Texas Administrative Code

(a) No provision of the Insurance Code may be construed to prevent a health carrier or other entity issuing a health benefit plan from applying deductible or copayment requirements to benefits and services, including state-mandated health benefits and services, in order to qualif…

This subchapter applies to coverage under a health benefit plan issued, amended to be effective, renewed, or issued for delivery on or after January 1, 2006. Notes 28 Tex. Admin. Code § 21.3905 The provisions of this §21.3905 adopted to be effective May 31, 2006, 31 TexReg 4439

The term misrepresentation, or the prohibited conduct, act, or practice that constitutes misrepresentation by a person subject to the provisions of these sections, is defined as any one of the following acts or omissions: (1) any untrue statement of a material fact; (2) any omiss…

This subchapter applies to group preferred provider benefit plans and evidences of coverage issued pursuant to Insurance Code Chapters 843 and 1301. The subchapter outlines a group policyholder's or group contract holder's liability for premium payment, and a health carrier's obl…

The following words and terms, when used in this subchapter, shall have the following meanings unless the context clearly indicates otherwise. (1) Evidence of coverage--Any certificate, agreement, or contract, including a blended contract, that: (A) is issued to an enrollee; and …

(a) Liability for Premiums for Individuals Who Are No Longer Part of the Covered Group. (1) A contract between a health carrier and a group policyholder or group contract holder under a health benefit plan contract must provide that: (A) the group policyholder or group contract h…

The purpose of these sections is to eliminate unfair discrimination based upon sex or marital status in the terms and conditions of insurance policies, in the underwriting criteria of insurers, and in the rates, rating plans, and rating classifications of insurers. Notes 28 Tex. …

(a) Health benefit plan issuer presumed compliance. Pursuant to the Insurance Code § 847.005(a) , a health benefit plan issuer shall be presumed to be in compliance with state statutory and regulatory requirements if: (1) a national accreditation organization has issued the healt…

(a) Delegations by health benefit plan issuers with nonconditional accreditation. If a health benefit plan issuer with nonconditional accreditation has delegated one or more functions to a delegated entity, delegated third party, or utilization review agent, those delegated funct…

(a) Analysis of standards. The department will compare statutory and regulatory requirements of the department for health benefit plan issuers with the standards of national accreditation organizations. The standards of national accreditation organizations that are the same as, s…

(a) Accreditation reports. Pursuant to the Insurance Code § 847.006(b) , accreditation reports submitted to the department are proprietary and confidential under the Government Code Chapter 552 and are not subject to subpoena. (b) Summary results. Pursuant to the Insurance Code §…

The purpose of this subchapter is to set forth standards to protect active duty service members of the United States Armed Forces from dishonest and predatory insurance sales practices by declaring certain identified insurance sales practices to be false, misleading, deceptive or…

This subchapter applies to any small employer health benefit plan issuer, any large employer health benefit plan issuer, any insurer issuing an individual or group accident and health insurance policy, or any health maintenance organization evidence of coverage, with respect to a…

The following words and terms, when used in this subchapter, have the following meanings, unless the context clearly indicates otherwise. (1) Health status-related factor--Health status; medical condition, including both physical and mental illnesses; claims experience; receipt o…

(a) Notwithstanding the provisions of Insurance Code Chapter 1501, §541.056(a) and §544.052, and the provisions of Chapter 26, Subchapter A of this title, an individual or group health benefit plan issuer, an accident and health insurance issuer, or a health maintenance organizat…

The purposes of this subchapter are to provide for the circumstances under which, and the constraints within which, a group health benefit plan issuer, an accident and health insurance issuer, or health maintenance organization may: (1) vary benefits, including cost-sharing mecha…

The purpose of this subchapter is to: (1) prescribe the process for requesting, initiating, and conducting mandatory mediation and mandatory binding arbitration of claims as authorized in Insurance Code Chapter 1467, concerning Out-of-Network Claim Dispute Resolution; (2) facilit…

The following words and terms have the following meanings when used in this subchapter unless the context clearly indicates otherwise. (1) Administrator--Has the meaning assigned by Insurance Code § 1467.001 , concerning Definitions. The term also includes an administrator of a n…

"Termination" includes nonrenewal, a refusal to renew, or discontinuation by a regulated entity for the purposes of Insurance Code § 35.004 , concerning Minimum Standards for Regulated Entities Electronically Conducting Business with Consumers. Notes 28 Tex. Admin. Code § 21.501 …

(a) Mediation request and notice. (1) An out-of-network provider that is a facility or a health benefit plan issuer or administrator may request mediation. To be eligible for mediation, the party requesting mediation must complete the mediation request information required on the…

All parties subject to mandatory mediation requested by an out-of-network provider that is a facility or a health benefit plan issuer or administrator under this subchapter must use best efforts to coordinate the informal settlement teleconference required by Insurance Code § 146…

Under Insurance Code § 1467.101 (concerning Bad Faith), conduct that constitutes bad faith mediation includes failing to: (1) participate in the mediation; (2) provide information that the mediator believes is necessary to facilitate an agreement; or (3) designate a representativ…

(a) Required criteria. An out-of-network provider that is not a facility or a health benefit plan issuer or administrator may request mandatory binding arbitration of an out-of-network claim under § 21.5021 of this title (relating to Arbitration Request Procedure) if the claim co…

