SECTION 13.523. Applicable Insurance Code Provisions

(a) The following provisions of the Insurance Code are applicable to an approved PEO to the same extent as the provisions apply to any entity TDI regulates under those provisions:

(1) Insurance Code Chapter 36, Subchapter C, concerning General Subpoena Powers; Witnesses and Production of Records;

(2) Insurance Code Chapter 36, Subchapter D, concerning Judicial Review;

(3) Insurance Code §38.001, concerning Inquiries;

(4) Insurance Code Chapter 38, Subchapter F, concerning Data Collecting and Reporting Relating to Mandated Health Benefits and Mandated Offers of Coverage;

(5) Insurance Code Chapter 38, Subchapter H, concerning Health Care Reimbursement Rate Information;

(6) Insurance Code Chapter 40, concerning Duties of State Office of Administrative Hearings and Commissioner in Certain Proceedings; Rate Setting Proceedings;

(7) Insurance Code Chapters 82, concerning Sanctions;

(8) Insurance Code Chapter 83, concerning Emergency Cease and Desist Orders;

(9) Insurance Code Chapter 84, concerning Administrative Penalties;

(10) Insurance Code Chapter 101, concerning Unauthorized Insurance;

(11) Insurance Code Chapter 461, concerning General Provisions;

(12) Insurance Code §521.005, concerning Notice to Accompany Policy;

(13) Insurance Code Chapter 541, Subchapter A, concerning General Provisions;

(14) Insurance Code Chapter 541, Subchapter B, concerning Unfair Methods of Competition and Unfair or Deceptive Acts or Practices Defined;

(15) Insurance Code Chapter 541, Subchapter B-1, concerning Advertising Requirements;

(16) Insurance Code Chapter 542, concerning Processing and Settlement of Claims;

(17) Insurance Code Chapter 543, concerning Prohibited Practices Related to Policy or Certificate of Membership;

(18) Insurance Code Chapter 544, Subchapter A, concerning General Prohibitions Against Discrimination by an Insurer or Health Maintenance Organization;

(19) Insurance Code Chapter 544, Subchapter B, concerning Other General Prohibitions Against Discrimination by Insurers;

(20) Insurance Code Chapter 544, Subchapter C, concerning English Fluency;

(21) Insurance Code Chapter 544, Subchapter D, concerning Family Violence;

(22) Insurance Code Chapter 544, Subchapter E, concerning Fibrocystic Breast Condition;

(23) Insurance Code Chapter 545, concerning HIV Testing;

(24) Insurance Code Chapter 546, concerning Use of Genetic Testing Information;

(25) Insurance Code §550.002, concerning Increase in Certain Premium Payments;

(26) Insurance Code Chapter 558, concerning Refund of Unearned Premium;

(27) Insurance Code Chapter 560, concerning Prohibited Rates;

(28) Insurance Code Chapter 601, concerning Privacy;

(29) Insurance Code Chapter 602, concerning Privacy of Health Information;

(30) Insurance Code Chapter 701, concerning Insurance Fraud Investigations;

(31) Insurance Code Chapter 705, concerning Misrepresentations by Policyholders;

(32) Insurance Code Chapter 801, concerning Certificate of Authority;

(33) Insurance Code Chapter 803, concerning Location of Books, Records, Accounts, and Offices Outside of this State;

(34) Insurance Code Chapter 804, concerning Service of Process;

(35) Insurance Code Chapter 823, Subchapter B, concerning Registration;

(36) Insurance Code Chapter 823, Subchapter C, concerning Transactions of Registered Insurer;

(37) Insurance Code Chapter 823, Subchapter D, concerning Control of Domestic Insurer; Acquisition or Merger;

(38) Insurance Code §1201.013, concerning Programs Promoting Disease Prevention, Wellness, and Health;

(39) Insurance Code §1201.059, concerning Termination of Coverage Based on Age of Child in Individual, Blanket, or Group Policy;

(40) Insurance Code §1201.062, concerning Coverage for Certain Children in Individual or Group Policy or in Plan or Program;

(41) Insurance Code §1201.063, concerning Prohibition of Certain Criteria Relating to a Child's Coverage in Individual or Group Policy;

(42) Insurance Code §1201.064, concerning Coverage for Child of Spouse in Individual or Group Policy;

(43) Insurance Code Chapter 1203, concerning Coordination of Benefits Provisions;

