TITLE 28. INSURANCE
PART 1. TEXAS DEPARTMENT OF INSURANCE
CHAPTER 5. PROPERTY AND CASUALTY INSURANCE
SUBCHAPTER
E.
The commissioner of insurance adopts new 28 TAC §5.4013 and amendments to §§5.4011, 5.4012, 5.4601, 5.4603, 5.4622, and 5.4642, concerning the adoption of the 2024 International Residential Code (IRC) and 2024 International Building Code (IBC), to update the building standards for structures that the Texas Windstorm Insurance Association (TWIA) insures. The new section and amendments are adopted with changes to the proposed text published in the November 21, 2025 issue of the Texas Register (50 TexReg 7505). The sections will be republished.
REASONED JUSTIFICATION. New §5.4013 and amendments to §§5.4011, 5.4012, 5.4601, 5.4603, 5.4622, and 5.4642 are necessary to adopt the 2024 IRC and IBC and make conforming changes to adopted forms. These amendments are also necessary to correct applicable dates for the 2006 and 2018 IRC and IBC because an emergency rule adopted under 28 TAC §35.3 in response to the coronavirus delayed the effective date. Insurance Code §2210.251(b) requires the commissioner to adopt the 2003 IRC and allows for the adoption of subsequent editions of, and supplements to, the IRC published by the International Code Council (ICC). Insurance Code §2210.252 allows the commissioner to supplement by rule the plan of operation building specifications with the structural provisions of the IRC, as well as to adopt by rule a subsequent edition of, or supplement to, the IRC.
The text of §§5.4012, 5.4013, 5.4601, and 5.4603 as proposed have been changed to reference April 1, 2026, instead of March 1, 2026, as the date on and after which the 2024 IRC and IBC apply. This change is made to allow affected parties sufficient time to implement the new codes. Nonsubstantive changes have also been made to §5.4011 as proposed to italicize "International Residential Code" and "International Building Code."
SUMMARY OF COMMENTS AND AGENCY RESPONSE. TDI provided an opportunity for public comment on the rule proposal for a period that ended on December 23, 2025.
Commenters: TDI received comments from one commenter. No commenters spoke at a public hearing on the proposal held on December 16, 2025. Commenters in support of the proposal were the Insurance Council of Texas (ICT).
Comment. A commenter supports the proposal, noting the adoption of the 2024 IRC and IBC would modernize TWIA eligibility standards, reinforce loss-mitigation principles, and advance shared objectives related to public safety, risk management, and long-term cost stability for Texas policyholders.
Agency Response. TDI agrees and thanks the commenter for its support.
DIVISION 1. PLAN OF OPERATION
28 TAC §§5.4011 - 5.4013STATUTORY AUTHORITY.
The commissioner adopts the amendments to §5.4011 and §5.4012 and new §5.4013 under Insurance Code §§2210.008, 2210.251(b), 2210.252, and 36.001.
Insurance Code §2210.008 authorizes the commissioner to adopt reasonable and necessary rules to implement Insurance Code Chapter 2210.
Insurance Code §2210.251(b) requires the commissioner to adopt the 2003 IRC and allows for the adoption of subsequent editions and supplements to the IRC published by the ICC.
Insurance Code §2210.252 allows the commissioner to supplement by rule the plan of operation building specifications with the structural provisions of the IRC, as well as to adopt by rule a subsequent edition of the IRC.
Insurance Code §36.001 provides that the commissioner may adopt any rules necessary and appropriate to implement the powers and duties of TDI under the Insurance Code and other laws of this state.
§5.4011.
(a) To be eligible for catastrophe property insurance, structures located in the designated catastrophe areas specified in §5.4008 of this title (relating to Applicable Building Code Standards in Designated Catastrophe Areas for Structures Constructed, Repaired or to Which Additions Are Made On and After September 1, 1998, and before February 1, 2003) and which are constructed, repaired, or to which additions are made on and after January 1, 2008, and before September 1, 2020, must comply with the 2006 editions of the International Residential Code and the International Building Code, as each is revised by the 2006 Texas Revisions and all of which are adopted by reference to be effective January 1, 2008. The codes are published by and available from the International Code Council at iccsafe.org or by calling toll-free 1-888-422-7233, and the 2006 Texas Revisions to both codes are available from the Windstorm Inspections Program of the Inspections Office at TDI and on the TDI website at www.tdi.texas.gov. The following wind speed requirements must apply.
(1) Areas seaward of the intracoastal canal. To be eligible for catastrophe property insurance, structures located in designated catastrophe areas which are seaward of the intracoastal canal and constructed, repaired, or to which additions are made on and after January 1, 2008, and before September 1, 2020, must be designed and constructed to resist a 3-second gust of 130 miles per hour.
(2) Areas inland of the intracoastal canal and within approximately 25 miles of the Texas coastline and east of the specified boundary line and certain areas in Harris County. To be eligible for catastrophe property insurance, structures located in designated catastrophe areas specified in §5.4008(b)(2)(A) and (B) of this title and constructed, repaired, or to which additions are made on and after January 1, 2008, and before September 1, 2020, must be designed and constructed to resist a 3-second gust of 120 miles per hour.
