CHAPTER 1367. COVERAGE OF CHILDREN

State Codes and Statutes

Statutes > Texas > Insurance-code > Title-8-health-insurance-and-other-health-coverages > Chapter-1367-coverage-of-children

INSURANCE CODE

TITLE 8. HEALTH INSURANCE AND OTHER HEALTH COVERAGES

SUBTITLE E. BENEFITS PAYABLE UNDER HEALTH COVERAGES

CHAPTER 1367. COVERAGE OF CHILDREN

SUBCHAPTER A. NEWBORN CHILDREN

Sec. 1367.001. APPLICABILITY OF SUBCHAPTER. This subchapter

applies only to a health benefit plan delivered or issued for

delivery in this state that is 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. 1367.002. APPLICABILITY OF GENERAL PROVISIONS OF OTHER LAW.

The provisions of Chapter 1201, including provisions relating to

the applicability, purpose, and enforcement of that chapter,

construction of policies under that chapter, rulemaking under

that chapter, and definitions of terms applicable in that

chapter, apply to this subchapter.

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

2005.

Sec. 1367.003. CERTAIN LIMITATIONS ON COVERAGE FOR NEWBORN

CHILDREN PROHIBITED. A health benefit plan that provides

maternity benefits or accident and health coverage for additional

newborn children may not be issued in this state if the plan

excludes or limits:

(1) initial coverage of a newborn child for a period of time; or

(2) coverage for congenital defects of a newborn child.

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

2005.

SUBCHAPTER B. CHILDHOOD IMMUNIZATIONS

Sec. 1367.051. APPLICABILITY OF SUBCHAPTER. This subchapter

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 an individual, group, blanket, or franchise insurance

policy or insurance agreement, a group hospital service contract,

or an individual or group evidence of coverage that is offered

by:

(A) an insurance company;

(B) a group hospital service corporation operating under Chapter

842;

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

(E) a health maintenance organization operating under Chapter

843; or

(F) a multiple employer welfare arrangement subject to

regulation under Chapter 846;

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

holds a certificate of authority under Chapter 844; or

(3) provides health and accident coverage through a risk pool

created under Chapter 172, Local Government Code, notwithstanding

Section 172.014, Local Government Code, or any other law.

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

2005.

Sec. 1367.052. EXCEPTION. This subchapter does not apply to:

(1) a plan that provides coverage:

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

(B) only for accidental death or dismemberment;

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 dental or vision care; or

(G) only for indemnity for hospital confinement;

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

1501;

(3) a Medicare supplemental policy as defined by Section

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

(4) a workers' compensation insurance policy;

(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 1367.051.

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

2005.

Sec. 1367.053. COVERAGE REQUIRED. (a) A health benefit plan

that provides coverage for a family member of an insured or

enrollee shall provide for each covered child from birth through

the date of the child's sixth birthday coverage for:

(1) immunization against:

(A) diphtheria;

(B) haemophilus influenzae type b;

(D) measles;

(E) mumps;

(F) pertussis;

(G) polio;

(H) rubella;

(I) tetanus; and

(J) varicella; and

(2) any other immunization that is required for the child by

law.

(b) For purposes of Subsection (a), a covered child is a child

who, as a result of the child's relationship to an insured or

enrollee in a health benefit plan, would be entitled to coverage

under an accident and health insurance policy under Section

1201.061, 1201.062, 1201.063, or 1201.064.

(a), a health maintenance organization that issues a health

benefit plan shall provide under the plan coverage for

immunization against rotovirus and any other immunization

required for a child by law.

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

2005.

Amended by:

Acts 2007, 80th Leg., R.S., Ch.

730, Sec. 3B.0281, eff. September 1, 2007.

Acts 2007, 80th Leg., R.S., Ch.

921, Sec. 9.0281, eff. September 1, 2007.

Sec. 1367.054. COPAYMENT, DEDUCTIBLE, OR COINSURANCE REQUIREMENT

PROHIBITED. (a) Coverage required under Section 1367.053(a) may

not be made subject to a deductible, copayment, or coinsurance

requirement.

(b) This section does not prohibit the application of a

deductible, copayment, or coinsurance requirement to another

service provided at the same time the immunization is

administered.

