State Codes and Statutes
Statutes > Texas > Insurance-code > Title-8-health-insurance-and-other-health-coverages > Chapter-1204-procedures-for-payment-of-certain-health-and-accident-insurance-policy-or-plan-benefits
INSURANCE CODE
TITLE 8. HEALTH INSURANCE AND OTHER HEALTH COVERAGES
SUBTITLE A. HEALTH COVERAGE IN GENERAL
CHAPTER 1204. PROCEDURES FOR PAYMENT OF CERTAIN HEALTH AND
ACCIDENT INSURANCE POLICY OR PLAN BENEFITS
SUBCHAPTER A. PAYMENTS TO CERTAIN PUBLIC HOSPITALS
Sec. 1204.001. NONAPPLICABILITY TO CERTAIN FACILITIES. This
subchapter does not apply to indigent care or chronic disease
care provided in or by an eleemosynary institution, sanitarium,
sanitorium, mental health treatment facility, tuberculosis
treatment facility, or cancer treatment facility that is owned or
controlled by the state or by a unit of local government.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1204.002. BENEFITS PAYABLE FOR TREATMENT PROVIDED BY
HOSPITAL OWNED BY STATE OR UNIT OF LOCAL GOVERNMENT. An
insurance policy providing hospital, nursing, medical, or
surgical coverage that is issued or delivered in this state after
August 27, 1973, may not include a provision that prevents the
payment of benefits for expenses of a nonindigent patient
incurred in a hospital facility that:
(1) is owned or controlled by the state or by a unit of local
government; and
(2) regularly and customarily demands and collects from
nonindigent persons payment for those expenses.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
SUBCHAPTER B. ASSIGNMENT OF BENEFIT PAYMENTS
Sec. 1204.051. DEFINITIONS. In this subchapter:
(1) "Covered person" means a person who is insured or covered by
a health insurance policy or is a participant in an employee
benefit plan. The term includes:
(A) a person covered by a health insurance policy because the
person is an eligible dependent; and
(B) an eligible dependent of a participant in an employee
benefit plan.
(2) "Employee benefit plan" or "plan" means a plan, fund, or
program established or maintained by an employer, an employee
organization, or both, to the extent that it provides, through
the purchase of insurance or otherwise, health care services to
employees, participants, or the dependents of employees or
participants.
(3) "Health care provider" means a person who provides health
care services under a license, certificate, registration, or
other similar evidence of regulation issued by this or another
state of the United States.
(4) "Health care service" means a service to diagnose, prevent,
alleviate, cure, or heal a human illness or injury that is
provided to a covered person by a physician or other health care
provider.
(5) "Health insurance policy" means an individual, group,
blanket, or franchise insurance policy, or an insurance
agreement, that provides reimbursement or indemnity for health
care expenses incurred as a result of an accident or sickness.
(6) "Insurer" means an insurance company, association, or
organization authorized to engage in business in this state under
Chapter 841, 861, 881, 882, 883, 884, 885, 886, 887, 888, 941,
942, or 982.
(7) "Person" means an individual, association, partnership,
corporation, or other legal entity.
(8) "Physician" means an individual licensed to practice
medicine in this or another state of the United States.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1204.052. APPLICABILITY TO CERTAIN PLANS OR PROGRAMS. This
subchapter applies to:
(1) an employee benefit plan, to the extent not preempted by the
Employee Retirement Income Security Act of 1974 (29 U.S.C.
Section 1001 et seq.);
(2) benefit programs under Chapters 1551 and 1601, to the extent
that the benefit programs are self-insuring; and
(3) insurance coverage provided under Chapter 1575.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1204.053. ASSIGNMENT OF BENEFITS. (a) An insurer may not
deliver, renew, or issue for delivery in this state a health
insurance policy that prohibits or restricts a covered person
from making a written assignment of benefits to a physician or
other health care provider who provides health care services to
the person.