(3) Areas inland and west of the specified boundary line. To be eligible for catastrophe property insurance, structures located in designated catastrophe areas specified in §5.4008(c) of this title and constructed, repaired, or to which additions are made on and after January 1, 2008, and before September 1, 2020, must be designed and constructed to resist a 3-second gust of 110 miles per hour.
(b) Repairs, alterations, and additions necessary for the preservation, restoration, rehabilitation, or continued use of a historic structure may be made without conformance to the requirements of subsection (a) of this section. For a historic structure to be exempted, at least one of the following conditions must be met.
(1) The structure is listed or is eligible for listing on the National Register of Historic Places.
(2) The structure is a Recorded Texas Historic Landmark (RTHL).
(3) The structure has been specifically designated by official action of a legally constituted municipal or county authority as having special historical or architectural significance, is at least 50 years old, and is subject to the municipal or county requirements relative to construction, alteration, or repair of the structure, in order to maintain its historical designation.
§5.4012.
(a) To be eligible for catastrophe property insurance, structures located in the designated catastrophe areas specified in paragraphs (1), (2), and (3) of this subsection that are constructed, repaired, or to which additions are made on and after September 1, 2020, and before April 1, 2026, must comply with the 2018 editions of the International Residential Code and the International Building Code, which are adopted by reference and applicable beginning September 1, 2020. The codes are published by and available from the International Code Council at iccsafe.org or by calling toll-free 1-888-422-7233. The designated catastrophe areas are those areas:
(1) seaward of the intracoastal canal;
(2) inland of the intracoastal canal and within approximately 25 miles of the Texas coastline and east of the specified boundary line and certain areas in Harris County as described in §5.4008(b)(2)(A) and (B) of this title (relating to Applicable Building Code Standards in Designated Catastrophe Areas for Structures Constructed, Repaired or to Which Additions Are Made On and After September 1, 1998, and before February 1, 2003); and
(3) inland and west of the specified boundary line as described in §5.4008(c) of this title.
(b) Repairs, alterations, and additions necessary for the preservation, restoration, rehabilitation, or continued use of a historic structure may be made without conformance to the requirements of subsection (a) of this section. For a historic structure to be exempted, at least one of the following conditions must apply to the structure.
(1) The structure is listed or is eligible for listing on the National Register of Historic Places.
(2) The structure is a Recorded Texas Historic Landmark by the Texas Historical Commission.
(3) The structure has been designated by official action of a legally constituted municipal or county authority as having special historical or architectural significance, is at least 50 years old, and is subject to the municipal or county requirements relative to construction, alteration, or repair of the structure to maintain its historical designation.
§5.4013.
(a) To be eligible for catastrophe property insurance, structures located in the designated catastrophe areas specified in paragraphs (1), (2), and (3) of this subsection that are constructed, repaired, or to which additions are made on and after April 1, 2026, must comply with the 2024 editions of the International Residential Code and the International Building Code, which are adopted by reference and applicable beginning April 1, 2026. The codes are published by and available from the International Code Council at iccsafe.org or by calling toll-free 1-888-422-7233. The designated catastrophe areas are those areas:
(1) seaward of the intracoastal canal;
(2) inland of the intracoastal canal and within approximately 25 miles of the Texas coastline and east of the specified boundary line and certain areas in Harris County as described in §5.4008(b)(2)(A) and (B) (relating to Applicable Building Code Standards in Designated Catastrophe Areas for Structures Constructed, Repaired or to Which Additions Are Made On and After September 1, 1998, and before February 1, 2003) of this title; and
(3) inland and west of the specified boundary line as described in §5.4008(c) of this title.
(b) Repairs, alterations, and additions necessary for the preservation, restoration, rehabilitation, or continued use of a historic structure may be made without conformance to the requirements of subsection (a) of this section. For a historic structure to be exempted, at least one of the following conditions must apply to the structure.
(1) The structure is listed or is eligible for listing on the National Register of Historic Places.
(2) The structure is an RTHL by the Texas Historical Commission.
(3) The structure has been designated by official action of a legally constituted municipal or county authority as having special historical or architectural significance, is at least 50 years old, and is subject to the municipal or county requirements relative to construction, alteration, or repair of the structure to maintain its historical designation.
The agency certifies that legal counsel has reviewed the adoption and found it to be a valid exercise of the agency's legal authority.
Filed with the Office of the Secretary of State on January 29, 2026.
TRD-202600378
Jessica Barta
General Counsel
Texas Department of Insurance
Effective date: February 18, 2026
Proposal publication date: November 21, 2025
For further information, please call: (512) 676-6555
DIVISION 7. INSPECTIONS FOR WINDSTORM AND HAIL INSURANCE
28 TAC §§5.4601, 5.4603, 5.4622, 5.4642STATUTORY AUTHORITY. The commissioner adopts amendments to §§5.4601, 5.4603, 5.4622, and 5.4642 under Insurance Code §§2210.008, 2210.251(b), 2210.252, and 36.001.
Insurance Code §2210.008 authorizes the commissioner to adopt reasonable and necessary rules to implement Insurance Code Chapter 2210.
Insurance Code §2210.251(b) requires the commissioner to adopt the 2003 IRC and allows for the adoption of subsequent editions and supplements to the IRC published by the ICC.
