Texas Administrative Code

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 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…

(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) 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…

The commissioner shall cause to be brought such legal action as is authorized by the Code in the enforcement of these sections and cause to be enjoined misrepresentation and other unfair trade practices. Notes 28 Tex. Admin. Code § 21.5 The provisions of this §21.5 adopted to be …

Consistent with Insurance Code § 1661.002 , a health benefit plan issuer or administrator must assist an enrollee with evaluating the enrollee's financial responsibility for a health care or medical service or supply based on the information in the notice and disclosure statement…

(a) For purposes of this section a "balance bill" is a bill for an amount greater than an applicable copayment, coinsurance, and deductible under an enrollee's health benefit plan, as specified in Insurance Code §§ 1271.157(c) , 1271.158(c) , 1275.052(c) , 1275.053(c) , 1301.164(…

(a) The purpose of this subchapter is to interpret and implement Insurance Code §§ 1271.157 , 1271.158 , 1275.052 , 1275.053 , 1301.164 , 1301.165 , 1551.229 , 1551.230 , 1575.172 , 1575.173 , 1579.110 , and 1579.111 ; and Insurance Code Chapter 1467. (b) Section 21.4903 of this …

(a) A noninsurance benefit may consist in whole or in part of discount cards for health care programs, vision care programs, dental care programs, prescriptions, physical fitness programs or facilities, or other similar programs. (b) Noninsurance benefits which include, in whole …

(a) A noninsurance benefit provided or disclosed as part of a policy, contract or certificate as set out in the Insurance Code § 1701.061 may not contain any provision that is unfairly deceptive. (b) A noninsurance benefit provided or disclosed as part of a policy, contract or ce…

A policy, contract or certificate form filing that includes a noninsurance benefit shall also include the items set out in paragraphs (1) - (3) of this section: (1) A description of the noninsurance benefit must be provided. The description must be sufficiently specific to provid…

(a) Applicable health benefit plans must include the following information as a cover page to each report: (1) reporting period; (2) company or plan name; (3) NAIC number, issued to the company by the National Association of Insurance Commissioners; (4) TDI company number; (5) co…

(a) Not later than May 1 of each year, each plan and applicable health benefit plan issuer identified in § 21.4502 (a) and (b) of this title, or the plan or issuer's authorized agent must submit to TDI the data required under § 21.4507 of this title. (b) The data filed under this…

(a) Each applicable health benefit plan issuer and plan specified in § 21.4502 (a) and (b) of this title must annually collect the data specified under § 21.4507 of this title and prepare and file data as provided. (b) Data elements and health care services specified under § 21.4…

Issuers must report data collected under this subchapter according to the three-digit ZIP code in which the health care service was provided. Publication of health care reimbursement rate information derived from the data collected under this subchapter may be aggregated by TDI a…

The following words and terms when used in this subchapter have the following meanings unless the context clearly indicates otherwise: (1) Allowed amount--The amount that the applicable health benefit plan issuer allows as payment for a health care service or group of services, i…

(a) This subchapter applies to the issuer of an applicable health benefit plan as defined in § 21.4503 of this title and as provided by Insurance Code § 38.353(a) : (1) an insurance company; (2) a group hospital service corporation; (3) a fraternal benefit society; (4) a stipulat…

The purpose of this subchapter is to: (1) prescribe the data collection and submission requirements for the submission of data related to health care reimbursement rates by health benefit plan issuers; (2) specify the definitions necessary to implement Insurance Code Chapter 38, …

When rates differ by sex or marital status, the insurer may be required to justify that the differential equitably reflects the difference in the risk assumed. Rates shall be based on a reasonable classification system according to actual or expected loss and expense data where a…

The amount of benefits payable, or any term, condition, or type of coverage may not be restricted, modified, excluded, or reduced on the basis of the sex or marital status of the insured or prospective insured. However, nothing in these sections shall prohibit an insurer from tak…

(a) In-network negotiated rate file schema. For the "in-network-rates" file published under this subchapter, an issuer must include data elements consistent with the In-Network File Schema contained in Machine-Readable Files: Data Schemas (version 1.1), published on the departmen…

Availability of any policy may not be denied to an insured or prospective insured on the basis of sex or marital status of the insured or prospective insured. However, nothing contained in this section shall be construed to prohibit any insurance underwriter or insurance agent re…

