Texas Administrative Code

For purposes of this subchapter, the following words and terms shall have the following meanings, unless the context clearly indicates otherwise. (1) Bid response--A response to a departmental request for goods or services, including a formal bid response, a formal bid proposal, …

This subchapter establishes procedures for the acceptance of donations by the Texas Department of Insurance to assist with the funding of the Health Coverage Awareness and Education Program and to establish procedures to govern the relationships between employees of the departmen…

An issuer must perform utilization review in compliance with Insurance Code Chapter 4201 and must maintain procedures for notification, review, and appeal of an adverse determination, as defined by this section. An issuer must implement and maintain an internal appeal system for …

Any person, including a person who has attempted to resolve complaints through an issuer complaint system process and who is dissatisfied with the resolution, may report an alleged violation of this subchapter to the Texas Department of Insurance at www.tdi.texas.gov or 1-800-252…

(a) Complaints System. Issuers must comply with this section; any requirements under a Medicaid contract, subject to Government Code, Chapter 533; and any other applicable law. The complaint system must provide reasonable procedures for the resolution of oral and written complain…

(a) An issuer must write all policies, health benefit plan certificates, endorsements, amendments, applications, and riders in plain language, in a readable and understandable format, and in compliance with all applicable requirements relating to minimum readability requirements …

An issuer is subject to the same credentialing criteria as outlined in § 11.1902 (4) of this title (relating to Quality Improvement Program). Notes 28 Tex. Admin. Code § 3.9207 The provisions of this §3.9207 adopted to be effective September 17, 2003, 28 TexReg 7993

(a) An issuer must establish and maintain procedures to assure that the health care services provided to insureds are rendered under reasonable standards of quality of care consistent with prevailing professionally recognized standards of medical practice. These procedures must i…

An issuer that uses subcontractors to perform one or more function(s) remains responsible for ensuring compliance with all applicable regulatory compliance requirements. A limited provider network shall comply with all statutory and regulatory requirements. Notes 28 Tex. Admin. C…

(a) An issuer shall notify, by publication or in writing, all health care providers in the service area of its intent to offer an EPP and of the opportunity to participate. The issuer shall provide such notice prior to issuance of the initial EPP and yearly thereafter. (b) An iss…

(a) Disclosure of complaint system. An EPP policy or certificate must contain the Complaints and Appeals Process found in this subchapter. This information must include a clear and understandable description of the issuer's methods for resolving complaints. An issuer must provide…

The following words and terms, when used in this subchapter, have the following meanings, unless the context clearly indicates otherwise: (1) Adverse determination--A determination by a utilization review agent that the health care services furnished or proposed to be furnished t…

This subchapter applies to an exclusive provider benefit plan (EPP) written by an issuer which has contracted with the Health and Human Services Commission (HHSC) to provide services under the Texas Children's Health Insurance Program (CHIP), Medicaid or with the Statewide Rural …

(a) If the elected method of compliance is notification to all existing policyholders as described in § 3.902 (a)(2) of this title (relating to Notification and Disclosure Requirements), the notice required by this subchapter shall be provided in the following manner: Attached Gr…

(a) For all new forms subject to this subchapter filed on or after September 1, 1995, the insurer must include with the form filing written notification to the department specifying the method of notification as set forth in § 3.909 of this title (relating to Notification and Dis…

The insurer shall pay the death benefit under an eligible policy if the insured dies within one year of the date of lapse and the requirements for submitting proof of mental incapacity and request for reinstatement are met. The insurer shall reduce the death benefit under a polic…

(a) For any ordinary life insurance policy delivered or issued for delivery in this state on and after May 1, 2003, that utilizes the same premium rates and charges for male and female lives or is issued in circumstances where applicable law does not permit distinctions on the ba…

(a) The 2001 CSO Mortality Table may be used in applying Chapter 3, Subchapter EE of this title (relating to Valuation of Life Insurance Policies) in the following manner, subject to the transition dates for use of the 2001 CSO Mortality Table in § 3.9103 of this title (relating …

(a) For each plan of insurance with separate rates for smokers and nonsmokers, an insurer may use: (1) Composite mortality tables to determine minimum reserve liabilities and minimum cash surrender values and amounts of paid-up nonforfeiture benefits; (2) Smoker and nonsmoker mor…

(a) At the election of the company for any one or more specified plans of insurance and subject to the conditions stated in this subchapter, the 2001 CSO Mortality Table may be used as the minimum standard for policies issued on or after May 1, 2003, and before the date specified…

The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise. (1) 2001 CSO Mortality Table--mortality tables, consisting of separate rates of mortality for male and female lives, developed by the Am…

The purpose of this subchapter is to recognize, permit, and prescribe the use of the 2001 Commissioners Standard Ordinary (CSO) Mortality Table in accordance with Insurance Code § 425.058(c)(3) and § 1105.055(h) and § 3.4505 of this title (relating to General Calculation Requirem…

(a) The insurer shall accept a request for reinstatement and proof of mental incapacity that is filed by: (1) the insured, or the owner, if the insured and owner are not the same party; (2) the legal guardian of the insured; (3) other legal representative of the insured; or (4) t…

(a) The insurer is required to send notice of the conditions set forth in this subchapter under which the policy may qualify for reinstatement due to the mental incapacity of the insured. The notice must be sent to the owner of any individual life policy which does not provide no…

An insurer is not required to reinstate coverage or pay benefits under this subchapter if the insured first became mentally incapacitated after the expiration of the grace period contained in the policy. Notes 28 Tex. Admin. Code § 3.908 The provisions of this §3.908 adopted to b…

Upon reinstatement, the policy will continue in force as though it had not lapsed. Notes 28 Tex. Admin. Code § 3.907 The provisions of this §3.907 adopted to be effective January 10, 1996, 20 TexReg 11121.

