reglab/statecodes huggingface dataset:
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter V - PHARMACY BENEFITS › Division 2 - IDENTIFICATION CARDS › Section 21.3004 - Issuance of Standard Identification Cards

Current through Reg. 49, No. 28; July 12, 2024
(a) An issuer of a health benefit plan, or an
					 administrator or pharmacy benefit manager, is not required to issue a standard
					 identification card in addition to an enrollee identification card if:
(1) the enrollee identification card contains
					 the information required by §
												21.3003(b) and
					 (c) of this title (relating to Standard
					 Identification Cards); and
(2) the
					 enrollee identification card is issued in accordance with §
												21.3003(a)
					 of this title and subsections (c) and (d) of this section.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter V - PHARMACY BENEFITS › Division 3 - OFF-LABEL DRUGS › Section 21.3010 - Definitions; Coverage of Off-Label Drugs

Current through Reg. 49, No. 28; July 12, 2024
The following words and terms, when used in this division
						have the following meanings, unless the context clearly indicates
						otherwise:
(1) Chronic illness--A
					 disease, syndrome, or condition of expected long duration, showing little
					 change or slow progression.
(2)
					 Contraindication--As defined in Insurance Code §
											1369.001(1).
(3) Disabling illness--A disease, syndrome,
					 or condition determined by an enrollee's health care practitioner to have
					 caused or have the potential to cause:
(A) a
					 physical or mental impairment that substantially limits, or may limit, one or
					 more of the activities of daily living of the enrollee including, but not
					 limited to, eating, bathing, dressing, grooming, routine hair and skin care,
					 meal preparation, exercising, toileting, and transfer and ambulation;
(B) an impairment substantially limiting an
					 enrollee's cognitive acuity;
(C) an
					 impairment substantially limiting an enrollee's ability to work, home make, or
					 engage in leisure or educational activities; or
(D) a condition regarded as an impairment by
					 an enrollee's licensed health care practitioner.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter V - PHARMACY BENEFITS › Division 3 - OFF-LABEL DRUGS › Section 21.3011 - Minimum Standards of Coverage for Off-Label Drug Use

Current through Reg. 49, No. 28; July 12, 2024
(a) An issuer of a health benefit plan that
					 provides coverage for drugs must provide coverage for any drug prescribed to
					 treat an enrollee for a covered chronic, disabling, or life-threatening illness
					 if the drug:
(1) has been approved by the
					 Food and Drug Administration for at least one indication; and
(2) is recognized for treatment of the
					 indication for which the drug is prescribed in:
(A) a standard drug reference compendium;
					 or
(B) substantially accepted
					 peer-reviewed medical literature.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter V - PHARMACY BENEFITS › Division 4 - PRESCRIPTION DRUG FORMULARY COVERAGE AND DISCLOSURE REQUIREMENTS › Section 21.3020 - Definitions; Prescription Drug Formulary

Current through Reg. 49, No. 28; July 12, 2024
The following words and terms when used in this division
						have the following meanings, unless the context clearly indicates
						otherwise:
(1) Adverse
					 determination--As defined in Insurance Code §
											4201.002.
(2) Allowed amount--The amount that the
					 applicable health benefit plan issuer allows as reimbursement for a health care
					 service, supply, or prescription drug, including reimbursement amounts for
					 which a patient is responsible due to deductibles, copayments, or
					 coinsurance.
(3) Contracted benefit
					 level--The copayment amount or coinsurance percentage established at the
					 beginning of the current plan year and described in the coverage
					 documentation.
(4) Coverage
					 documentation--A policy, certificate of coverage, evidence of coverage,
					 enrollee handbook, or a plan document distributed by an issuer or its delegated
					 entity to an enrollee or to the master contract holder, for distribution to
					 enrollees.
(5) Delegated entity--An
					 entity or an association of entities, including third-party administrators, as
					 they are defined in Insurance Code §
											4151.001(1),
					 and pharmacy benefit managers, as they are defined in Insurance Code §
											4151.151, that
					 provides reimbursement for covered services or undertakes to arrange for or
					 provide benefits or services to an enrollee under a health benefit plan, and
					 that performs on behalf of the issuer of a health benefit plan, any function
					 regulated by this division.
(6)
					 Direct electronic link--A hyperlink that, when clicked, delivers a user
					 directly to the applicable website destination.
(7) Drug--As defined in the Texas Pharmacy
					 Act, Occupations Code §
											551.003.
(8) Drug formulary or formulary--A list of
					 drugs for which a health benefit plan provides coverage, approves payment, or
					 encourages or offers incentives for physicians or other health care providers
					 to prescribe. This term does not include a health benefit plan that:
(A) offers coverage for any FDA approved
					 drug;
(B) does not include a tiered
					 structure;
(C) does not contain a
					 list of drugs; and
(D) does not
					 include utilization requirements for particular drugs or classes of
					 drugs.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter V - PHARMACY BENEFITS › Division 4 - PRESCRIPTION DRUG FORMULARY COVERAGE AND DISCLOSURE REQUIREMENTS › Section 21.3022 - Continuation of Benefits

