| (E) An HMO may limit an enrollee in the plan to self-referral
to one participating obstetrician and gynecologist for both gynecological
care and obstetrical care. The limitation must not affect the right
of the enrollee to select the physician who provides that care.
(F) An HMO must include in its enrollment form a space
in which an enrollee may select an obstetrician or gynecologist as
set forth in Insurance Code Chapter 1451, Subchapter F. The enrollment
form must specify that the enrollee is not required to select an obstetrician
or gynecologist, but may instead receive obstetrical or gynecological
services from the enrollee's primary care physician or primary care
provider. The enrollee must have the right at all times to select
or change a selected obstetrician or gynecologist. An HMO may limit
an enrollee's request to change an obstetrician or gynecologist to
no more than four changes in any 12-month period.
(G) An enrollee who elects to receive obstetrical or
gynecological services from a primary care physician (a family physician,
internal medicine physician, or other qualified physician) must adhere
to the HMO's standard referral protocol when accessing other specialty
obstetrical or gynecological services.
(23) Diagnosis of Alzheimer's disease. An HMO that
provides for the treatment of Alzheimer's disease must provide that
a clinical diagnosis of Alzheimer's disease under Insurance Code Chapter
1354 (concerning Eligibility for Benefits for Alzheimer's Disease)
by a physician licensed in this state satisfies any requirement for
demonstrable proof of organic disease.
(24) Drug Formulary. An agreement that covers prescription
drugs and uses one or more formularies must comply with Insurance
Code Chapter 1369, Subchapter B, (concerning Coverage of Prescription
Drugs Specified by Drug Formulary) and Chapter 21, Subchapter V, of
this title (relating to Pharmacy Benefits).
(25) Inpatient care by nonprimary care physician. If
an HMO or limited provider network provides for an enrollee's care
by a physician other than the enrollee's primary care physician while
the enrollee is in an inpatient facility, for example, hospital or
skilled nursing facility, a provision that on admission to the inpatient
facility a physician other than the primary care physician may direct
and oversee the enrollee's care.
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