INSURANCE CODE

TITLE 8. HEALTH INSURANCE AND OTHER HEALTH COVERAGES

SUBTITLE E. BENEFITS PAYABLE UNDER HEALTH COVERAGES

CHAPTER 1365. LOSS OR IMPAIRMENT OF SPEECH OR HEARING

SUBCHAPTER A. GENERAL PROVISIONS

Sec. 1365.001.  APPLICABILITY OF SUBCHAPTER. This subchapter applies only to a group health benefit plan that provides hospital and medical coverage on an expense-incurred, service, or prepaid basis, including a group policy, contract, or plan that is offered in this state by:
(1)  an insurer;
(2)  a group hospital service corporation operating under Chapter 842; or
(3)  a health maintenance organization operating under Chapter 843.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
Amended by: 
Acts 2023, 88th Leg., R.S., Ch. 8 (H.B. 109), Sec. 2, eff. September 1, 2023.

Sec. 1365.002.  APPLICABILITY OF GENERAL PROVISIONS OF OTHER LAW.  The provisions of Chapter 1201, including provisions relating to the applicability, purpose, and enforcement of that chapter, construction of policies under that chapter, rulemaking under that chapter, and definitions of terms applicable in that chapter, apply to this subchapter.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
Amended by: 
Acts 2023, 88th Leg., R.S., Ch. 8 (H.B. 109), Sec. 2, eff. September 1, 2023.

Sec. 1365.003.  OFFER OF COVERAGE REQUIRED.  (a)  A group health benefit 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.
(b)  Coverage required under this section:
(1)  may not be less favorable than coverage for physical illness generally under the plan;  and
(2)  must be subject to the same durational limits, dollar limits, deductibles, and coinsurance factors as coverage for physical illness generally under the plan.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.

Sec. 1365.004.  RIGHT TO REJECT COVERAGE OR SELECT ALTERNATIVE BENEFITS.  An offer of coverage required under Section 1365.003 is subject to the right of the group contract holder to reject the coverage or to select an alternative level of benefits that is offered by or negotiated with the group health benefit plan issuer.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
Amended by: 
Acts 2007, 80th Leg., R.S., Ch. 730 (H.B. 2636), Sec. 3B.028, eff. September 1, 2007.
Acts 2007, 80th Leg., R.S., Ch. 921 (H.B. 3167), Sec. 9.028, eff. September 1, 2007.

SUBCHAPTER B. HEARING AID COVERAGE

Sec. 1365.051.  APPLICABILITY.  (a)  This subchapter applies only to a health benefit plan that provides benefits for medical or surgical expenses incurred as a result of a health condition, accident, or sickness, including an individual, group, blanket, or franchise insurance policy or insurance agreement, a group hospital service contract, or an individual or group evidence of coverage or similar coverage document that is offered by:
(1)  an insurance company;
(2)  a group hospital service corporation operating under Chapter 842;
(3)  a health maintenance organization operating under Chapter 843;
(4)  an approved nonprofit health corporation that holds a certificate of authority under Chapter 844;
(5)  a multiple employer welfare arrangement that holds a certificate of authority under Chapter 846;
(6)  a stipulated premium company operating under Chapter 884;
(7)  a fraternal benefit society operating under Chapter 885;
(8)  a Lloyd's plan operating under Chapter 941; or
(9)  an exchange operating under Chapter 942.
(b)  This subchapter applies to coverage under a group health benefit plan described by Subsection (a) provided to a resident of this state, regardless of whether the group policy, agreement, or contract is delivered, issued for delivery, or renewed within or outside this state.
(c)  Notwithstanding any other law, this subchapter applies to:
(1)  a small employer health benefit plan subject to Chapter 1501, including coverage provided through a health group cooperative under Subchapter B of that chapter;
(2)  a standard health benefit plan issued under Chapter 1507;
(3)  a basic coverage plan under Chapter 1551;
(4)  a basic plan under Chapter 1575;
(5)  a primary care coverage plan under Chapter 1579;
(6)  a plan providing basic coverage under Chapter 1601;
(7)  a regional or local health care program operated under Section 75.104, Health and Safety Code; and
(8)  a self-funded health benefit plan sponsored by a professional employer organization under Chapter 91, Labor Code.
Added by Acts 2023, 88th Leg., R.S., Ch. 8 (H.B. 109), Sec. 3, eff. September 1, 2023.

Sec. 1365.052.  EXCEPTION.  This subchapter does not apply to:
(1)  a plan that provides coverage:
(A)  for wages or payments in lieu of wages for a period during which an employee is absent from work because of sickness or injury; or
(B)  only for hospital expenses; or
(2)  the state Medicaid program, including the Medicaid managed care program operated under Chapter 533, Government Code.
Added by Acts 2023, 88th Leg., R.S., Ch. 8 (H.B. 109), Sec. 3, eff. September 1, 2023.

Sec. 1365.053.  CHOICE OF HEARING AID.  (a) A health benefit plan that provides coverage for hearing aids may not deny an enrollee's claim for a hearing aid solely on the basis that the price of the hearing aid is more than the benefit available under the health benefit plan.
(b)  Notwithstanding Section 1367.253(d), this section applies to a health benefit plan subject to Subchapter F, Chapter 1367.
(c)  Nothing in this section requires a health benefit plan to pay an enrollee's claim for a hearing aid in an amount that is more than the benefit available under the health benefit plan.
Added by Acts 2023, 88th Leg., R.S., Ch. 8 (H.B. 109), Sec. 3, eff. September 1, 2023.