Title IN, Insurance Code

Sec. 1205.004. CREDITABLE COVERAGE. (a) An individual's coverage is creditable coverage for purposes of this chapter if the coverage is provided under: (1) a self-funded or self-insured employee welfare benefit plan that: (A) provides health benefits; and (B) is established in ac…

Sec. 1206.001. APPLICABILITY OF CHAPTER. This chapter applies only to a health benefit plan, including a small employer health benefit plan written under Chapter 1501, that provides benefits for medical or surgical expenses incurred as a result of a health condition, accident, or…

Sec. 1206.002. EXCEPTION. This chapter does not apply to: (1) a plan that provides coverage: (A) only for a specified disease or for another limited benefit; (B) only for accidental death or dismemberment; (C) for wages or payments in lieu of wages for a period during which an em…

Sec. 1206.003. DENIAL OF ENROLLMENT PROHIBITED. A health benefit plan issuer may not refuse to enroll an individual in the plan solely because the individual is enrolled in another health benefit plan at the time the individual applies for coverage under the plan. Added by Acts 2…

Sec. 1206.004. VIOLATION OF CHAPTER: UNFAIR DISCRIMINATION. A health benefit plan issuer who violates this chapter engages in unfair discrimination under Subchapter B, Chapter 544. Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.

Sec. 1207.001. APPLICABILITY OF CHAPTER. This chapter applies only to a group health benefit plan, including a small employer health benefit plan written under Chapter 1501, a plan provided under Chapter 1551, 1575, or 1601, or a successor to a plan provided under one of those ch…

Sec. 1207.002. ENROLLMENT REQUIRED. (a) A group health benefit plan issuer shall permit an individual who is otherwise eligible for enrollment in the plan to enroll in the plan, without regard to any enrollment period restriction, on receipt of written notice from the Health and …

Sec. 1207.003. EFFECTIVE DATE OF ENROLLMENT. (a) Unless enrollment occurs during an established enrollment period, enrollment in a group health benefit plan under Section 1207.002 takes effect on: (1) the eligibility enrollment date specified in the written notice from the Health…

Sec. 1207.004. TERMINATION OF ENROLLMENT. (a) Notwithstanding any other requirement of a group health benefit plan, the plan issuer shall permit an individual who is enrolled in the plan under Section 1207.002(a)(1), and any family member of the individual enrolled under Section …

Sec. 1208.001. APPLICABILITY OF CHAPTER. This chapter applies only to a health benefit plan that provides benefits for medical or surgical expenses incurred as a result of a health condition, accident, or sickness, including an individual, group, blanket, or franchise insurance p…

Sec. 1208.002. DISCLOSURE REQUIRED. After an oral or written request by an insured or enrollee of a health benefit plan, the plan issuer shall provide to the insured or enrollee the name or employee identifier of the issuer's employee who is available to respond to questions or o…

Sec. 1210.001. NOTICE REQUIRED. A policy, contract, or certificate of insurance that insures against loss resulting from sickness or accidental bodily injury and that is subject to an increase in the premium at time of renewal or to nonrenewal on the insured attaining a certain a…

Sec. 1211.001. WAIVER OF CERTAIN PROVISIONS FOR CERTAIN FEDERAL PLANS. If the commissioner of insurance, in consultation with the commissioner of health and human services, determines that a provision of Section 843.209 or 843.321, Subchapter J, Chapter 843, Chapter 1213, Subchap…

Sec. 1213.001. DEFINITION OF HEALTH BENEFIT PLAN. (a) In this chapter, "health benefit plan" means a plan that provides benefits for medical, surgical, or other treatment expenses incurred as a result of a health condition, a mental health condition, an accident, sickness, or sub…

Sec. 1213.002. ELECTRONIC SUBMISSION OF CLAIMS. (a) The issuer of a health benefit plan by contract may require that a health care professional licensed or registered under the Occupations Code or a health care facility licensed under the Health and Safety Code electronically sub…