(b) This section does not:
(1) provide a coverage or benefit that is not otherwise
available under the health insurance policy;
(2) allow assignment of a benefit to:
(A) a person who is not legally entitled to receive such a
direct payment; or
(B) another person if, under the health insurance policy or
plan, the benefit must be provided to the covered person by a
physician or other health care provider who is a contractor or
preferred provider under the policy; or
(3) prohibit an insurer from verifying, through the insurer's
normal process, the health care services the physician or other
health care provider provides to the covered person.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1204.054. PAYMENT OF BENEFITS ACCORDING TO ASSIGNMENT. An
insurer shall pay benefits directly to a physician or other
health care provider, and the insurer is relieved of the
obligation to pay, and of any liability for paying, those
benefits to the covered person if:
(1) the covered person makes a written assignment of those
benefits payable to the physician or other health care provider;
and
(2) the assignment is obtained by or delivered to the insurer
with the claim for benefits.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1204.055. CONTRACTUAL RESPONSIBILITY FOR DEDUCTIBLES AND
COPAYMENTS. (a) The payment of benefits under an assignment
does not relieve a covered person of a contractual obligation to
pay a deductible or copayment.
(b) A physician or other health care provider may not waive a
deductible or copayment by the acceptance of an assignment.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
SUBCHAPTER C. UNIFORM CLAIM BILLING FORMS
Sec. 1204.101. DEFINITIONS. In this subchapter:
(1) "Health benefit plan" means a group, blanket, or franchise
insurance policy, a group hospital service contract, or a group
subscriber contract or evidence of coverage issued by a health
maintenance organization, that provides benefits for health care
services.
(2) "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 hospital service corporation operating under Chapter
842;
(C) a health maintenance organization operating under Chapter
843; and
(D) a stipulated premium company operating under Chapter 884.
(3) "Provider" means a person who provides health care under a
license issued by this state. The term includes a health care
practitioner listed in Section 1451.001 and a nurse first
assistant, as defined by Section 1451.101.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1204.102. REQUIRED CLAIM BILLING FORMS. A provider who
seeks payment or reimbursement under a health benefit plan and
the health benefit plan issuer that issued the plan shall use
uniform claim billing form UB-82/HCFA or HCFA 1500, or a
successor to one of those forms, as developed by the National
Uniform Billing Committee or its successor.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
SUBCHAPTER D. PAYMENTS FOR CERTAIN PUBLICLY PROVIDED SERVICES
Sec. 1204.151. DEFINITION. In this subchapter, "policy" means
an individual or group policy of accident and health insurance,
including a policy issued by a group hospital service corporation
operating under Chapter 842.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1204.152. PAYMENT FOR CERTAIN EXPENSES INCURRED BY TEXAS
DEPARTMENT OF HUMAN SERVICES. Each policy delivered or issued
for delivery in this state must provide for the repayment of the
actual costs of medical expenses the Texas Department of Human
Services pays through medical assistance for an insured person
if, under the policy, the insured person is entitled to payment
for the medical expenses.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1204.153. PAYMENTS TO TEXAS DEPARTMENT OF HUMAN SERVICES
FOR CERTAIN CHILDREN. (a) This section applies only to a policy
that is delivered, issued for delivery, or renewed in this state
and that provides coverage for a child whose parent:
(1) purchased the policy; or
(2) is a member of the group covered under the policy.
(b) Each policy must include a requirement that, after written
notice to the insurer or group hospital service corporation at
the insurer's or group hospital service corporation's home
office, benefits payable on behalf of a child must be paid to the
Texas Department of Human Services if:
(1) the parent who purchased the policy or who is a group member
is required to pay child support by a court order or
court-approved agreement and:
(A) is a possessory conservator of the child under a court order
issued in this state; or
(B) is not entitled to possession of or access to the child;
(2) the Texas Department of Human Services is paying benefits on
behalf of the child under Chapter 31 or 32, Human Resources Code;
and
(3) the insurer or group hospital service corporation is
notified, through an attachment to the claim for benefits at the
time the claim is first submitted to the insurer or group
hospital service corporation, that the benefits must be paid
directly to the Texas Department of Human Services.
(c) The commissioner and the Texas Department of Human Services
may consult regarding implementation of this section.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1204.154. UNIFORM PROVISIONS. (a) The commissioner shall
adopt uniform policy provisions, riders, and endorsements for the
policy requirement of Section 1204.153.
