| (a) Each enrollee residing in Texas is entitled to
an evidence of coverage under a health care plan. An HMO may deliver
the evidence of coverage electronically but must provide a paper copy
on request.
(b) Each group, individual, and conversion contract
and group certificate must contain the following provisions:
(1) Face page. Where applicable, the name, address,
website address, and phone number of the HMO must appear. The toll-free
number referred to in Insurance Code §521.102 (concerning Health
Maintenance Organization or Insurer Toll-Free Number for Information
and Complaints) must appear on the face page.
(A) The face page of an agreement is the first page
that contains any written material.
(B) If the agreements or certificates are in booklet
form, the first page inside the cover is considered the face page.
(C) The HMO must provide the information regarding
the toll-free number referred to in Insurance Code Chapter 521, Subchapter
C, (concerning Health Maintenance Organization or Insurer Toll-Free
Number for Information and Complaints), in compliance with §1.601
of this title (relating to Notice of Toll-Free Telephone Numbers and
Information and Complaint Procedures).
(2) Benefits. A schedule of all health care services
that are available to enrollees under the basic, limited, or single
service plan must be included, together with any copayments or deductibles
and a description of where and how to obtain services. An HMO may
use a variable copayment or deductible schedule. The schedule must
clearly indicate the benefit to which it applies.
(A) Copayments. An HMO may require copayments to supplement
payment for health care services.
(i) Each basic health care service HMO may establish
one or more reasonable copayment options. A reasonable copayment option
may not exceed 50 percent of the total cost of services provided.
(ii) A basic health care service HMO may not impose
copayment charges on any enrollee in any calendar year, when the copayments
made by the enrollee in that calendar year total 200 percent of the
total annual premium cost which is required to be paid by or on behalf
of that enrollee. This limitation applies only if the enrollee demonstrates
that copayments in that amount have been paid in that year.
(iii) The HMO must state the copayment, the limit on
enrollee copayments, and the enrollee reporting responsibility in
the group, individual, or conversion agreement and group certificate.
(B) Deductibles. A deductible must be for a specific
dollar amount of the cost of the basic, limited, or single health
care service. Except for a consumer choice benefit plan authorized
by Insurance Code Chapter 1507 (concerning Consumer Choice of Benefits
Plans), an HMO may not charge a deductible for services received in
the HMO's delivery network. Except in cases involving emergency care
and services that are not available in the HMO's delivery network,
as described in §11.1611, an HMO may charge an out-of-network
deductible for services performed out of the HMO's service area or
for services performed by a physician or provider who is not in the
HMO's delivery network.
(C) Facility-based Physicians. In compliance with Insurance
Code §1456.003 (concerning Required Disclosure: Health Benefit
Plan), a statement that:
(i) a facility-based physician or other health care
practitioner may not be included in the health benefit plan's provider
network;
(ii) the non-network facility-based physician or other
health care practitioner may balance bill the enrollee for amounts
not paid by the health benefit plan; and
(iii) if the enrollee receives a balance bill, the
enrollee should contact the HMO.
(D) Immunizations. An HMO may not charge a copayment
or deductible for immunizations as described in Insurance Code Chapter
1367, Subchapter B, (concerning Childhood Immunizations) for a child
from birth through the date the child is six years of age, except
that a small employer health benefit plan as defined by Insurance
Code §1501.002 (concerning Definitions) that covers the immunizations
may charge a copayment, and a consumer choice benefit plan under Insurance
Code Chapter 1507 may charge a copayment and a deductible.
(3) Cancellation and nonrenewal. A statement specifying
the following grounds for cancellation and nonrenewal of coverage
and the minimum notice period that will apply.
(A) Unless otherwise prohibited by law, an HMO may
cancel coverage of a subscriber in a group and the subscriber's enrolled
dependents under circumstances described in this subparagraph, so
long as the circumstances do not include health status-related factors:
(i) for nonpayment of amounts due under the contract,
after not less than 30-days written notice, except no additional written
notice will be required for failure to pay premium;
(ii) after not less than 15-days written notice, in
the case of fraud or intentional misrepresentation of a material fact,
except as described in paragraph (13) of this subsection;
(iii) after not less than 15-days written notice, in
the case of fraud in the use of services or facilities;
(iv) immediately, subject to continuation of coverage
and conversion privilege provisions, if applicable, for failure to
meet eligibility requirements other than the requirement that the
subscriber reside, live, or work in the service area; and
(v) after not less than 30-days written notice, where
the subscriber does not reside, live, or work in the service area
of the HMO or area for which the HMO is authorized to do business,
but only if the HMO terminates coverage uniformly without regard to
any health status-related factor of enrollees, except that an HMO
may not cancel coverage for a child who is the subject of a medical
support order because the child does not reside, live, or work in
the service area.
(B) An HMO may cancel a group under circumstances described
below, unless otherwise prohibited by law:
(i) for nonpayment of premium, at the end of the grace
period as described in paragraph (12) of this subsection;
(ii) in the case of fraud on the part of the group,
after 15-days written notice;
(iii) for employer groups, for violation of participation
or contribution rules, under §26.8(h) of this title (relating
to Guaranteed Issue; Contribution and Participation Requirements)
and §26.303(j) of this title (relating to Coverage Requirements);
(iv) for employer groups, under §26.16 of this
title (relating to Refusal to Renew and Application to Reenter Small
Employer Market) and §26.309 of this title (relating to Refusal
to Renew and Application to Reenter Large Employer Market) on discontinuance
of:
(I) each of its small or large employer coverages;
or
(II) a particular type of small or large employer coverage;
(v) where no enrollee resides, lives, or works in the
service area of the HMO or area for which the HMO is authorized to
do business, but only if the coverage is terminated uniformly without
regard to any health status-related factor of enrollees after 30-days
written notice; and
(vi) if membership of an employer in an association
ceases, and if coverage is terminated uniformly without regard to
the health status of an enrollee, after 30-days written notice.
(C) A group or individual contract holder may cancel
a contract in the case of a material change by the HMO to any provisions
required to be disclosed to contract holders or enrollees under this
chapter or other law after not less than 30-days written notice to
the HMO.
(D) An HMO may cancel an individual contract under
circumstances described below, unless otherwise prohibited by law:
(i) for nonpayment of premiums under the terms of the
contract, including any timeliness provisions, without written notice,
subject to paragraph (12) of this subsection;
(ii) in the case of fraud or intentional material misrepresentation,
except as described in paragraph (13) of this subsection, after not
less than 15-days written notice;
(iii) in the case of fraud in the use of services or
facilities, after not less than 15-days written notice;
(iv) after not less than 30-days written notice where
the subscriber does not reside, live, or work in the service area
of the HMO or area in which the HMO is authorized to do business,
but only if coverage is terminated uniformly without regard to any
health status-related factor of enrollees, except that an HMO may
not cancel coverage for a child who is the subject of a medical support
order because the child does not reside, live, or work in the service
area;
Cont'd... |
