TAX ADMINISTRATION

The notice in this section is for policies that provide benefits for specified limited services, and shall follow the content and format of one of the two statements (but not both simultaneously) set out in this section, as follows: (1) Original disclosure statement: Attached Gra…

The notice in this section is for policies that reimburse expenses incurred for specified diseases or other specified impairments (including expense-incurred cancer, specified disease and other types of health insurance policies that limit reimbursement to named medical condition…

The notice in this section is for policies that pay fixed dollar amounts for specified diseases or other specified impairments (including cancer, specified disease, and other health insurance policies that pay a scheduled benefit or specific payment based on diagnosis of the cond…

The notice in this section is for indemnity policies and other policies that pay a fixed dollar amount per day, excluding long-term care policies, and shall follow the content and format of one of the two statements (but not both simultaneously) set out in this section, as follow…

The notice in this section is for policies that provide benefits upon both an expense-incurred and fixed indemnity basis, and shall follow the content and format of one of the two statements (but not both simultaneously) set out in this section, as follows: (1) Original disclosur…

The notice in this section is for other health insurance policies not specifically identified in §§ 3.3604 - 3.3609 of this title (relating to Required Disclosure Statements for Policies that Duplicate Medicare), and shall follow the content and format of one of the two statement…

Any accident and sickness insurance policy, subscriber contract, or evidence of coverage other than a Medicare supplement policy, disability income policy, or a policy issued pursuant to a contract under Section 1876 of the Federal Social Security Act (42 USC §§ 1395ss , et seq) …

(a) Except as otherwise specified in this subchapter, this subchapter applies to any preferred provider benefit plan or exclusive provider benefit plan as specified in this subsection. (1) This subchapter applies to any preferred or exclusive provider benefit plan policy that is …

(a) Words and terms defined in Insurance Code Chapter 1301, concerning Preferred Provider Benefit Plans, have the same meaning when used in this subchapter, unless the context clearly indicates otherwise. (b) The following words and terms, when used in this subchapter, have the f…

(a) Fairness requirements. A preferred provider benefit plan is not considered unjust under Insurance Code Chapter 1701, concerning Policy Forms, or to unfairly discriminate under Insurance Code Chapter 542, Subchapter A, concerning Unfair Claim Settlement Practices, or Chapter 5…

(a) Readability. All health insurance policies, health benefit plan certificates, endorsements, amendments, applications, or riders are required to be written in a readable and understandable format that meets the requirements of § 3.602 of this title (relating to Plain Language …

(a) Access to designation as a preferred provider. Physicians, practitioners, institutional providers, and health care providers other than physicians, practitioners, and institutional providers, if other health care providers are included by an insurer as preferred providers, th…

(a) Consistent with Insurance Code § 1301.0055(a)(3) , concerning Network Adequacy Standards, where necessary to avoid a violation of the network adequacy requirements of § 3.3704 of this title (relating to Freedom of Choice; Availability of Preferred Providers) in a county that …

(a) For an out-of-network claim for which the insured is protected from balance billing under Insurance Code Chapter 1301, concerning Preferred Provider Benefit Plans, or when no preferred provider is reasonably available, an insurer must pay the claim at the preferred level of c…

(a) Network adequacy report required. On or before April 1 of each year and prior to marketing any plan in a new service area, an insurer must submit a network adequacy report for each network to be used with a preferred or exclusive provider benefit plan. The network adequacy re…

(a) If the commissioner determines, after notice and opportunity for hearing, that the insurer's network and any access plan supporting the network are inadequate to ensure that preferred provider benefits are reasonably available to all insureds or are inadequate to ensure that …

For the purposes of this subchapter, the 11 Texas geographic regions that an insurer is required to use for reporting data under § 3.3709 of this title (relating to Annual Network Adequacy Report) are defined based on the public health regions designated under Health and Safety C…

(a) An insurer must submit network configuration information as specified in this section in connection with a request for a waiver under § 3.3707 of this title (relating to Waiver Due to Failure to Contract in Local Markets), an annual network adequacy report required under § 3.…

Sections 3.3721 of this title (relating to Preferred and Exclusive Provider Benefit Plan Network Approval Required), 3.3722 of this title (relating to Application for Preferred and Exclusive Provider Benefit Plan Approval; Qualifying Examination; Network Modifications), and 3.372…

An insurer may not offer, deliver, or issue for delivery a preferred or exclusive provider benefit plan in this state unless the commissioner has completed a qualifying examination to determine compliance with Insurance Code Chapter 1301 and this subchapter and has approved the i…

(a) Where to file application. An insurer that seeks to offer a preferred or exclusive provider benefit plan must file an application for approval with the Texas Department of Insurance as specified on the department's website and use the form titled Application for Approval of P…

(a) The commissioner may conduct an examination relating to a preferred or exclusive provider benefit plan as often as the commissioner considers necessary, but no less than once every three years. (b) On-site financial, market conduct, complaint, or quality of care exams will be…

(a) An insurer must develop and maintain an ongoing quality improvement (QI) program designed to objectively and systematically monitor and evaluate the quality and appropriateness of care and services provided within an exclusive provider benefit plan and to pursue opportunities…

This subchapter of rules of the Texas Department of Insurance is promulgated and adopted pursuant to the authority vested in the commissioner under the Insurance Code Chapter 1651 and §36.001. Notes 28 Tex. Admin. Code § 3.3801 The provisions of this §3.3801 adopted to be effecti…

