| (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).
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