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Texas Administrative Code (Last Updated: March 27,2024) |
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TITLE 28. INSURANCE |
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PART 1. TEXAS DEPARTMENT OF INSURANCE |
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CHAPTER 21. TRADE PRACTICES |
| SUBCHAPTER A. UNFAIR COMPETITION AND UNFAIR PRACTICES OF INSURERS, AND MISREPRESENTATION OF POLICIES |
| § 21.1. Deceptive Acts or Practices of Insurers, Agents, and Connected Persons |
| § 21.2. Interpretations |
| § 21.3. Unfair Trade Practices Prohibited |
| § 21.4. Misrepresentation Defined; Standards for Determining Misrepresentation |
| § 21.5. Enforcement |
| § 21.6. Prohibition against the Use of Guaranty Fund Protection in the Sale of Insurance |
| SUBCHAPTER B. ADVERTISING, CERTAIN TRADE PRACTICES, AND SOLICITATION |
| DIVISION 1. INSURANCE ADVERTISING |
| § 21.101. Purpose |
| § 21.102. Scope |
| § 21.103. Required Form and Content of Advertisements |
| § 21.104. Requirement of Identification of Policy or Insurer |
| § 21.105. Description of Benefits, Coverage, and Policy Provisions |
| § 21.106. Premiums |
| § 21.107. Testimonials, Appraisals, or Analyses |
| § 21.108. Use of Statistics and Citations |
| § 21.109. Unlawful Inducement |
| § 21.110. Disparagements |
| § 21.111. Comparisons |
| § 21.112. General Prohibition |
| § 21.113. Rules Pertaining Specifically to Accident and Health Insurance Advertising and Health Maintenance Organization Advertising |
| § 21.114. Rules Pertaining Specifically to Life Insurance and Annuity Advertising |
| § 21.115. Rules Pertaining Specifically to Property and Casualty Insurance Advertising |
| § 21.116. Special Enforcement Procedures for Rules Governing Advertising and Solicitation of Insurance |
| § 21.117. Conflict with and Affect on Other Regulations |
| § 21.118. Severability |
| § 21.119. Savings Clause |
| § 21.120. Filing for Review |
| § 21.121. Lead Solicitations |
| § 21.122. System of Control and Home Office Approval of Advertising Material Naming an Insurer |
| DIVISION 2. DISCOUNT HEALTH CARE PROGRAM ADVERTISING |
| § 21.151. Purpose and Scope |
| § 21.152. Definitions |
| § 21.153. Content of Advertisement |
| § 21.154. Severability |
| SUBCHAPTER C. UNFAIR CLAIMS SETTLEMENT PRACTICES |
| § 21.201. Short Title |
| § 21.202. Definitions |
| § 21.203. Unfair Claim Settlement Practices |
| § 21.204. Special Claim Reports and Statistical Plan |
| § 21.205. Minimum Standard of Performance |
| SUBCHAPTER D. STATISTICAL AGENTS |
| § 21.301. Performance Standards for Designated Statistical Agent |
| SUBCHAPTER E. UNFAIR DISCRIMINATION BASED ON SEX OR MARITAL STATUS |
| § 21.401. Purpose |
| § 21.402. Applicability and Scope |
| § 21.403. Definitions |
| § 21.404. Underwriting |
| § 21.405. Policy Terms and Conditions |
| § 21.406. Rates |
| § 21.407. Continuance of Coverage |
| § 21.408. Amendments |
| § 21.409. Severability Clause |
| SUBCHAPTER H. UNFAIR DISCRIMINATION |
| § 21.701. Purpose |
| § 21.702. Unfairly Discriminatory Acts or Practices |
| § 21.703. Definitions Concerning Discrimination |
| § 21.704. Unfair Discrimination |
| § 21.705. Nondiscriminatory Testing for Human Immunodeficiency Virus |
| SUBCHAPTER I. PROHIBITED AGENT PRACTICES |
| § 21.901. Prohibition Against Solicitation or Acceptance of Power of Attorney |
