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 Y - STANDARDS FOR LONG-TERM CARE INSURANCE, NON-PARTNERSHIP AND PARTNERSHIP LONG-TERM CARE INSURANCE COVERAGE UNDER INDIVIDUAL AND GROUP POLICIES AND ANNUITY CONTRACTS, AND LIFE INSURANCE POLICIES THAT PROVIDE LONG-TERM CARE BENEFITS WITHIN THE POLICY › Division 2 - NON-PARTNERSHIP AND PARTNERSHIP LONG-TERM CARE INSURANCE › Section 3.3845 - Permitted Refunds of Premium Provisions

Current through Reg. 49, No. 28; July 12, 2024
A long-term care policy that contains a refund of premium
						provision shall comply with the following:
(1) The refund of premium benefit provision
					 shall not provide a withdrawal value.
(2) The refund of premium provision shall be
					 appropriately captioned in the policy.
(3) The amount of premium being refunded
					 shall be equal to all or a stated portion of the premiums paid, less claims
					 paid, during a specified time or interval during the premium payment period for
					 the policy.
(4) The refund of
					 premiums shall be applied as a reduction in future premiums or to increase
					 future benefits. This provision does not apply to any refund on the death of
					 the insured or a complete surrender or cancellation of the contract, which
					 cannot exceed the aggregate premiums paid under the contract.
(5) The policy shall provide for the refund
					 of premium benefit to be paid automatically upon the death of the insured to
					 the insured's designated beneficiary.
(6) The policy shall provide that the insured
					 may discontinue the benefit on any anniversary date with a corresponding
					 reduction of premiums.
(7) The
					 premium applicable to the refund of premium benefit shall be fully disclosed to
					 the prospective insured in or with the outline of coverage and shall be stated
					 separately on the policy specifications page.
(8) A qualified actuary shall certify as to
					 the reasonability of rates charged for the refund of premium benefit and the
					 reserving required by §
											3.3819 of
					 this title (relating to Requirement for Reserve) shall include the refund of
					 premium benefit.
(9) The refund of
					 premium benefit shall not be marketed or titled as a cash-value,
					 return-of-premium or nonforfeiture benefit.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter Y - STANDARDS FOR LONG-TERM CARE INSURANCE, NON-PARTNERSHIP AND PARTNERSHIP LONG-TERM CARE INSURANCE COVERAGE UNDER INDIVIDUAL AND GROUP POLICIES AND ANNUITY CONTRACTS, AND LIFE INSURANCE POLICIES THAT PROVIDE LONG-TERM CARE BENEFITS WITHIN THE POLICY › Division 2 - NON-PARTNERSHIP AND PARTNERSHIP LONG-TERM CARE INSURANCE › Section 3.3846 - Incontestability Period

Current through Reg. 49, No. 28; July 12, 2024
(a) For a policy or
					 certificate that has been in force for less than two years, an insurer may
					 rescind a long-term care insurance policy or certificate or deny an otherwise
					 valid long-term care insurance claim upon a showing of misrepresentation and an
					 intent to deceive by the insured in the application for insurance.
(b) After a policy or certificate has been in
					 force for two years it is not contestable except for the grounds stated in the
					 Insurance Code §
											1251.103
					 for a group policy and the Insurance Code §
											1201.208
					 for an individual policy.
(c) No
					 long-term care insurance policy or certificate may be field issued based on
					 medical or health status. For purposes of this section, "field issued" means a
					 policy or certificate issued by an agent or a third-party administrator
					 pursuant to the underwriting authority granted to the agent or third-party
					 administrator by an insurer.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter Y - STANDARDS FOR LONG-TERM CARE INSURANCE, NON-PARTNERSHIP AND PARTNERSHIP LONG-TERM CARE INSURANCE COVERAGE UNDER INDIVIDUAL AND GROUP POLICIES AND ANNUITY CONTRACTS, AND LIFE INSURANCE POLICIES THAT PROVIDE LONG-TERM CARE BENEFITS WITHIN THE POLICY › Division 2 - NON-PARTNERSHIP AND PARTNERSHIP LONG-TERM CARE INSURANCE › Section 3.3847 - Qualified Long-Term Care Insurance Contracts: Prohibited Representations

