Texas Insurance Code Title 8, Chapter 1271 - Benefits Provided By Health Maintenance Organizations; Evidence Of Coverage; Charges
SUBCHAPTER A GENERAL PROVISIONS
- Texas Section 1271.001 - Applicability Of Definitions
In this chapter, terms defined by Section 843.002 have the meanings assigned by that section. Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3,...
- Texas Section 1271.002 - Right To Evidence Of Coverage; Issuance
(a) Each enrollee residing in this state is entitled to evidence of coverage under a health care plan. (b) The health maintenance organization shall issue...
- Texas Section 1271.003 - Evidence Of Coverage Not Health Insurance Policy
An evidence of coverage is not a health insurance policy as that term is defined by this code. Added by Acts 2003, 78th Leg., ch....
- Texas Section 1271.004 - Individual Health Care Plan
(a) In this section, "individual health care plan" means a health care plan: (1) that provides health care services for individuals and their dependents; (2)...
- Texas Section 1271.005 - Applicability Of Other Law
(a) Chapters 1368 and 1652 apply to a health maintenance organization other than a health maintenance organization that offers only a single health care service...
- Texas Section 1271.006 - Benefits To Dependent Child And Grandchild
(a) If children are eligible for coverage under the terms of an evidence of coverage, any limiting age applicable to an unmarried child of an...
SUBCHAPTER B CONTENTS OF EVIDENCE OF COVERAGE
- Texas Section 1271.007 - Religious Convictions
(a) This chapter, Chapters 843, 1272, and 1367, Subchapter A, Chapter 1452, and Subchapter B, Chapter 1507, do not require a health maintenance organization, physician,...
- Texas Section 1271.051 - Evidence Of Coverage: Contract And Certificate Requirements
(a) An evidence of coverage that is a contract must contain a clear and complete statement of the information required by Sections 1271.052, 1271.053, and...
- Texas Section 1271.052 - Information About Benefits And Limitations
An evidence of coverage must state: (1) the health care services, limited health care services, or single health care service to which the enrollee is...
- Texas Section 1271.053 - Information About Obtaining Services
An evidence of coverage must indicate where and in what manner information is available about how to obtain services. Added by Acts 2003, 78th Leg.,...
- Texas Section 1271.054 - Information About Complaints And Appeals
(a) An evidence of coverage must contain a clear and understandable description of the health maintenance organization's methods for resolving enrollee complaints, including: (1) the...
- Texas Section 1271.055 - Out-of-network Services
(a) An evidence of coverage must contain a provision regarding non-network physicians and providers in accordance with the requirements of this section. (b) If medically...
- Texas Section 1271.056 - Unfair Or Deceptive Provisions And Statements Prohibited
An evidence of coverage may not contain a provision or statement that: (1) is unjust, unfair, inequitable, misleading, or deceptive; (2) encourages misrepresentation; or (3)...
SUBCHAPTER C COMMISSIONER APPROVAL
- Texas Section 1271.057 - Discretionary Clauses Prohibited
(a) An evidence of coverage may not contain a discretionary clause provision. (b) A discretionary clause provision includes a provision that: (1) purports or acts...
- Texas Section 1271.101 - Approval Of Form Of Evidence Of Coverage Or Group Contract
(a) An evidence of coverage or an amendment of an evidence of coverage may not be issued or delivered to a person in this state...
- Texas Section 1271.102 - Procedures For Approval Of Form Of Evidence Of Coverage Or Group Contract; Withdrawal Of Approval
(a) The commissioner shall, within a reasonable period, approve the form of an evidence of coverage or group contract or an amendment to one of...
- Texas Section 1271.103 - Withdrawal Of Approval Of Form
(a) After notice and opportunity for hearing, the commissioner may withdraw approval of the form of an evidence of coverage or group contract or an...
