Texas Administrative Code

(a) An insurer shall not cancel or refuse to renew coverage of a child entitled to enrollment or enrolled under this subchapter unless satisfactory written evidence is filed with the insurer by the parent or the employer demonstrating that: (1) the court order or administrative o…

(a) With respect to a child who lives outside the insurer's service area but inside the United States whose coverage under the policy is required by a medical support order, an insurer must either: (1) cover the child under coverage for which the parent who has been ordered to pr…

(a) A violation of § 21.2002 of this title (relating to Prohibition Against Denial of Enrollment), § 21.2003 of this title (relating to Requirements Concerning Adopted Children or Children Placed for Adoption), § 21.2004 of this title (relating to Enrollment of Child Who Is the S…

The following words or phrases, as used in these regulations, shall have the meanings placed opposite them unless the explicit wording of a regulation shall otherwise direct. (1) Business day--A day other than a Saturday, Sunday, or holiday recognized by this state. (2) Claim--A …

No insurer may engage in unfair claim settlement practices. Unfair claim settlement practices means committing or performing any of the following: (1) misrepresenting to claimants pertinent facts or policy provisions relating to coverages at issue; (2) failing to acknowledge with…

If the department finds based on complaint or complaints of unfair claim settlement practices as described in § 21.203 of this title (relating to Unfair Claim Settlement Practices), that an insurer should be subjected to closer supervision with respect to such practices, it may r…

All insurers must maintain their affairs so that no unfair claims settlement practices are committed and the minimum standard of performance for all insurers (as that term is used in Insurance Code Chapter 542, Subchapter A) is to comply with the provisions of § 21.203 of this ti…

The purpose of this subchapter is: (1) to require notice to enrollees in a health benefit plan of coverage or benefits for: (A) prostate cancer examinations; (B) minimum inpatient stays for maternity and childbirth; (C) minimum inpatient stays for mastectomy or lymph node dissect…

Any violation of this subchapter constitutes a misrepresentation of the terms of an issued and unissued policy in violation of Insurance Code Chapter 541, Subchapter B, and to be a misrepresentation of the terms, benefits, and advantages of a policy within the meaning of Insuranc…

(a) Separability. If any provision of this subchapter or its application to any person or circumstance is for any reason held to be invalid by any court of law, the remainder of the subchapter and its application to other persons or circumstances shall not be affected. (b) Confli…

This subchapter shall apply to all policies sold on or after July 1, 2000. Notes 28 Tex. Admin. Code § 21.2214 The provisions of this §21.2214 adopted to be effective September 29, 1998, 23 TexReg 9753.

This subchapter provides rules to interpret, implement, and enforce Insurance Code Chapter 1355, Subchapter F, concerning Coverage for Mental Health Conditions and Substance Use Disorders. Except as identified in § 21.2404 of this title (relating to Differences from Federal Rules…

(a) Plans subject to this subchapter. This subchapter applies to all health benefit plans subject to Insurance Code Chapter 1355, Subchapter F, concerning Coverage for Mental Health Conditions and Substance Use Disorders. Health benefit plans subject to Insurance Code Chapter 135…

Annual reporting. The information and data an issuer must report as required by Division 2 of this subchapter are due annually. (1) Each reporting period is a calendar year. (2) The first reporting date for this subchapter is December 1, 2021, for data from January 1, 2020, throu…

(a) Requirement to collect and report data. An issuer must collect and report the data required by this division for each applicable health benefit plan using the data collection template titled "MH/SUD Parity Rule Division 2 Data Collection Reporting Form," consisting of multipl…

(a) Identifying issuer information. For each data collection template an issuer provides to TDI under § 21.2423 of this title (relating to Collecting and Reporting Data), within the "MH/SUD Parity Rule Division 2 Data Collection Reporting Form" template, in the worksheet titled "…

(a) Separate reporting. Within the "MH/SUD Parity Rule Division 2 Data Collection Reporting Form" template, in the worksheet titled "Claims and Utilization Review," an issuer must separately report claims and requests for utilization review for medical/surgical and MH/SUD. (b) IC…

(a) NQTLs in general. NQTLs generally are treatment limitations on the scope or duration of benefits for treatment. An issuer is prohibited from imposing NQTLs on MH/SUD benefits in any classification unless, under the terms of the plan or coverage as written and in operation, an…

(a) Identifying issuer information. Within the NQTL template, in the worksheet titled "Issuer and Plan Information," an issuer must provide the: (1) issuer name; (2) NAIC number, or if none, issuer license number; (3) date the analysis was completed (completion date); (4) version…

(a) Four-step analysis. An issuer must complete the four-step analysis detailed in this section for each NQTL contained in the plan documents for each plan. An issuer must report its NQTL analyses separately for each applicable classification or subclassification, using the class…

Applicability. This division applies only to health benefit plans that provide coverage for autism spectrum disorder as required by Insurance Code Chapter 1355, Subchapter A, concerning Group Health Benefit Plan Coverage for Certain Serious Mental Illnesses and Other Disorders. N…

(a) Applicability. This section applies only to a health benefit plan that is subject to both: (1) Insurance Code Chapter 1355, Subchapter A, concerning Group Health Benefit Plan Coverage for Certain Serious Mental Illnesses and Other Disorders; and (2) Insurance Code Chapter 135…