Current through Reg. 49, No. 28; July 12, 2024
(a) In marketing and issuing long-term care
					 insurance contracts in Texas, no person shall state that any such contract is
					 intended to be a "qualified long-term care insurance contract" as defined in
					 §
											3.3804 of
					 this title (relating to Definitions) unless the contract:
(1) provides insurance protection only for
					 services which are "qualified long-term care services," as defined in §
												3.3804 of
					 this title (relating to Definitions);
(2) does not provide for a cash surrender
					 value or other money that can be paid, assigned or pledged as collateral for a
					 loan or borrowed, except on a complete surrender or cancellation of the
					 contract;
(3) provides that all
					 refunds of premium and all policyholder dividends or similar amounts are
					 applied as a reduction in future premiums or to increase future benefits,
					 except for any refund on the death of the insured, or on a complete surrender
					 or cancellation of the contract, which cannot exceed the aggregate premiums
					 paid under the contract;
(4) does
					 not pay or reimburse expenses incurred under Medicare or which would be
					 reimbursable under Medicare but for the application of a deductible or
					 coinsurance amount, except expenses which are reimbursable under Medicare only
					 as a secondary payor; and
(5)
					 otherwise meets the applicable requirements of this subchapter.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter Y - STANDARDS FOR LONG-TERM CARE INSURANCE, NON-PARTNERSHIP AND PARTNERSHIP LONG-TERM CARE INSURANCE COVERAGE UNDER INDIVIDUAL AND GROUP POLICIES AND ANNUITY CONTRACTS, AND LIFE INSURANCE POLICIES THAT PROVIDE LONG-TERM CARE BENEFITS WITHIN THE POLICY › Division 2 - NON-PARTNERSHIP AND PARTNERSHIP LONG-TERM CARE INSURANCE › Section 3.3849 - Requirements for Insurers that Issue Long-Term Care Policies to Associations and Marketing Standards for Associations that Market the Policies

Current through Reg. 49, No. 28; July 12, 2024
(a) Insurer requirements.
(1) Any insurer issuing long-term care
					 insurance to an association, as defined in the Insurance Code §
												1251.052, must file
					 with the department in accordance with the requirements and procedures set
					 forth in Subchapter A of this chapter (relating to Submission Requirements for
					 Filings and Departmental Actions Related to Such Filings) the following:
(A) the long-term care policy and
					 certificate;
(B) a corresponding
					 outline of coverage; and
(C) annual
					 certification of the association's compliance with marketing standards for
					 long-term care policies and certificates in accordance with Form Number
					 LHL573(LTC) Insurer Certification of Association Compliance With Marketing
					 Standards for Long-Term Care Partnership and Non-Partnership Policies and
					 Certificates Form specified in Figure: 28 TAC § 3.3849(e)(1)(F).
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter Y - STANDARDS FOR LONG-TERM CARE INSURANCE, NON-PARTNERSHIP AND PARTNERSHIP LONG-TERM CARE INSURANCE COVERAGE UNDER INDIVIDUAL AND GROUP POLICIES AND ANNUITY CONTRACTS, AND LIFE INSURANCE POLICIES THAT PROVIDE LONG-TERM CARE BENEFITS WITHIN THE POLICY › Division 3 - NON-PARTNERSHIP LONG-TERM CARE INSURANCE ONLY › Section 3.3860 - Policy Summary Requirements for Non-Partnership Life Insurance Policies and Annuity Contracts that Provide Long-Term Care Benefits

Current through Reg. 49, No. 28; July 12, 2024
(a) At the time of delivery of a
					 non-partnership life insurance policy or annuity contract that provides
					 long-term care benefits by rider, a policy summary shall be delivered. In the
					 case of direct response solicitations, the insurer shall deliver the policy
					 summary upon the applicant's request, but regardless of request shall make
					 delivery no later than at the time of policy delivery. The policy summary must
					 comply with all applicable requirements of this section and must include:
(1) an explanation of how the long-term care
					 benefit interacts with other components of the policy, including deductions
					 from death benefits;
(2) an
					 illustration of the amount of benefits, the length of benefit, and the
					 guaranteed lifetime benefits if any, for each covered person;
(3) any exclusions, reductions and
					 limitations on benefits of long-term care;
(4) a statement that any long-term care
					 inflation protection option required by §
												3.3820
					 of this subchapter (relating to Requirement to Offer Inflation Protection) and
					 §
												3.3872
					 of this subchapter (relating to Inflation Protection Requirements for Long-Term
					 Care Partnership Policies and Certificates) is not available under this
					 policy;
(5) if applicable to the
					 policy type:
(A) a disclosure of the effects
					 of exercising other rights under the policy;
(B) a disclosure of guarantees related to
					 long-term care costs of insurance charges; and
(C) a disclosure of current and projected
					 maximum lifetime benefits.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter Y - STANDARDS FOR LONG-TERM CARE INSURANCE, NON-PARTNERSHIP AND PARTNERSHIP LONG-TERM CARE INSURANCE COVERAGE UNDER INDIVIDUAL AND GROUP POLICIES AND ANNUITY CONTRACTS, AND LIFE INSURANCE POLICIES THAT PROVIDE LONG-TERM CARE BENEFITS WITHIN THE POLICY › Division 4 - PARTNERSHIP LONG-TERM CARE INSURANCE ONLY › Section 3.3871 - Standards and Reporting Requirements for Approved Long-Term Care Partnership Policies and Certificates

