Texas Administrative Code

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…

This division defines and states standards that assure truthful and adequate disclosure of the information considered material and relevant to insurance advertisements and solicitations or to advertisements that lead to solicitations. This division prohibits in such matters the o…

The following words and terms, when used in this subchapter, have the following meanings, unless the context clearly indicates otherwise: (1) COBRA--Title X of the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended (29 U.S.C. Part 6 ). (2) COBRA continuation cover…

(a) Applicability. (1) The provisions of this section apply to: (A) an insurer or a group hospital service corporation subject to Insurance Code Chapter 842 that issues policies providing hospital, surgical, or major medical expense insurance coverage or any combination of those …

(a) Each carrier to which this subchapter applies is responsible for the timely offer of state continuation coverage options and must provide the notice for that coverage described in subsections (b) - (e) of this section. If the carrier delegates the responsibility of providing …

The purpose of this subchapter is to: (1) address continuation requirements; and (2) establish minimum standards for conversion coverage. Notes 28 Tex. Admin. Code § 21.5301 Adopted by Texas Register, Volume 39, Number 46, November 14, 2014, TexReg 9040 , eff. 11/17/2014

For the purpose of this division: (1) "Advertisement" includes, but is not limited to: (A) printed and published material, audio visual material and electronic media, descriptive literature of an insurer or agent used in direct mail, newspapers, magazines, radio, telephone and te…

(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) 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 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)…

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) 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…

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) 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) An insurer or group hospital service corporation must offer to any employee, member, or dependent whose insurance under a group policy has been terminated for any reason (except involuntary termination for cause), including discontinuance of the group policy in its entirety o…

Each group accident and health policy, certificate, contract, and evidence of coverage required to provide state continuation coverage must contain provisions addressing the state continuation coverage options available to an employee, member, dependent, or enrollee. Notes 28 Tex…

(a) Under Insurance Code § 1251.254 and § 1271.303 , the premium for state continuation coverage elected under § 21.5310 of this title must be the same premium charged for active employees, members, dependents, or enrollees, including any amount contributed by the employer or gro…

Prior to receiving a scholarship originating from and administered by an institution of higher education or university system , a student must file a written statement indicating whether the person is related within the third degree by consanguinity or the second degree by affini…

A person commits a Class B misdemeanor offense if the person knowingly files a false statement under § 21.472 of this title (relating to Declaration of Eligibility). Notes 19 Tex. Admin. Code § 21.473 The provisions of this §21.473 (adopted as §22.406) to be effective November 27…

The Board is responsible for publishing and disseminating general information and program rules for the provisions described in this subchapter. Notes 19 Tex. Admin. Code § 21.474 The provisions of this §21.474 (adopted as §22.407) to be effective November 27, 2007, 32 TexReg 849…

(a) A participating provider may, prior to providing services to an enrollee, request an eligibility statement using a method designated by the health benefit plan issuer. (b) A request under subsection (a) of this section must include: (1) the enrollee's full name; (2) the enrol…

(a) A health benefit plan issuer shall maintain a system to enable it to provide eligibility statements to participating providers using the information provided under § 21.3804 (b) and (c) of this subchapter (relating to Requests for Eligibility Statements). On receipt of a requ…

This subchapter applies to a health benefit plan issuer that enters into or renews a contract with a participating provider on or after January 31, 2006. The provisions of Insurance Code § 1274.002 and this subchapter are not applicable to Medicaid and Children's Health Insurance…

(a) Beginning January 31, 2006, a health benefit plan issuer shall, in writing, communicate to each participating provider that enters into or renews a contract with the health benefit plan issuer, the method or methods by which the provider may request an eligibility statement. …

(a) The issuer of a health benefit plan that provides pharmacy benefits, or a pharmacy benefit manager or administrator issuing standard identification cards to enrollees must issue standard identification cards as follows: (1) For a subscriber who is an enrollee, and who has no …

(a) An issuer of a health benefit plan, or its delegated entity, that covers prescription drugs and uses one or more drug formularies must provide, in plain language, the disclosures required by Insurance Code § 1369.054 . The plain language disclosure must be in the coverage doc…

(a) Except as permitted under subsection (c) of this section, an issuer of an individual health benefit plan must display the formulary information required under § 21.3032 and § 21.3033 of this title (relating to Formulary Disclosure Requirements for Individual Health Benefit Pl…

