State Codes and Statutes

Statutes > Texas > Insurance-code > Title-8-health-insurance-and-other-health-coverages > Chapter-1360-diagnosis-and-treatment-affecting-temporomandibular-joint

INSURANCE CODE

TITLE 8. HEALTH INSURANCE AND OTHER HEALTH COVERAGES

SUBTITLE E. BENEFITS PAYABLE UNDER HEALTH COVERAGES

CHAPTER 1360. DIAGNOSIS AND TREATMENT AFFECTING TEMPOROMANDIBULAR

JOINT

Sec. 1360.001. DEFINITION. In this chapter, "temporomandibular

joint" includes the jaw and the craniomandibular joint.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.

Sec. 1360.002. APPLICABILITY OF CHAPTER. This chapter applies

only to a group health benefit plan delivered or issued for

delivery in this state that:

(1) provides benefits for dental, medical, or surgical expenses

incurred as a result of a health condition, accident, or

sickness, including:

(A) a group, blanket, or franchise insurance policy or insurance

agreement, a group hospital service contract, or a group evidence

of coverage that is offered by:

(i) an insurance company;

(ii) a group hospital service corporation operating under

Chapter 842;

(iii) a fraternal benefit society operating under Chapter 885;

(iv) a stipulated premium company operating under Chapter 884;

or

(v) a health maintenance organization operating under Chapter

843; and

(B) to the extent permitted by the Employee Retirement Income

Security Act of 1974 (29 U.S.C. Section 1001 et seq.), a health

benefit plan that is offered by:

(i) a multiple employer welfare arrangement as defined by

Section 3 of that Act;

(ii) an entity not authorized under this code or another

insurance law of this state that contracts directly for health

care services on a risk-sharing basis, including a capitation

basis; or

(iii) another analogous benefit arrangement; or

(2) is offered by an approved nonprofit health corporation that

holds a certificate of authority under Chapter 844.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.

Sec. 1360.003. EXCEPTION. This chapter does not apply to:

(1) a plan that provides coverage:

(A) only for a specified disease or another limited benefit;

(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 because of sickness or

injury;

(D) as a supplement to a liability insurance policy;

(E) for credit insurance;

(F) only for vision care; or

(G) only for indemnity for hospital confinement;

(2) a Medicare supplemental policy as defined by Section

1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss);

(3) a workers' compensation insurance policy;

(4) a small employer health benefit plan written under Chapter

1501;

(5) medical payment insurance coverage provided under a motor

vehicle insurance policy; or

(6) a long-term care insurance policy, including a nursing home

fixed indemnity policy, unless the commissioner determines that

the policy provides benefit coverage so comprehensive that the

policy is a health benefit plan as described by Section 1360.002.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.

Sec. 1360.004. COVERAGE REQUIRED. (a) A health benefit plan

that provides coverage for medically necessary diagnostic or

surgical treatment of conditions affecting skeletal joints must

provide comparable coverage for diagnostic or surgical treatment

of conditions affecting the temporomandibular joint if the

treatment is medically necessary as a result of:

(1) an accident;

(2) a trauma;

(3) a congenital defect;

(4) a developmental defect; or

(5) a pathology.

(b) Coverage required under this section may be subject to any

provision in the health benefit plan that is generally applicable

to surgical treatment, including a requirement for

precertification of coverage.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.

Sec. 1360.005. DENTAL SERVICES COVERAGE NOT REQUIRED. (a) This

chapter does not require a health benefit plan to provide

coverage for dental services if dental services are not otherwise

scheduled or provided as part of the coverage provided under the

plan.

(b) A health benefit plan may not exclude from coverage under

the plan an individual who is unable to undergo dental treatment

in an office setting or under local anesthesia due to a

documented physical, mental, or medical reason as determined by

the individual's physician or by the dentist providing the dental

care.

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-1360-diagnosis-and-treatment-affecting-temporomandibular-joint

INSURANCE CODE

TITLE 8. HEALTH INSURANCE AND OTHER HEALTH COVERAGES

SUBTITLE E. BENEFITS PAYABLE UNDER HEALTH COVERAGES

CHAPTER 1360. DIAGNOSIS AND TREATMENT AFFECTING TEMPOROMANDIBULAR

JOINT

Sec. 1360.001. DEFINITION. In this chapter, "temporomandibular

joint" includes the jaw and the craniomandibular joint.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.

Sec. 1360.002. APPLICABILITY OF CHAPTER. This chapter applies

only to a group health benefit plan delivered or issued for

delivery in this state that:

(1) provides benefits for dental, medical, or surgical expenses

incurred as a result of a health condition, accident, or

sickness, including:

(A) a group, blanket, or franchise insurance policy or insurance

agreement, a group hospital service contract, or a group evidence

of coverage that is offered by:

(i) an insurance company;

(ii) a group hospital service corporation operating under

Chapter 842;

(iii) a fraternal benefit society operating under Chapter 885;

(iv) a stipulated premium company operating under Chapter 884;

or

(v) a health maintenance organization operating under Chapter

843; and

(B) to the extent permitted by the Employee Retirement Income

Security Act of 1974 (29 U.S.C. Section 1001 et seq.), a health

benefit plan that is offered by:

(i) a multiple employer welfare arrangement as defined by

Section 3 of that Act;

(ii) an entity not authorized under this code or another

insurance law of this state that contracts directly for health

care services on a risk-sharing basis, including a capitation

basis; or

(iii) another analogous benefit arrangement; or

(2) is offered by an approved nonprofit health corporation that

holds a certificate of authority under Chapter 844.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.

