CHAPTER 1507. CONSUMER CHOICE OF BENEFITS PLANS

State Codes and Statutes

Statutes > Texas > Insurance-code > Title-8-health-insurance-and-other-health-coverages > Chapter-1507-consumer-choice-of-benefits-plans

INSURANCE CODE

TITLE 8. HEALTH INSURANCE AND OTHER HEALTH COVERAGES

SUBTITLE G. HEALTH COVERAGE AVAILABILITY

CHAPTER 1507. CONSUMER CHOICE OF BENEFITS PLANS

SUBCHAPTER A. CONSUMER CHOICE OF BENEFITS HEALTH INSURANCE PLANS

Sec. 1507.001. PURPOSE. The legislature recognizes the need for

individuals, employers, and other purchasers of coverage in this

state to have the opportunity to choose health insurance plans

that are more affordable and flexible than existing market

policies offering accident and sickness insurance coverage. The

legislature, therefore, seeks to increase the availability of

health insurance coverage by allowing insurers authorized to

engage in the business of insurance in this state to issue

accident and sickness policies that, in whole or in part, do not

offer or provide state-mandated health benefits.

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

728, Sec. 11.074(a), eff. September 1, 2005.

Sec. 1507.002. DEFINITIONS. In this subchapter:

(1) "Health carrier" means any entity authorized under this code

or another insurance law of this state that provides health

insurance or health benefits in this state. The term includes an

insurance company, a group hospital service corporation under

Chapter 842, and a stipulated premium company under Chapter 884.

(2) "Standard health benefit plan" means an accident or sickness

insurance policy that, in whole or in part, does not offer or

provide state-mandated health benefits, but that provides

creditable coverage as defined by Section 1205.004(a) or

1501.102(a).

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

728, Sec. 11.074(a), eff. September 1, 2005.

Sec. 1507.003. STATE-MANDATED HEALTH BENEFITS. (a) For

purposes of this subchapter, "state-mandated health benefits"

means coverage required under this code or other laws of this

state to be provided in an individual, blanket, or group policy

for accident and health insurance or a contract for a

health-related condition that:

(1) includes coverage for specific health care services or

benefits;

(2) places limitations or restrictions on deductibles,

coinsurance, copayments, or any annual or lifetime maximum

benefit amounts; or

(3) includes a specific category of licensed health care

practitioner from whom an insured is entitled to receive care.

(b) For purposes of this subchapter, "state-mandated health

benefits" does not include benefits that are mandated by federal

law or standard provisions or rights required under this code or

other laws of this state to be provided in an individual,

blanket, or group policy for accident and health insurance that

are unrelated to a specific health illness, injury, or condition

of an insured, including provisions related to:

(1) continuation of coverage under:

(A) Subchapters F and G, Chapter 1251;

(B) Section 1201.059; and

(2) termination of coverage under Sections 1202.051 and

1501.108;

(3) preexisting conditions under Subchapter D, Chapter 1201, and

Sections 1501.102-1501.105;

(4) coverage of children, including newborn or adopted children,

under:

(A) Subchapter D, Chapter 1251;

(B) Sections 1201.053, 1201.061, 1201.063-1201.065, and

Subchapter A, Chapter 1367;

(D) Chapter 1503;

(E) Section 1501.157;

(F) Section 1501.158; and

(G) Sections 1501.607-1501.609;

(5) services of practitioners under:

(A) Subchapters A, B, and C, Chapter 1451; or

(B) Section 1301.052;

(6) supplies and services associated with the treatment of

diabetes under Subchapter B, Chapter 1358;

(7) coverage for serious mental illness under Subchapter A,

Chapter 1355;

(8) coverage for childhood immunizations and hearing screening

as required by Subchapters B and C, Chapter 1367, other than

Section 1367.053(c) and Chapter 1353;

(9) coverage for reconstructive surgery for certain craniofacial

abnormalities of children as required by Subchapter D, Chapter

1367;

(10) coverage for the dietary treatment of phenylketonuria as

required by Chapter 1359;

(11) coverage for referral to a non-network physician or

provider when medically necessary covered services are not

available through network physicians or providers, as required by

Section 1271.055; and

(12) coverage for cancer screenings under:

(A) Chapter 1356;

(B) Chapter 1362;

(D) Chapter 1370.

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

728, Sec. 11.074(a), eff. September 1, 2005.

Amended by:

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

730, Sec. 3B.029(a), eff. September 1, 2007.

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

921, Sec. 9.029(a), eff. September 1, 2007.

Sec. 1507.004. STANDARD HEALTH BENEFIT PLANS AUTHORIZED; MINIMUM

REQUIREMENT. (a) A health carrier may offer one or more

standard health benefit plans.

(b) Any standard health benefit plan must include coverage for

direct services to an obstetrical or gynecological care provider

as required by Subchapter F, Chapter 1451.

