Health plans - Texas

Summary of differences between federal and state regulations

Employee health plans are generally covered under the federal jurisdiction of the Employee Retirement Income Security Act (ERISA).

Federal ERISA plans generally do not have to comply with state laws. ERISA rules preempt or block state laws that relate to ERISA plans. State insurance laws, however, do apply. State laws include the following provisions:

• A plan may not require an enrollee to travel to a foreign country to receive a particular health care service under the health benefit plan. (§1215.004)
• The plan may not require that a covered service be provided by a particular hospital or person. (§1251.006)

• If the plan covers hospital, surgical, or medical expenses incurred as a result of accident or sickness, and it covers children of the insured, it must cover grandchildren of the insured if the grandchildren are unmarried, younger than 25 years of age, and a dependent of the insured for federal income tax purposes at the time the application for coverage of the grandchildren is made. (§1251.151)
• The plan may not exclude from coverage or limit coverage of a child of the insured solely because the child is adopted. (§1251.154)
• The plan must include coverage for cognitive rehabilitation therapy, cognitive communication therapy, neurocognitive therapy and rehabilitation, neurobehavioral, neurophysiological, neuropsychological, and psychophysiological testing and treatment, neurofeedback therapy, and remediation required for and related to treatment of an acquired brain injury. The plan must also include coverage for post-acute transition services, community reintegration services, including outpatient day treatment services, or other post-accute care treatment necessary as a result of and related to an acquired brain injury. The plan may not include, in any lifetime limitation on the number of days of acute care treatment covered under the plan, any post-acute care treatment covered under the plan.  Any limitation imposed under the plan on days of post-acute care treatment must be separately stated in the plan. (§1352.003)
• Unless the plan is a small employer health benefit plan issuer, each insured or enrollee must be notified annually in writing about the coverages described by section 1352.003. (§1352.005)
• A plan may not deny coverage based solely on the fact that the treatment or services are provided at a facility other than a hospital. Treatment for an acquired brain injury may be provided, as appropriate, at a facility at which appropriate services may be provided. This does not apply to a small employer health benefit plan. (§1352.007)
• The plan must cover, based on medical necessity, not less than the following treatments of serious mental illness in each calendar year: 45 days of inpatient treatment; and 60 visits for outpatient treatment, including group and individual outpatient treatment. (§1355.004)
• The plan does not have to cover the treatment of addiction to a controlled substance or marijuana that is used in violation of law; or mental illness that results from the use of a controlled substance or marijuana in violation of law. (§1355.006)
• A health plan must cover an enrollee from the date of a diagnosis of autism spectrum disorder through nine years of age. If the child/enrollee is being treated for autism spectrum disorder becomes 10 years of age or older and continues to need treatment, coverage for treatment and services may continue. (§1355.015)
• If the plan covers treatment of mental or emotional illness or disorder for a covered individual when the individual is confined in a hospital, it must also cover treatment in a residential treatment center for children and adolescents or a crisis stabilization unit that is at least as favorable as the coverage the plan provides for treatment of mental or emotional illness or disorder in a hospital. (§1355.053)
• If the plan covers treatment of mental or emotional illness or disorder when an individual is confined in a hospital, it must also cover treatment obtained under the direction and continued medical supervision of a doctor of medicine or doctor of osteopathy in a psychiatric day treatment facility that provides organizational structure and individualized treatment plans separate from an inpatient program. (§1355.104)
• If the plan covers the treatment of diabetes and conditions associated with diabetes, it must cover diabetes equipment, diabetes supplies, and diabetes self-management training. (§1358.054)
• The plan must cover new or improved diabetes equipment or supplies, including improved insulin or another prescription drug, approved by the United States Food and Drug Administration if the equipment or supplies are determined by a physician or other health care practitioner to be medically necessary and appropriate. (§1358.056)
• The plan must cover formulas necessary to treat phenylketonuria or a heritable disease. (§1359.003)
• If the plan covers medically necessary diagnostic or surgical treatment of conditions affecting skeletal joints, it must cover diagnostic or surgical treatment of conditions affecting the temporomandibular joint if the treatment is medically necessary as a result of an accident, a trauma, a congenital defect, a developmental defect; or a pathology. (§1360.004)
• The plan must cover (for qualified enrollees) medically accepted bone mass measurement to detect low bone mass and to determine the enrollee's risk of osteoporosis and fractures associated with osteoporosis. (§1361.003)
• If the plan covers diagnostic medical procedures, it must cover expenses for an annual medically recognized diagnostic examination for the detection of prostate cancer. (§1362.003)
• If the plan covers screening medical procedures, it must cover, for participants who are 50 years of age or older and at normal risk for developing colon cancer coverage, expenses incurred in conducting a medically recognized screening examination for the detection of colorectal cancer. (§1363.003)
• The plan may not exclude or deny coverage for human immunodeficiency virus (HIV), acquired immune deficiency syndrome (AIDS), or an HIV-related illness. (1364.003)
• The plan issuer shall offer and make available under the plan coverage for the necessary care and treatment of loss or impairment of speech or hearing. (§1365.003)
• If the plan covers family members, it must cover immunizations for children from birth through the date of the children’’ sixth birthday. (§1367.053)
• If the plan covers family members, it must cover screening tests for hearing loss from birth through the date children are 30 days of age. (§1367.103)
• The plan must cover the necessary care and treatment of chemical dependency. (§1368.004)
• If the plan covers drugs, it must cover any drug prescribed to treat an enrollee for a chronic, disabling, or life-threatening illness covered under the plan if the drug has been approved by the United States Food and Drug Administration for at least one indication; and is recognized by the following for treatment of the indication for which the drug is prescribed. (1369.004)
• Plans that provide coverage for screening medical procedures must provide coverage for of up to $200 for a noninvasive screening test for atherosclerosis and abnormal artery structure and function every five years. The coverage is to be provided to males between 45 and 76 years of age and females between 55 and 76 years of age who are diabetic or have a risk of developing coronary heart disease. (1376)
• Plans must provide coverage for medically necessary amino acid-based elemental formulas, regardless of the formula delivery method. (1377)
• The plan must provide benefits for routing patient care costs in connection with a phase I, phase II, phase III, pr phase IV clinical trial if the trial is conducted in relation to the prevention, detection, or treatment of a life-threatening disease or condition. (1379.052)
• The plan may not make a benefit contingent on treatment or examination by one or more particular health care practitioners unless the policy contains a provision that designates the practitioners whom the insurer will and will not recognize. The particular health care practitioners include acupuncturists, advance practice nurses, audiologists, chemical dependency counselors, chiropractors, dentists, dieticians, social workers, optometrists, podiatrists, psychologists, and speech-language pathologists. (This is not a complete list) (§1451.053)
• The plan may not exclude a telemedicine medical service or a telehealth service from coverage under the plan solely because the service is not provided through a face-to-face consultation. (§1455.004)
• The plan may not condition coverage for a child younger than 25 years of age on the child's being enrolled at an educational institution. A health benefit plan that requires as a condition of coverage for a child up to 25 years of age that the child be a full-time student at an educational institution must provide the coverage for the full academic term, and continuously until the 10th day of instruction of the subsequent academic term. (§1503.003)
• Employers (policy holders) are required to pay the premium through the end of the month for any employees terminated in that month. If the employer does not notify the carrier of the termination until the following month, the employer is required to pay the premium for that month, as well. This does not apply to self-funded plans. (§843.210, §1301.0061)
• Carriers are not prevented from applying deductible or copayment requirements to benefits, including state-mandated health benefits, in order to qualify the policy of coverage as a high deductible health plan. (§1653)
• Plan issuers must make information available via the telephone, electronically, or via an Internet website portal to participating health care providers. The information is that which is maintained in the ordinary course of business and sufficient for the provider to determine at the time of the enrollee’s visit, including such facts as the enrollee’s ID number assigned by the plan issuer, name of enrollee and dependents, birth dates, eligibility status, etc.
• Plans must cover prosthetic devices, orthotic devices, and professional services related to the fitting and use of those devices that equals the coverage provided under applicable federal laws for health insurance for the aged and disabled. (§1731.003, HB 806)
• Healthy Texas is a statewide health insurance program designed for small business owners and their employees. The program uses a state-funded pool to pay for above average health care claims costs.
• Plans are prohibited from using discretionary clauses in certain insurance policy forms and HMO evidence of coverage forms. (TAC §3.1201- 3.1203)
• An employee who is eligible for coverage under an employer health benefit plan and who is the spouse of another employee covered under the plan may elect whether to be treated under the plan as an employee or a dependent of the other employee. (TAC §26.7; 26.304)
• For plans that offer mental health or substance use disorder benefits, the Federal Mental Health Parity and Addiction Equity Act requires group health plans and group health plan issuers to ensure that financial requirements such as copayments or deductibles and treatment limitations such as visit limits applicable to mental health or substance use disorder benefits are no more restrictive than the predominant financial requirements or treatment limitations applied to substantially all medical/surgical benefits. Texas adopted amendments to Subchapter P, §§21.2401 – 21.2407, concerning requirements for such parity.
• Plans that cover cancer treatments must cover a prescribed, orally administered anticancer medication that is used to kill or slow the growth of cancerous cells on a basis no less favorable than intravenously administered or injected cancer medications that are covered as medical benefits by the plans. (§1369.204) See also HB 438.
• Effective for plan years beginning on or after November 1, 2015, §26.30 established the four-tier composite premium method as the required method in the small group market instead of the federal default method. The four tiers are employee only, employee and spouse, employee and child or children, and employee and family.