Sec. 1360.003. EXCEPTION. This chapter does not apply to:

(1) a plan that provides coverage:

(A) only for a specified disease or another limited benefit;

(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 because of sickness or

injury;

(D) as a supplement to a liability insurance policy;

(E) for credit insurance;

(F) only for vision care; or

(G) only for indemnity for hospital confinement;

(2) a Medicare supplemental policy as defined by Section

1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss);

(3) a workers' compensation insurance policy;

(4) a small employer health benefit plan written under Chapter

1501;

(5) medical payment insurance coverage provided under a motor

vehicle insurance policy; or

(6) a long-term care insurance policy, including a nursing home

fixed indemnity policy, unless the commissioner determines that

the policy provides benefit coverage so comprehensive that the

policy is a health benefit plan as described by Section 1360.002.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.

Sec. 1360.004. COVERAGE REQUIRED. (a) A health benefit plan

that provides coverage for medically necessary diagnostic or

surgical treatment of conditions affecting skeletal joints must

provide comparable coverage for diagnostic or surgical treatment

of conditions affecting the temporomandibular joint if the

treatment is medically necessary as a result of:

(1) an accident;

(2) a trauma;

(3) a congenital defect;

(4) a developmental defect; or

(5) a pathology.

(b) Coverage required under this section may be subject to any

provision in the health benefit plan that is generally applicable

to surgical treatment, including a requirement for

precertification of coverage.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.

Sec. 1360.005. DENTAL SERVICES COVERAGE NOT REQUIRED. (a) This

chapter does not require a health benefit plan to provide

coverage for dental services if dental services are not otherwise

scheduled or provided as part of the coverage provided under the

plan.

(b) A health benefit plan may not exclude from coverage under

the plan an individual who is unable to undergo dental treatment

in an office setting or under local anesthesia due to a

documented physical, mental, or medical reason as determined by

the individual's physician or by the dentist providing the dental

care.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.


State Codes and Statutes

State Codes and Statutes

Statutes > Texas > Insurance-code > Title-8-health-insurance-and-other-health-coverages > Chapter-1360-diagnosis-and-treatment-affecting-temporomandibular-joint

INSURANCE CODE

TITLE 8. HEALTH INSURANCE AND OTHER HEALTH COVERAGES

SUBTITLE E. BENEFITS PAYABLE UNDER HEALTH COVERAGES

CHAPTER 1360. DIAGNOSIS AND TREATMENT AFFECTING TEMPOROMANDIBULAR

JOINT

Sec. 1360.001. DEFINITION. In this chapter, "temporomandibular

joint" includes the jaw and the craniomandibular joint.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.

Sec. 1360.002. APPLICABILITY OF CHAPTER. This chapter applies

only to a group health benefit plan delivered or issued for

delivery in this state that:

(1) provides benefits for dental, medical, or surgical expenses

incurred as a result of a health condition, accident, or

sickness, including:

(A) a group, blanket, or franchise insurance policy or insurance

agreement, a group hospital service contract, or a group evidence

of coverage that is offered by:

(i) an insurance company;

(ii) a group hospital service corporation operating under

Chapter 842;

(iii) a fraternal benefit society operating under Chapter 885;

(iv) a stipulated premium company operating under Chapter 884;

or

(v) a health maintenance organization operating under Chapter

843; and

(B) to the extent permitted by the Employee Retirement Income

Security Act of 1974 (29 U.S.C. Section 1001 et seq.), a health

benefit plan that is offered by:

(i) a multiple employer welfare arrangement as defined by

Section 3 of that Act;

(ii) an entity not authorized under this code or another

insurance law of this state that contracts directly for health

care services on a risk-sharing basis, including a capitation

basis; or

(iii) another analogous benefit arrangement; or

(2) is offered by an approved nonprofit health corporation that

holds a certificate of authority under Chapter 844.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.

Sec. 1360.003. EXCEPTION. This chapter does not apply to:

(1) a plan that provides coverage:

(A) only for a specified disease or another limited benefit;

(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 because of sickness or

injury;

(D) as a supplement to a liability insurance policy;

(E) for credit insurance;

(F) only for vision care; or

(G) only for indemnity for hospital confinement;

(2) a Medicare supplemental policy as defined by Section

1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss);

(3) a workers' compensation insurance policy;

(4) a small employer health benefit plan written under Chapter

1501;

(5) medical payment insurance coverage provided under a motor

vehicle insurance policy; or

(6) a long-term care insurance policy, including a nursing home

fixed indemnity policy, unless the commissioner determines that

the policy provides benefit coverage so comprehensive that the

policy is a health benefit plan as described by Section 1360.002.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.

Sec. 1360.004. COVERAGE REQUIRED. (a) A health benefit plan

that provides coverage for medically necessary diagnostic or

surgical treatment of conditions affecting skeletal joints must

provide comparable coverage for diagnostic or surgical treatment

of conditions affecting the temporomandibular joint if the

treatment is medically necessary as a result of:

(1) an accident;

(2) a trauma;

(3) a congenital defect;

(4) a developmental defect; or

(5) a pathology.

(b) Coverage required under this section may be subject to any

provision in the health benefit plan that is generally applicable

to surgical treatment, including a requirement for

precertification of coverage.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.

Sec. 1360.005. DENTAL SERVICES COVERAGE NOT REQUIRED. (a) This

chapter does not require a health benefit plan to provide

coverage for dental services if dental services are not otherwise

scheduled or provided as part of the coverage provided under the

plan.

(b) A health benefit plan may not exclude from coverage under

the plan an individual who is unable to undergo dental treatment

in an office setting or under local anesthesia due to a

documented physical, mental, or medical reason as determined by

the individual's physician or by the dentist providing the dental

care.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.