Title IN, Insurance Code

Sec. 1454.109. APPEAL OF COMMISSIONER'S ORDER. (a) A person affected by an order of the commissioner regarding a violation of this chapter, including a person who intervenes under Section 1454.106, may file an appeal in district court. (b) The standard of review for an appeal fil…

Sec. 1455.001. DEFINITIONS. In this chapter: (1) "Dentist" means a person licensed to practice dentistry in this state under Subtitle D, Title 3, Occupations Code. (1-a) "Distant site" means the location where a health professional provides a telemedicine medical service, teleden…

Sec. 1455.002. APPLICABILITY OF CHAPTER. This chapter applies only to a health benefit plan that: (1) provides benefits for medical or surgical expenses incurred as a result of a health condition, accident, or sickness, including: (A) an individual, group, blanket, or franchise i…

Sec. 1455.003. 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. 1455.004. COVERAGE FOR TELEMEDICINE MEDICAL SERVICES, TELEDENTISTRY DENTAL SERVICES, AND TELEHEALTH SERVICES. (a) A health benefit plan: (1) must provide coverage for a covered health care service or procedure delivered by a preferred or contracted health professional to a c…

Sec. 1455.005. RULES. Subject to Section 111.004, Occupations Code, the commissioner may adopt rules necessary to implement this chapter. Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005. Amended by: Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 23.002(10), e…

Sec. 1455.006. TELEMEDICINE MEDICAL SERVICES, TELEDENTISTRY DENTAL SERVICES, AND TELEHEALTH SERVICES STATEMENT. (a) Each issuer of a health benefit plan shall adopt and display in a conspicuous manner on the health benefit plan issuer's Internet website the issuer's policies and …

Sec. 1456.001. DEFINITIONS. In this chapter: (1) "Balance billing" means the practice of charging an enrollee in a health benefit plan that uses a provider network to recover from the enrollee the balance of a non-network health care provider's fee for service received by the enr…

Sec. 1456.002. APPLICABILITY OF CHAPTER. (a) This chapter applies to any health benefit plan that: (1) 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 insur…

Sec. 1456.003. REQUIRED DISCLOSURE: HEALTH BENEFIT PLAN. (a) Each health benefit plan that provides health care through a provider network shall provide notice to its enrollees that: (1) a facility-based physician or other health care practitioner may not be included in the healt…

Sec. 1456.004. REQUIRED DISCLOSURE: FACILITY-BASED PHYSICIANS. (a) If a facility-based physician bills a patient who is covered by a health benefit plan described in Section 1456.002 that does not have a contract with the facility-based physician, the facility-based physician sha…

Sec. 1456.005. DISCIPLINARY ACTION AND ADMINISTRATIVE PENALTY. (a) The commissioner may take disciplinary action against a licensee that violates this chapter, in accordance with Chapter 84. (b) A violation of this chapter by a facility-based physician is grounds for disciplinary…

Sec. 1456.006. COMMISSIONER RULES; FORM OF DISCLOSURE. The commissioner by rule may prescribe specific requirements for the disclosure required under Section 1456.003. The form of the disclosure must be substantially as follows: NOTICE: "ALTHOUGH HEALTH CARE SERVICES MAY BE OR HA…

Sec. 1456.007. HEALTH BENEFIT PLAN ESTIMATE OF CHARGES. A health benefit plan that must comply with this chapter under Section 1456.002 shall, on the request of an enrollee, provide an estimate of payments that will be made for any health care service or supply and shall also spe…

Sec. 1457.001. DEFINITIONS. In this chapter: (1) "Enrollee" means an individual who is eligible to receive health care services through a health benefit plan. (2) "Physician" means an individual licensed to practice medicine in this state under the authority of Subtitle B, Title …

Sec. 1457.002. PROVISIONAL CREDENTIALING STATUS. (a) A health benefit plan shall have a process for provisional credentialing status in compliance with the requirements of the National Committee for Quality Assurance. (b) A health benefit plan may grant provisional credentialing …

