This section of the Texas Insurance Code states that certain state insurance laws do not apply to a benefit plan that is fully insured and subject to the Employee Retirement Income Security Act of 1974 (ERISA). This means that for fully insured plans covered by ERISA, state insurance regulations may be preempted by federal law.
Section 1551.011 exempts certain insurance plans from state laws that regulate insurance. This includes plans established or maintained under specific federal laws, which could encompass those governed by ERISA. The statute ensures that state insurance regulations do not conflict with federal requirements for these plans.
This section of the Texas Labor Code provides general provisions for workers' compensation benefits. While ERISA sets standards for private sector retirement and health plans, workers' compensation is a separate system that provides benefits to employees who suffer work-related injuries or illnesses. ERISA does not preempt state workers' compensation laws, so this statute operates alongside federal ERISA regulations.
Section 410.255 allows a party to be represented by an attorney in any proceeding under the subtitle relating to workers' compensation. While ERISA allows participants to sue for benefits and fiduciary breaches, this state statute specifies the right to attorney representation in workers' compensation proceedings, which is a separate area of employee benefits not preempted by ERISA.
This section of the Texas Business Organizations Code specifies the types of entities to which the code applies. While ERISA imposes fiduciary duties on plan managers, this state statute governs the general operations of business entities in Texas, which could include entities that manage ERISA plans. However, the fiduciary duties under ERISA are federal requirements and would take precedence over state law.
ERISA sets requirements for disclosure, funding, and fiduciary responsibility for private sector employee benefit plans. It mandates that plan participants receive information about plan features, funding, and management. Plan administrators are held to a fiduciary standard, meaning they must act in the best interest of the participants. ERISA also includes provisions for participants to address grievances and appeal for benefits, as well as the right to sue for benefits and fiduciary breaches.
COBRA provides eligible employees and their beneficiaries the option to extend their health insurance coverage in the event of job loss, reduction in work hours, transition between jobs, death, divorce, and other life events. This coverage can be extended for a limited period, typically 18 to 36 months, depending on the qualifying event, and requires that participants pay the full premium.
HIPAA provides protections against discrimination in health coverage based on health-related factors. It sets rules for pre-existing conditions, special enrollment rights, and prohibits discrimination based on health status. HIPAA also establishes standards for the privacy and security of protected health information (PHI).
The Newborns' and Mothers' Health Protection Act requires group health plans and health insurance issuers offering group or individual health insurance coverage to provide a minimum hospital stay for childbirth. For vaginal deliveries, a 48-hour stay is mandated, and for cesarean sections, a 96-hour stay is required, unless the mother and doctor agree to an earlier discharge.
The Mental Health Parity Act mandates that annual or lifetime dollar limits on mental health benefits are not lower than any such dollar limits for medical and surgical benefits offered by a group health plan or health insurance issuer in the group market.
The Women's Health and Cancer Rights Act requires group health plans and health insurers that cover mastectomies to also cover certain reconstructive surgery and associated services, including reconstruction of the other breast to achieve symmetry, prostheses, and treatment for complications arising from a mastectomy, including lymphedema.
The ACA, among other provisions, extends dependent coverage up to age 26, prohibits pre-existing condition exclusions, mandates coverage of preventive services without cost-sharing, and implements health insurance marketplaces. It also introduces the employer mandate, requiring certain employers to offer health insurance coverage, and the individual mandate, requiring most individuals to have health insurance or face penalties (although the penalty was reduced to $0 at the federal level starting in 2019).
The MHPAEA mandates that financial requirements (such as co-pays and deductibles) and treatment limitations (such as visit limits) applicable to mental health or substance use disorder benefits are no more restrictive than the predominant requirements or limitations applied to substantially all medical and surgical benefits. It also requires parity in out-of-network benefits and expanded disclosure requirements regarding the criteria for medical necessity determinations and the reason for any denial of reimbursement or payment for services.