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 S - MINIMUM STANDARDS AND BENEFITS AND READABILITY FOR INDIVIDUAL ACCIDENT AND HEALTH INSURANCE POLICIES › Section 3.3092 - Format, Content, and Readability for Outline of Coverage

Current through Reg. 49, No. 28; July 12, 2024
(a) Format.
(1) Each outline of coverage must contain the
				  appropriate text and be in the appropriate format of the outlines of coverage
				  set forth in this subchapter and may not contain any material of an advertising
				  nature, except for the insurer's logotype.
(2) The outline of coverage must be plainly
				  printed in light-faced type of a style in general use, the size of which must
				  be uniform except as provided in paragraph (4) of this subsection and not less
				  than 12 point with a lowercase unspaced alphabet length not less than 130
				  point, with a minimum of one-point leading.
(3) The contrast and legibility of the color
				  of ink and the color of paper of the outline of coverage must be substantially
				  the equivalent of that of black ink on white paper.
(4) Text that is capitalized or underscored
				  in the outline of coverage may be of a different style type the size of which
				  may be the same as or larger than that of other text.
(5) When an outline of coverage is integrated
				  with a sales brochure, multi-colored ink may be used on all portions of the
				  brochure except the outline of coverage.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter S - MINIMUM STANDARDS AND BENEFITS AND READABILITY FOR INDIVIDUAL ACCIDENT AND HEALTH INSURANCE POLICIES › Section 3.3093 - Prescribed Outlines of Coverage

Current through Reg. 49, No. 28; July 12, 2024
An outline of coverage in the following prescribed form and
					 drafted in accordance with the instructions set forth in §
										3.3092
					 of this title (relating to Format, Content, and Readability for Outline of
					 Coverage) shall be issued in connection with policies meeting the standards of
					 §§
										3.3071-3.3080 of
					 this title (relating to Minimum Standards and Benefits and Readability for
					 Accident and Health Insurance Policies). The items included in the outline of
					 coverage shall appear in the following prescribed sequence.
(1) Basic hospital expense coverage policies
				  shall be accompanied by an outline of coverage in the following form.
Attached
					 Graphic
(2)
				  Basic medical-surgical expense coverage policies shall be accompanied by an
				  outline of coverage in the following form.
Attached
					 Graphic
(3)
				  Hospital confinement indemnity coverage policies shall be accompanied by an
				  outline of coverage in the following form.
Attached
					 Graphic
(4)
				  Major medical expense coverage policies shall be accompanied by an outline of
				  coverage in the following form.
Attached
					 Graphic
(5)
				  Disability income protection coverage policies shall be accompanied by an
				  outline of coverage in the following form.
Attached
					 Graphic
(6)
				  Accident only coverage policies shall be accompanied by an outline of coverage
				  in the following form.
Attached
					 Graphic
(7)
				  Specified disease or specified accident coverage policies shall be accompanied
				  by an outline of coverage in either of the following forms as specified in
				  subparagraphs (A) or (B) of this paragraph, whichever is appropriate.
Attached
					 Graphic
(8)
				  Limited benefit coverage policies shall be accompanied by an outline of
				  coverage in the following form.
Attached
					 Graphic
(9)
				  Supplemental coverage policies shall be accompanied by an outline of coverage
				  in the following form.
Attached
					 Graphic
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter S - MINIMUM STANDARDS AND BENEFITS AND READABILITY FOR INDIVIDUAL ACCIDENT AND HEALTH INSURANCE POLICIES › Section 3.3100 - Policy Readability Generally

Current through Reg. 49, No. 28; July 12, 2024
(a) In
				  order to increase policyholder understanding of individual accident and
				  sickness policies, insurers are encouraged to draft individual accident and
				  sickness policies in a readable manner. In order not to devalue the policy as a
				  legal document the utmost care and caution must be used in its preparation.
				  Insurance Code Chapter 1201, Subchapter E, requires the use of certain policy
				  provisions in particular language or provisions not less favorable to the
				  insured or beneficiary than those set forth in said subchapter. The same is
				  true with respect to optional policy provisions as provided in Insurance Code
				  §§
										1201.219
				  -
				  1201.226.
				  Notwithstanding these requirements of law, insurers are urged to experiment
				  with new language in these areas.
(b) Insurers are encouraged to follow the
				  principles set forth in §
										3.3101
				  of this title (relating to Organization of Policy Format for Readability) and
				  §
										3.3102 of
				  this title (relating to Language Readability) when preparing individual
				  accident and sickness policies.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter S - MINIMUM STANDARDS AND BENEFITS AND READABILITY FOR INDIVIDUAL ACCIDENT AND HEALTH INSURANCE POLICIES › Section 3.3101 - Organization of Policy Format for Readability

