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;
(C) a fraternal benefit society operating under Chapter 885;
(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;
(C) for wages or payments in lieu of wages for a period during
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;
(C) hepatitis 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.
(c) In addition to the immunizations required under Subsection
(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;
(C) a fraternal benefit society operating under Chapter 885;
(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;
(C) for wages or payments in lieu of wages for a period during
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.
(c) This section does not require a health benefit plan to
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;
or
(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;
(C) for wages or payments in lieu of wages for a period during
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;
(C) a fraternal benefit society operating under Chapter 885;
(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;
(C) for wages or payments in lieu of wages for a period during
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.
(c) A child is entitled to benefits under this subchapter if the
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.