This subchapter applies to all insurers as defined in § 21.2502 of this title (relating to Definitions). The purpose of this subchapter is to prescribe the minimum information required to be maintained in the complaint record of an insurer, to provide a recommended format for the…

(a) A health benefit plan must provide diabetes self-management training or coverage for diabetes self-management training for which a physician or practitioner has written an order, including a written order of a practitioner practicing under protocols jointly developed with a p…

Unless otherwise specified, this subchapter applies to all health carriers that issue health benefit plans to associations or bona fide associations. This subchapter does not apply to coverage issued to employer associations. Notes 28 Tex. Admin. Code § 21.2701 The provisions of …

The following words and terms when used in this subchapter have the following meanings, unless the context clearly indicates otherwise. (1) Association--An association (other than an employer association), including but not limited to a labor union or organizations of such unions…

A health benefit plan issued to an association or a bona fide association is considered a group product, and shall comply with the statutes and regulations applicable to coverages and benefits relating to group products. Notwithstanding any other provisions of this subchapter to …

(a) Except as provided by subsection (d) of this section, a health carrier shall renew a health benefit plan issued to an association, or a bona fide association, at the option of the association or bona fide association, unless: (1) the association or bona fide association has f…

Each health carrier that issues a health benefit plan to members of an association or bona fide association shall provide a certification of coverage in accordance with §§ 21.1103 - 21.1107 of this title (relating to Notification of Creditable Coverage). Notes 28 Tex. Admin. Code…

After a change of claims payment address or a change in delegation of claims payment functions, an MCC may not premise the denial of a clean claim on a preferred provider's failure to file a claim within the claim filing deadline set out in § 21.2806 of this title (relating to Cl…

Any contract or delegation agreement between an MCC and an entity that processes or pays claims, obtains the services of physicians and providers to provide health care services, or issues verifications or preauthorizations may not limit the MCC's authority or responsibility to c…

If a prescription benefit does not require authorization by an MCC, the statutory claims payment period must begin on the date of affirmative adjudication of the claim for a prescription benefit. Notes 28 Tex. Admin. Code § 21.2814 The provisions of this §21.2814 adopted to be ef…

(a) An MCC that determines under § 21.2807 of this title (relating to Effect of Filing a Clean Claim) that a claim is payable must pay the contracted rate owed on the claim; and: (1) if the claim is paid on or before the 45th day after the end of the applicable statutory claims p…

(a) A written communication, including a claim, referenced under this subchapter is subject to and must comply with this section unless otherwise stated in this subchapter. (b) An entity subject to these rules may deliver written communications as follows: (1) submit the communic…

The following words and terms, when used in this subchapter have the following meanings, unless the context clearly indicates otherwise. (1) Corresponding benefits--Benefits provided under the indemnity portion of a point-of-service (POS) plan, as defined in Insurance Code § 1273…

(a) Written agreement between the HMO and the indemnity carrier. A POS plan offered under this subchapter must be evidenced by a written agreement between the HMO and indemnity carrier that must be filed with the department as a plan document and must provide the following: (1) t…

(a) Misrepresentation of insurance policies, unfair competition, and unfair practices by insurers, agents, and other connected persons are prohibited by Insurance Code Chapter 541 and Insurance Code § 543.001 or by other provisions of the Insurance Code and this chapter. No perso…

(a) Applicability. This subchapter implements the provisions of Insurance Code Chapter 1369 as follows: (1) Division 2 of this subchapter applies to a health benefit plan that is subject to Insurance Code Chapter 1369, Subchapter D, and relates to pharmacy identification cards. (…

The following words and terms, when used in this division, have the following meanings, unless the context clearly indicates otherwise: (1) Administrator--As defined in Insurance Code § 4151.001(1) , for plans subject to Insurance Code Chapter 1369, Subchapter D. (2) Drug--As def…

(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 an administrator or pharmacy benefit manager, is not required to issue a standard identification card in addition to an enrollee identification card if: (1) the enrollee identification card contains the information required by § 21.3003 …

(a) Definitions. The following words and terms when used in this section have the following meanings unless the context clearly indicates otherwise. (1) Agreed upon standards of performance--A set of standards of performance for each statistical agent which is negotiated and agre…

The following words and terms, when used in this division have the following meanings, unless the context clearly indicates otherwise: (1) Chronic illness--A disease, syndrome, or condition of expected long duration, showing little change or slow progression. (2) Contraindication…

(a) An issuer of a health benefit plan that provides coverage for drugs must provide coverage for any drug prescribed to treat an enrollee for a covered chronic, disabling, or life-threatening illness if the drug: (1) has been approved by the Food and Drug Administration for at l…

The following words and terms when used in this division have the following meanings, unless the context clearly indicates otherwise: (1) Adverse determination--As defined in Insurance Code § 4201.002 . (2) Allowed amount--The amount that the applicable health benefit plan issuer…

(a) An issuer of a health benefit plan that offers prescription drug benefits must make a prescription drug that was approved or covered for a medical condition or mental illness available to each enrollee at the contracted benefit level until the health benefit plan renewal date…

If the issuer of a health benefit plan, its delegated entity, or their employees or agents refuses to provide coverage for a prescription drug that is not included in a drug formulary, and the enrollee's physician or other health care provider with prescriptive authority has dete…