The insurer may require, as a condition of reinstatement, payment of past due premiums, plus interest at a rate not to exceed 6.0% per annum. Notes 28 Tex. Admin. Code § 3.906 The provisions of this §3.906 adopted to be effective January 10, 1996, 20 TexReg 11121.

An eligible policy that is subject to this subchapter shall be reinstated, without evidence of insurability, on payment of past due premiums and interest if it meets the requirements set forth in paragraphs (1)-(4) of this subsection: (1) it has been in force continuously for at …

The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise. (1) Commissioner--The Commissioner of Insurance. (2) Department--The Texas Department of Insurance. (3) Insured--The person whose life i…

Where any term or section of this subchapter is determined by a court of competent jurisdiction to be inconsistent with the statutes of this state or to be unconstitutional, the remaining terms and provisions of this subchapter shall remain in effect. Notes 28 Tex. Admin. Code § …

This subchapter applies to all individual life policies which do not provide nonforfeiture benefits issued to Texas residents by insurers licensed in this state, including stipulated premium companies and fraternal benefit societies, which lapse due to the mental incapacity of th…

The purpose of this subchapter is to address the reinstatement requirements for individual life policies that lapse due to the mental incapacity of the insured under certain conditions as prescribed in this subchapter. Notes 28 Tex. Admin. Code § 3.901 The provisions of this §3.9…

(a) Pursuant to Occupations Code § 651.159 the Texas Funeral Service Commission (TFSC), the Texas Department of Insurance (TDI), and the Texas Department of Banking (DOB) adopt the following joint memorandum of understanding (JMOU) relating to prepaid funeral benefits as defined …

(a) Occupations Code § 651.159 mandates the Texas Department of Insurance, the Texas Funeral Service Commission, and the Texas Department of Banking to adopt by rule a joint memorandum of understanding relating to prepaid funeral services and transactions that: (1) outlines the r…

Each cause of action, pending litigation, or matter in process before the Texas Department of Insurance or commissioner of insurance will be determined in accordance with and governed by the applicable statutes, rules, orders, or interpretations of the Texas Department of Insuran…

If any provision of §§ 3.801 - 3.811 of this title (relating to Variable Life Insurance) or the application thereof to any person or circumstance is for any reason held to be invalid, the remainder of the sections and the application of such provision to other persons or circumst…

Any insurer delivering or issuing for delivery in this state any variable life contracts shall mail to each variable life insurance contractholder at his or her last known address the following reports. (1) Within 30 days after each anniversary of the contract, a statement or sta…

The application for a variable life contract shall contain: (1) a prominent statement that the death benefit may be variable or fixed under specified conditions; (2) a prominent statement that cash values may increase or decrease in accordance with the experience of the separate …

An insurer delivering or issuing for delivery in this state any variable life insurance contracts shall deliver to the applicant for such contract, and obtain a written acknowledgment of receipt from such applicant coincident with or prior to the execution of the application, the…

The following requirements apply to the establishment and administration of variable life insurance separate accounts by any domestic insurer. (1) Establishment of separate accounts. Any domestic life insurance company issuing variable life contracts must establish one or more se…

(a) Reserve liabilities for variable life insurance contracts must be established under Insurance Code Chapter 425, Subchapter B, in accordance with actuarial procedures that recognize the variable nature of the benefits provided and any mortality guarantees. (b) For scheduled pr…

The commissioner will not approve any variable life insurance form filed pursuant to these rules unless it conforms to the requirement of applicable law. (1) Filing of variable life contracts. All variable life contracts, and all riders, endorsements, applications, and other docu…

The following requirements are applicable to all insurers either seeking authority to issue variable life insurance in this state or having the authority to issue variable life insurance in this state. (1) Licensing and approval to do business in this state. An insurer may not de…

The following words and terms, when used in this subchapter, have the following meanings, unless the context clearly indicates otherwise. (1) Affiliate of an insurer--Any person, directly or indirectly, controlling, controlled by, or under common control with such insurer; any pe…

These sections are promulgated to regulate individual variable life insurance contracts issued or delivered for issue in this state, on and after the effective date of these sections. Notes 28 Tex. Admin. Code § 3.801 The provisions of this §3.801 adopted to be effective June 5, …

(a) Purpose. This section implements Insurance Code § 1368.007 , concerning Treatment Standards. (b) Applicability. This section applies to a group health benefit plan that is subject to Insurance Code Chapter 1368, concerning Availability of Chemical Dependency Coverage. (c) Tre…

The provisions of these sections shall apply to any form received by the department on or after June 1, 2003. Forms received by this department prior to June 1, 2003 shall be governed by the laws in effect at the time of the submission. Notes 28 Tex. Admin. Code § 3.8 The provisi…