(b) Before the commissioner adopts or makes a change to a
provision, rider, or endorsement under Subsection (a), the
commissioner shall present each provision, rider, or endorsement,
and any amendment to a provision, rider, or endorsement, to the
Texas Department of Human Services for comment.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
SUBCHAPTER E. EXCLUSIONARY CLAUSES
Sec. 1204.201. PROHIBITION OF EXCLUSION OF CERTAIN MEDICAL
ASSISTANCE BENEFITS. An individual or group accident and health
insurance policy delivered or issued for delivery in this state,
including a policy issued by a group hospital service corporation
operating under Chapter 842, may not include a provision that
excludes or limits the insurer's or group hospital service
corporation's coverage from paying benefits covered by Chapter
32, Human Resources Code.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
SUBCHAPTER F. PAYMENT OF BENEFITS TO CONSERVATOR OF MINOR
Sec. 1204.251. PAYMENT TO CONSERVATOR OTHER THAN GROUP MEMBER.
(a) An insurer or group hospital service corporation operating
under Chapter 842 that delivers, issues for delivery, or renews
in this state a group accident and health insurance policy that
provides coverage for a minor child who qualifies as a dependent
of a group member may pay benefits on the child's behalf to a
person who is not a group member if an order providing for the
appointment of a possessory or managing conservator of the child
has been issued by a court in this or another state.
(b) A person who is not a group member is entitled to be paid
benefits under this section only if the person presents to the
insurer or group hospital service corporation, with the claim
application:
(1) written notice that the person is a possessory or managing
conservator of the child on whose behalf the claim is made; and
(2) a certified copy of a court order designating the person as
possessory or managing conservator of the child or other evidence
designated by rule of the commissioner that the person is
eligible for the benefits as this section provides.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1204.252. PRECONDITIONS FOR PAYMENT; EXCEPTIONS. (a) In
accordance with the terms of the policy and this subchapter, an
insurer or group hospital service corporation may be required to
pay benefits under a group accident and health insurance policy
to a person who is not a group member and who complies with:
(1) Section 1204.251;
(2) the insurer's or group hospital service corporation's claim
application procedures; and
(3) department rules.
(b) Any requirement imposed on a possessory or managing
conservator of a child under this subchapter does not apply with
regard to:
(1) an unpaid medical bill for which an assignment of benefits
has been exercised, whether in accordance with policy provisions
or otherwise; or
(2) a claim presented by a group member for which the group
member paid any portion of a medical bill that is covered under
the policy's terms.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1204.253. RULES. The commissioner may adopt rules to
ensure the effective implementation of this subchapter.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
State Codes and Statutes
Statutes > Texas > Insurance-code > Title-8-health-insurance-and-other-health-coverages > Chapter-1204-procedures-for-payment-of-certain-health-and-accident-insurance-policy-or-plan-benefits
INSURANCE CODE
TITLE 8. HEALTH INSURANCE AND OTHER HEALTH COVERAGES
SUBTITLE A. HEALTH COVERAGE IN GENERAL
CHAPTER 1204. PROCEDURES FOR PAYMENT OF CERTAIN HEALTH AND
ACCIDENT INSURANCE POLICY OR PLAN BENEFITS
SUBCHAPTER A. PAYMENTS TO CERTAIN PUBLIC HOSPITALS
Sec. 1204.001. NONAPPLICABILITY TO CERTAIN FACILITIES. This
subchapter does not apply to indigent care or chronic disease
care provided in or by an eleemosynary institution, sanitarium,
sanitorium, mental health treatment facility, tuberculosis
treatment facility, or cancer treatment facility that is owned or
controlled by the state or by a unit of local government.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1204.002. BENEFITS PAYABLE FOR TREATMENT PROVIDED BY
HOSPITAL OWNED BY STATE OR UNIT OF LOCAL GOVERNMENT. An
insurance policy providing hospital, nursing, medical, or
surgical coverage that is issued or delivered in this state after
August 27, 1973, may not include a provision that prevents the
payment of benefits for expenses of a nonindigent patient
incurred in a hospital facility that:
(1) is owned or controlled by the state or by a unit of local
government; and
(2) regularly and customarily demands and collects from
nonindigent persons payment for those expenses.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
SUBCHAPTER B. ASSIGNMENT OF BENEFIT PAYMENTS
Sec. 1204.051. DEFINITIONS. In this subchapter:
(1) "Covered person" means a person who is insured or covered by
a health insurance policy or is a participant in an employee
benefit plan. The term includes:
(A) a person covered by a health insurance policy because the
person is an eligible dependent; and
(B) an eligible dependent of a participant in an employee
benefit plan.