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

728, Sec. 11.074(a), eff. September 1, 2005.

Sec. 1507.005. NOTICE TO POLICYHOLDER. (a) Each written

application for participation in a standard health benefit plan

must contain the following language at the beginning of the

document in bold type:

"You have the option to choose this Consumer Choice of Benefits

Health Insurance Plan that, either in whole or in part, does not

provide state-mandated health benefits normally required in

accident and sickness insurance policies in Texas. This standard

health benefit plan may provide a more affordable health

insurance policy for you, although, at the same time, it may

provide you with fewer health benefits than those normally

included as state-mandated health benefits in policies in Texas.

If you choose this standard health benefit plan, please consult

with your insurance agent to discover which state-mandated health

benefits are excluded in this policy."

(b) Each standard health benefit plan must contain the following

language at the beginning of the document in bold type:

"This Consumer Choice of Benefits Health Insurance Plan, either

in whole or in part, does not provide state-mandated health

benefits normally required in accident and sickness insurance

policies in Texas. This standard health benefit plan may provide

a more affordable health insurance policy for you, although, at

the same time, it may provide you with fewer health benefits than

those normally included as state-mandated health benefits in

policies in Texas. Please consult with your insurance agent to

discover which state-mandated health benefits are excluded in

this policy."

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

728, Sec. 11.074(a), eff. September 1, 2005.

Sec. 1507.006. DISCLOSURE STATEMENT. (a) A health carrier

providing a standard health benefit plan must provide a proposed

policyholder or policyholder with a written disclosure statement

that:

(1) acknowledges that the standard health benefit plan being

purchased does not provide some or all state-mandated health

benefits;

(2) lists those state-mandated health benefits not included in

the standard health benefit plan; and

(3) if the standard health benefit plan is issued to an

individual policyholder, provides a notice that purchase of the

plan may limit the policyholder's future coverage options in the

event the policyholder's health changes and needed benefits are

not available under the standard health benefit plan.

(b) Each applicant for initial coverage and each policyholder on

renewal of coverage must sign the disclosure statement provided

by the health carrier under Subsection (a) and return the

statement to the health carrier. Under a group policy or

contract, the term "applicant" means the employer.

(1) retain the signed disclosure statement in the health

carrier's records; and

(2) on request from the commissioner, provide the signed

disclosure statement to the department.

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

728, Sec. 11.074(a), eff. September 1, 2005.

Sec. 1507.007. ADDITIONAL POLICIES. A health carrier that

offers one or more standard health benefit plans under this

subchapter must also offer at least one accident or sickness

insurance policy that provides state-mandated health benefits and

is otherwise authorized by this code.

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

728, Sec. 11.074(a), eff. September 1, 2005.

Sec. 1507.008. RATES. A health carrier shall file for

informational purposes the rates to be used with a standard

health benefit plan. Nothing in this section shall be construed

as granting the commissioner any power or authority to determine,

fix, prescribe, or promulgate the rates to be charged for any

individual accident and sickness insurance policy or policies.

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

728, Sec. 11.074(a), eff. September 1, 2005.

Sec. 1507.009. RULES. The commissioner shall adopt rules

necessary to implement this subchapter.

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

728, Sec. 11.074(a), eff. September 1, 2005.

SUBCHAPTER B. CONSUMER CHOICE OF BENEFITS HEALTH MAINTENANCE

ORGANIZATION PLANS

Sec. 1507.051. PURPOSE. The legislature recognizes the need for

individuals and employers in this state to have the opportunity

to choose health maintenance organization plans that are more

affordable and flexible than existing market health care plans

offered by health maintenance organizations. The legislature,

therefore, seeks to increase the availability of health care

plans by allowing health maintenance organizations authorized to

operate health maintenance organizations in this state to issue

group or individual evidences of coverage that, in whole or in

part, do not offer or provide state-mandated health benefits.

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

728, Sec. 11.074(a), eff. September 1, 2005.

Sec. 1507.052. DEFINITIONS. (a) In this subchapter, "standard

health benefit plan" means a group or individual evidence of

coverage that, in whole or in part, does not offer or provide

state-mandated health benefits but that provides creditable

coverage as defined by Section 1205.004(a) or 1501.102(a).

(b) In this subchapter, terms defined by Section 843.002 have

the meanings assigned by that section.

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

728, Sec. 11.074(a), eff. September 1, 2005.

Sec. 1507.053. STATE-MANDATED HEALTH BENEFITS. (a) For

purposes of this subchapter, "state-mandated health benefits"

means coverage required under this code or other laws of this

state to be provided in an evidence of coverage that:

(1) includes coverage for specific health care services or

benefits;

(2) places limitations or restrictions on deductibles,

coinsurance, copayments, or any annual or lifetime maximum

benefit amounts, including limitations provided in Section

1271.151; or

(3) includes a specific category of licensed health care

practitioner from whom an enrollee is entitled to receive care.