| SUBCHAPTER J. PROHIBITED TRADE PRACTICES |
| § 21.1001. Prohibition against Insurer's Non-renewing Personal Auto Policy Solely Because of Age of Young Driver |
| § 21.1004. Restrictions on Certain Claims in Residential Property Insurance and Transition Plan Requirement |
| § 21.1005. Prohibition of Underwriting Guidelines Based on the Purchase of Types or Amounts of Coverage in Excess of Minimum Limits Liability Coverage |
| § 21.1006. Prohibition Against Declining to Write Residential Property Insurance Based on the Age or Value of the Property |
| § 21.1007. Restrictions on Using Guidelines Based on a Water Damage Claim, Previous Mold Damage, or a Mold Damage Claim |
| SUBCHAPTER K. CERTIFICATION OF CREDITABLE COVERAGE |
| § 21.1101. Definitions |
| § 21.1102. Certification of Coverage |
| § 21.1103. Timing of Issuance of a Written Certificate of Creditable Coverage to an Individual |
| § 21.1104. Form and Content of Written Certificate of Creditable Coverage |
| § 21.1105. Delivery of Certificate of Creditable Coverage |
| § 21.1106. Dependent Coverage |
| § 21.1107. Creditable Coverage Established Through Means Other Than Written Certificate |
| § 21.1108. Notification of Creditable Coverage and Preexisting Condition Exclusion |
| § 21.1109. Severability |
| § 21.1110. Form CCC |
| SUBCHAPTER L. MEDICAL CHILD SUPPORT, UNFAIR PRACTICES |
| § 21.2001. Definitions |
| § 21.2002. Prohibition Against Denial of Enrollment |
| § 21.2004. Enrollment of Child Who Is the Subject of a Medical Support Order |
| § 21.2005. Prohibition on Cancellation or Nonrenewal |
| § 21.2006. Notice of Availability of Continuation or Conversion Coverage |
| § 21.2007. Assignment of Medical Support Rights to State Agency |
| § 21.2008. Information Provided by an Insurer |
| § 21.2009. Submission and Payment of Claims |
| § 21.2010. Prohibition on Service Area Restrictions |
| § 21.2011. Unfair or Deceptive Practices |
| SUBCHAPTER M. MANDATORY BENEFIT NOTICE REQUIREMENTS |
| § 21.2101. Scope |
| § 21.2102. Definitions |
| § 21.2103. Mandatory Benefit Notices |
| § 21.2105. Delivery of Mandatory Benefit Notices |
| § 21.2106. Forms |
| § 21.2107. Right To Medicare Supplement Coverage Notice |
| SUBCHAPTER N. LIFE INSURANCE ILLUSTRATIONS |
| § 21.2201. Purpose |
| § 21.2202. Authority |
| § 21.2203. Applicability and Scope |
| § 21.2204. Definitions |
| § 21.2205. Policies To Be Illustrated |
| § 21.2206. General Rules and Prohibitions |
| § 21.2207. Standards for Basic Illustrations |
| § 21.2208. Standards for Supplemental Illustrations |
| § 21.2209. Delivery of Illustration and Record Retention |
| § 21.2210. Annual Report; Notice to Policy Owners |
| § 21.2211. Annual Certification |
| § 21.2212. Penalties |
| § 21.2213. Separability, Conflict with and Effect on Other Regulations |
| § 21.2214. Effective Date |
| SUBCHAPTER P. MENTAL HEALTH AND SUBSTANCE USE DISORDER PARITY |
| DIVISION 1. GENERAL PROVISIONS AND PARITY REQUIREMENTS |
| § 21.2401. Purpose and Scope |
| § 21.2402. Applicability |
| § 21.2403. Coordination of Statutory Language |
| § 21.2404. Differences from Federal Rules |
| § 21.2405. Corrective Action; Severability |
| § 21.2406. Definitions |
| § 21.2407. Parity Requirements with Respect to Aggregate Lifetime and Annual Dollar Limits |
| § 21.2408. Parity Requirements with Respect to Financial Requirements and Treatment Limitations |