Sec. 1213.003. ELECTRONIC SUBMISSION OF CLAIMS: WAIVER. (a) A contract between the issuer of a health benefit plan and a health care professional or health care facility must provide for a waiver of any requirement for electronic submission established under this chapter. (b) The…

Sec. 1213.004. MODE OF TRANSMISSION. The issuer of a health benefit plan may not by contract limit the mode of electronic transmission that a health care professional or health care facility may use to submit information under this chapter. Added by Acts 2005, 79th Leg., Ch. 728 …

Sec. 1213.005. CERTAIN CHARGES PROHIBITED. A health benefit plan may not directly or indirectly charge or hold a health care professional, health care facility, or person enrolled in a health benefit plan responsible for a fee for the adjudication of a claim. Added by Acts 2005, …

Sec. 1213.006. RULES. The commissioner may adopt rules as necessary to implement this chapter. The commissioner may not require any data element for electronically filed claims that is not required to comply with federal law. Added by Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Se…

Sec. 1214.001. APPLICABILITY OF CHAPTER. This chapter applies only to a health benefit plan that provides benefits for medical or surgical expenses incurred as a result of a health condition, accident, or sickness, including an individual, group, blanket, or franchise insurance p…

Sec. 1214.002. EXCEPTION. This chapter does not apply to: (1) a health benefit plan that provides coverage: (A) only for a specified disease; (B) only for accidental death or dismemberment; or (C) for wages or payments in lieu of wages for a period during which an employee is abs…

Sec. 1214.003. RATE INFORMATION DISCLAIMERS. (a) Subject to Chapter 541 and Section 543.001, an advertisement for a health benefit plan may include rate information without including information about each benefit exclusion or limitation if the advertisement includes prominent di…

Sec. 1215.001. DEFINITIONS. (a) Except as provided by Subsection (b), in this chapter: (1) "Employer" has the meaning assigned by 29 U.S.C. Section 1002(5). (2) "Governmental entity" means a state agency or political subdivision of this state. (3) "Group health plan" has the mean…

Sec. 1215.002. APPLICABILITY OF CHAPTER TO GOVERNMENTAL ENTITY; APPLICABILITY OF OTHER LAW WITH REFERENCE TO GOVERNMENTAL ENTITY. (a) This chapter applies to a governmental entity that enters into a contract with a health insurance issuer that results in the health insurance issu…

Sec. 1215.003. RECEIPT OF AND RESPONSE TO REQUEST FOR CLAIM INFORMATION. (a) Not later than the 30th day after the date a health insurance issuer receives a written request for a written report of claim information from a plan, plan sponsor, or plan administrator, the health insu…

Sec. 1215.004. REQUEST FOR ADDITIONAL INFORMATION. (a) On receipt of the report required by Section 1215.003(a), the plan, plan sponsor, or plan administrator may review the report and, not later than the 10th day after the date the report is received, may make a written request …

Sec. 1215.005. COMPLIANCE WITH CHAPTER DOES NOT CREATE LIABILITY. A health insurance issuer that releases information, including protected health information, in accordance with this chapter has not violated a standard of care and is not liable for civil damages resulting from, a…

Sec. 1215.006. ADMINISTRATIVE PENALTIES. A health insurance issuer that does not comply with this chapter is subject to administrative penalties under Chapter 84. Added by Acts 2007, 80th Leg., R.S., Ch. 700 (H.B. 2015), Sec. 1, eff. September 1, 2007.

Sec. 1216.001. DEFINITIONS. In this chapter: (1) "Enrollee" means an individual entitled to coverage under a health benefit plan. (2) "Foreign country" means a governmental unit other than: (A) the United States; (B) a state, district, commonwealth, territory, or insular possessi…

Sec. 1216.002. APPLICABILITY OF CHAPTER. (a) This chapter applies only to a health benefit plan that provides benefits for health care services, including medical or surgical expenses, incurred as a result of a health condition, accident, or sickness, including: (1) an individual…

Sec. 1216.003. EXCEPTION. This chapter does not apply to: (1) a plan that provides coverage: (A) only for a specified disease; (B) only for accidental death or dismemberment; (C) for wages or payments in lieu of wages for a period during which an employee is absent from work beca…

