Tex.
Ins. Code Section 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 (Group and Blanket Health Insurance);(B)
Section 1201.059 (Termination of Coverage Based on Age of Child in Individual, Blanket, or Group Policy); and(C)
Subchapter B (Applicability of Subchapter), Chapter 1253 (Cancellation of Group Coverage in Certain Circumstances);(2)
termination of coverage under Sections 1202.051 (Renewability and Continuation of Individual Health Insurance Policies) and 1501.108 (Renewability of Coverage; Cancellation);(3)
preexisting conditions under Subchapter D (Compliance with Subchapter; Prohibition of Defense), Chapter 1201 (Accident and Health Insurance), and Sections 1501.102-1501.105;(4)
coverage of children, including newborn or adopted children, under:(A)
Subchapter D (Coverage for Certain Grandchildren), Chapter 1251 (Group and Blanket Health Insurance);(B)
Sections 1201.053 (Persons Insured), 1201.061 (Coverage for Adopted Child), 1201.063-1201.065, and Subchapter A (Applicability of Subchapter), Chapter 1367 (Coverage of Children);(C)
Chapter 1504 (Medical and Dental Child Support);(D)
Chapter 1503 (Coverage of Certain Students);(E)
Section 1501.157 (Coverage for Newborn Children);(F)
Section 1501.158 (Coverage for Adopted Children); and(G)
Sections 1501.607-1501.609;(5)
services of practitioners under:(A)
Subchapters A, B, and C, Chapter 1451 (Access to Certain Practitioners and Facilities); or(B)
Section 1301.052 (Designation of Advanced Practice Nurse or Physician Assistant as Preferred Provider);(6)
supplies and services associated with the treatment of diabetes under Subchapter B (Definitions), Chapter 1358 (Diabetes);(7)
coverage for serious mental illness under Subchapter A (Definitions), Chapter 1355 (Benefits for Certain Mental Disorders);(8)
coverage for childhood immunizations and hearing screening as required by Subchapters B (Applicability of Subchapter) and C, Chapter 1367 (Coverage of Children), other than Section 1367.053 (Coverage Required)(c) and Chapter 1353 (Immunization or Vaccination Protocols Under Managed Care Plans);(9)
coverage for reconstructive surgery for certain craniofacial abnormalities of children as required by Subchapter D (Applicability of Subchapter), Chapter 1367 (Coverage of Children);(10)
coverage for the dietary treatment of phenylketonuria as required by Chapter 1359 (Formulas for Individuals with Phenylketonuria or Other Heritable Diseases);(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 (Out-of-network Services); and(12)
coverage for cancer screenings under:(A)
Chapter 1356 (Mammography and Other Breast Imaging);(B)
Chapter 1362 (Certain Tests for Detection of Prostate Cancer);(C)
Chapter 1363 (Certain Tests for Detection of Colorectal Cancer); and(D)
Chapter 1370 (Certain Tests for Detection of Human Papillomavirus, Ovarian Cancer, and Cervical Cancer).
Source:
Section 1507.003 — State-mandated Health Benefits, https://statutes.capitol.texas.gov/Docs/IN/htm/IN.1507.htm#1507.003 (accessed Jun. 5, 2024).
