TAX ADMINISTRATION

"Disability income protection coverage" is a policy which provides for periodic payments, weekly or monthly, for a specified period during the continuance of disability resulting from either sickness or accident or a combination thereof, which: (1) provides for periodic payments …

"Accident only coverage" is a policy of accident insurance which provides coverage, singularly or in combination, for death, dismemberment, disability, or hospital and medical care caused by accident. Such coverage provided shall meet the following criteria. (1) Accidental death …

(a) "Specified disease coverage" is a policy written on a guaranteed renewable basis as prescribed in § 3.3050 (b) of this title (relating to Standards for Renewability Provisions) which meets one of the following definitions. (1) A policy which provides coverages for each person…

(a) Limited benefit coverage is a policy of accident and sickness insurance providing the types of coverage set forth in § 3.3071 of this title (relating to Minimum Standards for Basic Hospital Expense Coverage), § 3.3072 of this title (relating to Minimum Standards for Basic Med…

The minimum basis for cash values is stated in Insurance Code Chapter 1105, wherein the adjusted premiums are required to be computed as a "uniform percentage of the respective premiums specified by the policy." Maximum guaranteed premiums in the policy are specified premiums as …

Supplemental coverage is a policy of accident and sickness insurance which may be issued only to supplement in-force policies of individual and group accident and sickness insurance, employee benefit plans, hospital, medical, and dental service organization subscriber contracts, …

The commissioner may authorize approval of a policy that does not correspond with one of the categories as described in §§3.3071-3.3077 and 3.3079-3.3080 of this title (relating to Minimum Standards and Benefits and Readability for Accident and Health Insurance Policies) if such …

(a) In order to facilitate public understanding of coverages and to provide full and fair disclosure in the sale of individual accident and sickness insurance policies, no such policy may be delivered or issued for delivery in this state unless an appropriate outline of coverage,…

(a) The outline of coverage for policies that are approved under § 3.3079 of this title (relating to Minimum Standards for Limited Benefit Coverage) shall prominently display in no less than 14-point type that the policy is "limited benefit basic hospital expense coverage," "limi…

(a) Format. (1) Each outline of coverage must contain the appropriate text and be in the appropriate format of the outlines of coverage set forth in this subchapter and may not contain any material of an advertising nature, except for the insurer's logotype. (2) The outline of co…

An outline of coverage in the following prescribed form and drafted in accordance with the instructions set forth in § 3.3092 of this title (relating to Format, Content, and Readability for Outline of Coverage) shall be issued in connection with policies meeting the standards of …

(a) No insurer may incorporate an increment into a maximum premium in an indeterminate premium reduction policy in order to be able to show an increased reduction in later policy years or to reduce cash values if any, as provided in Insurance Code Chapter 1105, or reserves as pro…

(a) In order to increase policyholder understanding of individual accident and sickness policies, insurers are encouraged to draft individual accident and sickness policies in a readable manner. To maintain the value of the policy as a legal document, the utmost care and caution …

(a) The text of the policy must be organized so that it follows a logical sequence. (b) Coverages must be self-contained and independent. (c) The use of provisions which refer the reader to another section must be avoided to the extent possible. (d) General policy provisions appl…

(a) Words shall be selected carefully with preference given to short, familiar words. (b) Words which are generally familiar, or are common speech shall be used to the extent possible. (c) Use of technical or abstract words shall be avoided to the extent possible. (d) While provi…

A failure to follow and abide by the representations and disclosure provisions required by this subchapter in marketing the indeterminate premium reduction policy is grounds for a withdrawal of approval of the insurer's previously approved indeterminate premium reduction policy f…

(a) The sections of this subchapter, as amended and adopted by the commissioner, will be effective 20 days from the date they are filed with the Office of the Secretary of State and be applicable to all individual accident and sickness insurance policies and subscriber contracts …

If any provision of these sections or its application to any person or circumstance is held invalid, the invalidity does not affect other provisions or applications of the sections which can be given effect without the invalid provision or application, and to this end the provisi…

The purpose of these sections is to provide for the reasonable standardization of coverage and simplification of terms and benefits of Medicare supplement policies; to facilitate public understanding and comparison of such policies; to eliminate provisions contained in such polic…

(a) Except as otherwise specifically provided, this subchapter applies to: (1) all Medicare supplement policies as defined in Insurance Code § 1652.002 and § 3.3303 of this title (relating to Definitions) delivered or issued for delivery in this state on or after the effective da…

The following words and terms, when used in this subchapter, have the following meanings, unless the context clearly indicates otherwise. (1) 1990 Standardized Medicare supplement benefit plan, 1990 Standardized benefit plan, or 1990 plan--A group or individual policy of Medicare…

No insurance policy, subscriber contract, certificate, or evidence of coverage may be advertised, solicited, or issued for delivery in this state as a Medicare supplement policy unless the policy, subscriber contract, certificate, or evidence of coverage contains definitions or t…

(a) Except for permitted preexisting condition clauses described in § 3.3306 (b)(1)(A) of this title (relating to Minimum Benefit Standards), no policy or certificate may be advertised, solicited, or issued for delivery in this state as a Medicare supplement policy if the policy …

(a) Benefit standards for standardized Medicare supplement benefit plan policies or certificates issued to 2020 newly eligible individuals. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) provides that no policy or certificate that provides coverage of the Medica…

(a) Minimum aggregate loss ratio standard. A Medicare supplement individual or group policy form may not be delivered or issued for delivery unless the individual or group policy form can be expected, as estimated for the entire period for which rates are computed to provide cove…

