Texas Mandates

Besides the federal requirements listed above, Texas requires that health plans provide additional coverage benefits for consumers, often called mandates. Some of the state mandates do not apply to self-funded health plans, or others that are exempted from state law by ERISA.

Some examples of state mandates that provide additional insurance coverage for consumers include:

• Mastectomy and reconstructive surgery
• Maternity minimum stay (if maternity is covered)
• Chemical dependency treatment
• Cardiovascular disease screening tests
• Mammography
• HPV and cervical cancer screening

These mandates depend on a variety of factors; for example, whether a plan is an individual plan or a small group plan. For a comprehensive listing of federal and state mandates, and their applicability based on the type of plan, visit the Texas Department of Insurance (TDI)’s website.

Takeaway

Mandated health benefits can be confusing, especially when there is an overlap between both federal and state mandates. The easiest way to find out what your plan covers is to ask your health plan for your summary of benefits and coverage (SBC) document.

If you are concerned that your plan isn’t providing a mandated benefit, contact your health care provider. If that fails, you can file a complaint with TDI.

*️⃣  To learn more about health insurance, visit The Basics, Shopping Guide, and Using Your Insurance sections of our website.