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
(C) Subchapter B, Chapter 1253;
(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;
(C) Chapter 1504;
(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;
(C) Chapter 1363; and
(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.
(c) A health carrier must:
(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;
(C) Section 1501.157;
(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;
(C) Chapter 1363; and
(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.
(c) A health maintenance organization must:
(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.