Current through Reg. 49, No. 28; July 12, 2024
(a) Standards.
(1) General requirements. In addition to the
					 required filing and approval pursuant to §
												3.3873
					 of this title (relating to Filing Requirements for Long-Term Care Partnership
					 Policies), any policy or certificate marketed or represented to qualify as a
					 long-term care partnership policy or certificate must comply with the following
					 requirements:
(A) the insured individual was
					 a resident of Texas when coverage first became effective under the policy. If
					 the policy or certificate is later exchanged for a different long-term care
					 policy or certificate, the individual was a resident of Texas when coverage
					 under the first policy became effective;
(B) the policy is intended to be a qualified
					 long-term care insurance policy under the provisions of §
													3.3847
					 of this title (relating to Qualified Long-Term Care Insurance Contracts:
					 Prohibited Representations);
(C)
					 the policy or certificate is issued with and retains inflation coverage that
					 meets the inflation standards specified in §
													3.3872
					 of this title (relating to Inflation Protection Requirements for Long-Term Care
					 Partnership Policies and Certificates) based on the insured's then attained
					 age;
(D) the effective date of the
					 newly issued partnership policy, which is shown on the policy schedule page,
					 must be either the date that the partnership policy is issued or the date the
					 application for the partnership policy was signed. The insurer has the option
					 of using either date, but the insurer must use the same option in all
					 partnership policies issued by that insurer.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter Y - STANDARDS FOR LONG-TERM CARE INSURANCE, NON-PARTNERSHIP AND PARTNERSHIP LONG-TERM CARE INSURANCE COVERAGE UNDER INDIVIDUAL AND GROUP POLICIES AND ANNUITY CONTRACTS, AND LIFE INSURANCE POLICIES THAT PROVIDE LONG-TERM CARE BENEFITS WITHIN THE POLICY › Division 4 - PARTNERSHIP LONG-TERM CARE INSURANCE ONLY › Section 3.3872 - Inflation Protection Requirements for Long-Term Care Partnership Policies and Certificates

Current through Reg. 49, No. 28; July 12, 2024
(a) Pursuant to
					 §1917(b)(1)(C)(iii)(IV) of the Social Security Act (42
					 U.S.C.
					 §1396p(b)(1)(C)(iii)(IV)),
					 an insurer shall not issue a policy or certificate marketed or represented to
					 qualify as an approved long-term care partnership policy unless the policy or
					 certificate complies with the following inflation protection requirements:
(1) For a person who is less than 61 years of
					 age, as of the date of purchase, the policy or certificate must provide
					 compound annual inflation protection from the date of purchase until the person
					 attains 61 years of age.
(A) At the time of
					 purchase, insurers must offer to each applicant the option to purchase compound
					 annual inflation protection that automatically increases each year on a
					 compounded basis at a rate of not less than 5.0 percent annually throughout the
					 interval of coverage. The inflation protection is required to automatically
					 increase benefits each year on a compounded basis.
(B) If the applicant declines the offer of
					 inflation protection specified in subparagraph (A) of this paragraph, then the
					 insurer must offer and the applicant must purchase and retain compound annual
					 inflation protection until the insured attains age 61 or goes on claim status,
					 whichever comes first. The inflation protection is required to automatically
					 increase benefits each year on a compounded basis at a rate that the insured
					 elects which may be in a range of from one percent to four percent or tied to
					 the Consumer Price Index for All Urban Consumers (CPI-U).
(C) A person who is less than 61 years of age
					 that has purchased a long-term care partnership policy or certificate with the
					 required compound inflation protection specified in this paragraph may upon
					 attaining 61 years of age choose to amend the compound inflation protection
					 provision in the policy or certificate in accordance with the requirements
					 specified in paragraph (2) of this subsection.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter Y - STANDARDS FOR LONG-TERM CARE INSURANCE, NON-PARTNERSHIP AND PARTNERSHIP LONG-TERM CARE INSURANCE COVERAGE UNDER INDIVIDUAL AND GROUP POLICIES AND ANNUITY CONTRACTS, AND LIFE INSURANCE POLICIES THAT PROVIDE LONG-TERM CARE BENEFITS WITHIN THE POLICY › Division 4 - PARTNERSHIP LONG-TERM CARE INSURANCE ONLY › Section 3.3874 - Insurer Requirements for Agents That Market Partnership Policies and Certificates

Current through Reg. 49, No. 28; July 12, 2024
(a) Insurer
					 training verification and certification requirements for agents. The following
					 requirements apply to an insurer that is offering partnership policies or
					 certificates in this state.
(1) The insurer
					 is required to obtain verification that an agent has received the training
					 specified in §
												19.1022
					 of this title (relating to Long-Term Care Partnership Certification
					 Course).
(2) Pursuant to the
					 Insurance Code §
												1651.105(b),
					 the insurer is required to certify to the commissioner that each agent who
					 sells partnership policies or certificates on behalf of the insurer complies
					 with the training requirements of this subsection. The initial certification
					 must be submitted on Form Number LHL571(LTC) Long-Term Care Partnership Agent
					 Training Certification Initial Reporting Form as specified in Figure: 28 TAC
					 § 3.3874(b)(6)(A). Any subsequent certification must be submitted on Form
					 Number LHL572(LTC) Long-Term Care Partnership Agent Training Certification
					 Form, as specified in Figure: 28 TAC § 3.3874(b)(6)(B).
(3) The insurer is required to maintain
					 records of the verification required in paragraph (1) of this subsection for at
					 least four years from the date the verification is received, and the department
					 or its designee may review these records at any time.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter Z - EXEMPTION FROM REVIEW AND APPROVAL OF CERTAIN LIFE, ACCIDENT, HEALTH AND ANNUITY FORMS AND EXPEDITION OF REVIEW › Section 3.4001 - Purpose