| § 21.2409. Nonquantitative Treatment Limitations |
| § 21.2411. Availability of Plan Information |
| § 21.2413. Sale of Nonparity Health Benefit Plans |
| § 21.2414. Source-of-Injury Exclusions |
| DIVISION 2. PLAN INFORMATION AND DATA COLLECTION |
| § 21.2421. Definitions - Division 2 |
| § 21.2422. Deadline for Reporting Data |
| § 21.2423. Collecting and Reporting Data |
| § 21.2424. Issuer and Plan Information |
| § 21.2425. Claims and Utilization Review: Reporting Classifications |
| § 21.2426. Claims and Utilization Review: Aggregate Data Fields |
| § 21.2427. Plan Reimbursement Rates Compared with Medicare Rates |
| DIVISION 3. COMPLIANCE ANALYSIS FOR MH/SUD PARITY |
| § 21.2431. Required Analyses for Quantitative and Nonquantitative Parity; Alternative Tools |
| § 21.2432. Due Dates for Analyses |
| § 21.2433. Compliance Analysis for Quantitative Parity: General Requirements |
| § 21.2434. Quantitative Parity Analysis: Issuer and Plan Information |
| § 21.2435. Quantitative Parity Analysis: Methodology for Determining Expected Payments |
| § 21.2436. Quantitative Parity Analysis: Covered Benefits |
| § 21.2437. Quantitative Parity Analysis: "Substantially All" and "Predominant" Tests |
| § 21.2438. Compliance Analysis for Nonquantitative Parity: General Instructions |
| § 21.2439. Nonquantitative Treatment Limitations Generally |
| § 21.2440. Nonquantitative Parity Analysis: Issuer and Plan Information |
| § 21.2441. Four-Step Analysis of Nonquantitative Treatment Limitations |
| DIVISION 4. AUTISM SPECTRUM DISORDER |
| § 21.2451. Applicability |
| § 21.2452. Coordination of Provisions in Insurance Code Chapter 1355, Concerning Benefits for Certain Mental Disorders |
| SUBCHAPTER Q. COMPLAINT RECORDS TO BE MAINTAINED |
| § 21.2501. Applicability and Purpose |
| § 21.2502. Definitions |
| § 21.2503. Compliance Standard |
| § 21.2504. Complaint Record; Required Elements; Explanation and Instructions |
| § 21.2505. Complaint Record Form |
| § 21.2506. Maintenance Basis and Compilation Frequency of the Complaint Record |
| § 21.2507. Effective Date |
| SUBCHAPTER R. DIABETES |
| § 21.2601. Definitions |
| § 21.2602. Required Benefits for Persons with Diabetes |
| § 21.2603. Out of Pocket Expenses |
| § 21.2604. Minimum Standards for Benefits for Persons with Diabetes, Requirement for Periodic Assessment of Physician and Organizational Compliance |
| § 21.2605. Diabetes Equipment and Supplies |
| § 21.2606. Diabetes Self-Management Training |
| SUBCHAPTER S. ASSOCIATION PLANS |
| § 21.2701. Scope |
| § 21.2702. Definitions |
| § 21.2703. Health Care Plans Issued to Associations and Bona Fide Associations |
| § 21.2704. Mandatory Guaranteed Renewability Provisions for Health Benefit Plans Issued to Members of an Association or Bona Fide Association |
| § 21.2705. Certification of Creditable Coverage |
| § 21.2706. Coverage and Issuance Requirements to Bona Fide Associations |
| SUBCHAPTER T. SUBMISSION OF CLEAN CLAIMS |
| § 21.2801. Purpose and Scope |
| § 21.2802. Definitions |
| § 21.2803. Elements of a Clean Claim |
| § 21.2804. Requests for Additional Information from Treating Preferred Provider |
| § 21.2805. Requests for Additional Information from Other Sources |
| § 21.2806. Claims Filing Deadline |
| § 21.2807. Effect of Filing a Clean Claim |
| § 21.2808. Effect of Filing Deficient Claim |
| § 21.2809. Audit Procedures |
| § 21.2810. Date of Claim Payment |
