Texas Administrative Code

This subchapter is issued based upon the authority granted the Commissioner under Insurance Code § 543.001 ; Chapter 541, Subchapter J; and §36.001. Notes 28 Tex. Admin. Code § 21.2202 The provisions of this §21.2202 adopted to be effective September 29, 1998, 23 TexReg 9753; Ame…

Restrictions on coverage limitations. If a provision of the Insurance Code or Texas Department of Insurance regulations allows a health benefit plan issuer to place quantitative or nonquantitative treatment limitations on coverage for mental health and substance use disorder cond…

(a) Global substitution of terms. This subchapter substitutes the following terms for terms used in 45 CFR § 146.136 (concerning Parity in Mental Health and Substance Use Disorder Benefits) with no change in meaning: (1) the term "enrollees" is substituted for the term "participa…

(a) The department may require the issuer to: (1) submit a corrective action plan to correct deficiencies in the issuer's submissions and analyses under Divisions 2 and 3 of this subchapter. The corrective action plan will specify the actions the issuer will take to comply with t…

Definitions. For purposes of this subchapter, the following terms have the meanings indicated, except where the context clearly indicates otherwise: (1) Administrative denial--A denial of a claim that is not an adverse determination, including, but not limited to, denials of clai…

This section details application of the parity requirements under this subchapter with respect to aggregate lifetime and annual dollar limits that may be permitted by state or federal law. (1) General parity requirement. A health benefit plan that provides both medical/surgical b…

(a) Clarification of terms. (1) Classification of benefits. When reference is made in this subchapter to a classification of benefits, the term "classification" means a classification as described in subsection (b)(2) of this section. (2) Type of financial requirement or treatmen…

(a) General requirement. A health benefit plan may not impose a nonquantitative treatment limitation with respect to mental health or substance use disorder benefits in any classification unless, under the terms of the plan as written and in operation, any processes, strategies, …

Within the "MH/SUD Parity Rule Division 2 Data Collection Reporting Form" template, in the worksheet titled "Claims and Utilization Review," for medical/surgical, MH/SUD, and for each of the classifications listed in § 21.2425 (c) of this title (relating to Claims and Utilization…

(a) Reporting worksheet. An issuer must report the data required by this section within the "MH/SUD Parity Rule Division 2 Data Collection Reporting Form" template in the worksheet titled "Reimbursement Rates." (b) Categories of providers and billing codes. An issuer must report …

(a) QTL and NQTL templates. (1) For purposes of this division, "QTL template" is the template titled "Compliance Analysis for Quantitative Parity" and its associated technical instructions, available on TDI's website. (2) For purposes of this division, "NQTL template" is the temp…

(a) Deadline for quantitative parity analyses. An issuer must complete the parity analyses of its quantitative treatment limitations (QTLs) required by this division for each existing plan not later than the 180th day after the effective date of this subchapter. (b) Phase-in for …

(a) Template and instructions. Except as provided in § 21.2431 of this title (relating to Required Analyses for Quantitative and Nonquantitative Parity; Alternative Tools), an issuer must use the QTL template and associated technical instructions to: (1) provide the information r…

The following words or phrases, as used in these sections, shall have the meanings placed opposite them unless the explicit wording of a section or part of a section shall otherwise direct. (1) Complainant--A person making or having made a complaint. (2) Complaint--Any written co…

An insurer must maintain a complete record of all complaints which it has received during the preceding three years or since the date of its most recent financial examination by the commissioner of insurance, whichever time period is shorter, in substantial compliance with the pr…

(a) Complaint record: general information. The complaint record provided for in this subchapter shall be maintained by all insurers. The complaint record is based on the Model Regulation for Complaint Records to be Maintained adopted by the National Association of Insurance Commi…

(a) Recommended maintenance form. The recommended form for complaint record maintenance is available on TDI's website at www.tdi.texas.gov/forms . (b) Texas Department of Insurance Complaint Record Form. Attached Graphic Notes 28 Tex. Admin. Code § 21.2505 The provisions of this …

The complaint record shall be maintained on a calendar-year basis. All information items required to be maintained, including the number of complaints by line of insurance, function, reasons, disposition, complaint origin, and dates received and closed, shall be compiled not less…

Provisions of this subchapter addressing complaint record maintenance and presentation apply to all complaints of an insurer received on or after January 1, 1999. Notes 28 Tex. Admin. Code § 21.2507 The provisions of this §21.2507 adopted to be effective December 7, 1998, 23 TexR…

The following words and terms, when used in this subchapter, have the following meanings, unless the context clearly indicates otherwise. (1) Basic benefit--Health care service or coverage, which is included in the evidence of coverage, policy, or certificate, without additional …

(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…

Unless otherwise provided in this subchapter, contracts between MCCs and preferred providers may not include terms that: (1) extend the statutory or regulatory time frames; or (2) waive the preferred provider's right to recover reasonable attorney's fees and court costs under Ins…

(a) An MCC may recover a refund due to overpayment or completion of an audit if: (1) the MCC notifies the physician or the provider of the overpayment not later than the 180th day after the date of receipt of the overpayment; or (2) the MCC notifies the physician or the provider …

(a) An MCC, a physician, or a provider must notify the Texas Department of Insurance (TDI) if, due to a catastrophic event, it is unable to meet the deadlines in § 21.2804 of this title (relating to Requests for Additional Information from Treating Preferred Provider), § 21.2806 …

(a) An identification card, or other similar document that includes information necessary to allow enrollees and insureds to access services or coverage under an HMO evidence of coverage, a preferred provider benefit plan, or an exclusive provider benefit plan that is issued by a…

(a) An MCC that fails to comply with § 21.2807 of this title (relating to Effect of Filing a Clean Claim) for more than 2 percent of clean claims submitted to the MCC is subject to an administrative penalty under Insurance Code § 843.342(k) or § 1301.137(k) , as applicable. (b) T…

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…

(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…