Insurance Code §2210.252 allows the commissioner to supplement by rule the plan of operation building specifications with the structural provisions of the IRC, as well as to adopt by rule a subsequent edition of the IRC.
Insurance Code §36.001 provides that the commissioner may adopt any rules necessary and appropriate to implement the powers and duties of TDI under the Insurance Code and other laws of this state.
§5.4601.
The following definitions apply to this subchapter:
(1) Applicant--A person who submits a new or renewal application for appointment as an appointed qualified inspector.
(2) Appointed qualified inspector--An engineer licensed by the Texas Board of Professional Engineers and appointed by TDI as a qualified inspector under Insurance Code §2210.254(a)(2), concerning Qualified Inspectors.
(3) Appointed qualified inspector number--A number TDI assigns to each appointed qualified inspector.
(4) Constructed or construction--The act of building or erecting a structure or repairing (including reroofing), altering, remodeling, or enlarging an existing structure.
(5) Completed improvement--
(A) An improvement in which the original transfer of title from the builder to the initial owner of the improvement has occurred; or
(B) if a transfer under subparagraph (A) of this paragraph is not contemplated, an improvement that is substantially completed.
(6) Improvement--The construction of or repair (including reroofing), alteration, remodeling, or enlargement of a structure to which the plan of operation applies.
(7) Ongoing improvement--
(A) An improvement in which the original transfer of title from the builder to the initial owner of the improvement has not occurred; or
(B) if a transfer under subparagraph (A) of this paragraph is not contemplated, an improvement that is not substantially completed.
(8) Substantially completed--An improvement for which the final framing stage, including attachment of component and cladding items and installation of windborne debris protection, has been completed. If the improvement's windborne debris protection consists of wood structural panels, all the panels must be present at the improvement's location but need not be installed.
(9) TDI inspector--A qualified inspector authorized under Insurance Code §2210.254(a)(1) and employed by TDI.
(10) TDI--The Texas Department of Insurance.
(11) Texas Board of Professional Engineers and Land Surveyors, Texas Board of Professional Engineers, or TBPE--House Bill 1523, 86th Legislature, 2019, abolished the Texas Board of Professional Land Surveying and transferred its functions to the renamed Texas Board of Professional Engineers and Land Surveyors, effective September 1, 2019. All references to the Texas Board of Professional Engineers or the TBPE in this division are references to the Texas Board of Professional Engineers and Land Surveyors.
(12) Association--The Texas Windstorm Insurance Association.
(13) Windstorm building code standards--The requirements for building construction in §§5.4007 - 5.4013 of this title (relating to Applicable Building Code Standards in Designated Catastrophe Areas for Structures Constructed, Repaired or to Which Additions Are Made Prior to September 1, 1998; Applicable Building Code Standards in Designated Catastrophe Areas for Structures Constructed, Repaired or to Which Additions Are Made On and After September 1, 1998, and before February 1, 2003; Applicable Building Code Standards in Designated Catastrophe Areas for Structures Constructed, Repaired or to Which Additions Are Made On and After February 1, 2003 and before January 1, 2005; Applicable Building Code Standards in Designated Catastrophe Areas for Structures Constructed, Repaired or to Which Additions Are Made On and After January 1, 2005, and before January 1, 2008; Applicable Building Code Standards in Designated Catastrophe Areas for Structures Constructed, Repaired or to Which Additions Are Made On and After January 1, 2008, and before September 1, 2020; Applicable Building Code Standards in Designated Catastrophe Areas for Structures Constructed, Repaired, or to Which Additions Are Made On and After September 1, 2020, and Before April 1, 2026; and Applicable Building Code Standards in Designated Catastrophe Areas for Structures Constructed, Repaired, or to Which Additions Are Made On and After April 1, 2026; respectively).
§5.4603.
(a) TDI adopts the following forms by reference and will make them available on its website.
(1) Application for Certificate of Compliance, Form WPI-1, effective April 2021, for ongoing improvements. Information requested by Form WPI-1 can be found in §5.4621(1) of this title, relating to Certification of Ongoing Improvements Inspected by Appointed Qualified Inspectors.
(2) Inspection Verification, Form WPI-2-BC-6, effective April 2021, for use in windstorm inspection for structures constructed, repaired, or to which additions are made on and after January 1, 2008, and before September 1, 2020. Information requested by Form WPI-2-BC-6 can be found in §5.4621(4) of this title.
(3) Inspection Verification, Form WPI-2-BC-7, effective January 2026, for use in windstorm inspection for structures constructed, repaired, or to which additions are made on and after September 1, 2020, and before April 1, 2026. Information requested by Form WPI-2-BC-7 can be found in §5.4621(4) of this title.
(4) Inspection Verification, Form WPI-2-BC-8, effective January 2026, for use in windstorm inspection for structures constructed, repaired, or to which additions are made on and after April 1, 2026. Information requested by Form WPI-2-BC-8 can be found in §5.4621(4) of this title.
(5) Application for Certificate of Compliance for Completed Improvement, Form WPI-2E, effective January 2026. Information requested by Form WPI-2E can be found in §5.4604(a) and (b) of this title, relating to Certification Form for Completed Improvement.