Current through Reg. 49, No. 28; July 12, 2024
(a) An issuer of a
					 health benefit plan that offers prescription drug benefits must make a
					 prescription drug that was approved or covered for a medical condition or
					 mental illness available to each enrollee at the contracted benefit level until
					 the health benefit plan renewal date. Modifications to drug coverage are not
					 permitted until the plan's renewal date.
(b) A health benefit plan issuer may make
					 modifications to drug coverage provided under a health benefit plan if:
(1) the modification occurs at the time of
					 coverage renewal;
(2) the
					 modification is effective uniformly among all group health benefit plan
					 sponsors covered by identical or substantially identical health benefit plans,
					 or all individuals covered by identical or substantially identical individual
					 health benefit plans, as applicable; and
(3) not later than the 60th day before the
					 date the modification is effective, the issuer provides written notice of the
					 modification to the commissioner, each affected group health benefit plan
					 sponsor, each affected enrollee in an affected group health benefit plan, and
					 each affected individual health benefit plan holder for modifications that:
(A) remove a drug from a formulary;
(B) add a requirement that an enrollee
					 receive prior authorization for a drug;
(C) impose or alter a quantity limit for a
					 drug;
(D) impose a step-therapy
					 restriction for a drug; or
(E) move
					 a drug to a higher cost-sharing tier unless a generic drug alternative is
					 available.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter V - PHARMACY BENEFITS › Division 4 - PRESCRIPTION DRUG FORMULARY COVERAGE AND DISCLOSURE REQUIREMENTS › Section 21.3023 - Nonformulary Prescription Drugs; Adverse Determination

Current through Reg. 49, No. 28; July 12, 2024
If the issuer of a health benefit plan, its delegated
						entity, or their employees or agents refuses to provide coverage for a
						prescription drug that is not included in a drug formulary, and the enrollee's
						physician or other health care provider with prescriptive authority has
						determined the prescription drug is medically necessary to treat a condition
						covered by the enrollee's health benefit plan, the refusal to provide coverage
						for the prescription drug constitutes an adverse determination for the purpose
						of Insurance Code Chapter 4201 . An enrollee may appeal the adverse
						determination under Insurance Code Chapter 4201, Subchapters H and I , and the
						issuer of the health benefit plan, and its employees or agents, must review and
						resolve the appeal in accordance with those sections.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter V - PHARMACY BENEFITS › Division 4 - PRESCRIPTION DRUG FORMULARY COVERAGE AND DISCLOSURE REQUIREMENTS › Section 21.3030 - Availability of Formulary Information

Current through Reg. 49, No. 28; July 12, 2024
(a)
					 An issuer of a health benefit plan, or its delegated entity, that covers
					 prescription drugs and uses one or more drug formularies must provide, in plain
					 language, the disclosures required by Insurance Code §
											1369.054.
					 The plain language disclosure must be in the coverage documentation provided to
					 each enrollee and include the address and telephone number where the enrollee
					 may contact the issuer of the health benefit plan, or its delegated entity, to
					 determine if a specific prescription drug is on the formulary.
(b) An issuer of an individual health benefit
					 plan must allow a current or prospective enrollee to obtain a paper copy of the
					 formulary information required under §
											21.3032
					 and §
											21.3033
					 of this title (relating to Formulary Disclosure Requirements for Individual
					 Health Benefit Plans and Facilitating Comparison Shopping for Individual Health
					 Benefit Plans) by calling the toll-free number listed on the summary health
					 plan document.
(c) An issuer may
					 elect to exclude the plan-level cost-sharing information required under §
											21.3031(c)
					 of this title (relating to Formulary Information for Individual Health Benefit
					 Plans on Issuer's Website) from the paper format if the document provides a
					 toll-free number through which a current or prospective enrollee may obtain
					 formulary information contained in §21.3032 and §21.3033, including
					 the plan-specific cost-sharing information required under §21.3032(c), for
					 any formulary drug.
(d) The paper
					 copy of the formulary information must use at least 10-point font.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter V - PHARMACY BENEFITS › Division 4 - PRESCRIPTION DRUG FORMULARY COVERAGE AND DISCLOSURE REQUIREMENTS › Section 21.3031 - Formulary Information for Individual Health Benefit Plans on Issuer's Website

