What State Law Requires a Group Plan to Cover in Texas

Texas requires a fully insured small-group plan to carry a list of mandated benefits — but statutory gates sit between a Texas mandate and your plan, and one plan shape the state authorizes is allowed to leave some of them out and must say so in bold on its own application.

Which plans the Texas list reaches at all

The Texas Department of Insurance publishes the list itself, as Texas Mandated Health Benefits. Before reading a row, read its scope sentences — they are not boilerplate:

“The chart below shows the benefits that must be included in fully insured major medical plans in Texas. The state laws addressed in this chart do not apply to self-funded health plans commonly offered by large employers and exempted from state law by ERISA…”

— Texas Department of Insurance, Texas Mandated Health Benefits

“The chart reflects Texas requirements and is not designed to contain all federal requirements. The columns addressing state law for individual, small group, and large group plans describe the applicability of the Texas statutes as they were drafted. … The federal law (EHB) column reflects that most state mandates are considered EHBs, and in some cases, the federal EHB requirement effectively expands the applicability of the mandate to plans beyond those originally included in the state law. Certain mandated offers and laws specific to HMOs are not considered EHBs.”

— Texas Department of Insurance, Texas Mandated Health Benefits

That has consequences. Funding shape decides whether Texas mandates reach the plan at all — a self-funded arrangement exempted by ERISA is outside this chart by the department’s own statement. And as they were drafted is the whole applicability trap in four words: a small-group column reading No tells you the Texas statute’s reach, not whether the federal essential health benefits requirement reaches further. Every page of the chart states its vintage as laws in effect as of September 1, 2025.

The switch-off, and the plan that switches it back on

Here is the part most descriptions of Texas mandates leave out. Chapter 1501 begins by taking state mandates off a small employer plan:

“EXCEPTION FROM CERTAIN MANDATED BENEFIT REQUIREMENTS. Except as expressly provided by this chapter, a small employer health benefit plan is not subject to a law that requires coverage or the offer of coverage of a health care service or benefit.”

— Tex. Ins. Code § 1501.251

And then it puts them back. Tex. Ins. Code § 1501.252(a) requires the issuer to offer a standard health benefit plan as authorized by Chapter 1507, and § 1501.252(b) lets it add riders or extra mandatory benefits to that plan. Then comes the subsection that matters:

“(c) Subject to this chapter, a small employer health benefit plan issuer shall also offer to a small employer at least one other health benefit plan authorized under this code that provides state-mandated health benefits. Section 1501.251 does not apply to a health benefit plan offered to a small employer under this subsection.”

— Tex. Ins. Code § 1501.252(c)

Read together, those sections mean a Texas small employer is offered more than one shape of plan: a Chapter 1507 standard plan that may leave state mandates out, and at least one other that carries them. So “what does Texas law require my plan to cover” has a second half here, and it is which plan.

The consumer choice plan, and the notice the Legislature wrote for it

Chapter 1507 is where the standard plan lives, and the Legislature did not leave the disclosure to the market. Every written application for one carries this language at the beginning, in bold type:

“You have the option to choose this Consumer Choice of Benefits Health Insurance Plan that, either in whole or in part, does not provide state-mandated health benefits normally required in accident and sickness insurance policies in Texas. This standard health benefit plan may provide a more affordable health insurance policy for you, although, at the same time, it may provide you with fewer health benefits than those normally included as state-mandated health benefits in policies in Texas.”

— Tex. Ins. Code § 1507.005(a)

The notice continues past that point with a direction to consult before choosing the plan; that is where our own reading of the section stops, and we do not complete it from memory.

What is being waived is a defined term. Tex. Ins. Code § 1507.003(a) defines state-mandated health benefits as coverage Texas law requires for specific services or benefits, limits on cost-sharing or maximum benefit amounts, or a named category of licensed practitioner. Tex. Ins. Code § 1507.003(b) then excludes benefits mandated by federal law — which is why a consumer choice plan cannot drop a federal requirement. The department says the same in its own chart: Texas law allows consumer choice plans to exclude certain state mandates, but a consumer choice plan cannot exclude a benefit required by federal law.

