TX| Texas Department of Insurance (TDI) adopted amendments to 28 TAC §§3.205, 3.3403, 3.3703, 3.9208, and 3.9210 through Commissioner’s Order No. 2026-10139, issued September 21, 2026. The changes implement 2025 legislation affecting newborn coverage, coordination of benefits, pharmacy and pharmacy-benefit-manager contracting, and Medicaid statutory cross-references. Of greatest operational significance, insurers must ensure plan administration and provider-contract templates reflect the new 60-day newborn initial-coverage period and the added pharmacy/TPA contract requirements; the order text does not state a separate effective date, so insurers should verify the Texas Register publication/effective-date information and implement changes promptly.
Some Key Changes
- Technical citation updates: Insurers should update forms, policies, procedures, templates, and compliance references to replace the repealed rebate/inducement citation in §3.205 with Insurance Code §1702.102(c), and to replace Government Code Chapter 533 with Chapter 540 in exclusive-provider-benefit-plan network-access and complaint-system requirements. Existing complaint procedures and timing requirements otherwise remain in force, including acknowledgment generally within five business days, expedited emergency/continued-stay complaint handling within one business day, and resolution of other complaints within 30 calendar days after receipt of the required written complaint materials.
- Newborn coverage — 60-day minimum: Individual and group accident-and-sickness policies that cover newborns or provide maternity benefits may not exclude or limit a newborn’s initial coverage before the 61st day after birth, including for congenital defects. The mandatory initial coverage period is now at least 60 days, replacing the former 31-day period.
- Enrollment/premium administration after day 60: Insurers may require the policyholder to notify the insurer of the birth and pay any additional premium for coverage to continue after the initial 60-day period. Insurers may also charge an additional premium for the initial coverage period, where applicable. Enrollment materials, newborn workflows, billing rules, and policy forms should be reviewed for alignment.
- Coordination of benefits questionnaire: A preferred-provider-plan insurer may require a preferred provider to retain current information about a patient’s other health benefit plan coverage, consistent with Insurance Code §1203.153. This follows TDI’s adoption of uniform coordination-of-benefits questionnaire forms, LHL138 and LHL139, effective January 1, 2026; insurers should ensure provider communications and operational processes use the required uniform approach.
- Pharmacy and PBM/TPA contracts: Contracts between an insurer and a pharmacy or pharmacist must comply with Insurance Code Chapter 1369, and may not contain provisions prohibited by Insurance Code §4151.155 regarding protected pharmacist/pharmacy disclosures and communications. Contracts with third-party administrators—including pharmacy benefit managers—must comply with 28 TAC §7.1613, including the requirement that the TPA be contractually obligated to meet applicable statutory and regulatory requirements for functions it performs. Insurers should review and amend relevant pharmacy-network, PBM, and TPA agreements.