Current through Reg. 49, No. 28; July 12, 2024
The purpose of this subchapter is to exempt certain life
					 and accident and sickness policy forms and annuity contract forms from certain
					 of the requirements of Insurance Code Chapter 1701. Chapter 1701 requires that
					 these forms may not be delivered, issued, or used in Texas unless they have
					 been filed for review for approval with the Texas Department of Insurance as
					 provided in §
										1701.054.
					 Insurance Code §1701.005(b) provides for exemption by the commissioner of
					 policy forms from the requirements of Chapter 1701 under certain circumstances.
					 This subchapter exempts the forms specified from the requirement that they
					 either be approved before being used or reviewed after being used as provided
					 in §1701.054. However, this subchapter does not exempt such forms from the
					 requirement that they be filed before being used. An additional purpose of this
					 subchapter is to expedite the review process of forms filed under Insurance
					 Code Chapter 1701.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter Z - EXEMPTION FROM REVIEW AND APPROVAL OF CERTAIN LIFE, ACCIDENT, HEALTH AND ANNUITY FORMS AND EXPEDITION OF REVIEW › Section 3.4002 - All Forms To Be Filed for Review Unless Specifically Exempted

Current through Reg. 49, No. 28; July 12, 2024
All life and accident and sickness policy forms and annuity
					 contract forms intended for use in this state, including application, rider, or
					 endorsement forms not specifically exempted by this subchapter, must be filed
					 to be reviewed and approved in accordance with Insurance Code §
										1701.051 and
					 §
										1701.054.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter Z - EXEMPTION FROM REVIEW AND APPROVAL OF CERTAIN LIFE, ACCIDENT, HEALTH AND ANNUITY FORMS AND EXPEDITION OF REVIEW › Section 3.4004 - Exempt Forms

Current through Reg. 49, No. 28; July 12, 2024
(a) Group and
				  individual life forms. The group and individual life insurance forms specified
				  in this subsection are exempt from the review and approval requirements of
				  Insurance Code Chapter 1701, unless the forms are required by the laws of
				  Texas, another state, or the United States, to be specifically approved or are
				  otherwise excepted in subsection (b) of this section:
(1) group life insurance master policies,
				  contracts, certificates, applications, enrollment forms, riders, amendments,
				  and endorsements applicable thereto, issued under the authority of Insurance
				  Code §§
											1131.003,
				  1131.051 -
				  1131.058,
				  1131.060, and 1131.064(b), listed in subparagraphs (A) and (B) of this
				  paragraph:
(A) term policies and riders;
				  and
(B) cash value and endowment
				  policies with no more than five death benefit and/or premium changes;
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter Z - EXEMPTION FROM REVIEW AND APPROVAL OF CERTAIN LIFE, ACCIDENT, HEALTH AND ANNUITY FORMS AND EXPEDITION OF REVIEW › Section 3.4005 - General Information

Current through Reg. 49, No. 28; July 12, 2024
(a) This section
				  does not relieve any insurer or other licensee from complying with the
				  Insurance Code or the rules and regulations of the Texas Department of
				  Insurance.
(b) Insurers must cause
				  all forms to comply with all required provisions of all applicable law
				  including but not limited to the Insurance Code and the rules and regulations
				  of the department. In addition to other legal requirements:
(1) forms may not contain any ambiguous,
				  deceptive, misleading, unfair, inequitable or unjust wording or
				  terminology;
(2) title headings or
				  other indications of a form's provisions may not be misleading;
(3) forms may not contain any exception,
				  exclusion, limitation, or reduction that is deceptive, unjust, unfair,
				  encourages misrepresentation, or inequitable or that would deceptively affect
				  the risk purported to be assumed in the general coverage of the contract;
				  and
(4) forms may not be printed or
				  otherwise reproduced in such a manner as to render any provision of the form
				  substantially illegible or not easily legible to persons of normal
				  vision.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter Z - EXEMPTION FROM REVIEW AND APPROVAL OF CERTAIN LIFE, ACCIDENT, HEALTH AND ANNUITY FORMS AND EXPEDITION OF REVIEW › Section 3.4006 - New, Uncommon, and Unusual Forms

Current through Reg. 49, No. 28; July 12, 2024
Any form intended for use in Texas which contains
					 provisions or will create conditions or concepts which may be construed as new,
					 uncommon, or unusual must be filed for review and approval whether or not it
					 falls within one of the exempt filing categories as specified in these
					 sections.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter Z - EXEMPTION FROM REVIEW AND APPROVAL OF CERTAIN LIFE, ACCIDENT, HEALTH AND ANNUITY FORMS AND EXPEDITION OF REVIEW › Section 3.4007 - Newly Licensed Insurers