Sec. 1216.004. OUT-OF-COUNTRY CARE PROHIBITED. A health benefit plan issuer may not issue or offer for sale in this state a health benefit plan that requires an enrollee to travel to a foreign country to receive a particular health care service under the health benefit plan. Adde…

Sec. 1217.001. DEFINITIONS. In this chapter: (1) "Health benefit plan issuer" means an entity authorized under this code or another insurance law of this state that delivers or issues for delivery a health benefit plan or other coverage that is covered under this chapter as descr…

Sec. 1217.002. APPLICABILITY OF CHAPTER. (a) This chapter applies only to a health benefit plan that provides benefits for medical or surgical expenses incurred as a result of a health condition, accident, or sickness, including an individual, group, blanket, or franchise insuran…

Sec. 1217.003. EXCEPTION. This chapter does not apply to: (1) a health benefit plan that provides coverage: (A) only for a specified disease or for another single benefit; (B) only for accidental death or dismemberment; (C) only for wages or payments in lieu of wages for a period…

Sec. 1217.004. STANDARD FORM. (a) The commissioner by rule shall: (1) prescribe a single, standard form for requesting prior authorization of health care services; (2) require a health benefit plan issuer or the agent of the health benefit plan issuer that manages or administers …

Sec. 1217.005. ADVISORY COMMITTEE ON UNIFORM PRIOR AUTHORIZATION FORMS. (a) The commissioner shall appoint a committee to advise the commissioner on the technical, operational, and practical aspects of developing the single, standard prior authorization form required under Sectio…

Sec. 1217.006. FAILURE TO PRESCRIBE STANDARD FORM. Nothing in this chapter may be construed as authorizing the commissioner to decline to prescribe the form required by Section 1217.004. Added by Acts 2013, 83rd Leg., R.S., Ch. 1198 (S.B. 1216), Sec. 1, eff. September 1, 2013.

Sec. 1217.007. CONSTRUCTION WITH OTHER LAW. Nothing in this chapter may be construed as permitting a health benefit plan issuer or an agent of a health benefit plan issuer to require prior authorization of health care services benefits when otherwise prohibited by law. Added by A…

Sec. 1218.001. DEFINITION. In this chapter, "elective abortion" means an abortion, as defined by Section 245.002, Health and Safety Code, other than an abortion performed due to a medical emergency as defined by Section 171.002, Health and Safety Code. Added by Acts 2017, 85th Le…

Sec. 1218.002. APPLICABILITY OF CHAPTER. (a) This chapter applies only to a health benefit plan that provides benefits for medical or surgical expenses incurred as a result of a health condition, accident, or sickness, including an individual, group, blanket, or franchise insuran…

Sec. 1218.003. CERTAIN COVERAGE NOT AFFECTED. This chapter does not apply to health benefit plan coverage provided to an enrollee for any abortion other than an elective abortion as defined by Section 1218.001. Added by Acts 2017, 85th Leg., 1st C.S., Ch. 5 (H.B. 214), Sec. 2, ef…

Sec. 1218.004. COVERAGE BY HEALTH BENEFIT PLAN. A health benefit plan may provide coverage for elective abortion only if: (1) the coverage is provided to an enrollee separately from other health benefit plan coverage offered by the health benefit plan issuer; (2) the enrollee pay…

Sec. 1218.005. CALCULATION OF PREMIUM. (a) A health benefit plan issuer that provides coverage for elective abortion shall calculate the premium for the coverage so that the premium fully covers the estimated cost of elective abortion per enrollee, determined on an actuarial basi…

Sec. 1218.006. NOTICE BY ISSUER. A health benefit plan issuer that provides coverage for elective abortion shall at the time of enrollment in other health benefit plan coverage provide each enrollee with a notice that: (1) coverage for elective abortion is optional and separate f…

Sec. 1221.001. RULES; EMPLOYER CONTRIBUTIONS. The commissioner by rule, unless it would violate state or federal law, may develop procedures to allow an employer to make financial contributions to or premium payments for an employee or retiree's individual consumer directed healt…