(2) "Employee benefit plan" or "plan" means a plan, fund, or
program established or maintained by an employer, an employee
organization, or both, to the extent that it provides, through
the purchase of insurance or otherwise, health care services to
employees, participants, or the dependents of employees or
participants.
(3) "Health care provider" means a person who provides health
care services under a license, certificate, registration, or
other similar evidence of regulation issued by this or another
state of the United States.
(4) "Health care service" means a service to diagnose, prevent,
alleviate, cure, or heal a human illness or injury that is
provided to a covered person by a physician or other health care
provider.
(5) "Health insurance policy" means an individual, group,
blanket, or franchise insurance policy, or an insurance
agreement, that provides reimbursement or indemnity for health
care expenses incurred as a result of an accident or sickness.
(6) "Insurer" means an insurance company, association, or
organization authorized to engage in business in this state under
Chapter 841, 861, 881, 882, 883, 884, 885, 886, 887, 888, 941,
942, or 982.
(7) "Person" means an individual, association, partnership,
corporation, or other legal entity.
(8) "Physician" means an individual licensed to practice
medicine in this or another state of the United States.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1204.052. APPLICABILITY TO CERTAIN PLANS OR PROGRAMS. This
subchapter applies to:
(1) an employee benefit plan, to the extent not preempted by the
Employee Retirement Income Security Act of 1974 (29 U.S.C.
Section 1001 et seq.);
(2) benefit programs under Chapters 1551 and 1601, to the extent
that the benefit programs are self-insuring; and
(3) insurance coverage provided under Chapter 1575.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1204.053. ASSIGNMENT OF BENEFITS. (a) An insurer may not
deliver, renew, or issue for delivery in this state a health
insurance policy that prohibits or restricts a covered person
from making a written assignment of benefits to a physician or
other health care provider who provides health care services to
the person.
(b) This section does not:
(1) provide a coverage or benefit that is not otherwise
available under the health insurance policy;
(2) allow assignment of a benefit to:
(A) a person who is not legally entitled to receive such a
direct payment; or
(B) another person if, under the health insurance policy or
plan, the benefit must be provided to the covered person by a
physician or other health care provider who is a contractor or
preferred provider under the policy; or
(3) prohibit an insurer from verifying, through the insurer's
normal process, the health care services the physician or other
health care provider provides to the covered person.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1204.054. PAYMENT OF BENEFITS ACCORDING TO ASSIGNMENT. An
insurer shall pay benefits directly to a physician or other
health care provider, and the insurer is relieved of the
obligation to pay, and of any liability for paying, those
benefits to the covered person if:
(1) the covered person makes a written assignment of those
benefits payable to the physician or other health care provider;
and
(2) the assignment is obtained by or delivered to the insurer
with the claim for benefits.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1204.055. CONTRACTUAL RESPONSIBILITY FOR DEDUCTIBLES AND
COPAYMENTS. (a) The payment of benefits under an assignment
does not relieve a covered person of a contractual obligation to
pay a deductible or copayment.
(b) A physician or other health care provider may not waive a
deductible or copayment by the acceptance of an assignment.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
SUBCHAPTER C. UNIFORM CLAIM BILLING FORMS
Sec. 1204.101. DEFINITIONS. In this subchapter:
(1) "Health benefit plan" means a group, blanket, or franchise
insurance policy, a group hospital service contract, or a group
subscriber contract or evidence of coverage issued by a health
maintenance organization, that provides benefits for health care
services.