The purpose of this subchapter is to implement the Insurance Code Chapter 1651: (1) to promote the public interest; (2) to promote the availability of long-term care insurance coverage; (3) to protect applicants for long-term care insurance, as defined, from unfair or deceptive s…

(a) Applicability. (1) In accordance with the Insurance Code Chapter 1651, §§ 3.3801 - 3.3804 of this subchapter (relating to General Provisions) apply to all long-term care insurance coverage that is regulated under this subchapter. (2) In accordance with the Insurance Code Chap…

(a) Except as otherwise provided by law or this subchapter, no long-term care insurance policy, certificate, group hospital service corporation subscriber contract, rider attached to a life insurance policy or certificate or annuity contract or certificate may be delivered or iss…

(a) Except as otherwise provided by law or this subchapter, no long-term care insurance policy or certificate or group hospital service corporation subscriber contract, delivered or issued for delivery in this state, may contain provisions respecting the matters set forth in §§3.…

A long-term care insurance policy and/or certificate shall contain a provision which sets forth the individuals eligible to be covered under the policy and/or certificate and which specifies the conditions applicable to an individual who may become covered under the policy and/or…

(a) The term "guaranteed renewability" may be used only when the policyholder has the right to continue the long-term care insurance in force by the timely payment of premiums and when the insurer has no unilateral right to make any change in any provision of the policy or rider …

(a) The term "noncancellability" may be used only when the policyholder has the right to continue the long-term care insurance in force by the timely payment of premiums during which period the insurer has no right to make any change in any provision of the insurance or in the pr…

(a) A provider of services, including, but not limited to, assisted living facility, skilled nursing facility, extended care facility, intermediate care facility, convalescent nursing home, maintenance or personal care facility, and home health care agency, shall be defined in re…

(a) No long-term care insurance policy or certificate which provides benefits for home health care or adult day care services may exclude or limit benefits by requiring any of the following: (1) that the insured would need care in a nursing facility if home health care services w…

(a) A long-term care insurance policy or certificate shall contain provisions conditioning eligibility for benefits or services upon the occurrence of the following events: (1) the inability to perform, without assistance, any two activities of daily living, as set forth by the i…

Reserves for long-term care benefits provided pursuant to the terms and conditions of policies or certificates which are subject to the provisions of this subchapter shall be determined in accordance with Subchapter GG of this chapter (relating to Minimum Reserve Standards for In…

(a) No insurer or other entity may offer a long-term care insurance policy or certificate in this state unless such insurer or other entity also offers to the prospective insured, or to the group policyholder, if the group policy will be issued to an employer, labor union, or con…

No group long-term care insurance coverage may be offered to a resident of this state under a group policy issued in another state to a group described in the Insurance Code § 1251.056 and § 1131.064 , unless the Texas Department of Insurance has made a determination that the gro…

No long-term care insurance policy or certificate issued in this state shall contain renewal provisions less favorable to the policyholder than guaranteed renewability or noncancellability, as those terms are defined in § 3.3807 of this title (relating to Policy or Certificate St…

(a) No long-term care insurance policy may be cancelled, nonrenewed, or otherwise terminated on the grounds of age or the deterioration of the mental or physical health of the insured individual or certificate holder. (b) No long-term care insurance policy may contain a provision…

(a) No long-term care insurance policy or certificate issued under provisions of this subchapter may contain a provision which denies a claim for losses incurred more than six months from the effective date of coverage for a preexisting condition, as defined in § 3.3804 of this t…

(a) No long-term care insurance policy or certificate may be delivered or issued for delivery in this state which conditions the eligibility for benefits on prior hospitalization. (b) No long-term care insurance policy or certificate may be delivered or issued for delivery in thi…

(a) No policy or certificate may be delivered or issued for delivery in this state as a long-term care insurance policy or certificate if such policy or certificate limits or excludes coverage by type of illness, treatment, medical condition, or accident, except as follows: (1) a…

Termination of long-term care insurance shall be without prejudice to any benefits payable for institutionalization, if such institutionalization began while the long-term care insurance was in force and continues without interruption after termination. Such extension of benefits…

(a) Continuation or conversion. In conjunction with the provisions of § 3.3807 of this title (relating to Policy or Certificate Standards for Guaranteed Renewability) and § 3.3810 of this title (relating to Policy or Certificate Standards for Noncancellability), an insurer or oth…

(a) Required disclosure of policy provisions. (1) Long-term care insurance policies and certificates must contain a renewability provision as required by § 3.3822 of this title (relating to Minimum Standard for Renewability of Long-term Care Coverage). Such provision must be appr…

(a) Individual, direct-response-solicited, and group long-term care insurance application forms shall include questions designed to elicit information as to whether, as of the date of application, the applicant has another long-term care insurance policy or certificate in force o…

(a) Loss ratio standards. Except as noted in subsections (b) and (c) of this section, this subsection shall apply to all long-term care insurance policies and certificates. (1) Benefits provided under long-term care insurance policies and certificates shall be deemed reasonable i…

(a) An outline of coverage must be delivered to an applicant for an individual or group long-term care insurance policy or certificate at the time of initial solicitation through means which prominently direct the attention of the recipient to the document and its purpose. In the…

An outline of coverage is required on any group certificate issued for group long-term care insurance issued to a group as defined in the Insurance Code Chapter 1251 Subchapter B, but subject to the exemptions in the Insurance Code § 1651.002 . Such outline of coverage shall be i…

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