution to
				  enrollees if the carrier has an agreement with the group master contract holder
				  that the notice will be delivered within 60 days of the plan's issuance or
				  renewal; however, TDI will hold the carrier responsible for ensuring that
				  notice is provided to the enrollees.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter M - MANDATORY BENEFIT NOTICE REQUIREMENTS › Section 21.2106 - Forms

Current through Reg. 49, No. 28; July 12, 2024
(a) The forms identified in §
										21.2103
				  of this title (relating to Mandatory Benefit Notices) are included in
				  subsection (b) of this section in their entirety. The forms can be obtained
				  from the TDI website,
www.tdi.texas.gov
.
(b) The forms referenced in this chapter are:
(1) Figure Number 1: Form Number 349
				  Mastectomy:
Attached
					 Graphic
(2)
				  Figure Number 2: Form Number 1764 Reconstructive Surgery After
				  Mastectomy-Enrollment:
Attached
					 Graphic
(3)
				  Figure Number 3: Form Number 1764 Reconstructive Surgery After
				  Mastectomy-Annual:
Attached
					 Graphic
(4)
				  Figure Number 4: Form Number 258 Prostate:
Attached
					 Graphic
(5)
				  Figure Number 5: Form Number 102 Maternity:
Attached
					 Graphic
(6)
				  Figure Number 6: Form Number 1467 Colorectal Cancer Screening:
Attached
					 Graphic
(7)
				  Figure Number 7: Form Number LHL391 Human Papillomavirus, Ovarian Cancer, and
				  Cervical Cancer Screening:
Attached
					 Graphic
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter M - MANDATORY BENEFIT NOTICE REQUIREMENTS › Section 21.2107 - Right to Medicare Supplement Coverage Notice

Current through Reg. 49, No. 28; July 12, 2024
(a) At the time of an event described in
				  §
										3.3312(b)
				  of this title (relating to Guaranteed Issue for Eligible Persons) that causes
				  an individual to lose coverage or benefits due to the termination of a
				  contract, agreement, policy, or plan, the entity, as defined in §
										3.3312
				  of this title, must:
(1) notify the
				  individual of his or her rights under §3.3312(a), (c), (d), and (e) of
				  this title, and the obligations of issuers of Medicare supplement policies
				  under §
											3.3312(a)
				  of this title; and
(2) communicate
				  this notice at the same time as the notification of termination.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter N - LIFE INSURANCE ILLUSTRATIONS › Section 21.2201 - Purpose

Current through Reg. 49, No. 28; July 12, 2024
The purpose of this Subchapter is to provide rules for life
					 insurance policy illustrations that will protect consumers and foster consumer
					 education. The Subchapter provides illustration formats, prescribes standards
					 to be followed when illustrations are used, and specifies the disclosures that
					 are required in connection with illustrations. The goals of this Subchapter are
					 to ensure that illustrations do not mislead purchasers of life insurance and to
					 make illustrations more understandable. Insurers will, as far as possible,
					 eliminate the use of footnotes and caveats and define terms used in the
					 illustration in language that would be understood by a typical person within
					 the segment of the public to which the illustration is
					 directed.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter N - LIFE INSURANCE ILLUSTRATIONS › Section 21.2202 - Authority

Current through Reg. 49, No. 28; July 12, 2024
This subchapter is issued based upon the authority granted
					 the Commissioner under Insurance Code §
										543.001;
					 Chapter 541, Subchapter J; and §36.001.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter N - LIFE INSURANCE ILLUSTRATIONS › Section 21.2203 - Applicability and Scope

Current through Reg. 49, No. 28; July 12, 2024
This Subchapter applies to all group and individual life
					 insurance policies and certificates except:
(1) variable life insurance;
(2) individual and group annuity
				  contracts;
(3) credit life
				  insurance; or
(4) life insurance
				  policies with no illustrated death benefits on any individual exceeding
				  $10,000.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter N - LIFE INSURANCE ILLUSTRATIONS › Section 21.2204 - Definitions