The following words and terms, when used in this subchapter, have the following meanings unless the context clearly indicates otherwise. (1) Insurer--Includes, but is not be limited to, all life, health, and accident companies; capital stock companies; mutual assessment life insu…

These sections apply to all individual, group, and blanket policies and contracts, and individual certificates of insurance delivered or issued for delivery in this state on or after January 1, 1978. They apply to all group certificates issued pursuant to group policies when the …

(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…

(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) 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. …

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…

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) 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…

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…

The category of group to which the health carrier is issuing coverage determines which benefits are state-mandated health benefits for blanket indemnity insurance policies. Notes 28 Tex. Admin. Code § 21.3506 Adopted by Texas Register, Volume 42, Number 20, May 19, 2017, TexReg 2…

This subchapter applies only to an insurance policy, contract, or evidence of coverage delivered, issued for delivery, or renewed on or after the effective date of the subchapter. Notes 28 Tex. Admin. Code § 21.3505 The provisions of this §21.3505 adopted to be effective June 2, …

A holding that any provision of this subchapter or the application thereof to any person or circumstances is for any reason invalid may not affect the remainder of the subchapter and the application of its provisions to any persons under other circumstances. Notes 28 Tex. Admin. …

A health carrier may offer one or more consumer choice health benefit plans; however, if the health carrier is a small employer carrier, it must offer one or more consumer choice health benefit plans in accordance with this subchapter and other applicable law. Notes 28 Tex. Admin…

The following words and terms, when used in this subchapter, have the following meanings, unless the context clearly indicates otherwise: (1) Basic health care services--Health care services that the commissioner determines an enrolled population might reasonably need to maintain…

(a) Purpose and applicability. The purpose of this section is to identify the standardized credentialing application form required by Insurance Code § 1452.052 . Hospitals, health maintenance organizations, preferred provider benefit plans, and preferred provider organizations ar…

(a) Under Insurance Code § 1352.005 , health benefit plan issuers must provide to insureds and enrollees the notification specified in this subsection. A representation of this notification is as follows: Attached Graphic (b) The notice required by Insurance Code § 1352.005 and s…

(a) An advertisement in respect of the time within which claims are paid, the dollar amounts of claims paid, the number of claims paid, the number of persons insured under a particular policy or policies, or similar statistical information relating to an insurer or policy may not…

(a) An advertisement may not state or imply anything offering or tending to offer a good, service, or other guarantee or contractual right of pecuniary value outside of the express terms of the policy offered by the advertisement. (1) This subsection does not prohibit, in connect…

(a) An advertisement may not directly or indirectly unfairly disparage competitors, their policies, services, or business methods, and may not unfairly disparage or minimize competing methods of marketing insurance. (b) An advertisement may not contain statements that are untrue …

The following words and terms, when used in this subchapter, have the following meanings, unless the context clearly indicates otherwise. (1) Affiliation period--A period of time that under the terms of the coverage offered by an HMO, must expire before the coverage becomes effec…

Each issuer of a health benefit plan shall provide a certification of coverage in accordance with § 21.1103 of this title (relating to Timing of Issuance of Written Certificate of Creditable Coverage to an Individual) through § 21.1108 of this title (relating to Notification of C…

(a) Each issuer of a health benefit plan shall comply with the following: (1) For an individual who is a qualified beneficiary entitled to elect COBRA continuation coverage, a certificate of creditable coverage shall be provided at the time the individual would lose coverage unde…

(a) An advertisement may not directly or indirectly make an unfair or incomplete comparison of policies, benefits, dividends, or rates, or compare noncomparable policies. (b) An advertisement containing a comparison of policies of different insurers shall prominently state the fo…

(a) Form CCC relating to Insurance Code § 1205.002 and § 1357.056 for certification and disclosure of coverage under a health benefit plan is included in subsection (b) of this section in its entirety and has been filed with the Office of the Secretary of State. (b) Form CCC refe…

Failure to abide by §§21.101 - 21.122 of this division (relating to Insurance Advertising) is prohibited. An omission of information, false implication, or impression which is misleading or deceptive or has the tendency or capacity to be misleading or deceptive is prohibited. The…