(6) Application for Appointment as a Qualified Inspector, Form AQI-1, effective January 2024. Information requested by Form AQI-1 can be found in §5.4609(b) of this title, relating to Application for Qualified Inspector Appointment.
(7) Application Renewal for Appointment as a Qualified Inspector, Form AQI-R, effective June 2025. Information requested by Form AQI-R can be found in §5.4610(b)(1) of this title, relating to Renewal of Qualified Inspector Appointment.
(b) TDI inspection and certification forms. When appropriate, TDI will issue the following forms:
(1) Field Form, Form WPI-7;
(2) Certificate of Compliance for Ongoing Improvement, Form WPI-8; and
(3) Certificate of Compliance for Completed Improvement (Engineered), Form WPI-8E.
(c) The information required by the forms listed in subsection (a)(1) - (5) of this section must be submitted to TDI electronically using the Windstorm system, which is available on the TDI website. TDI will accept a completed Form WPI-1 or WPI-2 emailed to windstorm@tdi.texas.gov only when the Windstorm system is nonfunctional, unless the individual submitting is not a licensed professional engineer.
(d) In this subchapter, the first four alphanumeric characters in the designation of a form listed in this section, such as "WPI-2," refer to all forms with that prefix unless otherwise specified by all the characters in the designation.
§5.4622.
In submitting an Inspection Verification, Form WPI-2, an appointed qualified inspector verifies that:
(1) the ongoing improvement:
(A) complies with the wind load requirements of the applicable building code; or
(B) conforms to a design of the ongoing improvement that complies with the wind load requirements of the applicable building code under the plan of operation and that has a seal affixed by a professional engineer licensed by the Texas Board of Professional Engineers and Land Surveyors; or
(C) does not comply with the wind load requirements of the applicable building code; and
(2) if the ongoing improvement meets the requirements of paragraph (1)(A) or (B) of this section, the appointed qualified inspector is able to provide TDI with information and evidence substantiating compliance.
§5.4642.
(a) Revocation or denial of appointment. After notice and opportunity for hearing, the commissioner may revoke an appointed qualified inspector's appointment or deny an appointed qualified inspector's application for appointment if:
(1) the applicant or appointed qualified inspector violates or fails to comply with the Insurance Code or any rule in this chapter;
(2) the applicant has made a material misrepresentation in the appointment application;
(3) the applicant has attempted to obtain an appointment by fraud or misrepresentation; or
(4) the applicant or appointed qualified inspector has made a material misrepresentation in any form, report, or other information required to be submitted to TDI, including an Application for Certificate of Compliance for Ongoing Improvement, Form WPI-1; a construction inspection report; an Inspection Verification, Form WPI-2; or a Certification Form for Completed Improvement, Form WPI-2E.
(b) Cease and desist order. The commissioner, ex parte, may enter an emergency cease and desist order under Insurance Code Chapter 83, concerning Emergency Cease and Desist Orders, against an appointed qualified inspector, or a person acting as an appointed qualified inspector, if:
(1) the commissioner believes that:
(A) the appointed qualified inspector has:
(i) failed to demonstrate, through submitting or failing to submit to TDI, substantiating information as described in §5.4626 of this title (relating to Substantiating Information), that an ongoing improvement or a portion of an ongoing improvement subject to inspection meets the requirements of Insurance Code Chapter 2210, concerning Texas Windstorm Insurance Association, and TDI rules; or
(ii) refused to comply with requirements imposed under this chapter or TDI rules; or
(B) a person acting as an appointed qualified inspector is acting without appointment under Insurance Code §2210.254, concerning Qualified Inspectors, or §2210.2551, concerning Enforcement Authority; Rules; and
(2) the commissioner determines that the conduct described by paragraph (1) of this subsection is fraudulent, hazardous, or creates an immediate danger to the public.
(c) Alternative sanctions. Under Insurance Code §2210.2551(b) and §2210.256(b), concerning Disciplinary Proceedings Regarding Appointed Inspectors and Certain Other Persons, the commissioner, instead of revocation or denial, may impose one or more of the following sanctions if the commissioner determines from the facts that the alternative sanction would be fair, reasonable, or equitable:
(1) suspension of the appointment for a specific period, not to exceed one year; or
(2) issuance of an order directing the appointed qualified inspector to cease and desist from the specified activity or failure to act determined to be in violation of Insurance Code Chapter 2210, Subchapter F, concerning Property Inspections for Windstorm and Hail Insurance, or rules of the commissioner adopted under Insurance Code Chapter 2210, Subchapter F.
(d) Failure to comply with order. Under Insurance Code §2210.2551(b) and §2210.256(d), if the commissioner finds, after notice and a hearing, that an appointed qualified inspector has failed to comply with an order issued under subsections (a), (b), or (c) of this section, the commissioner will, unless the commissioner's order is lawfully stayed, revoke the appointed qualified inspector's appointment.
(e) Informal disposition. The commissioner may informally dispose of any matter under this section or under §5.4612 of this title (relating to Appointment as Qualified Inspector) by consent order or default.
(f) Automatic cancellation. If the Texas Board of Professional Engineers and Land Surveyors revokes or suspends an engineer's license, the engineer's appointment as an appointed qualified inspector is automatically canceled.