SUBCHAPTER D CERTAIN BENEFITS REQUIRED
- Texas Section 1271.104 - Information Required By Commissioner
The commissioner may require the submission of any relevant information the commissioner considers necessary in determining whether to approve or disapprove a filing under this...
- Texas Section 1271.151 - Provision Of Basic Health Care Services
A health maintenance organization that offers a basic health care plan shall provide or arrange for basic health care services to its enrollees as needed...
- Texas Section 1271.152 - Standards For Basic Health Care Services
The commissioner may adopt minimum standards relating to basic health care services. Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
- Texas Section 1271.153 - Periodic Health Evaluations
(a) The basic health care services provided under an evidence of coverage must include periodic health evaluations for each adult enrollee. (b) The services provided...
- Texas Section 1271.154 - Well-child Care From Birth
(a) In this section, "well-child care from birth" has the meaning used under Section 1302, Public Health Service Act (42 U.S.C. Section 300e-1), and its...
- Texas Section 1271.155 - Emergency Care
(a) A health maintenance organization shall pay for emergency care performed by non-network physicians or providers at the usual and customary rate or at an...
SUBCHAPTER E CHOICE OF PRIMARY CARE PHYSICIAN FOR CERTAIN ENROLLEES
- Texas Section 1271.156 - Benefits For Rehabilitation Services And Therapies
(a) If benefits are provided for rehabilitation services and therapies under an evidence of coverage, the provision of a rehabilitation service or therapy that, in...
- Texas Section 1271.201 - Designation Of Specialist As Primary Care Physician
(a) An evidence of coverage must provide that an enrollee with a chronic, disabling, or life-threatening illness may apply to the health maintenance organization's medical...
- Texas Section 1271.202 - Appeal
If a health maintenance organization denies a request under Section 1271.201, the enrollee may appeal the decision through the health maintenance organization's established complaint and...
SUBCHAPTER F SCHEDULE OF CHARGES
- Texas Section 1271.203 - Effective Date Of Designation
(a) The effective date of the designation of a nonprimary care physician specialist as an enrollee's primary care physician under Section 1271.201 may not be...
- Texas Section 1271.251 - Approval Of Formula Or Method For Computing Schedule Of Charges
(a) The formula or method for computing the schedule of charges for enrollee coverage for health care services must be filed with the commissioner before...
- Texas Section 1271.252 - Consideration Of Individual Health Status Prohibited
The charges resulting from the application of a formula or method described by Section 1271.251 may not be altered for an individual enrollee based on...
SUBCHAPTER G CONTINUATION OF COVERAGE, CONVERSION CONTRACTS, AND RENEWAL
- Texas Section 1271.253 - Information Required By Commissioner
The commissioner may require the submission of any relevant information the commissioner considers necessary in determining whether to approve or disapprove a filing under this...
- Texas Section 1271.301 - Entitlement To Continuation Of Group Coverage
(a) In this section, "involuntary termination for cause" does not include termination for any health-related reason. (b) A health maintenance organization shall provide a group...
- Texas Section 1271.302 - Request For Continued Coverage; Deadline
An enrollee must provide to the employer or group contract holder a written notice of election to continue group coverage under this subchapter not later...
- Texas Section 1271.303 - Payment For Continued Coverage
(a) An enrollee electing continuation of group coverage must pay to the employer or group contract holder the amount of contribution required by the employer...
- Texas Section 1271.304 - Termination Of Continued Coverage
Group continued coverage under this subchapter may not terminate until the earliest of: (1) the date the maximum continuation period provided by law would end,...
- Texas Section 1271.306 - Conversion Contracts
(a) A health maintenance organization may offer to each enrollee a conversion contract. (b) A health maintenance organization shall issue the conversion contract without evidence...
- Texas Section 1271.307 - Renewability Of Coverage: Individual Health Care Plans And Conversion Contracts
(a) In this section, "individual health care plan" has the meaning assigned by Section 1271.004. (b) An individual health care plan or a conversion contract...
Last modified: September 28, 2016