28 Tex. Admin. Code § 3.1 - Applicability and Scope
This subchapter applies to all filings related to a life insurance, annuity, life settlement, credit insurance, accident and health insurance, HMO, or point-of-service product that are filed with the department, including the following filing types:
(1) a form filing submitted under Insurance
Code §
1111A.005, concerning
Requirements for Contract Forms, Disclosure Forms, and Advertisements;
Insurance Code §
1153.051, concerning
Filing of Form; Insurance Code §
1271.101, concerning
Approval of Form of Evidence of Coverage or Group Contract; or Insurance Code
Chapter 1701, concerning Policy Forms, including:
(A) a policy, contract, group agreement,
certificate, evidence of coverage, application, enrollment form, rider,
amendment or endorsement, insert page, matrix filing, or limited partial
refiling; or
(B) any other coverage
document attached to or made part of a document described in subparagraph (A)
of this paragraph;
(2) a
rate filing submitted in connection with a form filing under this subsection or
otherwise required to be filed under Division 5 of this subchapter (relating to
Actuarial Filing Requirements), including a schedule of charges, actuarial
memorandum, or change to rating methodology;
(3) an advertising filing submitted in
connection with a product filed under this subchapter, including filings
identified under §
21.120 of this title (relating to
Filing for Review);
(4) a network
filing submitted in connection with an HMO plan under Chapter 11 of this title
(relating to Health Maintenance Organizations), a preferred or exclusive
provider benefit plan under Subchapter X of this chapter (relating to Preferred
and Exclusive Provider Plans), or a Medicare Select plan under §
3.3325 of this title (relating to
Medicare Select Policies, Certificates and Plans of Operation), including:
(A) provider contract forms (including a
template, executed contract, amendment, termination, or attestation of
compliance), delegated entity contract forms (including a template, executed
contract, amendment, or termination), and related filings;
(B) provider directories;
(C) network configuration filings, including:
(i) new applications;
(ii) limited provider networks;
(iii) annual network adequacy report
filings;
(iv) access
plans;
(v) service area expansions
or reductions; and
(vi) material
modification to a network configuration;
(D) notices, including a notice of a network
termination or an annual application period for physicians and providers to
contract; and
(E) quality assurance
program filings;
(5) a
group eligibility filing, as specified in §3.21 of this title (related to Group
Filings), including articles of incorporation, bylaws, constitution, or a trust
agreement, policy face page, and any other documentation needed to demonstrate
that a prospective group or blanket policyholder is eligible under Insurance
Code Chapter 1131, Subchapter B, concerning Group and Wholesale, Franchise, or
Employee Life Insurance: Eligible Policyholders; Insurance Code Chapter 1251,
Subchapter B, concerning Group Accident and Health Insurance: Eligible
Policyholders; or Insurance Code Chapter 1251, Subchapter H, concerning Blanket
Accident and Health Insurance: Eligible Policyholders;
(6) an informational filing, other than a
form filing, rate filing, advertising filing, network filing, or group
eligibility filing, that is required for compliance with Texas law but is not
subject to approval, including:
(A) a
disclosure, outline of coverage, or a similar plan summary;
(B) notices, including those relating to a
discontinuance, withdrawal, uniform benefit modification, and modification of
drug coverage;
(C) reports,
including reports required for Medicare Supplement in Subchapter T of this
title (relating to Minimum Standards for Medicare Supplement Policies) and
Long-Term Care in Subchapter Y of this title (relating to Standards for
Long-Term Care Insurance, Non-Partnership and Partnership Long-Term Care
Insurance Coverage Under Individual and Group Policies and Annuity Contracts,
and Life Insurance Policies That Provide Long-Term Care Benefits Within the
Policy);
(D) certifications related
to form filings, readability scores, actuarial memoranda, statements of
variability, and small and large employer health benefit plans;
(E) Medicare SELECT plans of operation and
amendments; and
(F) other documents
and information necessary to make a filing complete or for a comprehensive
review of the filing that are filed in an informational
mode.
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
This subchapter applies to all contracts, policies, applications, certificates of insurance, insert pages, riders, limited partial refilings, matrix filings, disclosure forms, rates, outline of coverage, and other documents subject to be filed with the Texas
(1) individual and group life insurance;
(2) individual and group annuities;
(3) individual and group accident and health insurance (including long-term care and Medicare supplement under Insurance Code Chapters 1651 and 1652);
(4) individual and group combination life and accident and health insurance;
(5) individual and group combination annuity and accident and health insurance;
(6) point of service products as described in Insurance Code Chapter 1273 and § 21.2901 of this title (relating to Definitions);
(7) individual and group credit life and individual and group credit accident and health insurance under Insurance Code Chapters 1131, 1153, and 1251;
(8) rates, subject to review and approval by the department including, but not limited to:
(A) individual and group credit life;
(B) individual and group credit accident and health insurance;
(C) Medicare supplement; and
(D) changes in rating methodologies for small employer plans;
(9) Medicare SELECT plans of operation and amendments;
(10) miscellaneous documents and information necessary to make a filing complete or for a comprehensive review of the filing including, but not limited to:
(A) documents that must be accompanied by the transmittal checklist described in § 3.3(b) of this title (relating to Transmittal Information) as follows:
(i) articles of incorporation;
(ii) constitutions and bylaws and/or trust agreements;
(iii) disclosures;
(iv) outlines of coverage;
(v) rates, other than the rates listed in paragraph (8) of this section, including the following:
(I) individual accident and health;
(II) long-term care; and
(III) life; and
(vi) certifications related to form filings, readability scores, and actuarial memoranda.
(B) documents that must be accompanied by the transmittal form described in § 3.3(c) of this title as follows:
(i) life insurance illustration information;
(ii) Medicare supplement refund calculations;
(iii) preferred provider health benefit plan provider directories;
(iv) preferred provider service or geographic descriptions;
(v) certifications including those related to small or large employer health benefit plans; and
(vi) annual reports including:
(I) long-term care lapse and replacement reports;
(II) long-term care rescission reports;
(III) long-term care denial of claims reports;
(IV) long-term care report required by Insurance Code § 1651.053;
(V) Medicare supplement rate reports; and
(VI) Medicare SELECT grievance reports.