Law:Title 8. Health Insurance And Other Health Coverages. Subtitle A. Health Coverage In General from Chapter 1216. Out-of-country Coverage Prohibited (Texas)

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Subtitle A. Health Coverage In General

Contents

Chapter 1216. Out-of-country Coverage Prohibited

Section 1216.001.  Definitions.

In this chapter:

(1)  "Enrollee" means an individual entitled to coverage under a health benefit plan.

(2)  "Foreign country" means a governmental unit other than:

(A)  the United States;

(B)  a state, district, commonwealth, territory, or insular possession of the United States;

(C)  the Panama Canal Zone; or

(D)  the Trust Territory of the Pacific Islands.

(3)  "Health care service" means a service to diagnose, prevent, alleviate, cure, or heal a health condition, sickness, or injury that is provided to an enrollee by a physician or other health care provider.

Added by Acts 2007, 80th Leg., R.S., Ch. 1322, Sec. 1, eff. September 1, 2007.

Renumbered from Insurance Code, Section 1215.001 by Acts 2009, 81st Leg., R.S., Ch. 87, Sec. 27.001(62), eff. September 1, 2009.



Section 1216.002.  Applicability Of Chapter.

(a) This chapter applies only to a health benefit plan that provides benefits for health care services, including medical or surgical expenses, incurred as a result of a health condition, accident, or sickness, including:

(1)  an individual, group, blanket, or franchise insurance policy or insurance agreement, a group hospital service contract, or an individual or group evidence of coverage that is offered by:

(A)  an insurance company;

(B)  a group hospital service corporation operating under Chapter 842;

(C)  a fraternal benefit society operating under Chapter 885;

(D)  a stipulated premium company operating under Chapter 884; or

(E)  a health maintenance organization operating under Chapter 843; and

(2)  to the extent permitted by the Employee Retirement Income Security Act of 1974 (29 U.S.C. Section 1001 et seq.), a health benefit plan that is offered by:

(A)  a multiple employer welfare arrangement as defined by Section 3 of that Act; or

(B)  another analogous benefit arrangement.

(b)  For purposes of Subsection (a), a health benefit plan includes a consumer choice of benefits plan issued under Chapter 1507.

Added by Acts 2007, 80th Leg., R.S., Ch. 1322, Sec. 1, eff. September 1, 2007.

Renumbered from Insurance Code, Section 1215.002 by Acts 2009, 81st Leg., R.S., Ch. 87, Sec. 27.001(62), eff. September 1, 2009.



Section 1216.003.  Exception.

This chapter does not apply to:

(1)  a plan that provides coverage:

(A)  only for a specified disease;

(B)  only for accidental death or dismemberment;

(C)  for wages or payments in lieu of wages for a period during which an employee is absent from work because of sickness or injury;

(D)  as a supplement to a liability insurance policy;

(E)  only for dental or vision care;

(F)  only for indemnity for hospital confinement; or

(G)  only for health care services provided to an enrollee while the enrollee is traveling to, visiting, or residing in a foreign country;

(2)  a Medicare supplemental policy as defined by Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss);

(3)  a workers' compensation insurance policy;

(4)  medical payment insurance coverage provided under a motor vehicle insurance policy; or

(5)  a long-term care insurance policy, including a nursing home fixed indemnity policy, unless the commissioner determines that the policy provides benefit coverage so comprehensive that the policy is a health benefit plan as described by Section 1216.002.

Added by Acts 2007, 80th Leg., R.S., Ch. 1322, Sec. 1, eff. September 1, 2007.

Renumbered from Insurance Code, Section 1215.003 by Acts 2009, 81st Leg., R.S., Ch. 87, Sec. 27.001(62), eff. September 1, 2009.

Renumbered from Insurance Code, Section 1215.003 and amended by Acts 2009, 81st Leg., R.S., Ch. 87, Sec. 27.002(12), eff. September 1, 2009.



Section 1216.004.  Out-of-country Care Prohibited.

A health benefit plan issuer may not issue or offer for sale in this state a health benefit plan that requires an enrollee to travel to a foreign country to receive a particular health care service under the health benefit plan.

Added by Acts 2007, 80th Leg., R.S., Ch. 1322, Sec. 1, eff. September 1, 2007.

Renumbered from Insurance Code, Section 1215.004 by Acts 2009, 81st Leg., R.S., Ch. 87, Sec. 27.001(62), eff. September 1, 2009.


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