Texas health insurance mandates, Medicare supplements and the ACA

The accident and health part of the Texas law section mixes state mandates with the federal Affordable Care Act. Each item usually turns on one rule.

Questions and answers, explained

All 12 questions above, with the correct answer and why it is correct. Everything here is on texas health insurance mandates, medicare supplements and the aca.

1. A Texas health plan provides maternity benefits. Which provision may it NOT contain under TIC 1367.003?

   • AAn exclusion of a newborn's congenital defectsCorrect
   • BA requirement that the newborn be added to the policy for continued coverage
   • CA network rule that applies to the newborn like other children
   • DA deductible that applies to newborn care like other care

   Why: TIC 1367.003 and 28 TAC 3.3403 bar a plan with maternity or newborn coverage from excluding or limiting a newborn's initial coverage for a period of time, coverage of congenital defects, or the state-required newborn screening tests. Newborn coverage must be at least as comprehensive as coverage for other children.

   Reference TIC 1367.003; 28 TAC 3.3403 — Texas outline III.A.1

2. Marisol's family health policy covers additional newborn children. Her son is born with a heart defect requiring surgery in his first week. Under Texas law, the policy:

   • AMay exclude the defect as a preexisting condition
   • BMay wait 30 days before newborn coverage begins
   • CMust cover him from birth, including the congenital defectCorrect
   • DCovers him only after he is examined and found insurable by the insurer

   Why: Because the policy covers additional newborns, TIC 1367.003 forbids any waiting period on a newborn's initial coverage and any exclusion of congenital defects. The heart surgery is covered from birth on the same terms as other covered children.

   Reference TIC 1367.003 — Texas outline III.A.1

3. Under the Texas definition of a dependent for employer health benefit plans (TIC 1501.002), a child qualifies as a dependent until what age?

   • AYounger than 30, but only while the child still lives in the parent's home
   • BUnder 25, or any age if certified disabled and dependent on the parentCorrect
   • CYounger than 18, with no exception for disability
   • DYounger than 21, or younger than 23 while enrolled as a full-time student

   Why: TIC 1501.002 defines a dependent to include a spouse, a child younger than 25 including a newborn, and a child of any age who is medically certified as disabled and dependent on the parent. Federal law separately requires plans offering dependent coverage to allow adult children up to age 26.

   Reference TIC 1501.002 — Texas outline III.A.2

4. How must a Texas health plan that covers chemical dependency treatment structure that coverage under TIC 1368.005?

   • ASubject to a separate deductible twice the medical deductible
   • BCovered only if the insured pays an additional rider premium
   • CLimited to one 7-day detox stay per lifetime, with no outpatient or follow-up care at all
   • DNo less favorable than physical illness coverage, with the same limits and cost sharingCorrect

   Why: TIC 1368.005 requires chemical dependency coverage to be no less favorable than coverage for physical illness generally and subject to the same durational limits, dollar limits, deductibles and coinsurance. A group plan may set less favorable limits only if they still allow appropriate care under the department's treatment standards.

   Reference TIC 1368.005 — Texas outline III.A.3

5. Carlos became eligible for Medicare in 2026. Why can he not buy Medicare supplement Plan F or Plan C in Texas?

   • ATexas has stopped approving every lettered Medicare supplement plan except the basic Plan A
   • BHe must first be enrolled in Medicaid for one full year
   • CPlans covering the Part B deductible cannot be sold to people newly eligible since 2020Correct
   • DPlans C and F are sold only to people over age 75

   Why: Under MACRA, carried into 28 TAC 3.3306, no policy covering the Medicare Part B deductible may be sold as a Medicare supplement to anyone newly eligible for Medicare on or after January 1, 2020. That removes Plans C and F (and high-deductible F) for new enrollees; people eligible before 2020 can still buy them.

   Reference 28 TAC 3.3306 — Texas outline III.B.1

6. How long does a Texas Medicare supplement buyer have to examine the policy and return it for a full refund?

   • A60 days
   • B30 daysCorrect
   • C15 days
   • D10 days

   Why: Medicare supplement policies sold in Texas must carry a 30-day right to return the policy for a full refund of premium, a minimum standard under the Medicare supplement rules (28 TAC 3.3301 and following). The 30-day free look is longer than the usual 10-day free look on many other health policies.