(g) Reasonable penalty. If TDI finds that a person acting as an appointed qualified inspector under Insurance Code §2210.254 has failed to provide complete and accurate information regarding an inspection for a certificate of compliance under Insurance Code §2210.2515, concerning Issuance of Certificates of Compliance, then TDI may impose a reasonable penalty on the inspector, including prohibiting the inspector from applying for certificates of compliance under Insurance Code §2210.2515.
The agency certifies that legal counsel has reviewed the adoption and found it to be a valid exercise of the agency's legal authority.
Filed with the Office of the Secretary of State on January 29, 2026.
TRD-202600379
Jessica Barta
General Counsel
Texas Department of Insurance
Effective date: February 18, 2026
Proposal publication date: November 21, 2025
For further information, please call: (512) 676-6555
CHAPTER 21. TRADE PRACTICES
The commissioner of insurance adopts amendments to 28 TAC §§21.4902, 21.5002, 21.5003, 21.5010, and 21.5040, concerning out-of-network provider disclosures and the claim dispute resolution process, and §21.5070 and §21.5071, concerning data submission and payment requirements for emergency medical services. The amendments are adopted without changes to the proposed text published in the October 3, 2025, issue of the Texas Register (50 TexReg 6461). The sections will not be republished.
REASONED JUSTIFICATION. Amendments to §§21.4902, 21.5002, 21.5003, and 21.5040 are necessary to implement Senate Bill 1409, 89th Legislature, 2025, which authorizes postsecondary educational institutions to offer health benefit plans under Insurance Code Chapter 1683. SB 1409 also amends Insurance Code Chapter 1275 to make higher education health benefit plans subject to state balance billing protections and independent dispute resolution processes. Insurance Code Chapter 1275 establishes balance billing protections for plans that are otherwise not subject to state regulation. The protections in Insurance Code Chapter 1275 closely align with the requirements for out-of-network billing that were originally established by Senate Bill 1264, 86th Legislature, 2019, for health maintenance organizations and preferred provider benefit plans, and health benefit plans administered by the Employees Retirement System of Texas and Teacher Retirement System of Texas.
The amendments to §§21.4902, 21.5002, and 21.5003 add health benefit plans offered under Insurance Code Chapter 1683 to the definition and scope sections to clarify that these plans are subject to the rules found in 28 TAC Chapter 21, Subchapters OO and PP. Insurance Code §1275.004 makes Insurance Code Chapter 1467 applicable to health benefit plans identified in Insurance Code Chapter 1275.
In addition, amendments to §21.5040 require health benefit plans offered by postsecondary educational institutions to include additional information in the explanation of benefits (EOB) provided to physicians and providers. Specifically, the EOB must include an instruction that is substantially similar to the following language: "The request for mediation or arbitration must identify the plan type as 'Higher Ed Plan.'" This addition is consistent with the treatment of other plan types under Insurance Code §1275.002 and should assist in identifying and processing eligible mediation and arbitration requests through the Texas IDR process.
Amendments to §21.5010 are necessary to implement Senate Bill 2544, 89th Legislature, 2025, which creates a statutory deadline for an out-of-network provider or health benefit plan issuer or administrator to request mandatory mediation under Insurance Code Chapter 1467, Subchapter B. The amendment to §21.5010 adds new subsection (d) to clarify that mediation under Subchapter PP, Division 2, must be requested by the out-of-network provider or health benefit plan issuer or administrator not later than 180 days after the date the initial payment is received. The amended language in new subsection (d) is consistent with the treatment of arbitration claims under §21.5020(d), except that the mediation deadline is 180 days.
Amendments to §21.5070 and §21.5071 are necessary to implement Senate Bill 916, 89th Legislature, 2025, which authorizes political subdivisions to annually adjust rates submitted to TDI under Insurance Code §38.006, subject to certain statutory limits. A political subdivision may not adjust a rate submitted to TDI under Insurance Code §38.006 by more than the lesser of (1) the Medicare Ambulance Inflation Factor or (2) 10% of the provider's previous calendar year rates.
Political subdivisions first submitted rates under Insurance Code §38.006 for calendar year 2024 to implement Senate Bill 2476, 88th Legislature, 2023, which expired on September 1, 2025. While SB 2476 included a method for plan payment rates to increase when plans renewed, it did not give political subdivisions an opportunity to submit rates for calendar year 2025. Since SB 916 is effective for emergency medical services provided on or after September 1, 2025, TDI announced a new reporting opportunity in Commissioner's Bulletin #B-0011-25 to allow political subdivisions to submit adjusted rates between August 1 and September 1, 2025. If a political subdivision did not submit a rate adjustment during this reporting window, the previously reported rates continue to apply to claims made between September 1, 2025, and December 31, 2025. On September 15, 2025, TDI published new rate data submitted by the September 1, 2025, deadline.
For calendar year 2026, the data submission deadline will be 30 days after the date this adoption order becomes effective. TDI will issue a message through the GovDelivery system that will announce when political subdivisions and their designees may begin submitting 2026 rate data. Sign up to receive messages through the GovDelivery system here: public.govdelivery.com/accounts/TXINSUR/subscriber/new?topic_id=TXINSUR_3.