| § 21.2811. Disclosure of Processing Procedures |
| § 21.2812. Denial of Clean Claim Prohibited for Change of Address |
| § 21.2813. Requirements Applicable to Other Contracting Entities |
| § 21.2814. Electronic Adjudication of Prescription Benefits |
| § 21.2815. Failure to Meet the Statutory Claims Payment Period |
| § 21.2816. Date of Receipt |
| § 21.2817. Terms of Contracts |
| § 21.2818. Overpayment of Claims |
| § 21.2819. Catastrophic Event |
| § 21.2820. Identification Cards |
| § 21.2821. Reporting Requirements |
| § 21.2822. Administrative Penalties |
| § 21.2823. Applicability to Certain Noncontracting Physicians and Providers |
| § 21.2824. Applicability |
| § 21.2825. Severability |
| § 21.2826. Waiver |
| SUBCHAPTER U. ARRANGEMENTS BETWEEN INDEMNITY CARRIERS AND HMOS FOR POINT-OF-SERVICE COVERAGE |
| § 21.2901. Definitions |
| § 21.2902. Arrangements between Indemnity Carriers and HMOs to Provide Coverage |
| SUBCHAPTER V. PHARMACY BENEFITS |
| DIVISION 1. GENERAL PROVISIONS |
| § 21.3001. Applicability and Severability |
| DIVISION 2. IDENTIFICATION CARDS |
| § 21.3002. Definitions; Pharmacy Identification Cards |
| § 21.3003. Standard Identification Cards |
| § 21.3004. Issuance of Standard Identification Cards |
| DIVISION 3. OFF-LABEL DRUGS |
| § 21.3010. Definitions; Coverage of Off-Label Drugs |
| § 21.3011. Minimum Standards of Coverage for Off-Label Drug Use |
| DIVISION 4. PRESCRIPTION DRUG FORMULARY COVERAGE AND DISCLOSURE REQUIREMENTS |
| § 21.3020. Definitions; Prescription Drug Formulary |
| § 21.3022. Continuation of Benefits |
| § 21.3023. Nonformulary Prescription Drugs; Adverse Determination |
| § 21.3030. Availability of Formulary Information |
| § 21.3031. Formulary Information for Individual Health Benefit Plans on Issuer's Website |
| § 21.3032. Formulary Disclosure Requirements for Individual Health Benefit Plans |
| § 21.3033. Facilitating Comparison Shopping for Individual Health Benefit Plans |
| SUBCHAPTER W. COVERAGE FOR ACQUIRED BRAIN INJURY |
| § 21.3101. General Provisions |
| § 21.3102. Definitions |
| § 21.3103. Coverage for Services |
| § 21.3104. Training |
| § 21.3105. Provision of CPT Codes |
| § 21.3106. Small Employer Health Benefit Plans |
| § 21.3107. Mandatory Annual Notice to Insureds and Enrollees |
| SUBCHAPTER X. EVALUATION OF NETWORK PHYSICIANS AND PROVIDERS |
| § 21.3201. Texas Standardized Credentialing Application for Physicians, Advanced Practice Nurses, and Physician Assistants |
| § 21.3202. Physician Ranking Requirements |
| SUBCHAPTER Y. UNFAIR DISCRIMINATION IN COMPENSATION FOR WOMEN'S HEALTH CARE |
| § 21.3301. Purpose |
| § 21.3302. Definitions |
| § 21.3303. Applicability |
| § 21.3304. Reimbursements |
| § 21.3305. Complaints |
| SUBCHAPTER Z. DATA COLLECTING AND REPORTING RELATING TO MANDATED HEALTH BENEFITS AND MANDATED OFFERS OF COVERAGE |
| § 21.3401. Purpose and Scope |
| § 21.3402. Definitions |
| § 21.3403. Collection of Data Necessary to Provide Report |
| § 21.3404. Deadline for Submission of Reports |
| § 21.3405. Exceptions to Required Reporting and Justification for Exceptions |
| § 21.3406. Mandates for Which Data Must Be Reported |
| § 21.3407. Reporting of Required Information |
| § 21.3408. Compliance |
| § 21.3409. Severability |
| SUBCHAPTER AA. CONSUMER CHOICE HEALTH BENEFIT PLANS |
| DIVISION 1. GENERAL PROVISIONS |
| § 21.3501. Statement of Purpose |