Current through Reg. 49, No. 28; July 12, 2024
All forms intended for use in Texas for all newly licensed
					 insurers shall be filed for review and approval for a period of two years from
					 the date the insurer receives a certificate of authority to do business in
					 Texas.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter Z - EXEMPTION FROM REVIEW AND APPROVAL OF CERTAIN LIFE, ACCIDENT, HEALTH AND ANNUITY FORMS AND EXPEDITION OF REVIEW › Section 3.4008 - Procedures for Corrections to Non-Compliant Exempt Forms

Current through Reg. 49, No. 28; July 12, 2024
(a) In order to monitor the appropriateness
				  and effectiveness of the exemption provisions, the department will conduct
				  periodic random and targeted audits of forms filed under these sections. Any
				  compliance deficiencies identified during the audit process will be
				  communicated to the insurer with a request for corrective action. Any failure
				  to acknowledge a request and provide a plan for corrective action will be
				  subject to the provisions of §
										3.4009 of
				  this title (relating to Sanctions).
(b) In the event that an insurer becomes
				  aware, without notification by the department, that a form filed as exempt
				  under the provisions of this subchapter (relating to Exemption from Review and
				  Approval of Certain Life, Accident, Health, and Annuity Forms and Expedition of
				  Review) does not comply with the Insurance Code or the rules of the Texas
				  Department of Insurance or the laws or regulations of the United States, the
				  insurer shall promptly notify the department in writing of the form number, the
				  nature of the non-compliance, and the insurer's plan for corrective action to
				  remedy the non-compliance situation.
(c) In the event that an insurer becomes
				  aware, without notification by the department, that a form filed as exempt
				  under the provisions of this subchapter was not eligible to be filed exempt,
				  the insurer shall promptly notify the department, withdraw the form filed as
				  exempt and refile the form in accordance with the applicable filing
				  requirements of this chapter.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter Z - EXEMPTION FROM REVIEW AND APPROVAL OF CERTAIN LIFE, ACCIDENT, HEALTH AND ANNUITY FORMS AND EXPEDITION OF REVIEW › Section 3.4009 - Sanctions

Current through Reg. 49, No. 28; July 12, 2024
(a) The privileges under these sections are
				  canceled for an insurer if either of the determinations in paragraphs (1) or
				  (2) of this subsection are made after notice and hearing as follows:
(1) an insurer's filing made under §
											3.4004 of
				  this title (relating to Exempt Forms) fails to comply with §
											3.4005 of
				  this title (relating to General Information); or
(2) an insurer's filing made under §
											3.4004(g)
				  of this title fails to be an exact copy of a filing previously
				  approved.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter Z - EXEMPTION FROM REVIEW AND APPROVAL OF CERTAIN LIFE, ACCIDENT, HEALTH AND ANNUITY FORMS AND EXPEDITION OF REVIEW › Section 3.4020 - Appendix

Current through Reg. 49, No. 28; July 12, 2024
The forms adopted and referenced in §
										3.4004(g)
					 of this title (relating to Copies of Previously Approved Forms) and §
										3.4005 of
					 this title (relating to General Information) are included in the following
					 appendix to these sections.
Attached
					 Graphic
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter AA - LIMITED EXEMPTION FOR INSURANCE COVERAGE FROM THE REQUIREMENTS OF INSURANCE CODE CHAPTER 1701 › Section 3.4101 - Purpose

Current through Reg. 49, No. 28; July 12, 2024
This subchapter provides for exempting certain contracts or
					 coverage from the requirement in Insurance Code Chapter 1701 that such
					 contracts or coverage be filed for review with the Texas Department of
					 Insurance before being delivered, issued, or used in this state; this exemption
					 is applicable only if the coverage is otherwise authorized for use in this
					 state and is appropriate under Insurance Code Chapter 1701, as if no provision
					 for exemption existed. The exemption is for 45 days from the effective date of
					 the coverage or until a later date as provided in this subchapter. The
					 department has determined that the filing of certain forms or coverage before
					 it goes into effect is not desirable or necessary for the protection of the
					 public, and further that the requirement in Insurance Code Chapter 1701 that
					 such forms be filed for review with the Texas Department of Insurance before
					 being delivered, issued, or used in this state may not practicably be applied
					 to such forms or coverage prior to its issuance or delivery in
					 Texas.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter AA - LIMITED EXEMPTION FOR INSURANCE COVERAGE FROM THE REQUIREMENTS OF INSURANCE CODE CHAPTER 1701 › Section 3.4102 - Coverage Which May Be Exempted