For subsequent years, the data submission deadline will be December 1 of the year prior to the calendar year for the data being reported. For example, a political subdivision that elects to submit a rate adjustment must submit data applicable for calendar year 2027 by December 1, 2026. TDI will publish data within 10 business days of the data submission deadline, according to §21.5070(e). Issuers must apply the published rate for the calendar year during which the service or transport was provided or, if rate data was not adjusted for that year, the most recent available rate.
TDI intends to continue to publish previously submitted data in the four emergency services billing rates datasets on the Texas Open Data Portal at data.texas.gov. Information in these datasets include code rates, National Provider Identifier Standard numbers, ZIP codes, and contact lists. For more information about rate data submission, including frequently asked questions and links to other resources, visit www.tdi.texas.gov/health/esbindex.html.
Consistent with SB 916, a political subdivision may annually adjust a rate by not more than the lesser of the Medicare Ambulance Inflation Factor or 10% of the provider's previous calendar rates. For 2025, the Medicare Ambulance Inflation Factor is 2.4%, so an adjusted rate that was submitted by a political subdivision for 2025 could not be more than 2.4% higher than the rate submitted for 2024 for the same service. TDI audited data submitted between August 1 and September 1, 2025, for compliance and referred noncompliant rates to the Texas Department of State Health Services for further action as authorized under Health and Safety Code §773.061(a-1). TDI will continue to review compliance and take necessary actions under SB 916.
Descriptions of the sections' amendments follow.
Section 21.4902. This section provides definitions for use in Subchapter OO. The amendments to §21.4902 expand the definition of an "administrator" to include an administrator of a health benefit plan offered by a postsecondary educational institution under new Insurance Code Chapter 1683, as added by SB 1409. The amendments also expand the definition of "health benefit plan" to include a plan offered by a postsecondary educational institution under Insurance Code Chapter 1683.
Section 21.5002. This section describes the scope of Subchapter PP. The amendments to §21.5002 expand the applicability of Subchapter PP to a qualified mediation or qualified arbitration claim filed under health benefit plan coverage administered by an administrator of a health benefit plan under new Insurance Code Chapter 1683. The amendments add a citation to Insurance Code Chapter 1683 in subsections (a) and (c) of §21.5002 to reflect this expanded applicability.
Section 21.5003. This section provides definitions for use in Subchapter PP. The amendments to §21.5003 expand the definition of an "administrator" to include an administrator of a health benefit plan offered by a postsecondary educational institution under new Insurance Code Chapter 1683. The amendments also expand the definition of "health benefit plan" to include a plan offered by a postsecondary educational institution under Insurance Code Chapter 1683.
Section 21.5010. The amendment to §21.5010 adds new subsection (d) to narrow the availability of mediation for eligible claim disputes that occur on or after June 20, 2025, consistent with SB 2544. Specifically, new subsection (d) requires the out-of-network provider or health benefit plan issuer or administrator to request mediation under the section not later than 180 days after the date the initial payment is received. The amendment also clarifies that the initial payment made to the out-of-network provider could be zero dollars if the allowable amount was applied to an enrollee's deductible, which is consistent with how arbitration claims are treated in 28 TAC §21.5020(d).
Section 21.5040. This section provides the content required in an EOB provided to an enrollee, physician, or provider. The amendment to §21.5040 adds new subsection (b)(3) to address the specific requirements for EOBs provided by a health benefit plan offered by a postsecondary educational institution under Insurance Code Chapter 1683. New subsection (b)(3) requires the health benefit plan to include in the EOB to the physician or provider an instruction to identify the plan type as "Higher Ed Plan" when requesting mediation or arbitration.
Section 21.5070. This section provides the requirements for political subdivisions or their designees to submit emergency medical service rates to TDI for publication under Insurance Code §38.006. The amendments to §21.5070 specify the deadlines for submission of a rate based on the calendar year the rates apply to. For calendar year 2026, the deadline for a political subdivision to submit new or adjusted rates is 30 days after the date §21.5070 becomes effective. The deadline for political subdivisions to submit new or adjusted rates to be used in the following calendar year is December 1 of the current year.
New subsection (g) limits the amount that a political subdivision or its designee may adjust a rate submitted under Insurance Code §38.006 compared with its rate for the previous calendar year. Consistent with SB 916, new subsection (g) states a political subdivision may annually adjust a rate by not more than the lesser of the Medicare Ambulance Inflation Factor or 10% of the provider's previous calendar year rates. For 2026 rates, the Medicare Ambulance Inflation Factor is 2%.
Section 21.5071. This section outlines the requirements that certain health benefit plan issuers or administrators must meet when making payments to emergency medical services providers. The amendments clarify that the health benefit plan issuer or administrator must pay the lesser of the billed charge or the EMS rate published by TDI in the EMS provider rate database for the calendar year that the service or transport was provided. The adopted section specifies that if a new or adjusted rate was not submitted and published in the EMS provider rate database for the calendar year in which the service or transport was provided, the health benefit plan issuer or administrator must use the most recently submitted rate published in the EMS provider rate database established by TDI.