Current through Reg. 49, No. 28; July 12, 2024
(a) Except as
					 permitted under subsection (c) of this section, an issuer of an individual
					 health benefit plan must display the formulary information required under
					 §
											21.3032
					 and §
											21.3033
					 of this title (relating to Formulary Disclosure Requirements for Individual
					 Health Benefit Plans and Facilitating Comparison Shopping for Individual Health
					 Benefit Plans) on a website that is publicly accessible to enrollees,
					 prospective enrollees, and others without requiring the use of paid software, a
					 password, user name, or personally identifiable information. The formulary
					 information must:
(1) be electronically
					 searchable by drug name; and
(2)
					 use at least 10-point font.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter V - PHARMACY BENEFITS › Division 4 - PRESCRIPTION DRUG FORMULARY COVERAGE AND DISCLOSURE REQUIREMENTS › Section 21.3032 - Formulary Disclosure Requirements for Individual Health Benefit Plans

Current through Reg. 49, No. 28; July 12, 2024
(a) The formulary information required under
					 this section must include each individual prescription drug covered under the
					 plan that is dispensed in a network pharmacy or administered by a physician or
					 health care provider and clearly differentiate between drugs covered under the
					 plan's pharmacy benefits and medical benefits. Information pertaining to drugs
					 covered under the plan's medical benefits may be provided as an addendum or
					 link to the formulary and must include each parameter that is
					 applicable.
(b) The formulary
					 information must include the following coverage information for each drug:
(1) an explanation of coverage under the
					 health benefit plan;
(2) an
					 indication of whether the drug is preferred, if applicable, under the
					 plan;
(3) a disclosure of any prior
					 authorization, step therapy, or other protocol requirement; and
(4) the specific tier the drug falls under,
					 if the plan uses a multitier formulary.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter W - COVERAGE FOR ACQUIRED BRAIN INJURY › Section 21.3101 - General Provisions

Current through Reg. 49, No. 28; July 12, 2024
(a) Purpose. The
				  purposes of this subchapter are to:
(1)
				  ensure that enrollees in health benefit plans receive coverage for certain
				  services for acquired brain injury and to facilitate the recovery and
				  progressive rehabilitation of survivors of acquired brain injuries to the
				  extent possible to their preinjury condition by making available therapies that
				  are medically necessary, clinically proven, goal-oriented, efficacious, based
				  on individualized treatment plans, and provided by, or ordered and provided
				  under, the direction of a licensed healthcare practitioner with the goal of
				  returning the individual to, or maintaining the individual in, the most
				  integrated living environment appropriate to the individual;
(2) ensure that an issuer provides coverage
				  for services related to an acquired brain injury under the medical and surgical
				  provisions of the health benefit plan; and
(3) require the issuer of a health benefit
				  plan to provide adequate training of individuals responsible for
				  preauthorization of coverage or utilization review under the plan in order to
				  prevent wrongful denial of coverage required under Insurance Code Chapter 1352
				  and this subchapter, and to avoid confusion of medical and surgical benefits
				  with mental and behavioral health benefits.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter W - COVERAGE FOR ACQUIRED BRAIN INJURY › Section 21.3103 - Coverage for Services

Current through Reg. 49, No. 28; July 12, 2024
(a) Required
				  Coverage. Under Insurance Code Chapter 1352, a health benefit plan must include
				  coverage for services specified in §
										1352.003,
				  including cognitive rehabilitation therapy, cognitive communication therapy,
				  neurocognitive therapy and rehabilitation, neurobehavioral, neurophysiological,
				  neuropsychological, and psychophysiological testing and treatment,
				  neurofeedback therapy, remediation, and postacute transition services,
				  community reintegration services, including outpatient day treatment services,
				  or other post-acute-care treatment services, if such services are necessary as
				  a result of and related to an acquired brain injury.
(b) Medically Necessary and Appropriate.
(1) For purposes of Insurance Code §
											1352.003
				  and this subchapter, the word "necessary" means "medically
				  necessary."
(2) Under Insurance
				  Code §
											1352.007(a),
				  a health benefit plan may not deny benefits for the coverage required under
				  Insurance Code Chapter 1352 based solely on the fact that the treatment or
				  services are provided at a facility other than a hospital. Medically necessary
				  treatment and services for an acquired brain injury must be provided under the
				  coverage required by Chapter 1352 at a facility where appropriate services may
				  be provided, including:
(A) a hospital
				  regulated under the Health and Safety Code Chapter 241, including an acute or
				  postacute rehabilitation hospital; and
(B) an assisted living facility regulated
				  under the Health and Safety Code Chapter 247.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter W - COVERAGE FOR ACQUIRED BRAIN INJURY › Section 21.3104 - Training

Current through Reg. 49, No. 28; July 12, 2024
(a) In this section, "preauthorization" has
				  the meaning assigned by Insurance Code §
										1352.004(a),
				  and includes benefit determinations for proposed medical or health care
				  services.
(b) Each issuer must
				  develop written preauthorization and utilization review policies and procedures
				  for the purpose of identifying services to be covered for acquired brain
				  injury, to be used by any individual responsible for preauthorization of
				  coverage or utilization review. Such policies and procedures must include:
(1) identification of all current Common
				  Procedural Terminology (CPT) codes associated with services for acquired brain
				  injury; and
(2) a means to identify
				  an enrollee initially diagnosed with an acquired brain injury.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter W - COVERAGE FOR ACQUIRED BRAIN INJURY › Section 21.3105 - Provision of CPT Codes