Current through Reg. 49, No. 28; July 12, 2024
(a) The text of the policy must be organized
				  so that it follows a logical sequence.
(b) Coverages must be self-contained and
				  independent.
(c) The use of
				  provisions which refer the reader to another section must be avoided to the
				  extent possible.
(d) General policy
				  provisions applying to all or several like coverages, such as defined words and
				  terms, must be located in a common area.
(e) Insurers may utilize a separate
				  definition section for words used throughout the policy. If a separate
				  definition section is used, it must appear early in the policy
				  format.
(f) Nonessential provisions
				  must be eliminated.
(g) Captions
				  must be of type size and style to clearly stand out.
(h) Type size and style must be legible and
				  comply with the requirements set forth in Insurance Code §
										1201.054.
(i) Ample blank space must separate the
				  policy provisions.
(j) Ample blank
				  space must appear between the columns of printing and the border of the
				  paper.
(k) A table of contents or
				  index may be utilized to enable the policyholder to readily locate particular
				  provisions.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter S - MINIMUM STANDARDS AND BENEFITS AND READABILITY FOR INDIVIDUAL ACCIDENT AND HEALTH INSURANCE POLICIES › Section 3.3102 - Language Readability

Current through Reg. 49, No. 28; July 12, 2024
(a) Words shall be
				  selected carefully with preference given to short, familiar words.
(b) Words which are generally familiar, or
				  are common speech shall be used to the extent possible.
(c) Use of technical or abstract words shall
				  be avoided to the extent possible.
(d) While provisions that are more
				  conceptually complex are more difficult to express in simplified language,
				  sentences shall be expressed in the shortest possible manner.
(e) Complex and compound sentences shall be
				  avoided to the extent possible.
(f)
				  The use of prefixes and suffixes shall be avoided to the extent
				  possible.
(g) Each insurer shall
				  submit the readability score for the policy along with the policy when it is
				  submitted for approval. The readability tests set forth in §
										3.3092(c)
				  of this title (relating to Format, Content, and Readability for Outline of
				  Coverage) are recommended as guides for insurers.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter S - MINIMUM STANDARDS AND BENEFITS AND READABILITY FOR INDIVIDUAL ACCIDENT AND HEALTH INSURANCE POLICIES › Section 3.3110 - Effective Date; Applicability of Certain Provisions to Policies Deemed Continuous under Insurance Code

Current through Reg. 49, No. 28; July 12, 2024
(a) The
				  sections of this subchapter, as amended and adopted by the commissioner, will
				  be effective 20 days from the date they are filed with the Office of the
				  Secretary of State and be applicable to all individual accident and sickness
				  insurance policies and subscriber contracts of hospital and medical and dental
				  service associations delivered, issued for delivery, or renewed on and after
				  such date. Individual accident and sickness insurance policies and subscriber
				  contracts of hospital and medical and dental service associations, delivered,
				  issued for delivery, or renewed in this state prior to the effective date of
				  this section are subject to the regulations in effect at the time the policy or
				  contract was delivered, issued for delivery, or renewed.
(b) In regard to policies issued before
				  December 22, 1997, and deemed continuous and not annually renewed pursuant to
				  Insurance Code §
										1202.001:
(1) Such policies will be considered
				  "renewed" for the purposes of complying with the mandatory guaranteed
				  renewability provisions of this subchapter, if applicable to the coverage
				  offered in such policies, as set forth in §
											3.3020
				  of this title (relating to Policy Definition of Guaranteed Renewable and
				  Limited Guarantee of Renewability) and §
											3.3038
				  of this title (relating to Mandatory Guaranteed Renewability Provisions for
				  Individual Hospital, Medical or Surgical Coverage; Exceptions), on the first
				  policy anniversary date after December 22, 1997.
(2) Such policies will not be subject to any
				  other provisions of this subchapter, unless the statutory period of continuity
				  prescribed by Insurance Code §
											1202.001
				  ends, and the policy is then renewed. During such period of continuity, the
				  policies will continue to be subject to applicable rules as they existed prior
				  to December 22, 1997.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter S - MINIMUM STANDARDS AND BENEFITS AND READABILITY FOR INDIVIDUAL ACCIDENT AND HEALTH INSURANCE POLICIES › Section 3.3111 - Severability Clause