Current through Reg. 49, No. 28; July 12, 2024
The following classes of insurance coverage may be
					 exempted:
(1) group life or accident
				  or health insurance coverage delivered or issued for delivery to the groups
				  authorized by Insurance Code §§
										1131.051,
				  1131.052,
				  1251.051, and
				  1251.052, insofar as
				  it applies to a labor union as group policyholder if the coverage conforms to
				  the following:
(A) it is a result of a
				  collective bargaining agreement between a labor organization and an
				  employer;
(B) it is required by the
				  collective bargaining agreement to go into effect within 60 days of the final
				  agreement;
(C) it is the subject of
				  aggressive and knowledgeable bargaining in a fully arms-length fashion on the
				  part of the policyholder; and
(D)
				  due to the economic posture of the parties involved, it is impracticable to
				  obtain prior approval before the policy is issued and delivered;
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter AA - LIMITED EXEMPTION FOR INSURANCE COVERAGE FROM THE REQUIREMENTS OF INSURANCE CODE CHAPTER 1701 › Section 3.4103 - Obtaining Exemptions

Current through Reg. 49, No. 28; July 12, 2024
The exemption specified in §
										3.4102
					 of this title (relating to Coverage Which May Be Exempted) is conditioned as
					 follows.
(1) The insurer has an
				  affirmative duty to comply with the following:
(A) the insurer must file with the Texas
				  Department of Insurance a statement signed by an officer of the company
				  certifying that each of the conditions specified in either §
											3.4102(1) or
				  (2) of this title (relating to Coverage Which
				  May Be Exempted) is satisfied, and stating the name of the insured, the nature
				  and extent of benefits, the date the parties concluded the agreement respecting
				  insurance coverage, and the effective date of coverage;
(B) the insurer must inform the group
				  policyholder in writing that the coverage is exempted from review by the Texas
				  Department of Insurance for a limited time;
(C) the insurer must file the statement
				  required by subparagraph (A) of this paragraph and a copy of the communication
				  required by subparagraph (B) of this paragraph with the Texas Department of
				  Insurance by the later of:
(i) 10 days from
				  the date the parties concluded the agreement respecting the insurance coverage;
				  or
(ii) 10 days from the effective
				  date of coverage; and
(D) the insurer must submit the exempted
				  forms for review with the Texas Department of Insurance in the usual manner
				  prescribed by Insurance Code Chapter 1701, as soon as possible after:
(i) the effective date of coverage;
				  or
(ii) the date the parties
				  concluded the agreement respecting the insurance coverage. In no event may the
				  insurer delay submission of the forms for review more than 45 days from the
				  later of:
(I) the effective date of coverage;
				  or
(II) the date the parties
				  concluded the agreement respecting the insurance coverage.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter AA - LIMITED EXEMPTION FOR INSURANCE COVERAGE FROM THE REQUIREMENTS OF INSURANCE CODE CHAPTER 1701 › Section 3.4104 - Duration of Exemptions

Current through Reg. 49, No. 28; July 12, 2024
Contracts submitted in accordance with §
										3.4103 of
					 this title (relating to Obtaining Exemption) will be reviewed in the normal
					 course. The duration of the period of an exemption provided for in these
					 sections, unless otherwise determined on either an individual or class basis by
					 the board, expires on the later of the following:
(1) 45 days from the date coverage becomes
				  effective;
(2) 45 days from the
				  date the parties reached an agreement on the insurance coverage; or
(3) 20 days after the form is either approved
				  or disapproved.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter AA - LIMITED EXEMPTION FOR INSURANCE COVERAGE FROM THE REQUIREMENTS OF INSURANCE CODE CHAPTER 1701 › Section 3.4105 - Disciplinary Measures

Current through Reg. 49, No. 28; July 12, 2024
The Texas Department of Insurance may at any time revoke
					 the exemption specified in this subchapter on the grounds that a
					 company:
(1) has not complied with
				  this subchapter ; or
(2) by failing
				  to abide by other applicable law is found to be unworthy of the exemption. The
				  department may, after hearing, revoke that company's right to future exemptions
				  under this subchapter and may also administer any sanction provided by
				  law.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter BB - PHARMACEUTICAL SERVICES › Section 3.4201 - Scope

Current through Reg. 49, No. 28; July 12, 2024
This subchapter applies to a health insurance policy,
					 including a health insurance policy that incorporates a preferred provider
					 benefit plan, issued, delivered, issued for delivery, entered into or renewed
					 in this state in which an insurer provides benefits for pharmaceutical services
					 under a contract or agreement entered into with a group contract holder or
					 beneficiary of the policy and requires or encourages policy beneficiaries to
					 use pharmaceutical services, pharmacies or pharmacists designated by the
					 insurer.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter BB - PHARMACEUTICAL SERVICES › Section 3.4202 - Definitions