| § 21.3502. Definitions |
| § 21.3503. Authority to Offer |
| § 21.3504. Severability |
| § 21.3505. Application Date |
| § 21.3506. State-Mandated Health Benefits in Blanket Indemnity Policies |
| DIVISION 3. REQUIRED NOTICES |
| § 21.3529. Duty of Agent |
| § 21.3530. Health Carrier Disclosure |
| § 21.3535. Retention of Disclosure |
| DIVISION 4. ADDITIONAL REQUIREMENTS |
| § 21.3540. Direct Access to Services |
| § 21.3541. Basic Health Care Services |
| § 21.3542. Offer of State-Mandated Plan |
| § 21.3543. Required Plan Filings |
| § 21.3544. Required Annual Reporting |
| SUBCHAPTER BB. DENTAL CARE BENEFITS |
| § 21.3601. Scope |
| § 21.3602. Definitions |
| § 21.3603. Right to Choose Dentist |
| § 21.3604. Payment of Benefits for Dental Care Services |
| § 21.3605. Applicability |
| § 21.3606. Severability |
| SUBCHAPTER CC. ELECTRONIC HEALTH CARE TRANSACTIONS |
| § 21.3701. Electronic Claims Filing Requirements |
| SUBCHAPTER DD. ELIGIBILITY STATEMENTS |
| § 21.3801. Scope and Applicability |
| § 21.3802. Definitions |
| § 21.3803. Method for Requesting Eligibility Statements |
| § 21.3804. Requests for Eligibility Statements |
| § 21.3805. Requirement to Provide Eligibility Statements |
| § 21.3806. Privacy Issues |
| § 21.3807. Effect of Eligibility Statement |
| § 21.3808. Severability |
| SUBCHAPTER EE. HIGH DEDUCTIBLE HEALTH PLANS |
| § 21.3901. Purpose |
| § 21.3902. Definitions |
| § 21.3903. Applicability of State Mandates to High Deductible Health Plans |
| § 21.3904. Exemption from State Mandates for High Deductible Health Plans |
| § 21.3905. Applicability |
| SUBCHAPTER FF. OBLIGATION TO CONTINUE PREMIUM PAYMENT AND COVERAGE AFTER NOTICE OF LOST GROUP ELIGIBILITY |
| § 21.4001. Purpose and Scope |
| § 21.4002. Definitions |
| § 21.4003. Group Policyholder, Group Contract Holder, and Carrier Premium Payment and Coverage Obligations |
| SUBCHAPTER GG. HEALTH CARE QUALITY ASSURANCE PRESUMED COMPLIANCE |
| § 21.4101. Purpose and Scope |
| § 21.4102. Definitions |
| § 21.4103. Presumed Compliance |
| § 21.4104. Health Benefit Plan Issuers Contracting with Delegated Entities, Delegated Third Parties, and Utilization Review Agents |
| § 21.4105. Department Monitoring and Analysis of National Accreditation Organization Standards |
| § 21.4106. Confidentiality |
| SUBCHAPTER HH. MILITARY SALES PRACTICES |
| § 21.4201. Purpose |
| § 21.4202. Scope |
| § 21.4203. Exemptions |
| § 21.4204. Definitions |
| § 21.4205. Practices Declared False, Misleading, Deceptive or Unfair on a Military Installation |
| § 21.4206. Practices Declared Deceptive or Unfair Regardless of Location |
| § 21.4207. Severability |
| SUBCHAPTER II. RECOGNITION OF NATIONAL CERTIFYING ORGANIZATIONS FOR NONINVASIVE SCREENING OF CARDIOVASCULAR DISEASE |
| § 21.4301. Recognition |
| SUBCHAPTER KK. HEALTH CARE REIMBURSEMENT RATE INFORMATION |
| § 21.4501. Purpose |
| § 21.4502. Applicability |
| § 21.4503. Definitions |
| § 21.4504. Geographic Regions |
| § 21.4505. Requirement to Collect Data |
| § 21.4506. Submission of Report |
| § 21.4507. Data Required |
| SUBCHAPTER MM. WELLNESS PROGRAMS |
| § 21.4701. Applicability and Scope |
| § 21.4702. Definitions |
| § 21.4703. Wellness Programs Exception |
| § 21.4704. Purposes |
| § 21.4705. General Provisions Applicable to Wellness Programs |
| § 21.4706. Wellness Programs With Participation as Sole Basis for Reward Eligibility |
