Texas Administrative Code

(a) The purpose and scope of these sections is to codify the notice requirements for the content and format of seven disclosure statements which must be provided to inform prospective buyers of health insurance policies about the extent to which benefits under such policies dupli…

(a) The purpose of this section is to define short-term limited-duration insurance and address requirements for short-term limited-duration coverage. This section applies to any individual or group accident and health insurance policy or certificate issued under Insurance Code Ch…

No policy or certificate of insurance may be delivered or issued for delivery in this state on or after January 1, 1987, if the policy or certificate excludes orthodontic coverage on the ground that overbite, overjet, openbite, or arch length discrepancies measure less than four …

(a) Subsection (d) of this section contains an optional model COB provision form for use in contracts. The use of this model form is subject to the provisions of § 3.3509 of this title (relating to Miscellaneous Provisions) and the provisions of § 3.3507 of this title (relating t…

(a) A secondary plan that provides benefits in the form of services may recover the reasonable cash value of providing the services from the primary plan, to the extent that benefits for the services are covered by the primary plan and have not already been paid or provided by th…

In determining the amount to be paid by the secondary plan on a claim, should the plan wish to coordinate benefits, the secondary plan must calculate the benefits it would have paid on the claim in the absence of other health care coverage and apply that calculated amount to any …

(a) Coverage by two or more plans. When a person is covered by two or more plans, the rules for determining the order of benefit payments will be determined as provided in paragraphs (1) - (5) of this subsection. (1) The primary plan must pay or provide its benefits as if the sec…

(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…

(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 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…

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) 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…

(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…

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…

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 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"…

(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…

(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,…

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) 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…

(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) 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) 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) 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…

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) 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…

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) 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, …

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) 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…

(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) 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) 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) 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 …

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…

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…

(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 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…

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…

(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 …

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) 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) 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) 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) 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…

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) 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…