Sec. 1458.001. GENERAL DEFINITIONS. In this chapter: (1) "Affiliate" means a person who, directly or indirectly through one or more intermediaries, controls, is controlled by, or is under common control with another person. (1-a) "Anti-steering clause" means a provision in a prov…

Sec. 1458.002. DEFINITION OF HEALTH BENEFIT PLAN. (a) In this chapter, "health benefit plan" means: (1) a hospital and medical expense incurred policy; (2) a nonprofit health care service plan contract; (3) a health maintenance organization subscriber contract; or (4) any other h…

Sec. 1458.003. EXEMPTIONS. This chapter does not apply: (1) under circumstances in which access to the provider network is granted to an entity that operates under the same brand licensee program as the contracting entity; or (2) to a contract between a contracting entity and a d…

Sec. 1458.004. RULEMAKING AUTHORITY. The commissioner may adopt rules to implement this chapter. Added by Acts 2013, 83rd Leg., R.S., Ch. 197 (S.B. 822), Sec. 1, eff. September 1, 2013. SUBCHAPTER B. REGISTRATION REQUIREMENTS

Sec. 1458.051. REGISTRATION REQUIRED. (a) Unless the person holds a certificate of authority issued by the department to engage in the business of insurance in this state or operates a health maintenance organization under Chapter 843, a person must register with the department n…

Sec. 1458.052. DISCLOSURE OF INFORMATION. (a) A person required to register under Section 1458.051 must disclose: (1) all names used by the contracting entity, including any name under which the contracting entity intends to engage or has engaged in business in this state; (2) th…

Sec. 1458.053. SUBMISSION OF INFORMATION. Information required under this subchapter must be submitted in a written or electronic format adopted by the commissioner by rule. Added by Acts 2013, 83rd Leg., R.S., Ch. 197 (S.B. 822), Sec. 1, eff. September 1, 2013.

Sec. 1458.054. FEES. The department may collect a reasonable fee set by the commissioner as necessary to administer the registration process. Fees collected under this chapter shall be deposited in the Texas Department of Insurance operating fund. Added by Acts 2013, 83rd Leg., R…

Sec. 1458.055. EXEMPTION FOR AFFILIATES. (a) The commissioner shall grant an exemption for affiliates of a contracting entity if the contracting entity holds a certificate of authority issued by the department to engage in the business of insurance in this state or is a health ma…

Sec. 1458.101. CONTRACT REQUIREMENTS. (a) In this section, the following are each considered a single separate line of business: (1) preferred provider benefit plans covering individuals and groups; (2) exclusive provider benefit plans covering individuals and groups; (3) health …

Sec. 1458.102. CONTRACT ACCESS. (a) A contracting entity may not provide a person access to health care services or contractual discounts under a provider network contract unless the provider network contract specifically states that the person must comply with all applicable ter…

Sec. 1458.103. ENFORCEMENT. The commissioner may impose a sanction under Chapter 82 or assess an administrative penalty under Chapter 84 on a contracting entity that violates this chapter or a rule adopted to implement this chapter. Added by Acts 2013, 83rd Leg., R.S., Ch. 197 (S…

Sec. 1460.001. DEFINITIONS. In this chapter: (1) "Health benefit plan issuer" means an entity authorized under this code or another insurance law of this state that provides health insurance or health benefits in this state, including: (A) an insurance company; (B) a group hospit…

Sec. 1460.002. EXEMPTION. This chapter does not apply to: (1) a Medicaid managed care program operated under Chapter 540 or 540A, Government Code, as applicable; (2) a Medicaid program operated under Chapter 32, Human Resources Code; (3) the child health plan program under Chapte…

Sec. 1460.003. PHYSICIAN RANKING REQUIREMENTS. (a) A health benefit plan issuer, including a subsidiary or affiliate, may not rank physicians or classify physicians into tiers based on performance unless: (1) the standards used by the health benefit plan issuer to rank or classif…

