Title IN, Insurance Code

Sec. 1451.120. SELECTION OF PHYSICAL THERAPIST. An insured may select a physical therapist to provide the services scheduled in the health insurance policy that are within the scope of the therapist's license. Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.

Sec. 1451.121. SELECTION OF PHYSICIAN ASSISTANT. An insured may select a physician assistant to provide the services scheduled in the health insurance policy that are within the scope of the assistant's license. Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.

Sec. 1451.122. SELECTION OF PODIATRIST. An insured may select a podiatrist to provide the medical or surgical services or procedures scheduled in the health insurance policy that are within the scope of the podiatrist's license. Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, ef…

Sec. 1451.123. SELECTION OF PSYCHOLOGICAL ASSOCIATE. An insured may select a psychological associate to provide the services scheduled in the health insurance policy that are within the scope of the associate's license. Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April …

Sec. 1451.124. SELECTION OF PSYCHOLOGIST. An insured may select a psychologist to provide the services or procedures scheduled in the health insurance policy that are within the scope of the psychologist's license. Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 20…

Sec. 1451.125. SELECTION OF SPEECH-LANGUAGE PATHOLOGIST. An insured may select a speech-language pathologist to evaluate speech or language, provide habilitative or rehabilitative services to restore speech or language loss, or correct a speech or language impairment if the servi…

Sec. 1451.126. REIMBURSEMENT FOR PHYSICAL MODALITIES AND PROCEDURES BY HEALTH INSURER, ADMINISTRATOR, HEALTH MAINTENANCE ORGANIZATION, OR PREFERRED PROVIDER BENEFIT PLAN ISSUER. (a) A health insurer or licensed third-party administrator may not deny reimbursement to a health care…

Sec. 1451.1261. REIMBURSEMENT FOR CERTAIN SERVICES AND PROCEDURES PERFORMED BY PHARMACISTS. (a) Notwithstanding any other law, in addition to applying to a policy, agreement, or contract described by Section 1451.102, this section applies to any other individual or group health b…

Sec. 1451.127. DUTY OF PERSON ARRANGING PROVIDER CONTRACTS FOR HEALTH INSURER OR HEALTH MAINTENANCE ORGANIZATION. (a) A person who arranges contracts with providers on behalf of a health maintenance organization or health insurer shall comply with laws related to the duties of th…

Sec. 1451.128. SELECTION OF PHARMACIST. An insured may select a pharmacist to provide the services scheduled in the health insurance policy that are within the scope of the pharmacist's license to practice pharmacy under Subtitle J, Title 3, Occupations Code. Added by Acts 2019, …

Sec. 1451.129. SELECTION OF PHYSICIAN GRADUATE. An insured may select a physician graduate to provide the services scheduled in the health insurance policy that are within the scope of the physician graduate's license under Subchapter E, Chapter 155, Occupations Code. Added by Ac…

Sec. 1451.151. DEFINITION. In this subchapter, "managed care plan" means a plan under which a health maintenance organization, preferred provider benefit plan issuer, vision benefit plan issuer, vision benefit plan administrator, or other organization provides or arranges for hea…

Sec. 1451.152. APPLICABILITY AND CONSTRUCTION OF SUBCHAPTER. (a) This subchapter applies only to a managed care plan that provides or arranges for benefits for vision or medical eye care services or procedures that are within the scope of an optometrist's or therapeutic optometri…

Sec. 1451.153. USE OF OPTOMETRIST OR THERAPEUTIC OPTOMETRIST. (a) A managed care plan may not: (1) discriminate against a health care practitioner because the practitioner is an optometrist or a therapeutic optometrist; (2) restrict or discourage a plan participant from obtaining…

Sec. 1451.154. PARTICIPATION OF THERAPEUTIC OPTOMETRIST. (a) In this section: (1) "Medical panel" means the health care practitioners who are listed as participating providers in a managed care plan or who a patient seeking diagnosis or treatment of a medical disease, disorder, o…