Current through Reg. 49, No. 28; July 12, 2024
Each issuer of a health benefit plan subject to Insurance
					 Code Chapter 1352 and this subchapter must, on request from the department,
					 submit to the department the list of CPT codes identified by the issuer under
					 §
										21.3104(b)(1)
					 of this subchapter.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter W - COVERAGE FOR ACQUIRED BRAIN INJURY › Section 21.3107 - Mandatory Annual Notice to Insureds and Enrollees

Current through Reg. 49, No. 28; July 12, 2024
(a) Under Insurance Code §
										1352.005,
				  health benefit plan issuers must provide to insureds and enrollees the
				  notification specified in this subsection. A representation of this
				  notification is as follows:
Attached Graphic
(b) The notice required by Insurance Code
				  §
										1352.005
				  and subsection (a) of this section is required by Insurance Code §
										1352.005
				  to be issued annually to each insured or enrollee under the plan.
(c) The notice must be printed in at least
				  12-point type and must comply with the following requirements:
(1) The notice must be provided during the
				  policy term for the plan, and no later than the 60th day after enrollment and
				  renewal.
(2) Except as specified in
				  paragraph (6) of this subsection, a health benefit plan issuer must deliver the
				  notice to insureds or enrollees through the U.S. Postal Service.
(3) The notice may be delivered with other
				  health benefit plan documents that are delivered through the U.S. Postal
				  Service as long as the time frames set forth in paragraph (1) of this
				  subsection are met. For example, the notice may be delivered with the policy,
				  certificate, evidence of coverage, or enrollment or insurance card.
(4) If the notice is provided to the primary
				  insured's or enrollee's last known address, the requirements of this section
				  are satisfied with respect to all insureds or enrollees residing at that
				  address.
(5) If the last known
				  address of a covered spouse or dependent is different than the primary
				  insured's or enrollee's last known address, separate notices are required to be
				  provided to the spouse or the dependent at the spouse's or dependent's last
				  known address.
(6) For group health
				  benefit plans, the notice may be provided to the group master contract holder
				  for distribution to insureds or enrollees if the health benefit plan issuer has
				  an agreement with the group master contract holder that the notice will be
				  delivered in compliance with the timelines specified in paragraph (1) of this
				  subsection; however, the health benefit plan issuer must ensure that the notice
				  is provided to the insureds or enrollees.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter X - EVALUATION OF NETWORK PHYSICIANS AND PROVIDERS › Section 21.3201 - Texas Standardized Credentialing Application for Physicians, Advanced Practice Nurses, and Physician Assistants

Current through Reg. 49, No. 28; July 12, 2024
(a) Purpose and applicability. The purpose of
				  this section is to identify the standardized credentialing application form
				  required by Insurance Code §
										1452.052.
				  Hospitals, health maintenance organizations, preferred provider benefit plans,
				  and preferred provider organizations are required to use this form for
				  credentialing and recredentialing of physicians, advanced practice nurses, and
				  physician assistants.
(b)
				  Definitions. The following words and terms when used in this section have the
				  following meanings.
(1) Advanced practice
				  nurse--An advanced practice nurse as that term is defined by Occupations Code
				  §
											301.152.
(2) Credentialing--The process of collecting,
				  assessing, and validating qualifications and other relevant information
				  pertaining to a physician or provider to determine eligibility to deliver
				  health care services.
(3)
				  Department--Texas Department of Insurance.
(4) Health maintenance organization--A health
				  maintenance organization as that term is defined by Insurance Code §
											843.002(14).
(5) Hospital--A licensed public or private
				  institution as defined by Health and Safety Code Chapter 241 and any hospital
				  owned or operated by state government.
(6) Physician--An individual licensed to
				  practice medicine in this state.
(7) Physician assistant--A person who holds a
				  license issued under Occupations Code Chapter 204.
(8) Preferred provider benefit plan--A plan
				  issued by an insurer under Insurance Code Chapter 1301.
(9) Preferred provider organization--An
				  organization contracting with an insurer issuing a preferred provider benefit
				  plan under Insurance Code Chapter 1301 for the purpose of providing a network
				  of preferred providers.
(10)
				  Recredentialing--The periodic process by which:
(A) qualifications of physicians, advanced
				  practice nurses and physician assistants are reassessed;
(B) performance indicators including
				  utilization and quality indicators are evaluated; and
(C) continued eligibility to provide services
				  is determined.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter X - EVALUATION OF NETWORK PHYSICIANS AND PROVIDERS › Section 21.3202 - Physician Ranking Requirements

