Texas Insurance Code Title 13, Chapter 4151 - Third-party Administrators

SUBCHAPTER A GENERAL PROVISIONS

• Texas Section 4151.001 - Definitions
  In this chapter: (1) "Administrator" means a person who, in connection with annuities or life benefits, health benefits, accident benefits, pharmacy benefits, or workers' compensation...
• Texas Section 4151.002 - Exemptions
  A person is not an administrator if the person is: (1) an employer, other than a certified workers' compensation self-insurer, administering an employee benefit plan...
• Texas Section 4151.0021 - Applicability To Certain Processing Agents
  (a) In this section, "processing agent" means a person described by Section 413.0111, Labor Code. (b) A processing agent is not an administrator for purposes...
• Texas Section 4151.0022 - Nonapplicability
  This chapter does not apply to a health care sharing ministry operated under Chapter 1681. Added by Acts 2013, 83rd Leg., R.S., Ch. 455 (S.B....
• Texas Section 4151.003 - Applicability Of Other Provisions Of Code
  An administrator is subject to Section 823.457, Subchapter H of Chapter 101, Chapter 541, Subchapter A of Chapter 542, and Chapter 804. Added by Acts...
• Texas Section 4151.0031 - Market Analysis
  The commissioner may conduct market analyses and examinations of an administrator under Chapter 751. Added by Acts 2007, 80th Leg., R.S., Ch. 1176 (H.B. 472),...
• Texas Section 4151.004 - Applicability To Certain Insurers And Health Maintenance Organizations
  An insurer or health maintenance organization that is not exempt under Section 4151.002(3) or (4) is subject to all provisions of this chapter other than...
• Texas Section 4151.005 - Administrator Not Insurance Agent
  (a) An administrator licensed in any state who accepts an agent's commission for coverage for a risk located in this state and disburses that commission...
• Texas Section 4151.0051 - Referral To Adjuster By Administrator
  (a) An administrator may not knowingly refer a claim or loss for adjustment in this state to an individual purporting to be or acting as...

SUBCHAPTER B CERTIFICATE OF AUTHORITY

• Texas Section 4151.006 - Rules
  The commissioner may adopt, in the manner prescribed by Subchapter A, Chapter 36, rules that are fair, reasonable, and appropriate to augment and implement this...
• Texas Section 4151.051 - Certificate Of Authority Required
  (a) An individual, corporation, organization, trust, partnership, or other legal entity may not act as or hold itself out as an administrator unless the entity...
• Texas Section 4151.052 - Application
  (a) An application for a certificate of authority to engage in business as an administrator must be in a form prescribed by the commissioner and...
• Texas Section 4151.053 - Approval Of Application
  The commissioner shall approve an application for a certificate of authority to engage in business in this state as an administrator if the commissioner is...
• Texas Section 4151.054 - Denial Of Application
  (a) If the commissioner is unable to approve an application for a certificate of authority, the commissioner shall: (1) provide the applicant with written notice...
• Texas Section 4151.055 - Fidelity Bond Required
  (a) If the commissioner approves an application for a certificate of authority, before the commissioner issues the certificate of authority, the applicant must: (1) obtain...