(a) The formulary information required under this section must include each individual prescription drug covered under the plan that is dispensed in a network pharmacy or administered by a physician or health care provider and clearly differentiate between drugs covered under the…

(a) The formulary information required by § 21.3032 of this title (relating to Formulary Disclosure Requirements for Individual Health Benefit Plans) must include a summary titled "Summary of Formulary Benefits" that includes this statement: "The information in this document is d…

(a) Purpose. The purposes of this subchapter are to: (1) ensure that enrollees in health benefit plans receive coverage for certain services for acquired brain injury and to facilitate the recovery and progressive rehabilitation of survivors of acquired brain injuries to the exte…

The following words and terms, when used in this subchapter, have the following meanings, unless the context clearly indicates otherwise: (1) Acquired brain injury--A neurological insult to the brain that is not hereditary, congenital, or degenerative. The injury to the brain has…

(a) Required Coverage. Under Insurance Code Chapter 1352, a health benefit plan must include coverage for services specified in § 1352.003, including cognitive rehabilitation therapy, cognitive communication therapy, neurocognitive therapy and rehabilitation, neurobehavioral, neu…

(a) In this section, "preauthorization" has the meaning assigned by Insurance Code § 1352.004(a) , and includes benefit determinations for proposed medical or health care services. (b) Each issuer must develop written preauthorization and utilization review policies and procedure…

(a) Reporting data. A reporting entity must submit the data required by this section electronically by completing the Mandated Benefits and Mandated Offers Reporting Form found on TDI's website, www.tdi.texas.gov. A reporting entity must use medical billing codes to identify appl…

A reporting entity that fails to comply with this subchapter will be subject to the sanctions and penalties provided in Insurance Code Chapters 82 (concerning Sanctions), 83 (concerning Emergency Cease and Desist Orders), 84 (concerning Administrative Penalties), 601 (concerning …

If a court holds invalid any section or portion of a section of this subchapter or holds invalid its applicability to any person or circumstance, the remainder of the subchapter or the applicability of the provision to other persons or circumstances will not be affected. Notes 28…

This subchapter implements the provisions of the Texas Consumer Choice of Benefits Health Insurance Plan Act to achieve the legislative goal of providing individuals, employers, and other purchasers of health care coverage in this state the opportunity to choose health benefit pl…

If any provision of this subchapter or the application thereof to any person or circumstances is for any reason held invalid, the invalidity shall not affect the other provisions or any application of this subchapter that can be given effect without the invalid provisions or appl…

(a) The purpose of this section is to implement Insurance Code Chapter 1213. This section applies to a contract between an issuer of a health benefit plan and a health care professional or health care facility (hereinafter referred to as "physicians or providers"). (b) Consistent…

The following words and terms, when used in this subchapter, have the following meanings unless the context clearly indicates otherwise. (1) Enrollee--An individual who is eligible for coverage under a health benefit plan, including a covered dependent. (2) Health benefit plan--A…

(a) Scope and application. This section applies to any person required to be licensed as an agent pursuant to the provisions of the Insurance Code or other insurance law of this state. For purposes of this section, "person" means both natural persons and business association enti…

A proposed insured for life or health and accident insurance, or for coverage by a company licensed under Insurance Code Chapter 842, or with a licensed health maintenance organization may be required to be tested for the presence of the human immunodeficiency virus (HIV). Requir…

(a) General propositions. (1) No inquiry in an application for health or life insurance coverage, or in an investigation conducted by or on behalf of an insurer in connection with an application for such coverage, may be directed toward determining the proposed insured's sexual o…

For the purpose of § 21.702 of this title (relating to Unfairly Discriminatory Acts or Practices) and to effectuate the objectives of Insurance Code § 544.002 , the definitions specified in this section are applicable. The words "physical or mental impairment" include, but are no…

(a) The following are hereby identified as acts or practices in life and health insurance which constitute unfair discrimination between individuals of the same class: (1) refusing to insure, or refusing to continue to insure, or limiting the amount, extent, or kind of coverage a…

(a) Applicability. (1) This subchapter is applicable to an individual, group, blanket, or franchise insurance policy, insurance agreement, health maintenance organization evidence of coverage, group hospital services contract, or employee benefit plan that provides benefits for h…

(a) This section applies to a health benefit plan issuer or administrator that is subject to one of the following statutes: (1) Insurance Code § 1271.159 , concerning Non-Network Emergency Medical Services Provider; (2) Insurance Code § 1275.054 , concerning Out-of-Network Emerge…