| (a) Written agreement between the HMO and the indemnity carrier.
A POS plan offered under this subchapter must be evidenced by a written agreement
between the HMO and indemnity carrier that must be filed with the department
as a plan document and shall provide the following:
(1) the identity of each entity, including the HMO, the indemnity
carrier, or any third party administrator (TPA) that will administer the coverages
offered under the POS plan;
(2) all duties of the HMO and indemnity carrier to each other
relating to the POS plan issued under this subchapter;
(3) all costs allocable to the HMO or the indemnity carrier
relating to the POS plan;
(4) the HMO's network of providers and, if the POS indemnity
coverage includes preferred provider benefits, as allowed by Article 3.70-3C
of the Code and applicable rules, the indemnity carrier's list of preferred
providers, which shall not be identical and;
(5) the respective premium rates for the POS HMO coverage and
for the POS indemnity coverage shall be derived separately by the HMO and
the indemnity carrier and shall be separately identified in each POS plan
contract; however, the agreement may provide that for a POS plan offered by
the entities under this subchapter:
(A) the HMO, the indemnity carrier or a TPA may collect the
premiums for both coverages;
(B) the purchaser may issue one payment for both coverages;
and
(C) the entity delegated to collect the premium shall then
disburse the appropriate premium to the other party or parties;
(6) premium rates charged by the HMO must be based on the actuarial
value of the POS HMO coverage and may be different from the premium rates
charged by the indemnity carrier, which must be based on the actuarial value
of the POS indemnity coverage offered by the indemnity carrier;
(7) the HMO and indemnity carrier must maintain separate books
and records for the POS plan, including but not limited to information regarding
premiums, lists of covered persons, claim payment data, complaint records,
maintenance tax records, and all other books and records required to be maintained
by law or rule;
(8) neither entity shall use the other to perform functions
or duties that are its own responsibility by law or rule, including but not
limited to, making all reports and filings required by law or rule;
(9) the entities may delegate those functions or duties permitted
by law or rule to be delegated to another party to perform, including but
not limited to contracting with providers, administering claims, and conducting
grievance procedures, provided that the delegating entity shall remain responsible
for ensuring that all delegated functions shall be conducted in compliance
with all applicable laws and rules;
(10) the agreement between the indemnity carrier and the HMO
may not be canceled or terminated until the coverage for each enrollee in
a POS plan issued by both the indemnity carrier and HMO is terminated or canceled
pursuant to the provisions of this subchapter; and
(11) the arrangements to be made in the event of insolvency,
loss of certification or any other circumstances affecting the ability of
the indemnity carrier, the HMO, or both to comply with this subchapter.
(b) Basic requirements. In addition to complying with all of
the requirements listed in subsection (a) of this section, a contract creating
a POS blended contract plan and contracts that together create a POS dual
contracts plan must provide the following:
(1) enrollees shall not be required to first use either the
POS indemnity coverage or POS HMO coverage;
(2) if the premiums necessary to maintain both the POS HMO
coverage and the POS indemnity coverage are not paid, both coverages shall
be cancelled simultaneously, and any premium the enrollee has remitted to
maintain coverage shall be returned to the enrollee;
(3) the POS HMO evidence of coverage must include all mandatory
HMO coverages and the POS indemnity coverage must contain all mandatory indemnity
coverages;
(4) corresponding coverage for a POS plan must include the
following:
(A) all mandatory benefit offers required by the Code that
are accepted or rejected by the purchaser must also be accepted or rejected
in the same manner with respect to both the POS HMO and the POS indemnity
coverage;
(B) benefits under the POS HMO coverage may not be reduced
by the benefits received under the POS indemnity coverage; and
(C) benefits for POS indemnity coverage under the plan may
be reduced by benefits received under the POS HMO coverage.
(5) if medically necessary covered services, benefits and supplies
are not available through the HMO's participating physicians or providers,
the HMO is not relieved of its obligation to provide out-of-network services
under Article 20A.09 of the Code on the basis that the same services are available
to an enrollee through POS indemnity coverage; and
(6) each POS contract must identify the respective premium
rates for the POS HMO coverage and for the POS indemnity coverage, as well
as the name and address of the entity to whom the premiums must be paid.
(c) POS blended contracts. Contracts for POS blended contract
plans must:
(1) list all POS HMO coverage;
(2) specify how services, benefits and supplies under the POS
HMO coverage are accessed;
(3) list all POS indemnity coverage;
(4) specify how claims are made for POS indemnity coverage;
(5) disclose all copayments required;
(6) disclose all coinsurance required for POS indemnity coverage,
which shall never exceed 50% of the total amount to be covered;
(7) disclose all deductibles required;
(8) disclose all precertification requirements for POS indemnity
coverage under the plan including any penalties for failing to comply with
any precertification or cost containment provisions, provided that any such
penalties shall not reduce benefits more than 50% in the aggregate;
(9) disclose how the enrollee may complain about a denial of
coverage and appeal an adverse determination rendered concerning the coverage
under the POS plan and disclose any rights the enrollee may have to an independent
review of an adverse determination under Article 21.58A of the Code;
(10) POS indemnity coverage issued to a group shall contain
provisions that comply with Article 3.51-6 Sec. (1)(d)(2)(vii) - (xiii) of
the Code; and
(11) POS indemnity coverage issued to an individual shall contain
provisions that comply with Article 3.70-3(A)(5) - (11) of the Code.
(d) POS dual contracts. Contracts comprising a POS dual contract
plan must comply with the following:
(1) The contract issued by the indemnity carrier shall comply
with all applicable requirements for indemnity carriers and shall:
(A) list all indemnity coverage;
(B) specify how claims are made;
(C) disclose all applicable copayments and coinsurance, which
shall never exceed 50% of the total amount to be covered;
(D) disclose all applicable deductibles;
(E) disclose all precertification requirements for POS indemnity
coverage under the plan including any penalties for failing to comply with
any precertification or cost containment provisions, provided that any such
penalties shall not reduce benefits more than 50% in the aggregate;
(F) disclose how the enrollee may complain about a denial of
coverage and appeal an adverse determination rendered concerning the coverage
under the POS indemnity coverage and disclose any rights the enrollee may
have to an independent review of an adverse determination under Article 21.58A
of the Code, if applicable;
(G) POS indemnity coverage issued to a group, shall contain
provisions that comply with Article 3.51-6 Sec (1)(d)(2)(vii) - (xiii) of
the Code;
(H) POS indemnity coverage issued to an individual shall contain
provisions that comply with Article 3.70-3(A)(5) - (11) of the Code.
(2) The contract issued by the HMO shall comply with all requirements
for an HMO evidence of coverage and shall:
(A) list all covered services, benefits and supplies;
(B) specify how covered services, benefits and supplies are
accessed by the enrollee; and
(C) disclose all applicable copayments.
(e) Filings. All plan documents for a POS plan offered under
this subchapter shall be submitted to the Filings Intake Division in accordance
with:
(1) Article 20A.09 of the Code and Chapter 11 of this title
(relating to Health Maintenance Organizations) including the filing fee requirements;
and
(2) Article 3.42 of the Code and Chapter 3, Subchapter A of
this title (relating to Requirements for Filing of Policy Forms, Riders, Amendments,
Endorsements for Life, Accident, and Health Insurance and Annuities) including
the filing fee requirements.
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