Current through Reg. 49, No. 28; July 12, 2024
For the purposes of this subchapter , the following terms
					 have the following meanings unless the explicit wording of a section or portion
					 of a section directs otherwise .
(1)
				  Actuarial Standards Board--the board established by the American Academy of
				  Actuaries to develop and promulgate standards of actuarial practice.
(2) Concept Illustration--the use of
				  non-guaranteed policy values to pay premiums or policy expenses (suspension or
				  reduction of premiums) or to generate distributions to the policyholder or
				  owner (cash flows).
(3) Contract
				  premium--the gross premium that is required to be paid under a fixed premium
				  policy, including the premium for a rider for which benefits are shown in the
				  illustration.
(4) Currently payable
				  scale--a scale of non-guaranteed elements in effect for a policy form as of the
				  illustration date or declared to become effective within 95 days of the
				  illustration date.
(5) Disciplined
				  current scale--a scale of non-guaranteed elements constituting a limit on
				  illustrations currently being illustrated by an insurer that is reasonably
				  based on actual recent historical experience, as certified annually by an
				  illustration actuary designated by the insurer. Further guidance in determining
				  the disciplined current scale as contained in standards established by the
				  Actuarial Standards Board may be relied upon if the standards:
(A) are consistent with all provisions of
				  this regulation;
(B) limit a
				  disciplined current scale to reflect only actions that have already been taken
				  or events that have already occurred;
(C) do not permit a disciplined current scale
				  to include any projected trends of improvements in experience or any assumed
				  improvements in experience beyond the illustration date; and
(D) do not permit assumed expenses to be less
				  than minimum assumed expenses.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter N - LIFE INSURANCE ILLUSTRATIONS › Section 21.2205 - Policies To Be Illustrated

Current through Reg. 49, No. 28; July 12, 2024
(a) Commissioner
				  notification. Each insurer marketing policies to which this Subchapter is
				  applicable shall notify the commissioner whether a policy form is to be
				  marketed with or without an illustration. For all policy forms being actively
				  marketed on the effective date of this Subchapter, the insurer shall identify
				  in writing those forms and whether or not an illustration will be used with
				  them. For policy forms filed after the effective date of this Subchapter, the
				  identification shall be made at the time of filing. Any previous identification
				  may be changed by notice to the commissioner.
(b) Prohibition. If the insurer identifies a
				  policy form as one to be marketed without an illustration, any use of an
				  illustration for any policy using that form prior to the first policy
				  anniversary is prohibited.
(c) When
				  delivery of illustration is required. If a policy form is identified by the
				  insurer as one to be marketed with an illustration, a basic illustration
				  prepared and delivered in accordance with this Subchapter is required, except
				  that a basic illustration need not be provided to individual members of a group
				  or to individuals insured under multiple lives coverage issued to a single
				  applicant unless the coverage is marketed to these individuals. The
				  illustration furnished an applicant for a group life insurance policy or
				  policies issued to a single applicant on multiple lives may be either an
				  individual or composite illustration representative of the coverage on the
				  lives of members of the group or the multiple lives covered.
(d) When delivery of quotation is required.
				  Potential enrollees of non-term group life subject to this Subchapter shall be
				  furnished a quotation with the enrollment materials. The quotation shall show
				  potential policy values for sample ages and policy years on a guaranteed and
				  non-guaranteed basis appropriate to the group and the coverage. This quotation
				  shall not be considered an illustration for purposes of this Subchapter, but
				  all information provided shall be consistent with the illustrated scale. A
				  basic illustration shall be provided at delivery of the certificate to
				  enrollees for non-term group life who enroll for more than the minimum premium
				  necessary to provide pure death benefit protection. In addition, the insurer
				  shall make a basic illustration available to any non-term group life enrollee
				  who requests it.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter N - LIFE INSURANCE ILLUSTRATIONS › Section 21.2207 - Standards for Basic Illustrations

Current through Reg. 49, No. 28; July 12, 2024
In addition to those matters set out in §
										21.2206
					 of this title (relating to General Rules and Prohibitions), the standards set
					 out in paragraphs (1)-(4) of this subsection shall apply to a basic
					 illustration.
(1) Format. A basic
				  illustration shall conform with the following requirements:
(A) the assumed dates of payment receipt and
				  benefit pay out within a policy year shall be clearly identified;
(B) the assumed payments on which the
				  illustrated benefits and values are based shall be identified as premium outlay
				  or contract premium, as applicable. For policies that do not require a specific
				  contract premium, the illustrated payments shall be identified as premium
				  outlay;
(C) guaranteed death
				  benefits and values available upon surrender, if any, for the illustrated
				  premium outlay or contract premium shall be shown and clearly labeled
				  guaranteed;
(D) the guaranteed
				  elements, if any, shall be shown before corresponding non-guaranteed elements
				  and shall be specifically referred to on any page of an illustration that shows
				  or describes only the non-guaranteed elements (e.g., "see page one for
				  guaranteed elements").
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter N - LIFE INSURANCE ILLUSTRATIONS › Section 21.2208 - Standards for Supplemental Illustrations

