INSURANCE CODE
TITLE 8. HEALTH INSURANCE AND OTHER HEALTH COVERAGES
SUBTITLE E. BENEFITS PAYABLE UNDER HEALTH COVERAGES
CHAPTER 1425. APPLICATION OF SUBTITLE TO CERTAIN COVERAGE
SUBCHAPTER A. EXCEPTED BENEFITS
Sec. 1425.001. EXEMPTION FROM APPLICATION OF SUBTITLE. (a) Except as provided by Section 1425.002, a provision of this subtitle that becomes effective on or after January 2, 2010, does not apply to:
(1) a plan that provides coverage only:
(A) for a specified disease or diseases or under an individual limited benefit policy;
(B) for accidental death or dismemberment;
(C) as a supplement to a liability insurance policy; or
(D) for dental or vision care;
(2) disability income insurance coverage or a combination of accident-only and disability income insurance coverage;
(3) credit insurance coverage;
(4) a hospital confinement indemnity policy;
(5) a Medicare supplemental policy as defined by Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss);
(6) a workers' compensation insurance policy;
(7) medical payment insurance coverage provided under a motor vehicle insurance policy;
(8) a long-term care insurance policy, including a nursing home fixed indemnity policy, except as provided by Subsection (b); or
(9) an occupational accident policy.
(b) A long-term care insurance policy, including a nursing home fixed indemnity policy, is subject to this subtitle if the commissioner determines that the policy provides benefits so comprehensive that it is a health benefit plan and should not be subject to the exemption provided under this section.
Added by Acts 2009, 81st Leg., R.S., Ch. 228 (S.B. 1479), Sec. 1, eff. May 27, 2009.
Sec. 1425.002. SPECIFIC LANGUAGE CONTROLS. A provision of this subtitle that becomes effective on or after January 2, 2010, and that requires coverage or the offer of coverage of a health care service or benefit applies to a plan or policy described by Section 1425.001(a) only to the extent expressly and specifically provided by law.
Added by Acts 2009, 81st Leg., R.S., Ch. 228 (S.B. 1479), Sec. 1, eff. May 27, 2009.
SUBCHAPTER B. BENEFITS REQUIRING DEFRAYAL
Sec. 1425.051. DEFINITION. In this subchapter, "qualified health plan" has the meaning assigned by 45 C.F.R. Section 155.20.
Added by Acts 2021, 87th Leg., R.S., Ch. 890 (S.B. 2016), Sec. 3, eff. June 16, 2021.
Sec. 1425.052. EXEMPTION FROM SUBTITLE FOR BENEFITS REQUIRING DEFRAYAL. (a) A provision of this subtitle that is enacted on or after January 1, 2012, does not apply to a qualified health plan if a determination is made under 45 C.F.R. Section 155.170 that:
(1) the provision requires the qualified health plan to offer benefits in addition to the essential health benefits required under 42 U.S.C. Section 18022(b); and
(2) this state must make payments to defray the cost of the additional benefits mandated by the provision.
(b) If a determination described by Subsection (a) is made as to a qualified health plan, the provision to which the determination relates does not apply to a non-qualified health plan if the non-qualified health plan is offered in the same market as the qualified health plan.
Added by Acts 2021, 87th Leg., R.S., Ch. 890 (S.B. 2016), Sec. 3, eff. June 16, 2021.