The adoption order also deletes former subsections (c) - (e), concerning payments by issuers and administrators, and Figure: 28 TAC §21.5071(e), which provided examples illustrating how a health benefit plan should apply published rates to a plan year under subsection (d). Subsections (c) - (e) and Figure: 28 TAC §21.5071(e) are no longer necessary because SB 916 removes the requirement that health benefit plans recalculate previously submitted rates and authorizes political subdivisions to submit adjusted rates annually.
SUMMARY OF COMMENTS AND AGENCY RESPONSE. TDI provided an opportunity for public comment on the rule proposal for a period that ended on November 3, 2025, and at a public rule hearing held on October 21, 2025.
Commenters: TDI received comments from four commenters. One commenter spoke at the public hearing. The three others submitted written comments. Commenters in support of the proposal were Texas Association of Health Plans and Texas EMS Alliance. Commenters in support of the proposal with changes were Texas College of Emergency Physicians and Texas Medical Association.
General Comments
Comment. One commenter thanks TDI for the proposed rules and recommends adoption.
Agency Response. TDI appreciates the commenter's support.
Comment. One commenter encourages TDI to proactively audit the rate data submitted to ensure compliance with the statutory limits on annual rate increases.
Agency Response. TDI agrees and has added a column containing a validation rate to the "Emergency Services Billing Rates - Code Rates" Open Data Portal dataset for each billing code for which a political subdivision submitted rates for the years of 2024 and 2025. The validation rate is calculated by multiplying the 2024 rate by 1.024, consistent with the Medicare Ambulance Inflation Factor of 2.4% for 2025. A rate for 2025 is marked as "Noncompliant" if it exceeds the validation rate. A rate for 2025 is marked as "N/A" in the "Compliance" column if no 2025 rate was submitted.
Comment. One commenter suggests that TDI establish a method to monitor which group numbers qualify for the Texas IDR process and notify providers of qualifying group numbers.
Agency Response. TDI already encourages health plans subject to Insurance Code Chapter 1467 to voluntarily submit group numbers that are not eligible for the Texas IDR process. This information is used in the Texas IDR portal to validate requests submitted in real time, which gives providers immediate feedback on requests that are ineligible and lessens the amount of time health plans use to manually identify ineligible requests. TDI also notes that Senate Bill 1236, 89th Legislature, 2025, requires health plans to use group numbers on identification cards for pharmacy benefits that differ based on whether the plan is subject to Insurance Code provisions. As health plans develop new processes to comply with SB 1236, TDI encourages the plans to consider how these processes may be leveraged to improve efficiency in validating IDR requests. TDI welcomes additional information provided by health plans regarding methods TDI could consider to validate IDR requests and make the Texas IDR portal more efficient. TDI declines to publish group number information, as it is provided on a voluntary basis and already used to validate IDR requests.
Comment. One commenter asks that TDI add a new section that requires TDI to establish and maintain a website that displays a list of health benefit plans subject to the Texas IDR process under Insurance Code Chapter 1275, including information about the plan year and the plans' registered agents. Another commenter suggests creating a website with similar information as a supplement to the information included on EOB notifications.
Agency Response. TDI agrees that this information may be of use to the public but declines to make a change to the rule text, as the requested action is outside the scope of the rule as proposed. TDI has existing webpages that explain which plans are eligible for the Texas IDR process and how to identify eligible plans based on ID cards. TDI also has a webpage that lists ERISA plans that have opted in to the Texas IDR process under Insurance Code Chapter 1275. Once self-funded student health plans begin registering with TDI, as is required under Insurance Code §1683.005, TDI will consider listing the plans on a webpage similar to the opt-in ERISA plans webpage.
Comments on §21.5040
Comment. Two commenters note that most claims are submitted and returned electronically in the form of an electronic remittance advice (ERA) file. However, certain payors may opt to provide the EOB in a hardcopy format or in a non-machine-readable PDF format, which creates administrative burdens to determine if the claim is eligible for the state or federal IDR process. One commenter recommends that plan identification or IDR eligibility information be included in ERA files, in lieu of or in addition to hardcopy EOBs. Another commenter recommends adding rule text to §21.5040 that would require health plans subject to Insurance Code Chapter 1275 to return EOBs in a searchable, standardized remark code.
Agency Response. TDI declines to make a change at this time, as the requested action is outside the scope of this rulemaking. As noted in TDI's 2023 rule adoption, TDI has monitored this issue but has not received complaints about payors providing this information using methods that are not standardized and searchable. TDI will continue monitoring the issue and encourages providers and facilities subject to Insurance Code Chapter 1467 to file complaints if payors are not meeting expectations for electronic claims processing.
SUBCHAPTER
OO.
STATUTORY AUTHORITY. The commissioner adopts amendments to §21.4902 under Insurance Code §§1275.004, 1467.003, and 36.001.
Insurance Code §1275.004 states that Insurance Code Chapter 1467 applies to a health benefit plan to which Insurance Code Chapter 1275 applies, and the administrator of a health benefit plan to which Insurance Code Chapter 1275 applies is an administrator for purposes of Insurance Code Chapter 1467.
Insurance Code §1467.003 directs the commissioner to adopt rules as necessary to implement the commissioner's powers and duties under Insurance Code Chapter 1467.