Current through Reg. 49, No. 28; July 12, 2024
If any provision of these sections or its application to
					 any person or circumstance is held invalid, the invalidity does not affect
					 other provisions or applications of the sections which can be given effect
					 without the invalid provision or application, and to this end the provisions of
					 each section are declared to be severable.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter T - MINIMUM STANDARDS FOR MEDICARE SUPPLEMENT POLICIES › Section 3.3301 - Purpose

Current through Reg. 49, No. 28; July 12, 2024
The purpose of these sections is to provide for the
					 reasonable standardization of coverage and simplification of terms and benefits
					 of Medicare supplement policies; to facilitate public understanding and
					 comparison of such policies; to eliminate provisions contained in such policies
					 which may be misleading or confusing in connection with the purchase of such
					 policies or with the settlement of claims; and to provide for full disclosures
					 in the sale of accident and sickness insurance coverages to persons eligible
					 for Medicare.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter T - MINIMUM STANDARDS FOR MEDICARE SUPPLEMENT POLICIES › Section 3.3302 - Applicability and Scope

Current through Reg. 49, No. 28; July 12, 2024
(a) Except as
				  otherwise specifically provided, this subchapter applies to:
(1) all Medicare supplement policies as
				  defined in Insurance Code §
											1652.002
				  and §
											3.3303 of
				  this title (relating to Definitions) delivered or issued for delivery in this
				  state on or after the effective date of this subchapter; and
(2) all certificates issued under group
				  Medicare supplement policies, for which certificates have been delivered or
				  issued for delivery in this state regardless of the place where the policy was
				  delivered or issued for delivery. In this subchapter, the required minimum
				  standards for Medicare supplement insurance, which make specific reference to a
				  policy or policies, are equally applicable to a group certificate or
				  certificates.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter T - MINIMUM STANDARDS FOR MEDICARE SUPPLEMENT POLICIES › Section 3.3303 - 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) 1990 Standardized
				  Medicare supplement benefit plan, 1990 Standardized benefit plan, or 1990
				  plan--A group or individual policy of Medicare supplement insurance issued or
				  issued for delivery on or after March 1, 1992, and with an effective date for
				  coverage before June 1, 2010.
(2)
				  2010 Standardized Medicare supplement benefit plans, 2010 Standardized benefit
				  plan, or 2010 plan--A group or individual policy of Medicare supplement
				  insurance with an effective date for coverage on or after June 1,
				  2010.
(3) 2020 newly eligible
				  individual--An individual who is newly eligible for Medicare on or after
				  January 1, 2020:
(A) by reason of attaining
				  age 65 on or after January 1, 2020; or
(B) by reason of entitlement to benefits
				  under Part A under section
				  42 U.S.C. §
												426(b) or 42 U.S.C.
				  §426-1, or who is deemed to be eligible for benefits under section
				  42 U.S.C. §
												426(a) on or after January
				  1, 2020. An individual who becomes Medicare eligible or turns 65 before January
				  1, 2020, is not a 2020 newly eligible individual.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter T - MINIMUM STANDARDS FOR MEDICARE SUPPLEMENT POLICIES › Section 3.3304 - Policy Definitions and Terms

Current through Reg. 49, No. 28; July 12, 2024
No insurance policy, subscriber contract, certificate, or
					 evidence of coverage may be advertised, solicited, or issued for delivery in
					 this state as a Medicare supplement policy unless the policy, subscriber
					 contract, certificate, or evidence of coverage contains definitions or terms
					 that conform to the requirements of this section.
(1) "Accident" or "Accidental Injury" or
				  "Accidental Means" must be defined to employ "result" language and may not
				  include words that establish an accidental means test or use words such as
				  "external, violent, visible wounds," or similar words of description or
				  characterization.
(A) The definition may not
				  be more restrictive than the following: "Injury or injuries for which benefits
				  are provided means accidental bodily injury sustained by the insured person
				  that is the direct result of an accident, independent of disease or bodily
				  infirmity or any other cause, and occurs while insurance or health coverage is
				  in force."
(B) The definition may
				  provide that injuries do not include injuries for which benefits are provided
				  under any workers' compensation, employer's liability, or similar law, or motor
				  vehicle no-fault plan, unless prohibited by law.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter T - MINIMUM STANDARDS FOR MEDICARE SUPPLEMENT POLICIES › Section 3.3305 - Policy Provisions