(2) "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 hospital service corporation operating under Chapter
842;
(C) a health maintenance organization operating under Chapter
843; and
(D) a stipulated premium company operating under Chapter 884.
(3) "Provider" means a person who provides health care under a
license issued by this state. The term includes a health care
practitioner listed in Section 1451.001 and a nurse first
assistant, as defined by Section 1451.101.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1204.102. REQUIRED CLAIM BILLING FORMS. A provider who
seeks payment or reimbursement under a health benefit plan and
the health benefit plan issuer that issued the plan shall use
uniform claim billing form UB-82/HCFA or HCFA 1500, or a
successor to one of those forms, as developed by the National
Uniform Billing Committee or its successor.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
SUBCHAPTER D. PAYMENTS FOR CERTAIN PUBLICLY PROVIDED SERVICES
Sec. 1204.151. DEFINITION. In this subchapter, "policy" means
an individual or group policy of accident and health insurance,
including a policy issued by a group hospital service corporation
operating under Chapter 842.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1204.152. PAYMENT FOR CERTAIN EXPENSES INCURRED BY TEXAS
DEPARTMENT OF HUMAN SERVICES. Each policy delivered or issued
for delivery in this state must provide for the repayment of the
actual costs of medical expenses the Texas Department of Human
Services pays through medical assistance for an insured person
if, under the policy, the insured person is entitled to payment
for the medical expenses.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1204.153. PAYMENTS TO TEXAS DEPARTMENT OF HUMAN SERVICES
FOR CERTAIN CHILDREN. (a) This section applies only to a policy
that is delivered, issued for delivery, or renewed in this state
and that provides coverage for a child whose parent:
(1) purchased the policy; or
(2) is a member of the group covered under the policy.
(b) Each policy must include a requirement that, after written
notice to the insurer or group hospital service corporation at
the insurer's or group hospital service corporation's home
office, benefits payable on behalf of a child must be paid to the
Texas Department of Human Services if:
(1) the parent who purchased the policy or who is a group member
is required to pay child support by a court order or
court-approved agreement and:
(A) is a possessory conservator of the child under a court order
issued in this state; or
(B) is not entitled to possession of or access to the child;
(2) the Texas Department of Human Services is paying benefits on
behalf of the child under Chapter 31 or 32, Human Resources Code;
and
(3) the insurer or group hospital service corporation is
notified, through an attachment to the claim for benefits at the
time the claim is first submitted to the insurer or group
hospital service corporation, that the benefits must be paid
directly to the Texas Department of Human Services.
(c) The commissioner and the Texas Department of Human Services
may consult regarding implementation of this section.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1204.154. UNIFORM PROVISIONS. (a) The commissioner shall
adopt uniform policy provisions, riders, and endorsements for the
policy requirement of Section 1204.153.
(b) Before the commissioner adopts or makes a change to a
provision, rider, or endorsement under Subsection (a), the
commissioner shall present each provision, rider, or endorsement,
and any amendment to a provision, rider, or endorsement, to the
Texas Department of Human Services for comment.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
SUBCHAPTER E. EXCLUSIONARY CLAUSES
Sec. 1204.201. PROHIBITION OF EXCLUSION OF CERTAIN MEDICAL
ASSISTANCE BENEFITS. An individual or group accident and health
insurance policy delivered or issued for delivery in this state,
including a policy issued by a group hospital service corporation
operating under Chapter 842, may not include a provision that
excludes or limits the insurer's or group hospital service
corporation's coverage from paying benefits covered by Chapter
32, Human Resources Code.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
SUBCHAPTER F. PAYMENT OF BENEFITS TO CONSERVATOR OF MINOR
Sec. 1204.251. PAYMENT TO CONSERVATOR OTHER THAN GROUP MEMBER.
(a) An insurer or group hospital service corporation operating
under Chapter 842 that delivers, issues for delivery, or renews
in this state a group accident and health insurance policy that
provides coverage for a minor child who qualifies as a dependent
of a group member may pay benefits on the child's behalf to a
person who is not a group member if an order providing for the
appointment of a possessory or managing conservator of the child
has been issued by a court in this or another state.