(a) General rules. (1) Medicare supplement policies and certificates must include a renewal or continuation provision. The language or specifications of the renewal or continuation provision must be consistent with the type of contract issued. The provision must be appropriately …

(a) Application forms shall include the following information, statements and questions designed to elicit information as to whether, as of the date of the application, the applicant currently has another Medicare supplement, Medicare Advantage, Medicaid coverage, or other health…

If any provision of these sections or the application thereof to any person or circumstance is for any reason held to be invalid, the remainder of these sections and the application of such provision to other persons or circumstances will not be affected thereby. Notes 28 Tex. Ad…

(a) Guaranteed issue. (1) Eligible persons are those individuals described in subsection (b) of this section who seek to enroll under the Medicare supplement policy during the period specified in subsection (d) of this section, and who submit evidence of the date of termination, …

A Medicare supplement policy shall not be deemed to meet the standards and requirements set forth in this subchapter unless the filing company has complied with the requirements of the following paragraphs. (1) Every issuer providing Medicare supplement insurance or benefits in t…

(a) Every issuer of Medicare supplement policies, contracts, certificates, or coverage for delivery in this state shall comply with the Social Security Act, §1882(c)(3) (as enacted by the Omnibus Budget Reconciliation Act of 1987 (OBRA) 1987, §4081(b)(2)(C) (Public Law Number 100…

Every issuer providing group Medicare supplement insurance benefits to a resident of this state under Insurance Code Chapter 1652 must, for information purposes, file with the department's Life and Health Lines Office a copy of any master policy issued in connection with any cert…

(a) An issuer or other entity designated in Insurance Code § 1652.003 may provide commission or other compensation to an agent for the sale of a Medicare supplement policy or certificate only if the first-year commission or other first-year compensation is no more than 200 percen…

(a) Every issuer marketing Medicare supplement coverage in this state, directly or through its agents, shall establish marketing procedures to ensure that: (1) any comparison of policies by its agents will be fair and accurate; (2) excessive insurance is not sold or issued; (3) a…

(a) In recommending the purchase or replacement of any Medicare supplement policy or certificate, an agent shall make reasonable efforts to determine the appropriateness of a recommended purchase or replacement. (b) Any sale of a Medicare supplement policy or certificate that wil…

(a) On or before March 1 of every year, every issuer of Medicare supplement coverage in this state must report the following information to the Texas Department of Insurance for every individual resident of this state for whom the insurer or entity has more than one Medicare supp…

(a) An issuer shall not deliver or issue for delivery a policy or certificate to a resident of this state unless the policy form or certificate form has been filed with and approved by the commissioner in accordance with filing requirements and procedures prescribed by the Insura…

Premium rates, rating schedules, and supporting documentation for a Medicare supplement policy or certificate to be used in this state must be filed with the department and approved by the Commissioner. Any request for an increase to rates for Medicare supplement policies or cert…

(a) No issuer may deny or condition the issuance or effectiveness of any Medicare supplement policy or certificate available for sale in this state, nor discriminate in the pricing of a policy or certificate because of the health status, claims experience, receipt of health care,…

(a) This section applies to Medicare Select policies, certificates, and plans of operation, as defined in this section. (b) No policy or certificate may be advertised as a Medicare Select policy or certificate unless it meets the requirements of this section. (c) The following wo…

This section applies to all Medicare supplement policies and certificates with policy years beginning on or after July 1, 2009. (1) The definitions in subparagraphs (A) - (F) of this paragraph apply to this section only. (A) "Issuer of a Medicare supplement policy or certificate"…

The purpose of this subchapter is implementation of Insurance Code § 1367.003 , so as to clarify the applicability of §1367.003 to insurance policies to be issued in the future and to existing policies. Notes 28 Tex. Admin. Code § 3.3401 The provisions of this §3.3401 adopted to …

This subchapter applies to all individual or group policies of accident and sickness insurance (including policies issued by companies subject to Insurance Code Chapter 842, as amended) delivered or issued for delivery to any person in this state which provides for either acciden…

(a) The purpose of this subchapter is to: (1) permit carriers to include a coordination of benefits (COB) provision in their plans; (2) identify plans with which COB is allowed; (3) establish an order in which plans with a COB provision must pay their claims; (4) reduce duplicati…

(a) This subchapter applies to: (1) group, blanket, or franchise accident and health insurance policies as described by Insurance Code Chapter 1251, concerning Group and Blanket Health Insurance; (2) individual and group health maintenance organization (HMO) evidences of coverage…

The following words and terms, when used in this subchapter, have the following meanings, unless the context clearly indicates otherwise. (1) Allowable expense--Except as otherwise provided in § 3.3505 of this title (relating to Allowable Expenses), or where a statute requires a …

A carrier may not coordinate benefits to reduce the benefits paid under a plan regulated by this subchapter in the absence of a COB provision in the contract that meets the requirements of this subchapter. Despite § 11.511 (1)(B) of this title (relating to Optional Provisions), a…

(a) If a covered person advises a plan that all plans covering the person are high-deductible health plans and the person intends to contribute to a health savings account established in accord with § 223 of the Internal Revenue Code of 1986, the primary high-deductible plan's de…

(a) Separate parts of a plan for members of a group that are provided through alternative contracts that are intended to be part of a coordinated package of benefits are considered one plan, and there is no COB among the separate parts of the plan. (b) If a plan coordinates benef…

Residual disability shall be defined in relation to the insured's reduction in earnings and may be related either to the inability to perform one or more, but not all, of the "major," "important," or "essential" duties of employment or occupation, or to the inability to perform a…