(b) For purposes of this subchapter, "state-mandated health

benefits" does not include coverage that is mandated by federal

law or standard provisions or rights required under this code or

other laws of this state to be provided in an evidence of

coverage that are unrelated to a specific health illness, injury,

or condition of an enrollee, including provisions related to:

(1) continuation of coverage under Subchapter G, Chapter 1251;

(2) termination of coverage under Sections 1202.051 and

1501.108;

(3) preexisting conditions under Subchapter D, Chapter 1201, and

Sections 1501.102-1501.105;

(4) coverage of children, including newborn or adopted children,

under:

(A) Chapter 1504;

(B) Chapter 1503;

(D) Section 1501.158; and

(E) Sections 1501.607-1501.609;

(5) services of providers under Section 843.304;

(6) coverage for serious mental health illness under Subchapter

A, Chapter 1355; and

(7) coverage for cancer screenings under:

(A) Chapter 1356;

(B) Chapter 1362;

(D) Chapter 1370.

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

728, Sec. 11.074(a), eff. September 1, 2005.

Amended by:

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

730, Sec. 3B.030(a), eff. September 1, 2007.

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

921, Sec. 9.030(a), eff. September 1, 2007.

Sec. 1507.054. STANDARD HEALTH BENEFIT PLANS AUTHORIZED. A

health maintenance organization authorized to issue an evidence

of coverage in this state may offer one or more standard health

benefit plans.

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

728, Sec. 11.074(a), eff. September 1, 2005.

Sec. 1507.055. NOTICE TO ENROLLEES. (a) Each written

application for enrollment in a standard health benefit plan must

contain the following language at the beginning of the document

in bold type:

"You have the option to choose this Consumer Choice of Benefits

Health Maintenance Organization health care plan that, either in

whole or in part, does not provide state-mandated health benefits

normally required in evidences of coverage in Texas. This

standard health benefit plan may provide a more affordable health

plan for you, although, at the same time, it may provide you with

fewer health plan benefits than those normally included as

state-mandated health benefits in Texas. If you choose this

standard health benefit plan, please consult with your insurance

agent to discover which state-mandated health benefits are

excluded in this evidence of coverage."

(b) Each standard health benefit plan must contain the following

language at the beginning of the document in bold type:

"This Consumer Choice of Benefits Health Maintenance Organization

health care plan, either in whole or in part, does not provide

state-mandated health benefits normally required in evidences of

coverage in Texas. This standard health benefit plan may provide

a more affordable health plan for you, although, at the same

time, it may provide you with fewer health plan benefits than

those normally included as state-mandated health benefits in

Texas. Please consult with your insurance agent to discover

which state-mandated health benefits are excluded in this

evidence of coverage."

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

728, Sec. 11.074(a), eff. September 1, 2005.

Sec. 1507.056. DISCLOSURE STATEMENT. (a) A health maintenance

organization providing a standard health benefit plan must

provide a proposed contract holder or a contract holder with a

written disclosure statement that:

(1) acknowledges that the standard health benefit plan being

purchased does not provide some or all state-mandated health

benefits;

(2) lists those state-mandated health benefits not included in

the standard health benefit plan; and

(3) if the standard health benefit plan is issued to an

individual certificate holder, provides a notice that purchase of

the plan may limit the certificate holder's future coverage

options in the event the certificate holder's health changes and

needed benefits are not available under the standard health

benefit plan.

(b) Each applicant for initial enrollment and each contract

holder on renewal must sign the disclosure statement provided by

the health maintenance organization under Subsection (a) and

return the statement to the health maintenance organization.

Under a group evidence of coverage, the term "applicant" means

the employer.

(1) retain the signed disclosure statement in the organization's

records; and

(2) on request from the commissioner, provide the signed

disclosure statement to the department.

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

728, Sec. 11.074(a), eff. September 1, 2005.

Sec. 1507.057. ADDITIONAL EVIDENCES OF COVERAGE. A health

maintenance organization that offers one or more standard health

benefit plans under this subchapter must also offer at least one

evidence of coverage that provides state-mandated health benefits

and is otherwise authorized by this code.

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

728, Sec. 11.074(a), eff. September 1, 2005.

Sec. 1507.058. RATES. A health maintenance organization shall

file for informational purposes the rates to be used with a

standard health benefit plan. Nothing in this section shall be

construed as granting the commissioner any power or authority to

determine, fix, prescribe, or promulgate the rates to be charged

for any evidence of coverage.

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

728, Sec. 11.074(a), eff. September 1, 2005.

Sec. 1507.059. RULES. The commissioner shall adopt rules

necessary to implement this subchapter.

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

728, Sec. 11.074(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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