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

2005.

Sec. 1367.055. RULES. The commissioner may adopt rules

necessary to implement this subchapter.

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

2005.

Amended by:

Acts 2005, 79th Leg., Ch.

728, Sec. 11.039, eff. September 1, 2005.

SUBCHAPTER C. HEARING TEST

Sec. 1367.101. APPLICABILITY OF SUBCHAPTER. (a) This

subchapter 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 an individual, group, blanket, or franchise insurance

policy or insurance agreement, a group hospital service contract,

or an individual or group evidence of coverage that is offered

by:

(A) an insurance company;

(B) a group hospital service corporation operating under Chapter

842;

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

(E) a health maintenance organization operating under Chapter

843; or

(F) a multiple employer welfare arrangement subject to

regulation under Chapter 846;

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

holds a certificate of authority under Chapter 844; or

(3) provides health and accident coverage through a risk pool

created under Chapter 172, Local Government Code, notwithstanding

Section 172.014, Local Government Code, or any other law.

(b) This subchapter applies to a health benefit plan described

by Subsection (a) that provides coverage to a resident of this

state, regardless of whether the plan issuer is located in or

outside this state.

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

2005.

Sec. 1367.102. EXCEPTION. This subchapter does not apply to:

(1) a plan that provides coverage:

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

(B) only for accidental death or dismemberment;

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 dental or vision care; or

(G) only for indemnity for hospital confinement;

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

1501;

(3) a Medicare supplemental policy as defined by Section

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

(4) a workers' compensation insurance policy;

(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 1367.101.

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

2005.

Sec. 1367.103. COVERAGE REQUIRED. (a) A health benefit plan

that provides coverage for a family member of an insured or

enrollee shall provide to each covered child coverage for:

(1) a screening test for hearing loss from birth through the

date the child is 30 days of age, as provided by Chapter 47,

Health and Safety Code; and

(2) necessary diagnostic follow-up care related to the screening

test from birth through the date the child is 24 months of age.

(b) For purposes of Subsection (a), a covered child is a child

who, as a result of the child's relationship to an insured or

enrollee in a health benefit plan, would be entitled to coverage

under an accident and health insurance policy under Section

1201.061, 1201.062, 1201.063, or 1201.064.

provide the coverage described by this section to a child of an

individual residing in this state if the individual is:

(1) employed outside this state; and

(2) covered under a health benefit plan maintained for the

individual by the individual's employer as an employment benefit.

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

2005.

Sec. 1367.104. COPAYMENT OR COINSURANCE REQUIREMENT PERMITTED;

DEDUCTIBLE REQUIREMENT OR DOLLAR LIMIT PROHIBITED; NOTICE

REQUIRED. (a) Coverage required under this subchapter:

(1) may be subject to a copayment or coinsurance requirement;

and

(2) may not be subject to a deductible requirement or a dollar

limit.

(b) The requirements of this section must be stated in the

coverage document.

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

2005.

Sec. 1367.105. RULES. The commissioner may adopt rules

necessary to implement this subchapter.

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

2005.

SUBCHAPTER D. CHILD CRANIOFACIAL ABNORMALITIES

Sec. 1367.151. APPLICABILITY OF SUBCHAPTER. This subchapter

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 insurance policy

or insurance agreement, a group hospital service contract, or an

individual or 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;

(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. 1367.152. EXCEPTION. This subchapter does not apply to:

(1) a plan that provides coverage:

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

(B) only for accidental death or dismemberment;

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 dental or vision care; or

(G) only for indemnity for hospital confinement or other

hospital expenses;

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

1501;

(3) a Medicare supplemental policy as defined by Section

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

(4) a workers' compensation insurance policy;

(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 1367.151.

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

2005.

Sec. 1367.153. RECONSTRUCTIVE SURGERY FOR CRANIOFACIAL

ABNORMALITIES; DEFINITION REQUIRED. A health benefit plan that

provides coverage for a child who is younger than 18 years of age

must define "reconstructive surgery for craniofacial

abnormalities" under the plan to mean surgery to improve the

function of, or to attempt to create a normal appearance of, an

abnormal structure caused by congenital defects, developmental

deformities, trauma, tumors, infections, or disease.