Current through Reg. 49, No. 28; July 12, 2024
The following words and terms, when used in this
					 subchapter, shall have the following meanings, unless the context clearly
					 indicates otherwise.
(1) Health
				  insurance policy--An individual, group, blanket, or franchise insurance policy,
				  insurance policy or agreement, or group hospital service contract that provides
				  benefits for pharmaceutical services that are necessary as a result of or to
				  prevent an accident or sickness. The term does not include evidence of coverage
				  provided by a health maintenance organization under the Health Maintenance
				  Organization Act (the Insurance Code, Chapter 20A). The term includes a health
				  insurance policy that incorporates a preferred provider benefit plan.
(2) Insurer--Any life, health and accident;
				  health and accident; or health insurance company or company operating pursuant
				  to the Insurance Code, Chapters 3, 10, 20, 22 and 26 authorized to issue,
				  deliver, issue for delivery or renew in this state health insurance policies
				  approved under the Insurance Code, Article 3.42.
(3) Pharmaceutical services--Services,
				  including dispensing prescription drugs as defined in the Pharmacy Act, Texas
				  Civil Statutes, Article 4542a-1, §5, that are ordinarily and customarily
				  rendered by a pharmacy or pharmacist licensed to practice pharmacy under the
				  Pharmacy Act, Texas Civil Statutes, Article 4542a-1. The term does not include
				  mail order services.
(4)
				  Pharmacist--A person licensed to practice pharmacy under the Pharmacy Act,
				  Texas Civil Statutes, Article 4542a-1.
(5) Pharmacy--A facility licensed under the
				  Pharmacy Act, Texas Civil Statutes, Article 4542a-1, §29.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter BB - PHARMACEUTICAL SERVICES › Section 3.4203 - Notification and Information to Pharmacies and Pharmacists

Current through Reg. 49, No. 28; July 12, 2024
(a) An insurer shall, upon request, provide
				  information concerning the application process and qualification requirements
				  for participation in providing pharmaceutical services under a health insurance
				  policy.
(b) An insurer must notify
				  a pharmacy or pharmacist of acceptance or non-acceptance of an application to
				  participate as a contract provider under a health insurance policy, in writing,
				  no later than 90 days from receipt of an application.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter BB - PHARMACEUTICAL SERVICES › Section 3.4204 - Pharmacy Application and Recertification

Current through Reg. 49, No. 28; July 12, 2024
(a) An insurer may establish reasonable
				  application and recertification fees for each licensed pharmacy which
				  participates or applies to participate as a contract provider under a health
				  insurance policy. An application or recertification fee charged under this
				  section shall be considered reasonable provided:
(1) the fee does not exceed $50 per licensed
				  pharmacy;
(2) the fee shall be
				  uniformly charged per application or recertification to each pharmacy holding a
				  license issued by the Texas State Board of Pharmacy;
(3) an insurer that contracts for the
				  pharmaceutical services of more than one licensed pharmacy under common
				  ownership or affiliation shall charge a separate fee for each licensed
				  pharmacy;
(4) no more than one fee
				  per licensed pharmacy is charged by an insurer for processing an application
				  for participation as a contract provider under all health insurance policies
				  and in any or all networks utilized by the insurer; and
(5) no more than one fee per licensed
				  pharmacy is charged by a health maintenance organization or insurer within an
				  insurance holding company system, as defined in Insurance Code, Article
				  21.49-1, §2, utilizing common networks.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter BB - PHARMACEUTICAL SERVICES › Section 3.4205 - Contracts for Pharmaceutical Services

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  An insurer must apply the same administrative, financial and professional
				  conditions to all pharmacies and pharmacists participating or applying to
				  participate as contract providers under a health insurance policy.
(b) An insurer may establish additional
				  compensation or reimbursement rates for the following pharmaceutical services
				  or products as long as the rates are uniformly applied to pharmacies and
				  pharmacists participating as contract providers under a health insurance
				  policy:
(1) compounding as defined under the
				  Pharmacy Act, Texas Civil Statutes, Article 4542a-1, §5;
(2) dispensing of controlled substances as
				  defined under the Pharmacy Act, Texas Civil Statutes, Article 4542a-1, §5;
				  and
(3) preparing and dispensing
				  injectable drug therapies.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter CC - STANDARDS FOR ACCELERATION-OF-LIFE-INSURANCE BENEFITS FOR INDIVIDUAL AND GROUP POLICIES AND RIDERS › Section 3.4301 - Purpose; Severability

Current through Reg. 49, No. 28; July 12, 2024
(a) The
				  commissioner enacts this subchapter to:
(1)
				  Expand the circumstances under which insurers can offer
				  acceleration-of-life-insurance benefits, thus enhancing financial choices for
				  insureds facing terminal or life-threatening illnesses or conditions;
(2) Implement revised statutory requirements
				  for certain group and individual life insurance contracts
(3) Set uniform standards for offering
				  acceleration-of-life-insurance benefits that will be applicable to all group
				  and individual life insurance plans, creating a level playing field for
				  insurers and key protections for consumers;
(4) Allow insurers, with proper disclosures,
				  to offer benefits that will qualify for favorable tax treatment under federal
				  law, as well as benefits that may not qualify for favorable tax treatment, but
				  that are available to a broader class of insureds; and
(5) Ensure that
				  acceleration-of-life-insurance benefit provisions that fund long-term care
				  expenses conform basic definitions and eligibility triggers to those in rules
				  setting minimum standards for long-term care insurance contracts.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter CC - STANDARDS FOR ACCELERATION-OF-LIFE-INSURANCE BENEFITS FOR INDIVIDUAL AND GROUP POLICIES AND RIDERS › Section 3.4302 - Acceleration-of-Life-Insurance: Scope of Benefits