(44) Insurance Code Chapter 1204, Subchapter A, concerning Payments to Certain Public Hospitals;

(45) Insurance Code Chapter 1204, Subchapter B, concerning Assignment of Benefit Payments;

(46) Insurance Code Chapter 1204, Subchapter D, concerning Payments for Certain Publicly Provided Services;

(47) Insurance Code Chapter 1204, Subchapter E, concerning Exclusionary Clauses;

(48) Insurance Code Chapter 1204, Subchapter F, concerning Payment of Benefits to Conservator of Minor;

(49) Insurance Code Chapter 1205, concerning Certificate of Creditable Coverage;

(50) Insurance Code Chapter 1206, concerning Denial of Health Benefit Plan Enrollment Based on Existing Coverage Prohibited;

(51) Insurance Code Chapter 1207, concerning Enrollment of Medical Assistance Recipients and Children Eligible for State Child Health Plan;

(52) Insurance Code Chapter 1208, concerning Identity of Available Employee of Health Benefit Plan Issuer;

(53) Insurance Code Chapter 1210, concerning Notice of Certain Policy Provisions;

(54) Insurance Code Chapter 1213, concerning Electronic Health Care Transactions;

(55) Insurance Code Chapter 1214, concerning Advertising for Certain Health Benefits;

(56) Insurance Code Chapter 1215, concerning Reporting of Claims Information;

(57) Insurance Code Chapter 1216, concerning Out-of-Country Coverage Prohibited;

(58) Insurance Code Chapter 1251, Subchapter C, concerning Group Accident and Health Insurance: Required Provisions;

(59) Insurance Code Chapter 1251, Subchapter D, concerning Group Accident and Health Insurance: Coverage for Dependents;

(60) Insurance Code Chapter 1251, Subchapter E, concerning Group Accident and Health Insurance: General Provisions;

(61) Insurance Code Chapter 1251, Subchapter F, concerning Continuation or Conversion Privilege on Termination of Coverage under Group Policy, except that an approved PEO may not offer a conversion policy under Insurance Code §1251.256, concerning Conversion of Group Policy;

(62) Insurance Code Chapter 1251, Subchapter G, concerning Continuation of Group Coverage for Certain Family Members and Dependents;

(63) Insurance Code Chapter 1252, concerning Discontinuation and Replacement of Group and Group-Type Health Benefit Plan Coverage;

(64) Insurance Code Chapter 1274, concerning Electronic Transmission of Eligibility and Payment Status;

(65) Insurance Code Chapter 1301, concerning Preferred Provider Benefit Plans, except that a small PEO plan is not subject to §1301.009, concerning Annual Report;

(66) Insurance Code Chapter 1351, concerning Home Health Services;

(67) Insurance Code Chapter 1352, concerning Brain Injury;

(68) Insurance Code Chapter 1355, concerning Benefits for Certain Mental Disorders;

(69) Insurance Code Chapter 1356, concerning Low-Dose Mammography;

(70) Insurance Code Chapter 1357, concerning Mastectomy;

(71) Insurance Code Chapter 1358, concerning Diabetes;

(72) Insurance Code Chapter 1359, concerning Formulas for Individuals with Phenylketonuria or Other Heritable Diseases;

(73) Insurance Code Chapter 1360, concerning Diagnosis and Treatment Affecting Temporomandibular Joint;

(74) Insurance Code Chapter 1361, concerning Detection and Prevention of Osteoporosis;

(75) Insurance Code Chapter 1362, concerning Certain Tests for Detection of Prostate Cancer;

(76) Insurance Code Chapter 1363, concerning Certain Tests for Detection of Colorectal Cancer;

(77) Insurance Code Chapter 1364, concerning Coverage Provisions Relating to HIV, Aids, or HIV-Related Illnesses;

(78) Insurance Code Chapter 1365, concerning Loss or Impairment of Speech or Hearing;

(79) Insurance Code Chapter 1366, concerning Benefits Related to Fertility and Childbirth;

(80) Insurance Code Chapter 1367, concerning Coverage of Children;

(81) Insurance Code Chapter 1368, concerning Availability of Chemical Dependency Coverage;

(82) Insurance Code Chapter 1369, concerning Benefits Related to Prescription Drugs and Devices and Related Services;