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

2005.

Sec. 1367.154. RULES. The commissioner shall adopt rules

necessary to administer this subchapter.

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

2005.

SUBCHAPTER E. DEVELOPMENTAL DELAYS

Sec. 1367.201. DEFINITION. In this subchapter, rehabilitative

and habilitative therapies include:

(1) occupational therapy evaluations and services;

(2) physical therapy evaluations and services;

(3) speech therapy evaluations and services; and

(4) dietary or nutritional evaluations.

Added by Acts 2005, 79th Leg., Ch.

728, Sec. 11.040(a), eff. September 1, 2005.

Sec. 1367.202. APPLICABILITY OF SUBCHAPTER. This subchapter

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 an individual, group, blanket, or franchise insurance

policy or insurance agreement, a group hospital service contract,

or an individual or group evidence of coverage that is offered

by:

(A) an insurance company;

(B) a group hospital service corporation operating under Chapter

842;

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

(E) a health maintenance organization operating under Chapter

843; or

(F) a multiple employer welfare arrangement subject to

regulation under Chapter 846;

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

holds a certificate of authority under Chapter 844; or

(3) provides health and accident coverage through a risk pool

created under Chapter 172, Local Government Code, notwithstanding

Section 172.014, Local Government Code, or any other law.

Added by Acts 2005, 79th Leg., Ch.

728, Sec. 11.040(a), eff. September 1, 2005.

Sec. 1367.203. EXCEPTION. This subchapter does not apply to:

(1) a plan that provides coverage:

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

(B) only for accidental death or dismemberment;

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 dental or vision care; or

(G) only for indemnity for hospital confinement;

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

1501;

(3) a Medicare supplemental policy as defined by Section

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

(4) a workers' compensation insurance policy;

(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 1367.202.

Added by Acts 2005, 79th Leg., Ch.

728, Sec. 11.040(a), eff. September 1, 2005.

Sec. 1367.204. OFFER OF COVERAGE REQUIRED. (a) A health

benefit plan issuer must offer coverage that complies with this

subchapter.

(b) The individual or group policy or contract holder may reject

coverage required to be offered under this section.

Added by Acts 2005, 79th Leg., Ch.

728, Sec. 11.040(a), eff. September 1, 2005.

Sec. 1367.205. COVERAGE OF CERTAIN THERAPIES. (a) A health

benefit plan that provides coverage for rehabilitative and

habilitative therapies under this subchapter may not prohibit or

restrict payment for covered services provided to a child and

determined to be necessary to and provided in accordance with an

individualized family service plan issued by the Interagency

Council on Early Childhood Intervention under Chapter 73, Human

Resources Code.

(b) Rehabilitative and habilitative therapies described by

Subsection (a) must be covered in the amount, duration, scope,

and service setting established in the child's individualized

family service plan.

child, as a result of the child's relationship to an insured or

enrollee in a health benefit plan, would be entitled to coverage

under an accident and health insurance policy under Section

1201.061, 1201.062, 1201.063, or 1201.064.

Added by Acts 2005, 79th Leg., Ch.

728, Sec. 11.040(a), eff. September 1, 2005.

Sec. 1367.206. PROHIBITED ACTIONS. Under the coverage required

to be offered under this subchapter, a health benefit plan issuer

may not:

(1) apply the cost of rehabilitative and habilitative therapies

described by Section 1367.205(a) to an annual or lifetime maximum

plan benefit or similar provision under the plan; or

(2) use the cost of rehabilitative or habilitative therapies

described by Section 1367.205(a) as the sole justification for:

(A) increasing plan premiums; or

(B) terminating the insured's or enrollee's participation in the

plan.

Added by Acts 2005, 79th Leg., Ch.

728, Sec. 11.040(a), eff. September 1, 2005.

Sec. 1367.207. RULES. The commissioner may adopt rules

necessary to implement this subchapter.

Added by Acts 2005, 79th Leg., Ch.

728, Sec. 11.040(a), eff. September 1, 2005.

State Codes and Statutes

State Codes and Statutes

State Codes and Statutes

State Codes and Statutes

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