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  Purpose. In accordance with the Insurance Code §
										1460.005, this
				  section specifies the standards and guidelines that are necessary to ensure
				  that a health benefit plan issuer, including a subsidiary or affiliate, that
				  utilizes rankings, tiers, ratings or other comparisons of a physician's
				  performance against standards, measures, or other physicians, uses a nationally
				  recognized physician ranking system that emphasizes quality of health
				  care.
(b) Applicability.
(1) This section applies to a health benefit
				  plan issuer as defined in the Insurance Code §
											1460.001.
(2) This section does not apply to:
(A) a plan specified in the Insurance Code
				  §
												1460.002; or
(B) a Medicare plan offered pursuant to Title
				  XVIII, Part C and D of the Social Security Act.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter Y - UNFAIR DISCRIMINATION IN COMPENSATION FOR WOMEN'S HEALTH CARE › Section 21.3301 - Purpose

Current through Reg. 49, No. 28; July 12, 2024
The purpose of this subchapter is to remedy unequal
					 reimbursements to physicians and providers by requiring issuers to pay
					 physicians and providers of women's health care services the same or similar
					 amounts for covered reproductive health or reproductive oncology services as
					 are paid to physicians and providers who provide covered services exclusively
					 to men or to the general population.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter Y - UNFAIR DISCRIMINATION IN COMPENSATION FOR WOMEN'S HEALTH CARE › Section 21.3302 - 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) Issuer--Those entities
				  that offer a health benefit plan as identified in Insurance Code §
										1454.002.
(2) Physician--A person licensed by the Texas
				  State Board of Medical Examiners to practice medicine and surgery in this
				  state.
(3) Provider--A hospital,
				  nurse practitioner, registered nurse, physician assistant, home health aide,
				  nurse midwife, surgery center, or other outpatient care center.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter Y - UNFAIR DISCRIMINATION IN COMPENSATION FOR WOMEN'S HEALTH CARE › Section 21.3303 - Applicability

Current through Reg. 49, No. 28; July 12, 2024
This subchapter applies to issuers that provide coverage
					 for reproductive health or reproductive oncology services for women and applies
					 to health benefit plans as described in Insurance Code §
										1454.002
					 that are delivered, issued for delivery, or renewed on or after January 1,
					 2002.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter Y - UNFAIR DISCRIMINATION IN COMPENSATION FOR WOMEN'S HEALTH CARE › Section 21.3304 - Reimbursements

Current through Reg. 49, No. 28; July 12, 2024
(a) An issuer that covers reproductive health
				  or reproductive oncology services provided for women must reimburse physicians
				  or providers for those services at an amount not less than the annual average
				  compensation per hour or unit as would be paid in the service area for the same
				  or similar covered medical, surgical, hospital, pharmaceutical, nursing or
				  other services, as applicable, provided exclusively to men or to the general
				  population.
(b) In determining
				  appropriate reimbursement for reproductive health or reproductive oncology
				  services, the relative value units (RVUs) published by the Centers for Medicare
				  & Medicaid Services (CMS) shall be considered, in addition to any other
				  reimbursement methodologies submitted by the physician or provider included as
				  part of the complaint documentation described in subparagraph (a)(6) of §
										21.3305 of
				  this subchapter (relating to Complaints), for comparing reimbursements of the
				  same or comparable covered services offered exclusively to men or to the
				  general population.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter Y - UNFAIR DISCRIMINATION IN COMPENSATION FOR WOMEN'S HEALTH CARE › Section 21.3305 - Complaints

Current through Reg. 49, No. 28; July 12, 2024
(a) A complaint against an issuer filed with
				  the Texas Department of Insurance for alleged violations of Insurance Code
				  §
										1454.051
				  must include:
(1) a description of the alleged
				  violation under Insurance Code §
											1454.051;
(2) the complainant's name, address,
				  telephone number and fax number;
(3) the physician's or provider's name, if
				  different from the complainant;
(4)
				  the name of the issuer;
(5) a
				  statement indicating the complaint applies to a health benefit plan as set
				  forth in §
											21.3303
				  of this subchapter (relating to Applicability); and
(6) documentation from the physician or
				  provider that:
(A) identifies the amount
				  reimbursed by the issuer for a covered reproductive health or reproductive
				  oncology service provided to a woman;
(B) identifies the amount of time and
				  resources spent in providing the covered reproductive health or reproductive
				  oncology service;
(C) using
				  objective criteria, identifies the same or comparable covered service provided
				  exclusively to men or to the general population offered by the
				  issuer;
(D) identifies the
				  difference, if any, in the amount of time and resources spent in providing the
				  covered reproductive health or reproductive oncology service and the same or
				  comparable covered service using objective criteria;
(E) identifies the level of expertise needed
				  to provide the covered reproductive health or reproductive oncology service and
				  the same or comparable covered service; and
(F) compares the difference in reimbursements
				  for the covered reproductive health or reproductive oncology service and the
				  same or comparable service from the issuer within the same geographic service
				  area as the physician or the provider performing the service.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter Z - DATA COLLECTING AND REPORTING RELATING TO MANDATED HEALTH BENEFITS AND MANDATED OFFERS OF COVERAGE › Section 21.3401 - Purpose and Scope