SUBCHAPTER C POWERS AND DUTIES OF ADMINISTRATORS AND INSURERS

• Texas Section 4151.056 - Duration Of Certificate Of Authority
  A certificate of authority issued to an administrator under this chapter is effective until it is suspended, canceled, or revoked. The issuance, denial, suspension, cancellation,...
• Texas Section 4151.101 - Written Agreement With Insurer Or Plan Sponsor Required
  (a) An administrator may provide services only under a written agreement with an insurer or plan sponsor. (b) The commissioner by rule may prescribe provisions...
• Texas Section 4151.102 - Contents Of Written Agreement
  (a) The written agreement must include each requirement prescribed by this subchapter except for a requirement that does not apply to any function the administrator...
• Texas Section 4151.103 - Retention Of Written Agreement; Inspection By Commissioner
  (a) The administrator and the insurer, plan, or plan sponsor shall retain a copy of the written agreement as part of their official records: (1)...
• Texas Section 4151.104 - Notice Of Use Of Administrator's Services
  (a) If an insurer, plan, or plan sponsor uses the services of an administrator, the administrator shall give written notice to each insured and injured...
• Texas Section 4151.1041 - Referral By Insurer
  (a) An insurer may not knowingly refer a claim or loss for administration in this state to a person purporting to be or acting as...
• Texas Section 4151.1042 - Responsibilities Of Insurer; Semiannual Audit
  (a) If an insurer uses the services of an administrator, the insurer is responsible for determining the benefits, premium rates, reimbursement procedures, and claims payment...
• Texas Section 4151.105 - Payments To Administrator
  (a) If an insurer, plan, or plan sponsor uses the services of an administrator: (1) a payment of a premium or contribution to the administrator...
• Texas Section 4151.106 - Certain Funds Collected Or Received By Administrator
  (a) An administrator who collects funds must identify and state separately in writing the amount of any premium or contribution specified by the insurer, plan,...
• Texas Section 4151.107 - Delivery Or Deposit Of Certain Funds Received By Administrator
  (a) On receiving a premium, contribution, or return premium, an administrator shall: (1) timely deliver the funds to the person entitled to the funds according...
• Texas Section 4151.108 - Withdrawals From Fiduciary Account
  A withdrawal from a fiduciary bank account established under Section 4151.107 may be made only as provided in the written agreement for any of the...
• Texas Section 4151.109 - Payment Of Claims From Fiduciary Account Prohibited
  An administrator may not pay a claim from a fiduciary bank account established under Section 4151.107. Added by Acts 2003, 78th Leg., ch. 1274, Sec....
• Texas Section 4151.110 - Underwriting Standards
  If an administrator has the authority to accept or reject a risk, the written agreement must address underwriting or other standards of the insurer or...
• Texas Section 4151.111 - Adjudication Of Claims
  (a) An administrator shall adjudicate a claim not later than the 60th day after the date on which the administrator receives valid proof of loss...
• Texas Section 4151.112 - Maintenance Of Books And Records
  (a) An administrator shall maintain at the administrator's principal administrative office adequate books and records of each transaction in which the administrator engages with an...
• Texas Section 4151.113 - Access To Books And Records
  (a) For the purpose of examination, audit, and inspection, the administrator shall provide to the commissioner and the commissioner's designee access to the books and...
• Texas Section 4151.114 - Disposition Of Books And Records On Termination Of Written Agreement
  On termination of the written agreement, an administrator may fulfill the requirements of Sections 4151.112 and 4151.113 by: (1) delivering the books and records: (A)...
• Texas Section 4151.115 - Confidentiality Of Personal Information
  (a) Information that identifies an individual covered by a plan is confidential. (b) During the time information described by Subsection (a) is in an administrator's...
• Texas Section 4151.116 - Advertising
  Before an administrator uses advertising relating to business underwritten by an insurer, plan, or plan sponsor, the insurer, plan, or plan sponsor must approve use...

SUBCHAPTER D PHARMACY BENEFIT PLANS

• Texas Section 4151.117 - Compensation Of Administrator
  (a) An administrator's compensation may be determined: (1) as a percentage of the premiums or charges the administrator collects or the amount of claims the...
• Texas Section 4151.151 - Definition
  In this subchapter, "pharmacy benefit manager" means a person, other than a pharmacy or pharmacist, who acts as an administrator in connection with pharmacy benefits....
• Texas Section 4151.152 - Identification Cards
  (a) Except as provided by rules adopted by the commissioner, an administrator for a plan that provides pharmacy benefits shall issue an identification card to...
• Texas Section 4151.153 - Disclosure Of Certain Patient Information Prohibited
  (a) A pharmacy benefit manager may not sell a list of patients that contains information through which the identity of an individual patient is disclosed....

