SECTION 3.601. Purpose and Scope, Applicability, and Definitions Used in This Subchapter

(a) Purpose and scope. The sections contained in this subchapter are intended to implement Insurance Code §1501.260 and to establish plain language requirements for health benefit plans or forms that will be approved by the department and issued by health carriers in this state. This subchapter establishes the plain language requirements and minimum score for readability for such health benefit plans or forms, in accordance with Insurance Code §1501.260. This subchapter also establishes procedures that health carriers must follow to demonstrate and assure compliance with the new requirements.

(b) Applicability. This subchapter applies to all health benefit plans, including policies, certificates, evidences of coverage, riders, endorsements, amendments, and/or applications, approved by the commissioner on or after January 1, 1994, and issued in the State of Texas after such date. This subchapter does not apply to a health benefit plan group master policy or to a health benefit plan group master policy application or to an enrollment form for a health benefit plan group master policy when the enrollment form is used solely to enroll individuals in the plan. This subchapter also does not apply to any health benefit plan forms approved by the commissioner under department rules before January 1, 1994.

(c) Definitions.

(1) Commissioner--The commissioner of insurance of the State of Texas.

(2) Form--Any health benefit plan certificate, policy, evidence of coverage, endorsement, amendment, application, or rider.

(3) Franchise insurance policy--An individual health benefit plan under which a number of individual policies are offered to a selected group. The rates for such a policy may differ from the rate applicable to individually solicited policies of the same type and may differ from the rate applicable to individuals of essentially the same class.

(4) Health benefit plan--A group, blanket, or franchise insurance policy, a certificate issued under a group policy, a group hospital service contract, or a group subscriber contract or evidence of coverage issued by a health maintenance organization that provides benefits for health care services. The term does not include:

(A) accident-only insurance coverage;

(B) credit insurance coverage;

(C) disability insurance coverage;

(D) specified disease coverage or other limited benefit policies;

(E) coverage of Medicare services under a federal contract;

(F) Medicare supplement and Medicare Select policies regulated in accordance with federal law;

(G) long-term care insurance coverage;

(H) coverage limited to dental care;

(I) coverage limited to care of vision;

(J) coverage provided by a single-service health maintenance organization;

(K) insurance coverage issued as a supplement to liability insurance;

(L) insurance coverage arising out of a workers' compensation system or similar statutory system;

(M) automobile medical payment insurance coverage;

(N) jointly managed trusts authorized under 29 United States Code §141 et seq. that contain a plan of benefits for employees that is negotiated in a collective bargaining agreement governing wages, hours, and working conditions of the employees that is authorized under 29 United States Code §157;

(O) hospital confinement indemnity coverage; or

(P) reinsurance contracts issued on a stop-loss, quota-share, or similar basis.

(5) Health carrier--Any entity authorized under the Insurance Code to provide health insurance or health benefits in this state, including an insurance company, a group hospital service corporation under Insurance Code Chapter 842, a health maintenance organization under Insurance Code Chapter 843, and a stipulated premium company under Insurance Code Chapter 884.

(6) Limited benefit policy--A policy that meets the requirements of "limited benefit policy," as defined in §26.4 of this title (relating to Definitions).

Source Note: The provisions of this §3.601 adopted to be effective January 5, 1994, 18 TexReg 9854; amended to be effective May 11, 2022, 47 TexReg 2758