Current through Reg. 49, No. 28; July 12, 2024
(a) Except for
				  permitted preexisting condition clauses described in §
										3.3306(b)(1)(A)
				  of this title (relating to Minimum Benefit Standards), no policy or certificate
				  may be advertised, solicited, or issued for delivery in this state as a
				  Medicare supplement policy if the policy or certificate contains limitations or
				  exclusions on coverage that are more restrictive than those of
				  Medicare.
(b) No Medicare
				  supplement policy or certificate may use waivers to exclude, limit, or reduce
				  coverage or benefits for specifically named or described preexisting diseases
				  or physical conditions.
(c) No
				  Medicare supplement policy, contract, or certificate in force in this state may
				  contain benefits that duplicate benefits provided by Medicare.
(d) Subject to §
										3.3306(b)(1)(D) and
				  (E) of this title, a Medicare supplement
				  policy with benefits for outpatient prescription drugs in existence before
				  January 1, 2006, must be renewed for current policyholders who do not enroll in
				  Part D at the option of the policyholder.
(e) A Medicare supplement policy with
				  benefits for outpatient prescription drugs may not be issued after December 31,
				  2005.
(f) After December 31, 2005,
				  a Medicare supplement policy with benefits for outpatient prescription drugs
				  may not be renewed after the policyholder enrolls in Medicare Part D unless:
(1) the policy is modified to eliminate
				  outpatient prescription coverage for expenses of outpatient prescription drugs
				  incurred after the effective date of the individual's coverage under a Part D
				  plan; and
(2) premiums are adjusted
				  to reflect the elimination of outpatient prescription drug coverage at the time
				  of Medicare Part D enrollment, accounting for any claims paid, if
				  applicable.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter T - MINIMUM STANDARDS FOR MEDICARE SUPPLEMENT POLICIES › Section 3.3306 - Minimum Benefit Standards

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  Benefit standards for standardized Medicare supplement benefit plan policies or
				  certificates issued to 2020 newly eligible individuals. The Medicare Access and
				  CHIP Reauthorization Act of 2015 (MACRA) provides that no policy or certificate
				  that provides coverage of the Medicare Part B deductible may be advertised,
				  solicited, delivered, or issued for delivery in this state as a Medicare
				  supplement policy or certificate to individuals newly eligible for Medicare on
				  or after January 1, 2020. Benefit standards applicable to Medicare supplement
				  policies and certificates issued to individuals eligible for Medicare before
				  January 1, 2020, remain subject to the requirements of subsections (b) and (c)
				  of this section. All policies issued to a 2020 newly eligible individual, as
				  defined in this subchapter, must comply with the following benefit standards:
(1) Benefit requirements. The standards and
				  requirements of subsections (b) and (c) of this section apply to all Medicare
				  supplement policies or certificates delivered or issued for delivery to 2020
				  newly eligible individuals, with the exception of subsections (b)(3)(C),
				  (c)(5)(C), (c)(5)(E), and (c)(5)(F) of this section.
(2) Eligibility to purchase. A 2020 newly
				  eligible individual is only eligible to purchase standardized Medicare
				  supplement benefit plans A, B, D, G, High Deductible G, K, L, M, and N.
				  Standardized Medicare supplement benefit plans C, F, and High Deductible F may
				  not be offered to 2020 newly eligible individuals.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter T - MINIMUM STANDARDS FOR MEDICARE SUPPLEMENT POLICIES › Section 3.3307 - Loss Ratio Standards and Refund or Credit of Premiums

Current through Reg. 49, No. 28; July 12, 2024
(a) Minimum aggregate loss ratio standard. A
				  Medicare supplement individual or group policy form may not be delivered or
				  issued for delivery unless the individual or group policy form can be expected,
				  as estimated for the entire period for which rates are computed to provide
				  coverage, to return to policyholders and certificate holders in the form of
				  aggregated benefits (not including anticipated refunds or credits) provided
				  under the individual policy form or group policy form, on the basis of incurred
				  claims experience or incurred health care expenses where coverage is provided
				  by an HMO on a service, rather than reimbursement, basis and earned premiums
				  for the applicable period, not including any changes in additional reserves and
				  in accordance with generally accepted actuarial principles and practices:
(1) at least 75% of the aggregate amount of
				  premiums earned in the case of group policies; or
(2) at least 65% of the aggregate amount of
				  premiums earned in the case of individual policies.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter T - MINIMUM STANDARDS FOR MEDICARE SUPPLEMENT POLICIES › Section 3.3310 - Severability

Current through Reg. 49, No. 28; July 12, 2024
If any provision of these sections or the application
					 thereof to any person or circumstance is for any reason held to be invalid, the
					 remainder of these sections and the application of such provision to other
					 persons or circumstances will not be affected thereby.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter T - MINIMUM STANDARDS FOR MEDICARE SUPPLEMENT POLICIES › Section 3.3312 - Guaranteed Issue for Eligible Persons