Current through Reg. 49, No. 28; July 12, 2024
(a) Purpose of
				  subchapter. The purpose of this subchapter is to require certain health benefit
				  plan issuers to collect and report to the commissioner data on certain mandated
				  health benefits and mandated offers of coverage.
(b) Scope of subchapter. This subchapter
				  applies to a health benefit plan issuer that is subject to Insurance Code
				  §
										38.251 (concerning
				  Applicability), and that reports on its submission to the National Association
				  of Insurance Commissioners (NAIC), for the year for which it is reporting data,
				  a total of $10 million or more in direct premiums earned in Texas for
				  individual comprehensive health coverage, small group comprehensive health
				  coverage, or large group comprehensive health coverage.
(c) This subchapter does not apply to a
				  governmental plan as defined by
				  29
				  U.S.C. §
											1002(32).
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter Z - DATA COLLECTING AND REPORTING RELATING TO MANDATED HEALTH BENEFITS AND MANDATED OFFERS OF COVERAGE › Section 21.3402 - 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) Claims incurred--Paid
				  claims plus amounts held in reserve for claims that have been incurred but have
				  not yet been paid.
(2) Direct
				  premium--The amount of health premiums earned for comprehensive health coverage
				  as reported on an issuer's submission to the NAIC for the year for which it is
				  reporting data.
(3) Health benefit
				  plan--A health benefit plan regulated under Insurance Code Title 8 (concerning
				  Health Insurance and Other Health Coverages), Subtitles A (concerning Health
				  Coverage in General), B (concerning Group Health Coverage), C (concerning
				  Managed Care), D (concerning Provider Plans), and G (concerning Health Coverage
				  Availability).
(4) Mandated
				  benefit--A health benefit listed in §
										21.3406(b)
				  of this title (relating to Mandates for Which Data Must Be Reported) that must
				  be included in a health benefit plan.
(5) Mandated offer--An offer of coverage
				  listed in §
										21.3406(c)
				  of this title (relating to Mandates for Which Data Must Be Reported) that must
				  be offered and made available to the holder or sponsor of an individual or
				  group health benefit plan.
(6)
				  Medical billing codes--Standard code sets used to bill for specific medical
				  services, including the Healthcare Common Procedure Coding System (HCPCS) and
				  diagnosis-related group (DRG) system established by the Centers for Medicare
				  and Medicaid Services (CMS), the Current Procedural Terminology (CPT) code set
				  maintained by the American Medical Association, and the International
				  Classification of Diseases (ICD) code sets developed by the World Health
				  Organization. TDI's list of suggested mandated benefit codes is shown on its
				  website, www.tdi.texas.gov.
(7)
				  Member months--The cumulative number of months that all enrollees were covered
				  during the reporting year.
(8)
				  Reporting entity--A health benefit plan issuer or a third-party administrator
				  that performs claims payment services for a health benefit plan issuer to which
				  this subchapter applies.
(9)
				  Reporting year--A one-year period, beginning each January 1 and ending the
				  following December 31, for which health benefit plan issuers must collect the
				  data required by §
										21.3407
				  of this title (relating to Reporting of Required Information).
(10) Third-party administrator--An
				  administrator holding a certificate of authority under Insurance Code Chapter
				  4151 (concerning Third-Party Administrators).
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter Z - DATA COLLECTING AND REPORTING RELATING TO MANDATED HEALTH BENEFITS AND MANDATED OFFERS OF COVERAGE › Section 21.3403 - Collection of Data Necessary to Provide Report

Current through Reg. 49, No. 28; July 12, 2024
A reporting entity must collect the data required by this
					 subchapter for each mandated benefit and mandated offer listed in §
										21.3406
					 of this title (relating to Mandates for Which Data Must Be Reported) and must
					 prepare and submit a report as required by §
										21.3407
					 of this title (relating to Reporting of Required
					 Information).
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter Z - DATA COLLECTING AND REPORTING RELATING TO MANDATED HEALTH BENEFITS AND MANDATED OFFERS OF COVERAGE › Section 21.3404 - Deadline for Submission of Reports

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  First reporting date. The first reporting date for the rule will be June 1,
				  2018, for data collected from January 1, 2017, through December 31, 2017.
				  Subsequent annual reporting will follow this schedule.
(b) Submission of annual reports. A reporting
				  entity must submit the report required by this subchapter no later than June 1
				  following the reporting year.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter Z - DATA COLLECTING AND REPORTING RELATING TO MANDATED HEALTH BENEFITS AND MANDATED OFFERS OF COVERAGE › Section 21.3405 - Exceptions to Required Reporting and Justification for Exceptions