(83) Insurance Code Chapter 1370, concerning Certain Tests for Detection of Human Papillomavirus, Ovarian Cancer, and Cervical Cancer;

(84) Insurance Code Chapter 1371, concerning Coverage for Certain Prosthetic Devices, Orthotic Devices, and Related Services;

(85) Insurance Code Chapter 1376, concerning Certain Tests for Early Detection of Cardiovascular Disease;

(86) Insurance Code Chapter 1377, concerning Coverage for Certain Amino Acid-Based Elemental Formulas;

(87) Insurance Code Chapter 1379, concerning Coverage for Routine Patient Care Costs for Enrollees Participating in Certain Medical Trials;

(88) Insurance Code Chapter 1451, concerning Access to Certain Practitioners and Facilities;

(89) Insurance Code Chapter 1453, concerning Disclosure of Reimbursement Guidelines under Managed Care Plan;

(90) Insurance Code Chapter 1454, concerning Equal Health Care for Women;

(91) Insurance Code Chapter 1455, concerning Telemedicine and Telehealth;

(92) Insurance Code Chapter 1456, concerning Disclosure of Provider Status;

(93) Insurance Code Chapter 1460, concerning Standards Required Regarding Certain Physician Rankings by Health Benefit Plans;

(94) Insurance Code Chapter 1467, concerning Out-of-Network Claim Dispute Resolution;

(95) Insurance Code Chapter 1501, Subchapter A, concerning General Provisions;

(96) Insurance Code Chapter 1501, Subchapter C, concerning Provision of Coverage;

(97) Insurance Code Chapter 1501, Subchapter M, concerning Large Employer Health Benefit Plans;

(98) Insurance Code Chapter 1502, concerning Health Benefit Plans for Children;

(99) Insurance Code Chapter 1503, concerning Coverage of Certain Students;

(100) Insurance Code Chapter 1504, concerning Medical Child Support;

(101) Insurance Code Chapter 1507, Subchapter A, concerning Consumer Choice of Benefits Health Insurance Plans;

(102) Insurance Code Chapter 1653, concerning High Deductible Health Plan;

(103) Insurance Code Chapter 1661, concerning Information Technology;

(104) Insurance Code Chapter 1701, concerning Policy Forms;

(105) Insurance Code Chapter 4201, concerning Utilization Review Agents; and

(106) Insurance Code Chapter 4202, concerning Independent Review Organizations.

(b) Approved PEO as insurer; client as policyholder. For purposes of applying provisions addressing refunds of unearned premiums in Insurance Code Chapter 558, an approved PEO is the equivalent of an insurer, and the approved PEO's client is the equivalent of a policyholder.

(c) Client as plan sponsor. For purposes of applying Insurance Code Chapter 1215, a client is the equivalent of a plan sponsor as defined by Insurance Code §1215.001, concerning Definitions.

(d) Approved PEO as insurer and employer. For purposes of applying Insurance Code Chapter 1251, Subchapters E, F, and G, an approved PEO is the equivalent of both an insurer and an employer.

(e) Approved PEO as insurer; client as group policyholder. For purposes of applying Insurance Code §1301.0061, an approved PEO is the equivalent of an insurer, and the approved PEO's client is the equivalent of a group policyholder.

(f) Approved PEO as employer. For purposes of applying provisions addressing required offers of coverage in Insurance Code Title 8, Subtitle E, concerning Benefits Payable under Health Coverages, an approved PEO is the equivalent of an employer entitled to elect or decline an offer of coverage required by the Insurance Code.

(g) Approved PEO as carrier; client as policyholder. For purposes of applying Insurance Code Chapter 1501, Subchapter A, an approved PEO is the equivalent of a health insurance carrier, and the approved PEO's client is the equivalent of a policyholder.

(h) Approved PEO as large employer issuer; client as employer. For purposes of applying Insurance Code Chapter 1501, Subchapter C, an approved PEO is the equivalent of a large employer health benefit plan issuer, and the approved PEO's client is the equivalent of an employer.

(i) Approved PEO as issuer; client as group contract holder. For purposes of applying provisions in Insurance Code Chapter 1365 addressing required offers of coverage, an approved PEO is the equivalent of a group health benefit plan issuer, and the approved PEO's client is the equivalent of a group contract holder.

Source Note: The provisions of this §13.523 adopted to be effective May 17, 2016, 41 TexReg 3479