Texas Health Mandates and Supplemental Coverage

Texas requires fully insured health plans to include several specific benefits and protections. Most self-funded employer plans are governed by the federal ERISA law rather than state insurance law, so these mandates generally reach insured plans.

Texas mandated health benefits

Coverage for newborn children (TIC 1367.003, 1501.157, 1501.607, as amended by SB 896)

Texas’s newborn coverage rules were updated by Senate Bill 896 from the 89th Legislature. The change applies to health benefit plans delivered, issued for delivery, or renewed on or after January 1, 2026; a plan delivered, issued, or renewed before that date keeps the earlier rule until it renews. A health benefit plan that covers newborn children may not exclude or limit a newborn’s initial coverage before the 61st day after birth, and in a small or large employer plan the newborn’s coverage continues past the 61st day if the insurer receives notice of the birth and any required additional premium by the 60th day:

Coverage for chemical dependency (TIC 1368.005)

Texas requires group health benefit plans to provide coverage for the necessary care and treatment of chemical dependency (TIC 1368.004), at a level not less favorable than the plan’s coverage for physical illness generally:

• Durational limits, dollar limits, deductibles, and coinsurance factors must be the same as those applied to physical illness coverage in the plan.
• A plan may set less favorable dollar or durational limits only if they are sufficient to provide appropriate care under guidelines and standards the Commissioner has adopted (TIC 1368.005(b)).
• The coverage may be limited to a lifetime maximum of three separate treatment series for each covered individual (TIC 1368.006(b)).

This is Texas’s chemical dependency parity rule. It supplements the federal Mental Health Parity and Addiction Equity Act (MHPAEA).

AIDS testing requirements (TAC § 21.704–.705)

Texas regulates HIV/AIDS testing in connection with insurance underwriting carefully because of the consumer-protection and confidentiality stakes:

• Informed written consent (TAC § 21.704(b)(8)). When a proposed insured is asked to take an HIV-related test, the use of the test must be revealed and the proposed insured’s written authorization obtained, on a separate form that contains the language of TDI’s “Notice and Consent for HIV-Related Testing.”
• Nondiscriminatory testing (TAC § 21.705). Testing may be required only on a nondiscriminatory basis for everyone in the same class, using FDA-approved tests, and no applicant may be denied coverage or rated substandard on the basis of the testing unless two ELISA tests and a confirming Western Blot test were performed.
• Confidentiality (TAC § 21.704(b)(10)). HIV test results are confidential. An insurer may not release them except as the law requires or on the written request or authorization of the proposed insured, and then only to a defined list of recipients — such as the proposed insured, a physician the proposed insured designates, an insurance medical information exchange under confidentiality procedures, or a reinsurer involved in the underwriting.
• Notice of a positive result. The insurer must give written notice of a positive HIV-related test result to a physician the proposed insured designates or, without a designation, to the state health department; the proposed insured may also ask to receive the result directly by restricted registered mail (TAC § 21.704(b)(10)).

Texas Medicare supplement (TAC § 3.3301–.3325)

Texas adopts the NAIC standardized Medicare supplement framework, with state-specific consumer-protection layering:

• Standardized plans (TAC § 3.3306). Texas Medicare supplement policies follow the standardized plans. A person newly eligible for Medicare on or after January 1, 2020 may buy Plans A, B, D, G, high-deductible G, K, L, M, and N; Plans C, F, and high-deductible F, which cover the Part B deductible, may not be sold to them (42 U.S.C. 1395ss(z)). Every Medicare supplement issuer must make available a policy with only the basic (core) benefits, Plan A.
• Open enrollment period (TAC § 3.3324). Texas requires a 6-month Medicare supplement open enrollment beginning with the first day of the first month in which the applicant is first enrolled in Medicare Part B. It also protects a person who qualifies for Medicare before age 65, to whom an issuer must make at least Plan A available (TAC § 3.3324(a)–(b)). During open enrollment, applicants cannot be denied or rated up based on health.
• Free look (TAC § 3.3308). Texas requires a Medicare supplement free look of at least 30 days from delivery.
• Guaranteed renewability. Medicare supplement policies are guaranteed renewable; the insurer cannot cancel or nonrenew except for nonpayment of premium or material misrepresentation (42 U.S.C. 1395ss(q)(1)).
• Refund disclosure (TAC § 3.3308). The outline of coverage must state whether the policy refunds premium, in whole or in part, on the insured’s death or on surrender of the policy.
• Replacement (TAC § 3.3306, 3.3309). The issuer or agent must give the applicant a notice regarding replacement before the policy is issued or delivered, and the replacing issuer must credit time spent under the original policy toward any preexisting condition waiting period, with none allowed once the original has been in force at least six months.
• Marketing standards (TAC § 3.3319–.3320). Texas prohibits specific Medicare supplement marketing practices, including twisting, high-pressure sales tactics, and cold-lead advertising that fails to disclose that its purpose is to solicit insurance, and requires reasonable efforts to determine that a recommended purchase is appropriate and does not leave the buyer with excessive insurance.

Texas long-term care insurance (TIC 1651.054; TAC § 3.3820, 3.3842)

Texas applies the NAIC’s LTC consumer-protection framework, with several Texas-specific accents:

• Free look — 30 days (TIC 1651.054). Every individual LTC policy must give the insured at least 30 days from delivery to return for a full refund.
• Mandatory inflation protection offer (TAC § 3.3820). Before issuing a Texas LTC policy, the insurer must offer the applicant inflation protection: benefits that increase at least 5% a year compounded, a guaranteed right to increase benefits by at least 5% compounded each year without evidence of insurability, or coverage of a percentage of actual or reasonable charges. The applicant may decline in writing.
• Mandatory nonforfeiture offer (TAC § 3.3844). The insurer must offer a nonforfeiture benefit (reduced paid-up, extended term, shortened benefit period, or another approved option). If the applicant declines it, the policy must still provide a contingent benefit upon lapse.
• Suitability requirements (TAC § 3.3842). In recommending an LTC purchase or replacement, the insurer and agent must make reasonable efforts to determine whether it is appropriate, considering the applicant’s ability to pay, goals and needs for long-term care, and existing coverage, using the LTC personal worksheet.
• Texas LTC Partnership. Texas participates in the federal-state LTC Partnership program; partnership policies must meet additional standards and give the buyer dollar-for-dollar asset disregard for Medicaid (TIC 1651.104, 1651.106). An agent must complete a partnership certification course of at least 8 hours before selling partnership policies (28 TAC § 19.1022).