Current through Reg. 49, No. 28; July 12, 2024
A supplemental illustration may be provided so long as it
					 meets all standards set out in paragraphs (1)-(4) of this section, as
					 follows:
(1) it is appended to,
				  accompanied by or preceded by a basic illustration that complies with this
				  Subchapter;
(2) the non-guaranteed
				  elements shown are not more favorable to the policy owner than the
				  corresponding elements based on the scale used in the basic
				  illustration;
(3) it conforms to
				  §
										21.2206
				  of this title (relating to General Rules and Prohibitions); and
(4) for a policy that has a contract premium,
				  the contract premium underlying the supplemental illustration is equal to the
				  contract premium shown in the basic illustration. For policies that do not
				  require a contract premium, the premium outlay underlying the supplemental
				  illustration shall be equal to the premium outlay shown in the basic
				  illustration.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter N - LIFE INSURANCE ILLUSTRATIONS › Section 21.2210 - Annual Report; Notice to Policy Owners

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  Annual report provision. If an illustration is used in the sale of a life
				  insurance policy after the effective date of this Subchapter, the insurer shall
				  provide each policy owner with an annual report on the status of the policy
				  that shall contain, at a minimum, the applicable information set out in
				  paragraphs (1)-(3) of this subsection.
(1)
				  Universal life policies. For universal life policies, the report shall include:
(A) the beginning and end date of the current
				  report period;
(B) the policy value
				  at the end of the previous report period and at the end of the current report
				  period;
(C) the total amounts that
				  have been credited or debited to the policy value during the current report
				  period, identifying each by type (e.g., interest, mortality, expense and
				  riders);
(D) the current death
				  benefit at the end of the current report period on each life covered by the
				  policy;
(E) the net cash surrender
				  value of the policy as of the end of the current report period;
(F) the amount of outstanding loans, if any,
				  as of the end of the current report period; and
(G) for fixed premium policies, if, assuming
				  guaranteed interest, mortality and expense loads and continued scheduled
				  premium payments, the policy's net cash surrender value is such that it would
				  not maintain insurance in force until the end of the next reporting period, a
				  notice to this effect shall be included in the report; or
(H) for flexible premium policies, if,
				  assuming guaranteed interest, mortality and expense loads, the policy's net
				  cash surrender value will not maintain insurance in force until the end of the
				  next reporting period unless further premium payments are made, a notice to
				  this effect shall be included in the report.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter N - LIFE INSURANCE ILLUSTRATIONS › Section 21.2212 - Penalties

Current through Reg. 49, No. 28; July 12, 2024
Any violation of this subchapter constitutes a
					 misrepresentation of the terms of an issued and unissued policy in violation of
					 Insurance Code Chapter 541, Subchapter B, and to be a misrepresentation of the
					 terms, benefits, and advantages of a policy within the meaning of Insurance
					 Code §
										543.001.
					 Violations of this subchapter subject the insurer and agent to the penalties
					 provided in Insurance Code Chapter 541 and other applicable provisions of the
					 Insurance Code.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter N - LIFE INSURANCE ILLUSTRATIONS › Section 21.2213 - Separability, Conflict with and Effect on Other Regulations

Current through Reg. 49, No. 28; July 12, 2024
(a) Separability. If any provision of this
				  subchapter or its application to any person or circumstance is for any reason
				  held to be invalid by any court of law, the remainder of the subchapter and its
				  application to other persons or circumstances shall not be affected.
(b) Conflict with or effect on other rules.
				  This subchapter is not intended to conflict with or supersede and is to be
				  interpreted when possible as not to conflict with Subchapters A and B of this
				  chapter (relating to Unfair Competition and Unfair Practices of Insurers, and
				  Misrepresentation of Policies and Insurance Advertising, Certain Trade
				  Practices, and Solicitation).
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter N - LIFE INSURANCE ILLUSTRATIONS › Section 21.2214 - Effective Date

Current through Reg. 49, No. 28; July 12, 2024
This subchapter shall apply to all policies sold on or
					 after July 1, 2000.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter P - MENTAL HEALTH PARITY › Division 1 - GENERAL PROVISIONS AND PARITY REQUIREMENTS › Section 21.2401 - Purpose and Scope

Current through Reg. 49, No. 28; July 12, 2024
This subchapter provides rules to interpret, implement,
						and enforce Insurance Code Chapter 1355, Subchapter F, concerning Coverage for
						Mental Health Conditions and Substance Use Disorders. Except as identified in
						§
											21.2404
						of this title (relating to Differences from Federal Rules), these rules are
						intended to be consistent with the Insurance Code and to closely track the
						federal rules found at
						45 CFR
						§
												146.136 (concerning Parity in Mental
						Health and Substance Use Disorder Benefits),
						45
						CFR §
												146.121(b)(2)(iii)
						(concerning Prohibiting Discrimination Against Participants and Beneficiaries
						Based on a Health Factor), and
						45 CFR
						§
												147.160 (concerning Parity in Mental
						Health and Substance Use Disorder Benefits) as published in the
Federal
						Register,
Vol. 78, No. 219 on November 13, 2013.