Current through Reg. 49, No. 28; July 12, 2024
(a) Guaranteed issue.
(1) Eligible persons are those individuals
				  described in subsection (b) of this section who seek to enroll under the
				  Medicare supplement policy during the period specified in subsection (d) of
				  this section, and who submit evidence of the date of termination,
				  disenrollment, or Medicare Part D enrollment with the application for a
				  Medicare supplement policy.
(2)
				  With respect to eligible persons, an issuer must not deny or condition the
				  issuance or effectiveness of a Medicare supplement policy described in
				  subsection (c) of this section that is offered and is available for issuance to
				  newly enrolled individuals by the issuer, and must not discriminate in the
				  pricing of a Medicare supplement policy because of health status, claims
				  experience, receipt of health care, or medical condition, and must not impose
				  an exclusion of benefits based on a preexisting condition under a Medicare
				  supplement policy.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter T - MINIMUM STANDARDS FOR MEDICARE SUPPLEMENT POLICIES › Section 3.3313 - Filing Requirements for Advertising

Current through Reg. 49, No. 28; July 12, 2024
A Medicare supplement policy shall not be deemed to meet
					 the standards and requirements set forth in this subchapter unless the filing
					 company has complied with the requirements of the following paragraphs.
(1) Every issuer providing Medicare
				  supplement insurance or benefits in this state shall provide to the department
				  for review a copy of any Medicare supplement advertisement, as defined in
				  §
										21.102 of this
				  title (relating to Scope), other than an institutional advertisement, as
				  defined in §21.102(6) that only references "Medicare supplement" as a line
				  of coverage offered, but which does not otherwise describe Medicare supplement
				  insurance or benefits. The copy of the advertisement shall be submitted to the
				  department no later than 60 days prior to its first use. At the expiration of
				  the 60-day period provided by this paragraph, any advertisement filed with the
				  department shall be deemed acceptable, unless before the end of that 60-day
				  period the department has notified the entity of its nonacceptance.
(2) All advertisements shall comply with all
				  applicable federal and state laws and shall be submitted in accordance with
				  §
										21.120 of this
				  title (relating to Filing for Review). This section does not require prior
				  departmental approval of the advertisement. Nothing in this section relieves
				  any person from otherwise complying with all applicable laws or from any
				  sanction imposed by law.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter T - MINIMUM STANDARDS FOR MEDICARE SUPPLEMENT POLICIES › Section 3.3315 - Standards for Claims Payment

Current through Reg. 49, No. 28; July 12, 2024
(a) Every
				  issuer of Medicare supplement policies, contracts, certificates, or coverage
				  for delivery in this state shall comply with the Social Security Act,
				  §1882(c)(3) (as enacted by the Omnibus Budget Reconciliation Act of 1987
				  (OBRA) 1987, §4081(b)(2)(C) (Public Law Number 100-203), by:
(1) accepting a notice from a Medicare
				  carrier on duly assigned claims submitted by participating physicians and
				  suppliers as a claim for benefits in place of any other claim form otherwise
				  required and making a payment determination on the basis of the information
				  contained in that notice;
(2)
				  notifying the participating physician or supplier and the beneficiary of the
				  payment determination;
(3) paying
				  the participating physician or supplier directly;
(4) furnishing, at the time of enrollment,
				  each enrollee with a card listing the policy name, number, and a central
				  mailing address to which notices from a Medicare carrier may be sent;
(5) paying user fees for claim notices that
				  are transmitted electronically or otherwise; and
(6) providing to the secretary of health and
				  human services, at least annually, a central mailing address to which all
				  claims may be sent by Medicare carriers.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter T - MINIMUM STANDARDS FOR MEDICARE SUPPLEMENT POLICIES › Section 3.3316 - Filing Requirements for Out-of-State Group Policies

Current through Reg. 49, No. 28; July 12, 2024
Every issuer providing group Medicare supplement insurance
					 benefits to a resident of this state under Insurance Code Chapter 1652 must,
					 for information purposes, file with the department's Life and Health Lines
					 Office a copy of any master policy issued in connection with any certificate
					 used in this state; all such certificates must be filed in accordance with the
					 filing requirements and procedures applicable to group Medicare supplement
					 policies issued in this state.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter T - MINIMUM STANDARDS FOR MEDICARE SUPPLEMENT POLICIES › Section 3.3317 - Permitted Compensation Arrangements