Current through Reg. 49, No. 28; July 12, 2024
(a) Exceptions for confidential information.
				  A reporting entity is not required to report data that:
(1) could reasonably be used to identify a
				  specific enrollee; or
(2) violates
				  confidentiality requirements of state or federal law or regulations applicable
				  to an enrollee.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter Z - DATA COLLECTING AND REPORTING RELATING TO MANDATED HEALTH BENEFITS AND MANDATED OFFERS OF COVERAGE › Section 21.3406 - Mandates for Which Data Must Be Reported

Current through Reg. 49, No. 28; July 12, 2024
(a) Data to be reported separately. For all
				  mandated benefits and mandated offers to be reported, a reporting entity must
				  report separately its data for individual, small group, and large group health
				  benefit plans.
(b) Mandated
				  benefits. The following is a list of mandated benefits about which data
				  relating to a health benefit plan must be filed under §
										21.3403
				  of this title (relating to Collection of Data Necessary to Provide Report):
(1) Certain Benefits Related to Acquired
				  Brain Injury, Insurance Code §
											1352.003
				  and §
											1352.0035;
(2) Serious Mental Illness, Insurance Code
				  §
											1355.004;
(3) Autism Spectrum Disorder, Insurance Code
				  §
											1355.015;
(4) Low-Dose Mammography, Insurance Code
				  §
											1356.005;
(5) Reconstructive Surgery Following
				  Mastectomy, Insurance Code §
											1357.004;
(6) Diabetes Equipment, Supplies, and
				  Self-Management Training, Insurance Code §
											1358.054;
(7) Formulas for Phenylketonuria (PKU) or
				  Other Heritable Diseases, Insurance Code §
											1359.003;
(8) Temporomandibular Joint (TMJ) Diagnosis
				  and Treatment, Insurance Code §
											1360.004;
(9) Osteoporosis, Detection and Prevention,
				  Insurance Code §
											1361.003;
(10) Certain Tests for Detection of Prostate
				  Cancer, Insurance Code §
											1362.003;
(11) Certain Tests for Detection of
				  Colorectal Cancer, Insurance Code §
											1363.003;
(12) Childhood Immunizations, Insurance Code
				  §
											1367.053;
(13) Hearing Screening for Children,
				  Insurance Code §
											1367.103;
(14) Chemical Dependency Coverage, Insurance
				  Code §§
											1368.004,
				  1368.005,
				  and
				  1368.007;
(15) Prescription Contraceptive Drugs and
				  Devices and Related Services, Insurance Code §
											1369.104;
(16) Certain Tests for Detection of Human
				  Papillomavirus and Cervical Cancer, Insurance Code §
											1370.003;
(17) Certain Tests for Detection of Ovarian
				  Cancer, Insurance Code §
											1370.003;
(18) Certain Tests for Early Detection of
				  Cardiovascular Disease, Insurance Code §
											1376.003;
				  and
(19) Certain Amino Acid-Based
				  Elemental Formulas, Insurance Code §
											1377.051.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter Z - DATA COLLECTING AND REPORTING RELATING TO MANDATED HEALTH BENEFITS AND MANDATED OFFERS OF COVERAGE › Section 21.3407 - Reporting of Required Information

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  Reporting data. A reporting entity must submit the data required by this
				  section electronically by completing the Mandated Benefits and Mandated Offers
				  Reporting Form found on TDI's website, www.tdi.texas.gov. A reporting entity
				  must use medical billing codes to identify applicable claims for each mandated
				  benefit and mandated offer of coverage.
(b) Issuer's information. For each reporting
				  year, a reporting entity must provide the following information:
(1) the year for which the data is being
				  reported;
(2) the health benefit
				  plan issuer's NAIC Number;
(3) the
				  health benefit plan issuer's name;
(4) the health benefit plan issuer's mailing
				  address;
(5) the issuer type
				  (insurance or HMO);
(6) whether a
				  third-party administrator is submitting the report;
(7) the name, title, direct telephone number,
				  email address, and mailing address of an individual who is responsible for the
				  report;
(8) whether the contact
				  person's email address can be released;
(9) the submission date; and
(10) whether the health benefit plan issuer
				  meets the reporting threshold for each reporting category (individual, small
				  group, and large group).
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter Z - DATA COLLECTING AND REPORTING RELATING TO MANDATED HEALTH BENEFITS AND MANDATED OFFERS OF COVERAGE › Section 21.3408 - Compliance

Current through Reg. 49, No. 28; July 12, 2024
A reporting entity that fails to comply with this
					 subchapter will be subject to the sanctions and penalties provided in Insurance
					 Code Chapters 82 (concerning Sanctions), 83 (concerning Emergency Cease and
					 Desist Orders), 84 (concerning Administrative Penalties), 601 (concerning
					 Privacy), and 602 (concerning Privacy of Health Information).
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter Z - DATA COLLECTING AND REPORTING RELATING TO MANDATED HEALTH BENEFITS AND MANDATED OFFERS OF COVERAGE › Section 21.3409 - Severability