State

Contact

Texas Department of Insurance

Regulations

Texas Statutes, Insurance Code

Title 8 Health Insurance and Other Health Coverages

Chapter 843 Health Maintenance Organizations

Chapter 1251 Group and Blanket Health Insurance

Chapter 1301 Preferred Provider Benefit Plans

Chapter 1352 Brain Injury

Chapter 1355 Benefits for Certain Mental Disorders

Chapter 1358 Diabetes

Chapter 1359 Formulas for Individuals with Phenylketonuria or Other Heritable Diseases

Chapter 1360 Diagnosis and Treatment Affecting Temporomandibular Joint

Chapter 1361 Detection and Prevention of Osteoporosis

Chapter 1362 Certain Tests for Detection of Prostate Cancer

Chapter 1363 Certain Tests for Detection of Colorectal Cancer

Chapter 1364 Coverage Provisions Relating to HIV, Aids, or HIV-Related Illnesses

Chapter 1365 Loss or Impairment of Speech or Hearing

Chapter 1367 Coverage of Children

Chapter 1368 Availability of Chemical Dependency Coverage

Chapter 1369 Benefits Related to Prescription Drugs and Devices and Related Services

Subtitle F Physicians and Health Care Providers

Chapter 1451 Access to Certain Practitioners and Facilities

Chapter 1455 Telemedicine and Telehealth

Subtitle G Health Coverage Availability

Chapter 1503 Coverage of Certain Students

Subtitle I Special Coverages

Chapter 1653 High Deductible Health Plan

(seeHouse Bill 1602 )

Texas Administrative Code

Title 28 Insurance, Part I Texas Department of Insurance

Federal

Contact

Employee Benefits Security Administration (EBSA)

Regulations

29 CFR chapter XXV (Parts 2509 – 2590)