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  An issuer or other entity designated in Insurance Code §
										1652.003
				  may provide commission or other compensation to an agent for the sale of a
				  Medicare supplement policy or certificate only if the first-year commission or
				  other first-year compensation is no more than 200 percent of the commission or
				  other compensation paid for selling or servicing the policy or certificate in
				  the first renewal year, or the first 12-month service period immediately
				  following the initial 12-month service period of the policy in instances where
				  premium payment is other than on an annual basis.
(b) The commission or other compensation
				  provided in the second and subsequent renewal years where payment of premium is
				  on an annual basis, or the second and subsequent 12-month service periods of
				  the policy in instances where premium payment is other than on an annual basis,
				  must be the same as that provided in the first renewal year, or first 12-month
				  service period of the policy in instances where premium payment is other than
				  on an annual basis, and must be provided for a reasonable number of renewal
				  years, or successive 12-month service periods, but not less than six years
				  following the inception of the first renewal year in the instance of premium
				  payment on an annual basis, or the 12-month service period immediately
				  following the initial 12-month service period of the policy in instances where
				  premium payment is other than on an annual basis.
(c) No issuer may provide compensation to its
				  agents and no agent may receive compensation greater than the renewal
				  compensation payable by the replacing issuer on renewal policies or
				  certificates if an existing policy or certificate is replaced.
(d) For purposes of this section,
				  "compensation" includes pecuniary or nonpecuniary remuneration of any kind
				  relating to the sale or renewal of the policy or certificate including, but not
				  limited to, bonuses, gifts, prizes, awards, and finders fees.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter T - MINIMUM STANDARDS FOR MEDICARE SUPPLEMENT POLICIES › Section 3.3319 - Standards for Marketing

Current through Reg. 49, No. 28; July 12, 2024
(a) Every issuer
				  marketing Medicare supplement coverage in this state, directly or through its
				  agents, shall establish marketing procedures to ensure that:
(1) any comparison of policies by its agents
				  will be fair and accurate;
(2)
				  excessive insurance is not sold or issued;
(3) all prospective policyholders are advised
				  prior to the time an application is taken, that the basic "core" benefit
				  package is available, including the contents of such basic "core" benefit
				  package;
(4) every reasonable
				  effort and inquiry is made to identify whether a prospective applicant or
				  enrollee for Medicare supplement insurance already has accident and sickness
				  insurance and the types and amounts of any such insurance; and
(5) auditable procedures for verifying
				  compliance with provisions of this section are in place and utilized.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter T - MINIMUM STANDARDS FOR MEDICARE SUPPLEMENT POLICIES › Section 3.3320 - Appropriateness of Recommended Purchase and Excessive Insurance

Current through Reg. 49, No. 28; July 12, 2024
(a) In recommending the purchase or
				  replacement of any Medicare supplement policy or certificate, an agent shall
				  make reasonable efforts to determine the appropriateness of a recommended
				  purchase or replacement.
(b) Any
				  sale of a Medicare supplement policy or certificate that will provide an
				  individual more than one Medicare supplement policy or certificate is
				  prohibited.
(c) An issuer shall not
				  issue a Medicare supplement policy or certificate to an individual enrolled in
				  Medicare Part C unless the effective date of the coverage is after the
				  termination date of the individual's Part C coverage.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter T - MINIMUM STANDARDS FOR MEDICARE SUPPLEMENT POLICIES › Section 3.3321 - Reporting of Multiple Policies

Current through Reg. 49, No. 28; July 12, 2024
(a) On or
				  before March 1 of every year, every issuer of Medicare supplement coverage in
				  this state must report the following information to the Texas Department of
				  Insurance for every individual resident of this state for whom the insurer or
				  entity has more than one Medicare supplement policy or certificate in force:
(1) policy and/or certificate number;
				  and
(2) date of issuance.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter T - MINIMUM STANDARDS FOR MEDICARE SUPPLEMENT POLICIES › Section 3.3322 - Filing and Approval of Policies, Certificates and Premium Rates; Discontinuance of Forms