Current through Reg. 49, No. 28; July 12, 2024
If a court holds invalid any section or portion of a
					 section of this subchapter or holds invalid its applicability to any person or
					 circumstance, the remainder of the subchapter or the applicability of the
					 provision to other persons or circumstances will not be
					 affected.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter AA - CONSUMER CHOICE HEALTH BENEFIT PLANS › Division 1 - GENERAL PROVISIONS › Section 21.3501 - Statement of Purpose

Current through Reg. 49, No. 28; July 12, 2024
This subchapter implements the provisions of the Texas
						Consumer Choice of Benefits Health Insurance Plan Act to achieve the
						legislative goal of providing individuals, employers, and other purchasers of
						health care coverage in this state the opportunity to choose health benefit
						plans that are more affordable and flexible than plans available in the
						existing market. To that end, the Legislature has authorized health carriers to
						issue policies or evidences of coverage that, in whole or in part, do not offer
						or provide certain state-mandated health benefits.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter AA - CONSUMER CHOICE HEALTH BENEFIT PLANS › Division 1 - GENERAL PROVISIONS › Section 21.3502 - 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) Basic health care
					 services--Health care services that the commissioner determines an enrolled
					 population might reasonably need to maintain good health.
(2) Commissioner--The commissioner of
					 insurance.
(3) Consumer choice
					 health benefit plan--A group or individual accident or sickness insurance
					 policy or evidence of coverage that, in whole or in part, does not offer or
					 provide state-mandated health benefits, but that provides creditable coverage
					 as defined by Insurance Code §
											1205.004(a)
					 or §
											1501.102(a).
(4) Consumer choice of benefits health
					 insurance plan--A consumer choice health benefit plan.
(5) Department--The Texas Department of
					 Insurance.
(6) HMO--a person
					 defined in Insurance Code §
											843.002(14).
(7) Health carrier--Any entity authorized
					 under the Insurance Code or another insurance law of this state that provides
					 health benefits in this state, including an insurance company, a group hospital
					 service corporation under the Insurance Code Chapter 842, an HMO under the
					 Insurance Code Chapter 843, and a stipulated premium company under the
					 Insurance Code Chapter 884.
(8)
					 Health insurer--Any entity authorized under the Insurance Code or another
					 insurance law or regulation of this state that provides health insurance or
					 health benefits in this state, including an insurance company, a group hospital
					 service corporation under Chapter 842 of the Insurance Code, and a stipulated
					 premium company under Chapter 884 of the Insurance Code.
(9) Standard health benefit plan--A consumer
					 choice health benefit plan.
(10)
					 State-mandated health benefits--
(A) Coverage
					 required under the Insurance Code, the Administrative Code, or other law of
					 this state to be provided in an individual, blanket, or group policy for
					 accident and health insurance, a contract for coverage of a health-related
					 condition, or an evidence of coverage that:
(i) includes coverage for specific health
					 care services or benefits;
(ii)
					 places limitations or restrictions on deductibles, coinsurance, copayments, or
					 any annual or lifetime maximum benefit amounts, including limitations provided
					 in Insurance Code §
													1271.151;
					 or
(iii) includes a specific
					 category of licensed health care practitioner from whom an insured or enrollee
					 is entitled to receive care.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter AA - CONSUMER CHOICE HEALTH BENEFIT PLANS › Division 1 - GENERAL PROVISIONS › Section 21.3503 - Authority to Offer

Current through Reg. 49, No. 28; July 12, 2024
A health carrier may offer one or more consumer choice
						health benefit plans; however, if the health carrier is a small employer
						carrier, it must offer one or more consumer choice health benefit plans in
						accordance with this subchapter and other applicable law.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter AA - CONSUMER CHOICE HEALTH BENEFIT PLANS › Division 1 - GENERAL PROVISIONS › Section 21.3504 - Severability

Current through Reg. 49, No. 28; July 12, 2024
A holding that any provision of this subchapter or the
						application thereof to any person or circumstances is for any reason invalid
						may not affect the remainder of the subchapter and the application of its
						provisions to any persons under other circumstances.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter AA - CONSUMER CHOICE HEALTH BENEFIT PLANS › Division 1 - GENERAL PROVISIONS › Section 21.3505 - Application Date

Current through Reg. 49, No. 28; July 12, 2024
This subchapter applies only to an insurance policy,
						contract, or evidence of coverage delivered, issued for delivery, or renewed on
						or after the effective date of the subchapter.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter AA - CONSUMER CHOICE HEALTH BENEFIT PLANS › Division 1 - GENERAL PROVISIONS › Section 21.3506 - State-Mandated Health Benefits in Blanket Indemnity Policies

Current through Reg. 49, No. 28; July 12, 2024
The category of group to which the health carrier is
						issuing coverage determines which benefits are state-mandated health benefits
						for blanket indemnity insurance policies.