Insurance Code §36.001 provides that the commissioner may adopt any rules necessary and appropriate to implement the powers and duties of TDI under the Insurance Code and other laws of this state.
The agency certifies that legal counsel has reviewed the adoption and found it to be a valid exercise of the agency's legal authority.
Filed with the Office of the Secretary of State on January 30, 2026.
TRD-202600387
Jessica Barta
General Counsel
Texas Department of Insurance
Effective date: February 19, 2026
Proposal publication date: October 3, 2025
For further information, please call: (512) 676-6555
SUBCHAPTER
PP.
DIVISION 1. GENERAL PROVISIONS
28 TAC §21.5002, §21.5003STATUTORY AUTHORITY. The commissioner adopts amendments to §21.5002 and §21.5003 under Insurance Code §§1275.004, 1467.003, and 36.001.
Insurance Code §1275.004 provides that Insurance Code Chapter 1467 applies to a health benefit plan to which Insurance Code Chapter 1275 applies, and the administrator of a health benefit plan to which Insurance Code Chapter 1275 applies is an administrator for purposes of Insurance Code Chapter 1467.
Insurance Code §1467.003 directs the commissioner to adopt rules as necessary to implement the commissioner's powers and duties under Insurance Code Chapter 1467.
Insurance Code §36.001 provides that the commissioner may adopt any rules necessary and appropriate to implement the powers and duties of TDI under the Insurance Code and other laws of this state.
The agency certifies that legal counsel has reviewed the adoption and found it to be a valid exercise of the agency's legal authority.
Filed with the Office of the Secretary of State on January 30, 2026.
TRD-202600388
Jessica Barta
General Counsel
Texas Department of Insurance
Effective date: February 19, 2026
Proposal publication date: October 3, 2025
For further information, please call: (512) 676-6555
DIVISION 2. MEDIATION PROCESS
28 TAC §21.5010STATUTORY AUTHORITY. The commissioner adopts amendments to §21.5010 under Insurance Code §§1467.003, 1467.0505, and 36.001.
Insurance Code §1467.003 directs the commissioner to adopt rules as necessary to implement the commissioner's powers and duties under Insurance Code Chapter 1467.
Insurance Code §1467.0505 authorizes the commissioner to adopt rules, forms, and procedures necessary for the implementation and administration of the mediation program.
Insurance Code §36.001 provides that the commissioner may adopt any rules necessary and appropriate to implement the powers and duties of TDI under the Insurance Code and other laws of this state.
The agency certifies that legal counsel has reviewed the adoption and found it to be a valid exercise of the agency's legal authority.
Filed with the Office of the Secretary of State on January 30, 2026.
TRD-202600389
Jessica Barta
General Counsel
Texas Department of Insurance
Effective date: February 19, 2026
Proposal publication date: October 3, 2025
For further information, please call: (512) 676-6555
DIVISION 5. EXPLANATION OF BENEFITS
28 TAC §21.5040STATUTORY AUTHORITY. The commissioner adopts amendments to §21.5040 under Insurance Code §§1275.004, 1467.003, and 36.001.
Insurance Code §1275.004 provides that Insurance Code Chapter 1467 applies to a health benefit plan to which Insurance Code Chapter 1275 applies, and the administrator of a health benefit plan to which Insurance Code Chapter 1275 applies is an administrator for purposes of Insurance Code Chapter 1467.
Insurance Code §1467.003 directs the commissioner to adopt rules as necessary to implement the commissioner's powers and duties under Insurance Code Chapter 1467.
Insurance Code §36.001 provides that the commissioner may adopt any rules necessary and appropriate to implement the powers and duties of TDI under the Insurance Code and other laws of this state.
The agency certifies that legal counsel has reviewed the adoption and found it to be a valid exercise of the agency's legal authority.
Filed with the Office of the Secretary of State on January 30, 2026.
TRD-202600390
Jessica Barta
General Counsel
Texas Department of Insurance
Effective date: February 19, 2026
Proposal publication date: October 3, 2025
For further information, please call: (512) 676-6555
DIVISION 8. EMERGENCY MEDICAL SERVICE RATE SUBMISSION AND PAYMENT REQUIREMENTS
28 TAC §21.5070, §21.5071STATUTORY AUTHORITY. The commissioner adopts amendments to §21.5070 and §21.5071 under Insurance Code §§38.006, 1301.007, and 36.001.
Insurance Code §38.006 authorizes the commissioner to prescribe the form and manner by which political subdivisions may submit rates for ground ambulance services.
Insurance Code §1301.007 directs the commissioner to adopt rules as necessary to implement Insurance Code Chapter 1301 and ensure reasonable accessibility and availability of preferred provider services to residents of Texas.
Insurance Code §36.001 provides that the commissioner may adopt any rules necessary and appropriate to implement the powers and duties of TDI under the Insurance Code and other laws of this state.
The agency certifies that legal counsel has reviewed the adoption and found it to be a valid exercise of the agency's legal authority.
Filed with the Office of the Secretary of State on January 30, 2026.
TRD-202600391
Jessica Barta
General Counsel
Texas Department of Insurance
Effective date: February 19, 2026
Proposal publication date: October 3, 2025
For further information, please call: (512) 676-6555