(b) A person who is not a group member is entitled to be paid
benefits under this section only if the person presents to the
insurer or group hospital service corporation, with the claim
application:
(1) written notice that the person is a possessory or managing
conservator of the child on whose behalf the claim is made; and
(2) a certified copy of a court order designating the person as
possessory or managing conservator of the child or other evidence
designated by rule of the commissioner that the person is
eligible for the benefits as this section provides.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1204.252. PRECONDITIONS FOR PAYMENT; EXCEPTIONS. (a) In
accordance with the terms of the policy and this subchapter, an
insurer or group hospital service corporation may be required to
pay benefits under a group accident and health insurance policy
to a person who is not a group member and who complies with:
(1) Section 1204.251;
(2) the insurer's or group hospital service corporation's claim
application procedures; and
(3) department rules.
(b) Any requirement imposed on a possessory or managing
conservator of a child under this subchapter does not apply with
regard to:
(1) an unpaid medical bill for which an assignment of benefits
has been exercised, whether in accordance with policy provisions
or otherwise; or
(2) a claim presented by a group member for which the group
member paid any portion of a medical bill that is covered under
the policy's terms.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1204.253. RULES. The commissioner may adopt rules to
ensure the effective implementation of this subchapter.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
State Codes and Statutes
Statutes >
Texas >
Insurance-code >
Title-8-health-insurance-and-other-health-coverages >
Chapter-1204-procedures-for-payment-of-certain-health-and-accident-insurance-policy-or-plan-benefits INSURANCE CODE
TITLE 8. HEALTH INSURANCE AND OTHER HEALTH COVERAGES
SUBTITLE A. HEALTH COVERAGE IN GENERAL
CHAPTER 1204. PROCEDURES FOR PAYMENT OF CERTAIN HEALTH AND
ACCIDENT INSURANCE POLICY OR PLAN BENEFITS
SUBCHAPTER A. PAYMENTS TO CERTAIN PUBLIC HOSPITALS
Sec. 1204.001. NONAPPLICABILITY TO CERTAIN FACILITIES. This
subchapter does not apply to indigent care or chronic disease
care provided in or by an eleemosynary institution, sanitarium,
sanitorium, mental health treatment facility, tuberculosis
treatment facility, or cancer treatment facility that is owned or
controlled by the state or by a unit of local government.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1204.002. BENEFITS PAYABLE FOR TREATMENT PROVIDED BY
HOSPITAL OWNED BY STATE OR UNIT OF LOCAL GOVERNMENT. An
insurance policy providing hospital, nursing, medical, or
surgical coverage that is issued or delivered in this state after
August 27, 1973, may not include a provision that prevents the
payment of benefits for expenses of a nonindigent patient
incurred in a hospital facility that:
(1) is owned or controlled by the state or by a unit of local
government; and
(2) regularly and customarily demands and collects from
nonindigent persons payment for those expenses.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
SUBCHAPTER B. ASSIGNMENT OF BENEFIT PAYMENTS
Sec. 1204.051. DEFINITIONS. In this subchapter:
(1) "Covered person" means a person who is insured or covered by
a health insurance policy or is a participant in an employee
benefit plan. The term includes:
(A) a person covered by a health insurance policy because the
person is an eligible dependent; and
(B) an eligible dependent of a participant in an employee
benefit plan.
(2) "Employee benefit plan" or "plan" means a plan, fund, or
program established or maintained by an employer, an employee
organization, or both, to the extent that it provides, through
the purchase of insurance or otherwise, health care services to
employees, participants, or the dependents of employees or
participants.
(3) "Health care provider" means a person who provides health
care services under a license, certificate, registration, or
other similar evidence of regulation issued by this or another
state of the United States.
(4) "Health care service" means a service to diagnose, prevent,
alleviate, cure, or heal a human illness or injury that is
provided to a covered person by a physician or other health care
provider.
(5) "Health insurance policy" means an individual, group,
blanket, or franchise insurance policy, or an insurance
agreement, that provides reimbursement or indemnity for health
care expenses incurred as a result of an accident or sickness.