Current through Reg. 49, No. 28; July 12, 2024
(a) An
				  acceleration-of-life-insurance benefit provision provides a special benefit
				  under a life insurance contract, which prepays all or a portion of the death
				  benefit, based either on a long-term care illness, specified disease, or
				  terminal illness.
(b) The following
				  words and terms, when used in this subchapter, shall have the following
				  meanings, unless the context clearly indicates otherwise:
(1) Life insurance contract--An individual
				  life insurance policy, a group life insurance policy or certificate of
				  insurance, or a rider to an individual or group life insurance policy or group
				  certificate of insurance.
(2)
				  Long-term care illness--An illness or physical condition that results in the
				  inability to perform the activities of daily living or the substantial and
				  material duties of any occupation. Evidence of a long-term care illness
				  includes, but is not limited to, illnesses or conditions which require:
(A) confinement in a convalescent nursing
				  home, residential care or intermediate nursing facility, defined consistently
				  with the provisions of §
												3.3812
				  of this title (relating to Policy Standards for Provider); or
(B) adult day care services, as defined and
				  provided consistently with §
												3.3804(b)
				  of this title (relating to Definitions), and home health care services, as
				  defined and provided consistently with §
												3.3804(b)
				  of this title.
(3)
				  Specified disease--An illness or physical condition that is likely to cause
				  permanent disability or premature death, including, but not limited to, the
				  following:
(A) AIDS;
(B) a malignant tumor;
(C) a condition requiring organ
				  transplantation;
(D) a coronary
				  artery disease resulting in acute infarction or requiring surgery;
(E) a permanent neurological deficit
				  resulting from cerebral vascular accident; or
(F) a condition of similar severity as
				  specified in the life insurance contract, which would be expected to impair the
				  insured's quality or length of life in the absence of appropriate medical
				  attention.
(4) Terminal
				  illness--An illness or physical condition, including a physical injury, that
				  can reasonably be expected to result in death in two years or less.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter CC - STANDARDS FOR ACCELERATION-OF-LIFE-INSURANCE BENEFITS FOR INDIVIDUAL AND GROUP POLICIES AND RIDERS › Section 3.4303 - Required Policy Definitions; Evidence of Total and Permanent Disability

Current through Reg. 49, No. 28; July 12, 2024
(a) Acceleration-of-life-insurance benefits,
				  and the illness, condition, care or confinement necessary to evidence that the
				  insured has either a long-term care illness, specified disease or terminal
				  illness, shall be clearly defined in the life insurance contract consistently
				  with this subchapter.
(b) Such
				  illness, condition, care, or confinement is evidence of total and permanent
				  disability for purposes of meeting the standards for providing
				  acceleration-of-life-insurance benefits set forth in the Insurance Code, §
										1111.052
				  and §
										1201.003,
				  and §
										3.4302
				  of this title (relating to Acceleration-of-Life-Insurance: Scope of
				  Benefits).
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter CC - STANDARDS FOR ACCELERATION-OF-LIFE-INSURANCE BENEFITS FOR INDIVIDUAL AND GROUP POLICIES AND RIDERS › Section 3.4304 - Standards for Medical Diagnoses

Current through Reg. 49, No. 28; July 12, 2024
The acceleration-of-life-insurance benefit provision may
					 require a medical diagnosis of conditions and/or documentation of care or
					 confinement as defined in the life insurance contract to establish eligibility
					 for acceleration-of-life-insurance benefits. This may include a written medical
					 opinion, satisfactory to the company, that the insured has a terminal illness,
					 a long-term care illness, or a specified disease. If additional diagnoses by a
					 physician selected by the company are required, the
					 acceleration-of-life-insurance benefit provision, or a disclosure statement
					 attached to the front of the policy or rider, must specify that the additional
					 diagnoses are at the expense of the company and how conflicting diagnoses will
					 be reconciled. The specific standards sufficient to meet such eligibility
					 requirements shall be defined in the life insurance contract, and any
					 acceleration-of-life-insurance benefit shall be conditioned only upon such
					 requirement or requirements as defined.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter CC - STANDARDS FOR ACCELERATION-OF-LIFE-INSURANCE BENEFITS FOR INDIVIDUAL AND GROUP POLICIES AND RIDERS › Section 3.4305 - Termination of Benefit upon Exercise of Nonforfeiture Option

Current through Reg. 49, No. 28; July 12, 2024
The life insurance contract may contain a provision
					 terminating the acceleration-of-life-insurance benefit if the contract is
					 continued under a nonforfeiture option.