Current through Reg. 49, No. 28; July 12, 2024
(a) An issuer shall
				  not deliver or issue for delivery a policy or certificate to a resident of this
				  state unless the policy form or certificate form has been filed with and
				  approved by the commissioner in accordance with filing requirements and
				  procedures prescribed by the Insurance Code and applicable
				  regulations.
(b) An issuer shall
				  file any riders or amendments to policy or certificate forms to delete
				  outpatient prescription drug benefits as required by the MMA only with the
				  commissioner in the state in which the policy or certificate was
				  issued.
(c) An issuer shall not use
				  or change premium rates for a Medicare supplement policy or certificate unless
				  the rates, rating schedule and supporting documentation have been filed with
				  and approved by the commissioner in accordance with the filing requirements and
				  procedures prescribed by the Insurance Code and this subchapter.
(d) Except as provided in paragraphs (1) -
				  (4) of this subsection, an issuer shall not file for approval more than one
				  form of a policy or certificate of each type for each standard Medicare
				  supplement benefit plan. For the purposes of this section, a "type" means an
				  individual policy, a group policy, an individual Medicare Select policy, or a
				  group Medicare Select policy. An issuer may offer, with the approval of the
				  commissioner, up to four policy forms or certificate forms of the same type for
				  the same standard Medicare supplement benefit plan, one for each of the
				  following cases:
(1) the inclusion of new or
				  innovative benefits;
(2) the
				  addition of either direct response or agent marketing methods;
(3) the addition of either guaranteed issue
				  or underwritten coverage; and
(4)
				  the offering of coverage to individuals eligible for Medicare by reason of
				  disability.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter T - MINIMUM STANDARDS FOR MEDICARE SUPPLEMENT POLICIES › Section 3.3323 - Increases to Premium Rates

Current through Reg. 49, No. 28; July 12, 2024
Premium rates, rating schedules, and supporting
					 documentation for a Medicare supplement policy or certificate to be used in
					 this state must be filed with the department and approved by the Commissioner.
					 Any request for an increase to rates for Medicare supplement policies or
					 certificates issued before or after March 1, 1992, is subject to review by and
					 hearing before the Commissioner if one or more of the following conditions, as
					 determined by an actuary for the department, is present:
(1) The increase, exclusive of any increase
				  occasioned by changes in the laws regulating Medicare supplement coverages, is
				  not necessary to maintain an anticipated lifetime loss ratio at least equal to
				  the minimum that is required by statute and set out in §
										3.3307
				  of this title (relating to Loss Ratio Standards and Refund or Credit of
				  Premiums).
(2) An increase to
				  premium has been effected on the same block or blocks of business within the
				  preceding 12 months.
(3) An
				  increase to premium would result in unfair discrimination, as provided in
				  Insurance Code Chapter 544, between individuals of the same class and of
				  essentially the same hazard in the amount of premium, policy fees, or rates
				  charged for a policy or contract.
(4) An increase to premium would result in
				  the benefits offered under the policy form to be unreasonable in relation to
				  the premiums charged.
(5) An
				  increase to premium would have the practical effect of altering the rating
				  structure of the policy form to which it is applied, or would create a new set
				  of rating criteria under the policy form.
(6) A contemplated increase to premium has
				  the practical effect of resulting in a series of planned future increases to
				  premium rather than a one-time increase.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter T - MINIMUM STANDARDS FOR MEDICARE SUPPLEMENT POLICIES › Section 3.3324 - Open Enrollment

Current through Reg. 49, No. 28; July 12, 2024
(a) No issuer may
				  deny or condition the issuance or effectiveness of any Medicare supplement
				  policy or certificate available for sale in this state, nor discriminate in the
				  pricing of a policy or certificate because of the health status, claims
				  experience, receipt of health care, or medical condition of an applicant where
				  an application for a policy or certificate is submitted before or during the
				  six-month period beginning with the first day of the first month in which an
				  individual is first enrolled for benefits under Medicare Part B. No issuer may
				  engage in a premium rating practice that results in higher premiums for any
				  policy solely because the policy is issued under the provisions of this
				  section. For individuals 65 years of age or older when first enrolled for
				  benefits under Medicare Part B who apply for Medicare supplement coverage under
				  this subsection, each Medicare supplement policy and certificate currently
				  available from an issuer must be made available to all applicants without
				  regard to age.
(b) The provisions
				  of paragraphs (1) and (2) of this subsection apply to Medicare supplement
				  issuers with respect to persons who qualify for Medicare before attaining 65
				  years of age.
(1) An issuer must comply with
				  the first two sentences of subsection (a) of this section with respect to a
				  person who:
(A) qualifies for Medicare before
				  attaining 65 years of age, who first enrolls for benefits under Medicare Part B
				  on or after January 1, 1997, and who applies for a Medicare supplement policy
				  or certificate during the period of eligibility described in subsection (a) of
				  this section; or
(B) enrolled in
				  Medicare Part B before attaining 65 years of age, who applies for a Medicare
				  supplement policy or certificate upon attaining 65 years of age, during the
				  period of eligibility described in subsection (a) of this section that would
				  apply if the person first enrolled in Medicare Part B on attaining 65 years of
				  age.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter T - MINIMUM STANDARDS FOR MEDICARE SUPPLEMENT POLICIES › Section 3.3325 - Medicare Select Policies, Certificate, and Plans of Operations