| § 21.4707. Activity-only Wellness Programs |
| § 21.4708. Outcome-Based Wellness Programs |
| SUBCHAPTER NN. NONINSURANCE BENEFITS AND FEATURES |
| § 21.4801. Applicability and Scope |
| § 21.4802. Definition of Noninsurance Benefit |
| § 21.4803. Purpose |
| § 21.4804. Reasonable Relation to Policy, Contract or Certificate |
| § 21.4805. Disclosure Requirements for Form Filings that Include Noninsurance Benefits |
| § 21.4806. Additional Provisions Applicable to Noninsurance Benefits |
| § 21.4807. Noninsurance Benefits Composed of Certain Discount Programs |
| SUBCHAPTER OO. DISCLOSURES BY OUT-OF-NETWORK PROVIDERS |
| § 21.4901. Purpose and Applicability |
| § 21.4902. Definitions |
| § 21.4903. Out-of-Network Notice and Disclosure Requirements |
| § 21.4904. Health Benefit Plan Issuer and Administrator Responsibility |
| SUBCHAPTER PP. OUT-OF-NETWORK CLAIM DISPUTE RESOLUTION |
| DIVISION 1. GENERAL PROVISIONS |
| § 21.5001. Purpose |
| § 21.5002. Scope |
| § 21.5003. Definitions |
| DIVISION 2. MEDIATION PROCESS |
| § 21.5010. Qualified Mediation Claim Criteria |
| § 21.5011. Mediation Request Procedure |
| § 21.5012. Informal Settlement Teleconference |
| § 21.5013. Mediation Participation |
| DIVISION 3. ARBITRATION PROCESS |
| § 21.5020. Qualified Arbitration Claim Criteria |
| § 21.5021. Arbitration Request Procedure |
| § 21.5022. Informal Settlement Teleconference |
| § 21.5023. Arbitration Participation |
| DIVISION 4. COMPLAINT RESOLUTION AND OUTREACH |
| § 21.5030. Complaint Resolution |
| DIVISION 5. EXPLANATION OF BENEFITS |
| § 21.5040. Required Explanation of Benefits and Enrollee Identification Card Information |
| DIVISION 6. BENCHMARKING |
| § 21.5050. Submission of Information |
| DIVISION 7. SUBMISSION REQUIREMENTS FOR ELECTION BY ERISA PLANS |
| § 21.5060. Election Submission Requirements |
| DIVISION 8. EMERGENCY MEDICAL SERVICE RATE SUBMISSION AND PAYMENT REQUIREMENTS |
| § 21.5070. Rate Database for Emergency Medical Services Providers |
| § 21.5071. Payments to Emergency Medical Services Providers |
| SUBCHAPTER RR. STANDARD PROOF OF HEALTH INSURANCE FOR MEDICAL BENEFITS FOR INJURIES INCURRED AS A RESULT OF A MOTORCYCLE ACCIDENT |
| § 21.5201. Identification Cards - Health Coverage for Motorcycle Injuries |
| SUBCHAPTER SS. CONTINUATION AND CONVERSION PROVISIONS |
| DIVISION 1. GENERAL PROVISIONS |
| § 21.5301. Purpose |
| § 21.5302. Definitions |
| DIVISION 2. GROUP CONTINUATION PROVISIONS |
| § 21.5310. Mandatory Group Continuation Privilege |
| § 21.5311. Notification Requirement of Insurers, Employer and Group Policyholders, and HMOs |
| § 21.5312. Continuation Election and Effective Dates |
| § 21.5313. Continuation Premium |
| § 21.5314. Mandatory Group Continuation Provisions |
| DIVISION 3. GROUP CONVERSION PROVISIONS |
| § 21.5320. Offer of Conversion |
| § 21.5321. Notice of Conversion Options |
| § 21.5322. Coverage for Children |
| SUBCHAPTER TT. ALL-PAYOR CLAIMS DATABASE |
| § 21.5401. Applicability |
| § 21.5402. Definitions |
| § 21.5403. Texas APCD Common Data Layout and Submission Guide |
| § 21.5404. Data Submission Requirements |
| § 21.5405. Timing and Frequency of Data Submissions |
| § 21.5406. Stakeholder Advisory Group Terms |
| SUBCHAPTER UU. MACHINE-READABLE FILES |
| § 21.5501. Applicability and Effective Date |
| § 21.5502. Form and Method of Publishing Machine-Readable Files |
| § 21.5503. Data Schemas |