Sec. 1460.004. DUTIES OF PHYSICIANS. A physician may not require or request that a patient of the physician enter into an agreement under which the patient agrees not to: (1) rank or otherwise evaluate the physician; (2) participate in surveys regarding the physician; or (3) in a…

Sec. 1460.005. RULES; STANDARDS. (a) The commissioner shall adopt rules as necessary to implement this chapter. (b) The commissioner shall adopt rules as necessary to ensure that a health benefit plan issuer that uses a physician ranking system complies with the standards and gui…

Sec. 1460.006. DUTIES OF HEALTH BENEFIT PLAN ISSUER. A health benefit plan issuer shall ensure that: (1) physicians currently in clinical practice are actively involved in the development of the standards used under this chapter; and (2) the measures and methodology used in the c…

Sec. 1460.007. SANCTIONS; DISCIPLINARY ACTIONS. (a) A health benefit plan issuer that violates this chapter or a rule adopted under this chapter is subject to sanctions and disciplinary actions under Chapters 82 and 84. (b) A violation of this chapter by a physician constitutes g…

Sec. 1461.001. DEFINITIONS. In this chapter: (1) "Enrollee" means an individual who is eligible to receive health care services under a managed care plan. (2) "Maintenance of certification" has the meaning assigned by Section 151.002, Occupations Code. (3) "Managed care plan" mea…

Sec. 1461.002. APPLICABILITY. (a) This chapter applies to a physician regardless of whether the physician is a participating physician. (b) This chapter applies to a person with whom a managed care plan issuer contracts to: (1) process or pay claims; (2) obtain the services of ph…

Sec. 1461.003. DISCRIMINATION BASED ON MAINTENANCE OF CERTIFICATION. (a) Except as provided by Subsection (b), a managed care plan issuer may not differentiate between physicians based on a physician's maintenance of certification in regard to: (1) paying the physician; (2) reimb…

Sec. 1467.001. DEFINITIONS. In this chapter: (1) "Administrator" means: (A) an administering firm for a health benefit plan providing coverage under Chapter 1551, 1575, or 1579; and (B) if applicable, the claims administrator for the health benefit plan. (1-a) "Arbitration" means…

Sec. 1467.002. APPLICABILITY OF CHAPTER. This chapter applies to: (1) a health benefit plan offered by a health maintenance organization operating under Chapter 843; (2) a preferred provider benefit plan, including an exclusive provider benefit plan, offered by an insurer under C…

Sec. 1467.003. RULES. (a) The commissioner, the Texas Medical Board, and any other appropriate regulatory agency shall adopt rules as necessary to implement their respective powers and duties under this chapter. (b) Section 2001.0045, Government Code, does not apply to a rule ado…

Sec. 1467.004. REMEDIES NOT EXCLUSIVE. The remedies provided by this chapter are in addition to any other defense, remedy, or procedure provided by law, including the common law. Added by Acts 2009, 81st Leg., R.S., Ch. 1290 (H.B. 2256), Sec. 1, eff. June 19, 2009.

Sec. 1467.005. REFORM. This chapter may not be construed to prohibit: (1) a health benefit plan issuer or administrator from, at any time, offering a reformed claim settlement; or (2) an out-of-network provider from, at any time, offering a reformed charge for health care or medi…

Sec. 1467.006. BENCHMARKING DATABASE. (a) In this section, "geozip area" means an area that includes all zip codes with identical first three digits. For purposes of this section, a health care or medical service or supply provided at a location that does not have a zip code is c…

Sec. 1467.050. APPLICABILITY OF SUBCHAPTER. (a) This subchapter applies only with respect to a health benefit claim submitted by an out-of-network provider that is a facility. (b) This subchapter does not apply to a health benefit claim for the professional or technical component…

Sec. 1467.0505. ESTABLISHMENT AND ADMINISTRATION OF MEDIATION PROGRAM. (a) The commissioner shall establish and administer a mediation program to resolve disputes over out-of-network provider charges in accordance with this subchapter. (b) The commissioner: (1) shall adopt rules,…