SUBCHAPTER E DEPARTMENT REGULATION OF ADMINISTRATORS

• Texas Section 4151.154 - Discount Health Care Programs
  A pharmacy benefit manager may not require a pharmacist or pharmacy to: (1) accept or process a claim for prescription drugs under a discount health...
• Texas Section 4151.201 - Examination Of Administrator
  (a) The commissioner may examine an administrator with regard to its business in this state. (b) The commissioner may designate one or more employees to...
• Texas Section 4151.202 - Contents Of Examination; On-site Evaluation
  (a) An examination under Section 4151.201 must include a review of: (1) each existing written agreement between the administrator and an insurer or plan sponsor;...
• Texas Section 4151.203 - Cost Of Examination
  The cost of an examination under Section 4151.201 shall be paid from the fee collected under Section 4151.206(a)(2) and with revenue from the maintenance tax...
• Texas Section 4151.204 - Examination Under Oath
  If necessary to make a complete evaluation of the activities and operations of an administrator, the commissioner may summon and examine under oath the administrator...
• Texas Section 4151.205 - Annual Report
  (a) An administrator shall annually, not later than June 30, file with the commissioner a report on a form prescribed by the commissioner. The report...
• Texas Section 4151.206 - Fees
  (a) The commissioner shall collect and an applicant or administrator shall pay to the commissioner fees in an amount to be determined by the commissioner...
• Texas Section 4151.210 - Effect Of Revocation Of Other Certificates
  An officer or a director or a shareholder with a controlling interest of an entity whose certificate of authority to engage in the business of...
• Texas Section 4151.211 - Restrictions On Acquisition Of Ownership Interest
  (a) A person may not acquire an ownership interest in an entity that holds a certificate of authority under this chapter if the person is,...

SUBCHAPTER F WORKERS' COMPENSATION BENEFIT PLANS

• Texas Section 4151.212 - Maintenance Of Qualifications Required
  The department may, in the manner prescribed by Section 4151.056 and by Subchapter G, revoke, suspend, or refuse to renew the certificate of authority of...
• Texas Section 4151.251 - Definition
  For purposes of this subchapter only, "insurance carrier" means: (1) an insurance company; or (2) a certified self-insurer for workers' compensation insurance, other than a...
• Texas Section 4151.252 - Application
  (a) This subchapter applies to the administration of workers' compensation insurance coverage. (b) This subchapter does not apply to an employer that does not elect...
• Texas Section 4151.253 - Agreements Between Administrators And Carriers
  (a) An administrator shall enter into a contract in connection with workers' compensation benefits for collecting premium or contributions, adjusting claims, or settling claims with...
• Texas Section 4151.254 - Agreements Between Administrators And Employers
  (a) In addition to the contract required by Section 4151.253, an administrator may also enter into a contract with an employer in connection with workers'...
• Texas Section 4151.255 - Administrator Compensation
  Except as provided by Section 4151.117, an administrator may accept compensation of any kind for the performance of administrative services in connection with workers' compensation...
• Texas Section 4151.256 - Large Deductible Policies
  An employer who enters into a contract with an insurance carrier under Section 2053.202(b) may not use or contract with an administrator to perform administrative...

SUBCHAPTER G DISCIPLINARY ACTIONS; PENALTIES

• Texas Section 4151.257 - Rules
  The commissioner shall adopt rules to implement the requirements of this subchapter, including rules prescribing requirements for contracts and master services agreements and requirements for...
• Texas Section 4151.301 - Grounds For Denial, Suspension, Or Revocation Of Certificate Of Authority
  The department may deny an application for a certificate of authority or discipline the holder of a certificate of authority under this subchapter if the...
• Texas Section 4151.302 - Remedies For Violation Of Insurance Laws Or Commissioner Rules
  In addition to any other remedy available under Chapter 82 for a violation of this code, another insurance law of this state, or a commissioner...
• Texas Section 4151.303 - Probated Suspension
  If the suspension of a certificate of authority is probated, the commissioner may require the holder to: (1) report regularly to the department on any...
• Texas Section 4151.304 - Hearing
  If the department proposes to deny an application for a certificate of authority, or to suspend or revoke a certificate of authority, the applicant or...
• Texas Section 4151.305 - Application For Certificate Of Authority After Denial Or Revocation
  (a) A person, or officer, director, or shareholder of a person, whose application has been denied or whose certificate of authority has been revoked under...
• Texas Section 4151.306 - Disciplinary Proceeding For Conduct Committed Before Surrender Or Forfeiture Of Certificate
  (a) The department may institute a disciplinary proceeding against a former certificate holder, or officer, director, or shareholder of a former certificate holder, for conduct...
• Texas Section 4151.307 - Emergency Certificate Suspension
  (a) The commissioner may suspend the certificate of an administrator without notice or hearing if the commissioner determines that: (1) the administrator is insolvent or...
• Texas Section 4151.308 - General Administrative Sanctions
  An administrator or other person who violates this chapter is subject to the sanctions provided by Chapter 82. Added by Acts 2003, 78th Leg., ch....
• Texas Section 4151.309 - Criminal Penalty
  (a) An administrator commits an offense if the administrator knowingly violates this chapter or a rule of the commissioner adopted under this chapter. (b) An...

Last modified: September 28, 2016