(6) "Insurer" means an insurance company, association, or
organization authorized to engage in business in this state under
Chapter 841, 861, 881, 882, 883, 884, 885, 886, 887, 888, 941,
942, or 982.
(7) "Person" means an individual, association, partnership,
corporation, or other legal entity.
(8) "Physician" means an individual licensed to practice
medicine in this or another state of the United States.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1204.052. APPLICABILITY TO CERTAIN PLANS OR PROGRAMS. This
subchapter applies to:
(1) an employee benefit plan, to the extent not preempted by the
Employee Retirement Income Security Act of 1974 (29 U.S.C.
Section 1001 et seq.);
(2) benefit programs under Chapters 1551 and 1601, to the extent
that the benefit programs are self-insuring; and
(3) insurance coverage provided under Chapter 1575.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1204.053. ASSIGNMENT OF BENEFITS. (a) An insurer may not
deliver, renew, or issue for delivery in this state a health
insurance policy that prohibits or restricts a covered person
from making a written assignment of benefits to a physician or
other health care provider who provides health care services to
the person.
(b) This section does not:
(1) provide a coverage or benefit that is not otherwise
available under the health insurance policy;
(2) allow assignment of a benefit to:
(A) a person who is not legally entitled to receive such a
direct payment; or
(B) another person if, under the health insurance policy or
plan, the benefit must be provided to the covered person by a
physician or other health care provider who is a contractor or
preferred provider under the policy; or
(3) prohibit an insurer from verifying, through the insurer's
normal process, the health care services the physician or other
health care provider provides to the covered person.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1204.054. PAYMENT OF BENEFITS ACCORDING TO ASSIGNMENT. An
insurer shall pay benefits directly to a physician or other
health care provider, and the insurer is relieved of the
obligation to pay, and of any liability for paying, those
benefits to the covered person if:
(1) the covered person makes a written assignment of those
benefits payable to the physician or other health care provider;
and
(2) the assignment is obtained by or delivered to the insurer
with the claim for benefits.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1204.055. CONTRACTUAL RESPONSIBILITY FOR DEDUCTIBLES AND
COPAYMENTS. (a) The payment of benefits under an assignment
does not relieve a covered person of a contractual obligation to
pay a deductible or copayment.
(b) A physician or other health care provider may not waive a
deductible or copayment by the acceptance of an assignment.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
SUBCHAPTER C. UNIFORM CLAIM BILLING FORMS
Sec. 1204.101. DEFINITIONS. In this subchapter:
(1) "Health benefit plan" means a group, blanket, or franchise
insurance policy, a group hospital service contract, or a group
subscriber contract or evidence of coverage issued by a health
maintenance organization, that provides benefits for health care
services.
(2) "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 hospital service corporation operating under Chapter
842;
(C) a health maintenance organization operating under Chapter
843; and
(D) a stipulated premium company operating under Chapter 884.
(3) "Provider" means a person who provides health care under a
license issued by this state. The term includes a health care
practitioner listed in Section 1451.001 and a nurse first
assistant, as defined by Section 1451.101.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1204.102. REQUIRED CLAIM BILLING FORMS. A provider who
seeks payment or reimbursement under a health benefit plan and
the health benefit plan issuer that issued the plan shall use
uniform claim billing form UB-82/HCFA or HCFA 1500, or a
successor to one of those forms, as developed by the National
Uniform Billing Committee or its successor.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
SUBCHAPTER D. PAYMENTS FOR CERTAIN PUBLICLY PROVIDED SERVICES
Sec. 1204.151. DEFINITION. In this subchapter, "policy" means
an individual or group policy of accident and health insurance,
including a policy issued by a group hospital service corporation
operating under Chapter 842.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1204.152. PAYMENT FOR CERTAIN EXPENSES INCURRED BY TEXAS
DEPARTMENT OF HUMAN SERVICES. Each policy delivered or issued
for delivery in this state must provide for the repayment of the
actual costs of medical expenses the Texas Department of Human
Services pays through medical assistance for an insured person
if, under the policy, the insured person is entitled to payment
for the medical expenses.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1204.153. PAYMENTS TO TEXAS DEPARTMENT OF HUMAN SERVICES
FOR CERTAIN CHILDREN. (a) This section applies only to a policy
that is delivered, issued for delivery, or renewed in this state
and that provides coverage for a child whose parent:
(1) purchased the policy; or
(2) is a member of the group covered under the policy.
