| (a) Prescribed mandatory benefit notices consist of the following: (1) For a health benefit plan that provides coverage and/or benefits for the treatment of breast cancer, a carrier shall issue a notice which includes the language provided in Figure 1 of subsection (b) of §21.2106 of this title (relating to Forms, Form Number 349 Mastectomy). (2) For a health benefit plan that provides coverage and/or benefits for a mastectomy, a carrier shall issue: (A) an enrollment notice which includes the language provided in Figure 2 of subsection (b) of §21.2106 of this title (relating to Forms, Form Number 1764 Reconstructive Surgery After Mastectomy-Enrollment); and (B) an annual notice, which includes either: (i) the language provided in Figure 3 of subsection (b) of §21.2106 of this title (relating to Forms, Form Number 1764 Reconstructive Surgery After Mastectomy-Annual); or (ii) the language provided in Figure 2 of subsection (b) of §21.2106 of this title (relating to Forms, Form Number 1764 Reconstructive Surgery after Mastectomy-Enrollment). (3) For a health benefit plan that provides coverage and/or benefits for diagnostic medical procedures, a carrier shall issue a notice which includes the language provided in Figure 4 of subsection (b) of §21.2106 of this title (relating to Forms, Form Number 258 Prostate). (4) For a health benefit plan that provides coverage and/or benefits for maternity, including benefits for childbirth, a carrier shall issue a notice which includes the language provided in Figure 5 of subsection (b) of §21.2106 of this title (relating to Forms, Form Number 102 Maternity). (5) If the health benefit plan described in paragraph 4 of this subsection includes benefits and/or coverage for in-home postdelivery care, the following language, or substantially similar language, shall be inserted immediately before the "Prohibitions" portion of the notice language at Figure 5 of subsection (b) of §21.2106 of this title (relating to Forms): "Since we provide in-home postdelivery care, we are not required to provide the minimum number of hours outlined above unless (a) the mother's or child's physician determines the inpatient care is medically necessary or (b) the mother requests the inpatient stay." (6) For a health benefit plan that provides coverage and/or benefits for medical screening procedures, a carrier shall issue a notice which includes the language provided in Figure 6 of subsection (b) of §21.2106 of this title (relating to Forms, Form Number 1467 Colorectal Cancer Screening). (7) For a health benefit plan that provides coverage and/or benefits for medical screening procedures, a carrier shall issue a notice which includes the language provided in Figure 7 of subsection (b) of §21.2106 of this title (relating to Forms, Form Number LHL391 Human Papillomavirus and Cervical Cancer Screening). (b) In lieu of the prescribed notices outlined in subsection (a) of this section, a carrier may opt to provide notices with substantially similar language rather than the notices contained in subsection (b) of §21.2106 of this title. The substantially similar language must be in a readable and understandable format, and must include a clear, complete, and accurate description of these items in the following order: (1) a heading in bold print and all capital letters indicating the information in the notice relates to mandated benefits; (2) a statement that the notice is being provided to advise the enrollee of the appropriate coverage and/or benefits, including the carrier's complete licensed name; (3) a heading in bold print describing the coverage and/or benefits being provided, for example, Examinations for Detection of Prostate Cancer; (4) a description of the coverage and/or benefits for which the notice is being provided. For a carrier who issues a health benefit plan that provides coverage and/or benefits for a mastectomy, the following shall also apply: (A) the enrollment notice required by subsection (a)(2)(A) of this section shall disclose that the coverage and/or benefits shall be provided in a manner determined to be appropriate in consultation with the attending physician and the enrollee and shall state the specific deductibles, copayments and/or coinsurance, which may not be greater than the deductibles, copayments and/or coinsurance applicable to other benefits under the health benefit plan; and (B) the annual notice required by subsection (a)(2)(B) of this section shall at a minimum describe that the health benefit plan provides coverage and/or benefits for reconstructive surgery after mastectomy, surgery and reconstruction of the other breast for symmetry, prostheses and treatment of complications resulting from a mastectomy (including lymphedema). (5) for the notice required by subsection (a)(1), (2)(A) and (4) of this section, the heading "Prohibitions" in bold print, followed by a summary of the prohibited acts by a carrier in providing the coverage and/or benefits for which the notice is being provided; and (6) a statement identifying the carrier, and providing a phone number and address to which an enrollee may direct questions regarding the coverage and/or benefits for which the notice is being provided. (c) If a health benefit plan provides coverage and/or benefits of more than one of the required notices described in subsection (a) of this section, the carrier may combine the language of the required notices into one notice. (d) If, before the effective date of the amendments to this subchapter relating to a notice listed in paragraphs (1) - (3) of this subsection, a carrier has provided to its enrollees notice(s) that contains the information concerning the required coverage or benefit, such notice(s) shall be deemed to comply with the requirements of this subchapter as to those enrollees; (1) reconstructive surgery after mastectomy as required by subsection (a)(2) or (b) of this section; (2) tests for detection of colorectal cancer as required by subsection (a)(6) or (b) of this section; and (3) tests for detection of human papillomavirus and cervical cancer as required by subsection (a)(7) or (b) of this section. |
| Source Note: The provisions of this §21.2103 adopted to be effective March 29, 1998, 23 TexReg 3009; amended to be effective April 14, 1999, 24 TexReg 3356; amended to be effective January 8, 2001, 26 TexReg 202; amended to be effective April 2, 2002, 27 TexReg 2506; amended to be effective January 19, 2006, 31 TexReg 295 |
