(a) A health benefit plan issued by a health carrier
through a health group cooperative is not subject to the following
provisions of the Insurance Code or this title:
(1) the offer of in vitro fertilization coverage as
required by Insurance Code Chapter 1366, Subchapter A (Coverage for
In Vitro Fertilization Procedures);
(2) coverage of HIV, AIDS, or HIV-related illnesses
as required by Insurance Code Chapter 1364, Subchapter A (concerning
Exclusion from or Denial of Coverage Prohibited);
(3) coverage of chemical dependency and stays in a
chemical dependency treatment facility as required by Insurance Code
Chapter 1368 (concerning Availability of Chemical Dependency Coverage);
(4) coverage or offer of coverage of serious mental
illness as required by Insurance Code §§1355.001 - 1355.007
(concerning Definitions, Applicability of Subchapter, Exception, Required
Coverage for Serious Mental Illness, Managed Care Plan Authorized,
Coverage for Certain Conditions Related to Controlled Substance or
Marihuana Not Required, Small Employer Coverage);
(5) the offer of mental or emotional illness coverage
as required by Insurance Code §1355.106 (concerning Offer of
Coverage Required; Alternative Benefits);
(6) coverage of inpatient mental health and stays in
a psychiatric day treatment facility as required by Insurance Code
Chapter 1355, Subchapter C (concerning Psychiatric Day Treatment Facilities);
(7) the offer of speech and hearing coverage as required
by Insurance Code Chapter 1365 (concerning Loss or Impairment of Speech
or Hearing);
(8) coverage of mammography screening for the presence
of occult breast cancer as required by Insurance Code §1356.005
(concerning Coverage Required);
(9) standards for proof of Alzheimer's disease as required
by Insurance Code §1354.002 (concerning Proof of Organic Disease);
(10) coverage of stays in a crisis stabilization unit
or residential treatment center for children and adolescents as required
by Insurance Code §1355.055 (concerning Determinations for Treatment
in a Residential Treatment Center for Children and Adolescents) and
§1355.056 (concerning Determinations for Treatment by a Crisis
Stabilization Unit);
(11) coverage for formulas necessary for the treatment
of phenylketonuria as required by Insurance Code Chapter 1359 (concerning
Formulas for Individuals with Phenylketonuria or Other Heritable Diseases);
(12) coverage of contraceptive drugs and devices as
required by Insurance Code Chapter 1369, Subchapter C (concerning
Coverage of Prescription Contraceptive Drugs and Devices and Related
Services) and §21.404(3) of this title (relating to Underwriting);
(13) coverage of diagnosis and treatment affecting
temporomandibular joint and treatment for a person unable to undergo
dental treatment in an office setting or under local anesthesia as
required by Insurance Code Chapter 1360 (concerning Diagnosis and
Treatment Affecting Temporomandibular Joint);
(14) coverage of bone mass measurement for osteoporosis
as required by Insurance Code Chapter 1361 (concerning Detection and
Prevention of Osteoporosis);
(15) coverage of diabetes care as required by Insurance
Code Chapter 1358 (concerning Diabetes);
(16) coverage of childhood immunizations as required
by Insurance Code Chapter 1367, Subchapter B (concerning Childhood
Immunizations);
(17) coverage for screening tests for hearing loss
in children and related diagnostic follow-up care as required by Insurance
Code Chapter 1367 Subchapter C (concerning Hearing Test);
(18) offer of coverage for therapies for children with
developmental delays as required by Insurance Code Chapter 1367, Subchapter
E (concerning Developmental Delays);
(19) coverage of certain tests for detection of prostate
cancer as required by Insurance Code Chapter 1362 (concerning Certain
Tests for Detection of Prostate Cancer);
(20) coverage of acquired brain injury treatment and
services as required by Insurance Code Chapter 1352 (concerning Brain
Injury);
(21) coverage of certain tests for detection of colorectal
cancer as required by Insurance Code Chapter 1363 (concerning Certain
Tests for Detection of Colorectal Cancer);
(22) coverage for reconstructive surgery for craniofacial
abnormalities in a child as required by Insurance Code Chapter 1367,
Subchapter D (concerning Childhood Craniofacial Abnormalities);
(23) coverage of rehabilitation therapies as required
by Insurance Code §1271.156 (concerning Benefits for Rehabilitation
Services and Therapies);
(24) limitations on the treatment of complications
in pregnancy established by §21.405 of this title (relating to
Policy Terms and Conditions);
(25) coverage for services related to immunizations
and vaccinations under managed care plans as required by Insurance
Code Chapter 1353 (concerning Immunization or Vaccination Protocols
under Managed Care Plans);
(26) coverage of a minimum stay for maternity as required
by Insurance Code Chapter 1366, Subchapter B (concerning Minimum Inpatient
Stay Following Birth of Child and Postdelivery Care);
(27) coverage of reconstructive surgery incident to
mastectomy as required by Insurance Code Chapter 1357, Subchapter
A (concerning Reconstructive Surgery Following Mastectomy);
(28) coverage of a minimum stay for mastectomy treatment
and services as required by Insurance Code Chapter 1357, Subchapter
B (concerning Hospital Stay Following Mastectomy and Certain Related
Procedures);
(29) coverage of autism spectrum disorder as required
by the Insurance Code §1355.015 (concerning Required Coverage
for Certain Enrollees);
(30) transplant donor coverage, as established by 28
TAC §3.3040(h) of this title (relating to Prohibited Policy Provisions);
(31) coverage for certain tests for detection of human
papillomavirus, ovarian cancer, and cervical cancer as required by
Insurance Code Chapter 1370 (concerning Certain Tests for Detection
of Human Papillomavirus, Ovarian Cancer, and Cervical Cancer);
(32) coverage of certain tests for detection of cardiovascular
disease as required by Insurance Code Chapter 1376 (concerning Certain
Tests for Early Detection of Cardiovascular Disease);
(33) coverage of certain amino acid-based elemental
formulas as required by Insurance Code Chapter 1377 (concerning Coverage
for Certain Amino Acid-Based Elemental Formulas);
(34) coverage of prosthetic devices, orthotic devices,
and related services as required by Insurance Code Chapter 1371 (concerning
Coverage for Certain Prosthetic Devices, Orthotic Devices, and Related
Services); and
(35) coverage of orally-administered anticancer medications
as required by Insurance Code Chapter 1369 (concerning Benefits Related
to Prescription Drugs and Devices and Related Services).
(b) A health benefit plan issued by an HMO through
a health group cooperative must provide for the basic health care
services as provided in §11.508 or §11.509 of this title
(relating to Mandatory Benefit Standards: Group, Individual and Conversion
Agreements; and Additional Mandatory Benefit Standards: Group Agreement
Only).
(c) A health benefit plan offered by an insurer through
a health group cooperative is not subject to §3.3704(a)(6) of
this title (relating to Freedom of Choice; Availability of Preferred
Providers).
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Source Note: The provisions of this §26.409 adopted to be effective August 31, 2004, 29 TexReg 8360; amended to be effective January 31, 2006, 31 TexReg 512; amended to be effective October 4, 2009, 34 TexReg 6656; amended to be effective May 17, 2017, 42 TexReg 2539 |