(a) Arbitration request and notice. (1) An out-of-network provider or a health benefit plan issuer or administrator may request arbitration. To be eligible for arbitration, the party requesting arbitration must complete the arbitration request information required on the departme…

A party subject to mandatory arbitration requested by an out-of-network provider or a health benefit plan issuer or administrator under this division must use best efforts to coordinate an informal settlement teleconference, as required by Insurance Code § 1467.084 (concerning Av…

Under Insurance Code § 1467.101 (concerning Bad Faith), conduct that constitutes bad faith arbitration includes failing to: (1) participate in the informal settlement teleconference under §1467.084(d) or an arbitration; (2) provide information that the arbitrator believes is nece…

(a) Written complaint. A party may submit a written complaint on the department's website regarding the settlement of an out-of-network health benefit claim that is subject to Insurance Code Chapter 1467. (b) Complaint information. The recommended information for filing a complai…

(a) An insurer or group hospital service corporation must provide notice of conversion privileges, if any, available to each employee, member, or dependent whose coverage is terminating, at least 30 days and no more than 60 days prior to actual termination of coverage. (b) An HMO…

A conversion policy or contract must provide for the addition of newborn children, adopted children, and children for whom a court or administrative order has mandated coverage. The policy or contract may provide that coverage terminates when the converted person's coverage termi…

(a) This subchapter applies to a payor that issues, sponsors, or administers a plan subject to reporting under subsection (b) of this section. (b) Payors must submit data files as required by this subchapter with respect to health benefit plans or dental benefit plans issued in T…

The following words and terms, when used in this subchapter, have the following meanings unless the context clearly indicates otherwise. (1) Allowed amount--Has the meaning assigned by Insurance Code § 38.402 , concerning Definitions. (2) Center--The Center for Health Care Data a…

(a) Payors must submit complete and accurate data files for all applicable plans as required by this subchapter and consistent with the data elements and technical requirements found in the Texas APCD CDL v3.0.1. The Texas APCD CDL v3.0.1 is available on the Center's website. (b)…

(a) Payors must submit the data files required by subsection (c) of this section to the Center according to the schedule provided in § 21.5405 of this title (relating to Timing and Frequency of Data Submissions). Payors are responsible for submitting or arranging to submit all ap…

(a) Payors must submit monthly data files according to the following schedule: (1) January data must be submitted no later than March 7 of that year; (2) February data must be submitted no later than April 7 of that year; (3) March data must be submitted no later than May 7 of th…

(a) The fee calculation is based on the authorized limits contained in wastewater permits and water rights as of September 1 each year, without regard to the actual amount or quality of effluent discharged or the actual amount of water used. (b) Assessment for wastewater permits.…

(a) Definitions. The following words and terms, when used in this chapter, shall have the following meanings, unless the context clearly indicates otherwise. (1) Aquaculture--The commercial propagation and/or rearing of aquatic species utilizing ponds, lakes, fabricated tanks and…

(a) It is the purpose of this chapter to implement the Water Quality Fee Program. (b) An annual fee will be assessed against wastewater permit holders authorized to treat or discharge wastewater into or adjacent to the waters in the state under Texas Water Code (TWC), Chapter 26,…

(a) Tex. Gov't Code, § 2306.187 requires that the Department develop and adopt rules relating to Minimum Energy Efficiency requirements for new construction, reconstruction, and rehabilitation activities in Single Family Programs. (b) This chapter describes the Minimum Energy Eff…

(a) Motions for clarification. This subsection only applies to motions for clarification of arbitration awards. Motions for clarification of an arbitration award may be made to the presiding officer requesting that an ambiguity be clarified or an error, other than an error of law…

(a) Consolidation of dockets. The commission or presiding officer may on its own motion or upon a motion from a party, to the extent practical, consolidate separate dispute resolution proceedings and the approval proceedings pursuant to this chapter. (b) Consolidation of issues. …

(a) Causes for imposition of sanctions. A presiding officer, on his or her own motion or on the motion of a party, after notice and an opportunity for a hearing, may impose appropriate sanctions against a party or its representative for: (1) filing a motion or pleading that was b…

(a) Standards of conduct for parties. (1) Every person appearing in any proceeding shall comport himself or herself with dignity, courtesy, and respect for the commission, presiding officer, and all other persons participating in the proceeding. Professional representatives shall…

(a) Motion for summary decision. The presiding officer may grant a motion for summary decision on any or all issues to the extent that the pleadings, affidavits, materials obtained by discovery or otherwise, admissions, matters officially noticed, or evidence of record show that …

(a) Motions for dismissal. (1) Upon the motion of the presiding officer or the motion of any party, the presiding officer may dismiss, with or without prejudice, any proceeding, or claim within a proceeding, without an evidentiary hearing, for any of the following reasons: (A) la…

(a) Construction of pleadings and documents. All documents shall be construed so as to do substantial justice. (b) Procedural sufficiency of pleadings and documents. All pleadings and documents that do not comply in all material respects with other sections of this chapter shall …

Unless otherwise noted, this chapter only applies to single family Programs. Program rules may impose additional requirements related to any provision of this chapter. Elements of local residential building codes that require a greater degree of energy efficiency than this chapte…

(a) General. If any party believes that any material it files with the commission or provides to the presiding officer during any proceeding under this chapter should be exempt from disclosure under the Texas Public Information Act (TPIA), it may designate such material as confid…