(b) Each policy must include a requirement that, after written
notice to the insurer or group hospital service corporation at
the insurer's or group hospital service corporation's home
office, benefits payable on behalf of a child must be paid to the
Texas Department of Human Services if:
(1) the parent who purchased the policy or who is a group member
is required to pay child support by a court order or
court-approved agreement and:
(A) is a possessory conservator of the child under a court order
issued in this state; or
(B) is not entitled to possession of or access to the child;
(2) the Texas Department of Human Services is paying benefits on
behalf of the child under Chapter 31 or 32, Human Resources Code;
and
(3) the insurer or group hospital service corporation is
notified, through an attachment to the claim for benefits at the
time the claim is first submitted to the insurer or group
hospital service corporation, that the benefits must be paid
directly to the Texas Department of Human Services.
(c) The commissioner and the Texas Department of Human Services
may consult regarding implementation of this section.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1204.154. UNIFORM PROVISIONS. (a) The commissioner shall
adopt uniform policy provisions, riders, and endorsements for the
policy requirement of Section 1204.153.
(b) Before the commissioner adopts or makes a change to a
provision, rider, or endorsement under Subsection (a), the
commissioner shall present each provision, rider, or endorsement,
and any amendment to a provision, rider, or endorsement, to the
Texas Department of Human Services for comment.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
SUBCHAPTER E. EXCLUSIONARY CLAUSES
Sec. 1204.201. PROHIBITION OF EXCLUSION OF CERTAIN MEDICAL
ASSISTANCE BENEFITS. An individual or group accident and health
insurance policy delivered or issued for delivery in this state,
including a policy issued by a group hospital service corporation
operating under Chapter 842, may not include a provision that
excludes or limits the insurer's or group hospital service
corporation's coverage from paying benefits covered by Chapter
32, Human Resources Code.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
SUBCHAPTER F. PAYMENT OF BENEFITS TO CONSERVATOR OF MINOR
Sec. 1204.251. PAYMENT TO CONSERVATOR OTHER THAN GROUP MEMBER.
(a) An insurer or group hospital service corporation operating
under Chapter 842 that delivers, issues for delivery, or renews
in this state a group accident and health insurance policy that
provides coverage for a minor child who qualifies as a dependent
of a group member may pay benefits on the child's behalf to a
person who is not a group member if an order providing for the
appointment of a possessory or managing conservator of the child
has been issued by a court in this or another state.
(b) A person who is not a group member is entitled to be paid
benefits under this section only if the person presents to the
insurer or group hospital service corporation, with the claim
application:
(1) written notice that the person is a possessory or managing
conservator of the child on whose behalf the claim is made; and
(2) a certified copy of a court order designating the person as
possessory or managing conservator of the child or other evidence
designated by rule of the commissioner that the person is
eligible for the benefits as this section provides.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1204.252. PRECONDITIONS FOR PAYMENT; EXCEPTIONS. (a) In
accordance with the terms of the policy and this subchapter, an
insurer or group hospital service corporation may be required to
pay benefits under a group accident and health insurance policy
to a person who is not a group member and who complies with:
(1) Section 1204.251;
(2) the insurer's or group hospital service corporation's claim
application procedures; and
(3) department rules.
(b) Any requirement imposed on a possessory or managing
conservator of a child under this subchapter does not apply with
regard to:
(1) an unpaid medical bill for which an assignment of benefits
has been exercised, whether in accordance with policy provisions
or otherwise; or
(2) a claim presented by a group member for which the group
member paid any portion of a medical bill that is covered under
the policy's terms.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1204.253. RULES. The commissioner may adopt rules to
ensure the effective implementation of this subchapter.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
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