If you are comparing a group health plan quote against a cheaper one, this is the first question to ask.

The subchapter a consumer choice plan cannot leave out

There is a limit on the machinery above that the chart does not advertise, and it is written into the mandate itself rather than into Chapter 1501 or Chapter 1507:

“(b) Notwithstanding Section 1501.251 or any other law, this subchapter applies to coverage under a small employer health benefit plan subject to Chapter 1501. (c) This subchapter applies to a standard health benefit plan issued under Chapter 1507.”

— Tex. Ins. Code § 1355.252(b)–(c)

That is the applicability section of the subchapter covering mental health conditions and substance use disorders, added in 2017. Subsection (b) names § 1501.251 — the switch-off — and overrides it. Subsection (c) names Chapter 1507 and reaches into it. So parity is one of the things a Texas consumer choice plan cannot be built to leave out, and it travels with both shapes of plan.

The requirement itself is short: under Tex. Ins. Code § 1355.254(a) a plan must provide benefits and coverage for mental health conditions and substance use disorders under the same terms and conditions applicable to its medical and surgical benefits, and Tex. Ins. Code § 1355.254(b) bars treatment limitations that are generally more restrictive than those on medical or surgical benefits.

“Yes” and “Offer” are different answers

The department’s small-group column does not use one value. Yes means the benefit has to be in the plan; Offer means the issuer has to offer it and the employer may decline it; HMO only means it attaches if the plan is an HMO plan; and Yes, subject to carries a named qualification such as a religious exemption or a limit to children.

The distinction matters most on the Offer rows, because their mandate names read exactly like requirements. In vitro fertilization is an Offer row for small group. So is the group covering serious mental illness, crisis stabilization units, residential treatment centers for children and adolescents and psychiatric day treatment facilities (Tex. Ins. Code § 1355.004, Tex. Ins. Code § 1355.053 and Tex. Ins. Code § 1355.104), inpatient treatment of mental or emotional illness (Tex. Ins. Code § 1355.106), speech and hearing (Tex. Ins. Code Ch. 1365), and home health (Tex. Ins. Code Ch. 1351, which the chart marks as required for an HMO).

The Legislature states the offer rule in its own voice: Tex. Ins. Code § 1355.007 provides that an issuer of a group health benefit plan to a small employer must offer the coverage described by Section 1355.004 but is not required to provide it if the employer rejects it. The department explains what an offer obligation does to a buying process:

“benefits for in vitro fertilization in the small group market fall outside of the EHB requirements. Carriers must continue to offer these benefits to Texas consumers. … An issuer also must notify the consumer of the option to purchase an identical plan that also includes the benefits required under the mandated offer in instances where a consumer applies to purchase a plan that does not contain benefits for a mandated offer. Federal guidance emphasizes that the issuer is responsible to ensure that state-mandated offers are presented to consumers.”

— Texas Department of Insurance

Mandates that shape a benefit you already have

A distinction the chart does not draw: some Texas mandates are free-standing and some are contingent. A contingent mandate shapes a benefit the plan already provides rather than putting that benefit into a plan that lacks it, and the statute says so in its own opening words. The ovarian, cervical and human papillomavirus screening mandate is the clearest case:

“(a) A health benefit plan that provides coverage for diagnostic medical procedures must provide to each woman 18 years of age or older enrolled in the plan coverage for expenses for an annual medically recognized diagnostic examination for the early detection of ovarian cancer and cervical cancer.”

— Tex. Ins. Code § 1370.003(a)

The section goes on to set what that coverage includes at a minimum. But read the opening clause: the duty attaches to a plan that already provides coverage for diagnostic medical procedures.