Sec. 1451.1545. PARTICIPATION IN VISION CARE PLAN; EFFECT ON OTHER PLANS. (a) In this section, "vision care plan" has the meaning assigned by Section 1451.157(a). (b) A vision care plan issuer must include on the issuer's Internet website a method for a licensed optometrist or th…

Sec. 1451.155. CONTRACTS WITH OPTOMETRISTS OR THERAPEUTIC OPTOMETRISTS. (a) In this section: (1) "Chargeback" means a dollar amount, fee, surcharge, or item of value that reduces, modifies, or offsets all or part of the patient responsibility, provider reimbursement, or fee sched…

Sec. 1451.156. CERTAIN CONDUCT PROHIBITED. (a) A managed care plan, as described by Section 1451.152(a), may not directly or indirectly: (1) control or attempt to control the professional judgment, manner of practice, or practice of an optometrist or therapeutic optometrist; (2) …

Sec. 1451.157. VISION PLAN CONDUCT. (a) In this section: (1) "Extrapolation" means a mathematical process or technique used by a vision care plan in the audit of an optometrist or therapeutic optometrist to estimate audit results or findings for a larger batch or group of claims …

Sec. 1451.158. ENFORCEMENT OF SUBCHAPTER. (a) A violation of this subchapter by a managed care plan is subject to an administrative penalty under Chapter 84. (b) The commissioner shall take all reasonable actions to ensure compliance with this subchapter, including issuing orders…

Sec. 1451.201. DEFINITIONS. In this subchapter: (1) "Dental care service" means a service provided to a person to prevent, alleviate, cure, or heal a human dental illness or injury. (2) "Employee benefit plan" means a plan, fund, or program established or maintained by an employe…

Sec. 1451.202. APPLICABILITY AND CONSTRUCTION OF SUBCHAPTER. (a) This subchapter applies only to an employee benefit plan or health insurance policy delivered, issued for delivery, renewed, or contracted for in this state to the extent that: (1) the employee benefit plan is estab…

Sec. 1451.203. CONFLICTING PROVISIONS. A provision of an employee benefit plan or health insurance policy that conflicts with this subchapter is void to the extent of the conflict. Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.

Sec. 1451.204. CERTAIN CONDUCT PERMITTED. (a) Notwithstanding any other provision of this subchapter, a dentist may contract directly with a patient to provide dental care services to the patient as authorized by law. (b) Notwithstanding any other provision of this subchapter, a …

Sec. 1451.205. DISCLOSURE OF BENEFIT TERMS. (a) An employee benefit plan or health insurance policy shall: (1) if applicable, disclose that the benefit for dental care services offered is limited to the least costly treatment; and (2) specify in dollars and cents the amount of th…

Sec. 1451.206. PAYMENT OR REIMBURSEMENT OF DENTIST. (a) The employee benefit plan or health insurance policy shall: (1) provide: (A) that payment or reimbursement for a noncontracting provider dentist shall be the same as payment or reimbursement for a contracting provider dentis…

Sec. 1451.2065. CONTRACTS WITH DENTISTS. (a) In this section: (1) "Covered service" means a dental care service for which reimbursement is available under a patient's employee benefit plan or health insurance policy, or for which reimbursement is available subject to a contractua…

Sec. 1451.207. PROHIBITED CONDUCT. (a) An employee benefit plan or health insurance policy may not: (1) interfere with or prevent an individual who is a party to or beneficiary of the plan or policy from selecting a dentist of the individual's choice to provide a dental care serv…

Sec. 1451.208. PRIOR AUTHORIZATION OF DENTAL CARE SERVICES. (a) For purposes of this section, "prior authorization" means a written and verifiable determination that one or more specific dental care services are covered under the patient's employee benefit plan or health insuranc…

Sec. 1451.209. REQUIREMENTS FOR THIRD PARTY ACCESS TO PROVIDER NETWORKS. (a) At the time a provider network contract is entered into or when material modifications are made to the contract relevant to granting a third party access to the contract, an employee benefit plan or heal…

Sec. 1451.251. DEFINITION. In this subchapter, "enrollee" means an individual enrolled in a health benefit plan. Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.