Current through Reg. 49, No. 28; July 12, 2024
(a) This section applies to Medicare Select
				  policies, certificates, and plans of operation, as defined in this
				  section.
(b) No policy or
				  certificate may be advertised as a Medicare Select policy or certificate unless
				  it meets the requirements of this section.
(c) The following words and terms, when used
				  in this section, have the following meanings, unless the context indicates
				  otherwise. These words and terms must be defined and included in all Medicare
				  Select policies, certificates, and plans of operation.
(1) Complaint--Any dissatisfaction expressed
				  by an individual concerning a Medicare Select issuer or its network
				  providers.
(2) Emergency care--Bona
				  fide emergency services provided after the sudden onset of a medical condition
				  manifesting itself by acute symptoms of sufficient severity, including severe
				  pain, such that the absence of immediate medical attention could reasonably be
				  expected to result in:
(A) placing the
				  patient's health in serious jeopardy;
(B) serious impairment to bodily functions;
				  or
(C) serious dysfunction of any
				  bodily organ or part.
(3)
				  Grievance--Dissatisfaction expressed in writing by an individual insured under
				  a Medicare Select policy or certificate with the administration, claims
				  practices, or provision of services concerning a Medicare Select issuer or its
				  network providers.
(4) Medicare
				  Select issuer--An issuer offering, or seeking to offer, a Medicare Select
				  policy or certificate.
(5) Medicare
				  Select policy or Medicare Select certificate--A Medicare supplement policy or
				  certificate, respectively that contains restricted network
				  provisions.
(6) Network provider--A
				  provider of health care, or a group of providers of health care, which has
				  entered into a written agreement with the issuer to provide benefits covered
				  under a Medicare Select policy.
(7)
				  Nonnetwork provider--A provider of health care, or a group of providers of
				  health care, that has not entered into a written agreement with the issuer to
				  provide benefits covered under a Medicare Select policy.
(8) Restricted network provisions--Any
				  provision that conditions the payment of benefits, in whole or in part, on the
				  use of network providers.
(9)
				  Service area--The geographic area approved by the Commissioner as part of the
				  plan of operation or amended plan of operation, within which an issuer is
				  authorized to offer a Medicare Select policy.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter U - NEWBORN CHILDREN COVERAGE › Section 3.3401 - Purpose

Current through Reg. 49, No. 28; July 12, 2024
The purpose of this subchapter is implementation of
					 Insurance Code §
										1367.003,
					 so as to clarify the applicability of §1367.003 to insurance policies to
					 be issued in the future and to existing policies.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter U - NEWBORN CHILDREN COVERAGE › Section 3.3402 - Applicability and Scope

Current through Reg. 49, No. 28; July 12, 2024
This subchapter applies to all individual or group policies
					 of accident and sickness insurance (including policies issued by companies
					 subject to Insurance Code Chapter 842, as amended) delivered or issued for
					 delivery to any person in this state which provides for either accident and
					 sickness coverage of additional newborn children or for maternity
					 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 3.3501 - Purpose

Current through Reg. 49, No. 28; July 12, 2024
(a) The purpose of this subchapter is to:
(1) permit carriers to include a coordination
				  of benefits (COB) provision in their plans;
(2) identify plans with which COB is
				  allowed;
(3) establish an order in
				  which plans with a COB provision must pay their claims;
(4) reduce duplication of benefits by
				  permitting a reduction of the benefits to be paid by plans that do not have to
				  pay their benefits first; and
(5)
				  provide greater efficiency in the processing of claims when a person is covered
				  under more than one 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 3.3502 - Applicability

Current through Reg. 49, No. 28; July 12, 2024
(a) This subchapter applies to:
(1) group, blanket, or franchise accident and
				  health insurance policies as described by Insurance Code Chapter 1251,
				  concerning Group and Blanket Health Insurance;
(2) individual and group health maintenance
				  organization (HMO) evidences of coverage as defined by Insurance Code §
											843.002, concerning
				  Definitions;
(3) individual
				  accident and health insurance policies as defined by Insurance Code §
											1201.001, concerning
				  Definitions;
(4) individual and
				  group preferred provider benefit plans and exclusive provider benefit plans as
				  described by Insurance Code Chapter 1301, concerning Preferred Provider Benefit
				  Plans;
(5) group insurance
				  contracts, individual insurance contracts, and subscriber contracts that pay or
				  reimburse for the cost of dental care;
(6) individual and group health benefit plans
				  or vision benefit plans, as described by Insurance Code Chapter 1203,
				  Subchapter C, concerning Vision and Eye Care Benefits; and
(7) the medical care components of individual
				  and group long-term care contracts.