The newest mandate on the chart is built the same way. Tex. Ins. Code § 1367.302 provides that a plan that provides coverage for general anesthesia may not exclude medically necessary general anesthesia in connection with dental services for a covered individual younger than 13 years of age who cannot undergo the service without it for a documented reason. Its applicability section names small employers expressly: Tex. Ins. Code § 1367.301(b)(1) applies the subchapter, notwithstanding any other law, to a small employer health benefit plan subject to Chapter 1501. It took effect on September 1, 2025 — the same day as the chart’s stated vintage.

The maternity minimum-stay mandate is labeled by the department itself as applying if maternity is covered, and the Alzheimer’s disease mandate is not a benefit at all but an evidentiary rule: a clinical diagnosis satisfies any requirement for proof of organic disease (Tex. Ins. Code Ch. 1354).

Some of what the chart marks affirmative — and two rows where it does not

The chart’s affirmative small-group rows are a long list and this is not all of it. Among them: acquired brain injury (Tex. Ins. Code Ch. 1352); autism spectrum disorder (Tex. Ins. Code § 1355.015); chemical dependency (Tex. Ins. Code Ch. 1368); breast cancer screening and diagnostic imaging (Tex. Ins. Code Ch. 1356); colorectal cancer screening (Tex. Ins. Code Ch. 1363); biomarker testing (Tex. Ins. Code Ch. 1372); limits on step therapy (Tex. Ins. Code § 1369.0547); prescription contraceptives, including a 12-month supply, subject to a religious exemption (Tex. Ins. Code Ch. 1369, Subch. C); newborn screening (Tex. Ins. Code § 1271.154); and emergency care with balance-billing protections (Tex. Ins. Code § 1271.155 for an HMO).

Some rows mislead if you read only the mandate name.

The chart carries diabetes in separate rows. Minimum coverage, services, supplies and self-management training (Tex. Ins. Code Ch. 1358, Subchapters A and B) reads No in the small-group column; limits on cost-sharing (Tex. Ins. Code Ch. 1358, Subch. C) reads Yes. The affirmative small-group requirement is the cost-sharing one.

Reconstructive surgery following mastectomy is a split row: the surgery component reads Yes for small group and the companion minimum-stay component reads No, so a sentence pairing the two is wrong on its second half.

The federal floor underneath all of it

Under the Texas layer sits a federal one, which is why the department warns that its chart is not designed to contain all federal requirements. Small group coverage has to include the essential health benefits package, built from a fixed set of categories:

“§ 156.110 EHB-benchmark plan standards. An EHB-benchmark plan must meet the following standards: (a) EHB coverage. Provide coverage of at least the following categories of benefits: (1) Ambulatory patient services. (2) Emergency services. (3) Hospitalization. (4) Maternity and newborn care. (5) Mental health and substance use disorder services, including behavioral health treatment. (6) Prescription drugs. (7) Rehabilitative and habilitative services and devices. (8) Laboratory services. (9) Preventive and wellness services and chronic disease management. (10) Pediatric services, including oral and vision care.”

“(f) Determining habilitative services. If the base-benchmark plan does not include coverage for habilitative services, the State may determine which services are included in that category.”

— 45 C.F.R. § 156.110

Note the last category. Pediatric oral and vision care sits inside the medical package for children, which is a different thing from the adult group dental and vision plans bought alongside the medical one — worth getting straight before you compare proposals.

What the chart does not answer, and what to ask instead

The chart tells you whether a Texas statute reaches a small-group plan. It does not tell you which plan you have been quoted, whether that plan is fully insured, or whether a mandate’s trigger condition is met by the benefits already in it. Those are the questions that actually decide what your plan covers.

So ask them directly: is this a fully insured Texas small employer health benefit plan or a self-funded arrangement; is it a Chapter 1507 standard plan or a plan carrying state-mandated benefits; and for any mandate you care about, does the plan already provide the benefit that mandate shapes. Our Texas page carries the state-level background, and a quote request is the quickest way to get those answers in writing rather than in a brochure.