Sec. 1451.252. APPLICABILITY OF SUBCHAPTER. This subchapter applies only to a health benefit plan that requires an enrollee to obtain certain specialty health care services through a referral made by a primary care physician or other gatekeeper and that: (1) provides benefits for…

Sec. 1451.253. EXCEPTION. This subchapter 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 instead of wages for a period during which an employee is absent from work b…

Sec. 1451.254. RULES. The commissioner shall adopt rules necessary to implement this subchapter. Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.

Sec. 1451.255. RIGHT OF FEMALE ENROLLEE TO SELECT OBSTETRICIAN OR GYNECOLOGIST. (a) Except as provided by Subsection (b), a health benefit plan shall permit a female enrollee to select, in addition to a primary care physician, an obstetrician or gynecologist to provide the enroll…

Sec. 1451.256. DIRECT ACCESS TO SERVICES OF OBSTETRICIAN OR GYNECOLOGIST. (a) In this section, "health care services" includes: (1) one well-woman examination each year; (2) care related to pregnancy; (3) care for any active gynecological condition; and (4) diagnosis, treatment, …

Sec. 1451.257. AVAILABILITY OF PROVIDERS. To ensure access to services that are within the scope of the professional specialty practice of a properly credentialed obstetrician or gynecologist, a health benefit plan shall include in the classification of persons authorized to prov…

Sec. 1451.258. NOTICE OF AVAILABLE PROVIDERS. (a) A health benefit plan issuer shall provide to each person covered under the plan a timely written notice of the choices of the types of physician providers available for the direct access required under this subchapter. (b) The no…

Sec. 1451.259. LIMITS ON PHYSICIAN SANCTIONS. (a) A health benefit plan may not sanction or terminate a primary care physician because of female enrollees' access to participating obstetricians and gynecologists under this subchapter. (b) A health benefit plan may not impose a fi…

Sec. 1451.260. ADMINISTRATIVE PENALTY. An entity that operates a health benefit plan in violation of this subchapter is subject to an administrative penalty as provided by Chapter 84. Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005. SUBCHAPTER G. ACCESS TO DIE…

Sec. 1451.301. APPLICABILITY OF GENERAL PROVISIONS OF OTHER LAW. The provisions of Chapter 1201, including provisions relating to the applicability, purpose, and enforcement of that chapter, the construction of policies under that chapter, rulemaking under that chapter, and defin…

Sec. 1451.302. DIETITIAN SERVICES. An individual or group accident and health insurance policy delivered or issued for delivery in this state may not: (1) exclude or deny coverage for services performed by: (A) a dietitian; or (B) a provisionally licensed dietitian acting under t…

Sec. 1451.351. LOSS OF INCOME BENEFITS FOR DISABILITY TREATABLE BY PODIATRIST. (a) This section applies only to an insurance policy delivered, issued for delivery, or renewed in this state that provides benefits covering loss of income as a result of an acute temporary disability…

Sec. 1451.401. CONTRACT WITH OSTEOPATHIC HOSPITAL. A health maintenance organization or preferred provider benefit plan issuer that contracts with a hospital to provide services to covered individuals may not refuse to contract with an osteopathic hospital solely because the hosp…

Sec. 1451.402. SERVICES AT OSTEOPATHIC HOSPITAL. A health maintenance organization or preferred provider benefit plan issuer that provides benefits for inpatient or outpatient services provided by an allopathic hospital shall seek to provide benefits for similar services provided…

Sec. 1451.403. REQUEST FOR ACTION OF COMMISSIONER. An aggrieved party may request that the commissioner conduct an investigation, review, hearing, or other proceeding to determine compliance with this subchapter. Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005…