   Reference 28 TAC 3.3301 et seq. — Texas outline III.B

7. A Texas insurer requires HIV testing for all applicants in a class. Before it may deny coverage or rate an applicant substandard based on the test, what must occur under 28 TAC 21.705?

   • ATwo positive ELISA tests, confirmed by a Western Blot testCorrect
   • BA single positive rapid test performed at the agent's office
   • CThe applicant's written admission of risk factors
   • DA questionnaire about the applicant's sexual orientation

   Why: 28 TAC 21.705 allows HIV testing if it is required on a nondiscriminatory basis for everyone in the same class, but no adverse decision may rest on it unless an initial ELISA and a second ELISA are positive and a Western Blot confirms them, using FDA-approved tests. 28 TAC 21.704 bars any question designed to establish sexual orientation.

   Reference 28 TAC 21.704-.705 — Texas outline III.C

8. Which application question is prohibited in Texas life and health underwriting under 28 TAC 21.704?

   • AWhether the applicant uses tobacco products
   • BWhether the applicant has been diagnosed with AIDS
   • CWhether the applicant has been treated for heart disease in the last ten years
   • DA question designed to establish the applicant's sexual orientationCorrect

   Why: 28 TAC 21.704 forbids any application question or investigation aimed at the applicant's sexual orientation, and sexual orientation may not be used in underwriting. Factual questions about having been diagnosed with AIDS or AIDS-related complex are permitted, as are ordinary medical history questions.

   Reference 28 TAC 21.704 — Texas outline III.C

9. What is the least favorable renewal provision a long-term care insurance policy may have in Texas under 28 TAC 3.3822?

   • AOptionally renewable
   • BCancelable on 31 days' notice
   • CConditionally renewable
   • DGuaranteed renewableCorrect

   Why: 28 TAC 3.3822 bars any long-term care policy from having renewal provisions less favorable than guaranteed renewable or noncancellable. Under guaranteed renewable the insurer must renew but may raise premiums by class; noncancellable also locks the premium.

   Reference 28 TAC 3.3822 — Texas outline III.D

10. When must a Texas agent deliver the outline of coverage for a long-term care policy?

    • AOnly if the applicant asks for it in writing
    • BBefore presenting the application or enrollment formCorrect
    • CWithin 30 days after the first premium is paid
    • DWith the delivered policy, after the insurer issues it

    Why: 28 TAC 3.3832 requires the outline of coverage to be delivered at initial solicitation, and for agent solicitations before the application or enrollment form is presented; in direct-response sales it comes with the application. It must be a freestanding document in at least 12-point type with no advertising.

    Reference 28 TAC 3.3832 — Texas outline III.D

11. Which list matches the activities of daily living defined in Texas long-term care rules (28 TAC 3.3804)?

    • ADriving, shopping, cooking, cleaning, banking and working
    • BReading, writing, walking, talking, hearing and seeing
    • CBathing, continence, dressing, eating, toileting and transferringCorrect
    • DSleeping, exercising, cooking, medication, telephone use and travel

    Why: 28 TAC 3.3804 defines the activities of daily living as bathing, continence, dressing, eating, toileting and transferring. Benefit triggers are commonly tied to needing help with a set number of these, or to cognitive impairment.

    Reference 28 TAC 3.3804 — Texas outline III.D

12. A Texas business with two eligible employees applies for a small employer health benefit plan. Under 28 TAC 26.8, the carrier:

    • AMust issue regardless of health status, and may require both employees to enrollCorrect
    • BMay decline the whole group if either of the two employees reports a serious illness
    • CMay issue the plan only to the healthier of the two employees
    • DMust decline the group because small employers need at least 10 employees

    Why: 28 TAC 26.8 requires a small employer carrier to issue a health benefit plan to any small employer that elects coverage and meets the plan's requirements, without regard to health-status factors. A small employer with only two eligible employees is subject to a 100 percent participation requirement.

    Reference 28 TAC 26.8; TIC 1501 — Texas outline III.E.1

Drill the whole domain

• Texas Statutes and Rules — Accident and Health Only (5.4%)

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