| (A) If payment is not received within the 30 days,
coverage may be canceled after the 30th day and the terminated members
may be held liable for the cost of services received during the grace
period, if this requirement is disclosed in the agreement.
(B) Despite subparagraph (A) of this paragraph, provisions
regarding the liability of group contract holder for an enrollee's
premiums must comply with Insurance Code §843.210 (concerning
Terms of Enrollee Eligibility) and §21.4003 of this title (relating
to Group Policyholder, Group Contract Holder, and Carrier Premium
Payment and Coverage Obligations).
(13) Incontestability:
(A) All statements made by the subscriber on the enrollment
application are considered representations and not warranties. The
statements are considered truthful and made to the best of the subscriber's
knowledge and belief. A statement may not be used in a contest to
void, cancel, or nonrenew an enrollee's coverage or reduce benefits
unless:
(i) it is in a written enrollment application signed
by the subscriber; and
(ii) a signed copy of the enrollment application is
or has been furnished to the subscriber or the subscriber's personal
representative.
(B) An individual contract or group certificate may
only be contested because of fraud or intentional misrepresentation
of material fact made on the enrollment application. For small employer
coverage, the misrepresentation must be other than a misrepresentation
related to health status.
(C) For a group contract or certificate, the HMO may
increase its premium to the appropriate level if the HMO determines
that the subscriber made a material misrepresentation of health status
on the application. The HMO must provide the contract holder 31-days
prior written notice of any premium rate change.
(14) Out-of-network services. Each contract between
an HMO and a contract holder must provide that if medically necessary
covered services are not available through network physicians or providers,
the HMO must, on the request of a network physician or provider, within
the time appropriate to the circumstances relating to the delivery
of the services and the condition of the patient, but in no event
to exceed five business days after receipt of reasonably requested
documentation, allow a referral to a non-network physician or provider
and must fully reimburse the non-network provider at the usual and
customary or an agreed rate.
(A) For purposes of determining whether medically necessary
covered services are available through network physicians or providers,
the HMO must offer its entire network, rather than limited provider
networks within the HMO delivery network.
(B) The HMO may not require the enrollee to change
primary care physician or specialist providers to receive medically
necessary covered services that are not available within the limited
provider network.
(C) Each contract must further provide for a review
by a specialist of the same or similar specialty as the type of physician
or provider to whom a referral is requested before the HMO may deny
a referral.
(15) Schedule of charges. A statement that discloses
the HMO's right to change the rate charged with 60-days written notice
under Insurance Code §843.2071 (concerning Notice of Increase
in Charge for Coverage) and Insurance Code Chapter 1254 (concerning
Notice of Rate Increase for Group Health and Accident Coverage).
(16) Service area. A description and a map of the service
area, with key and scale, that identifies the county, or counties,
or portions of counties to be served, and indicating primary care
physicians, hospitals, and emergency care sites. A ZIP code map and
a physician and provider list may be used to meet the requirement.
(17) Termination due to attaining limiting age. A provision
that a child's attainment of a limiting age does not operate to terminate
the child's coverage while that child is incapable of self-sustaining
employment due to mental retardation or physical disability, and chiefly
dependent on the subscriber for support and maintenance. The HMO may
require the subscriber to furnish proof of incapacity and dependency
within 31 days of the child's attainment of the limiting age and subsequently
as required, but not more frequently than annually following the child's
attainment of the limiting age.
(18) Termination due to student dependent's change
in status. A provision regarding coverage of student dependents that
complies with Insurance Code Chapter 1503 (concerning Coverage of
Certain Students), if applicable.
(19) Conformity with state law. A provision that if
the agreement or certificate contains any provision or part of a provision
not in conformity with Insurance Code Chapter 1271 (concerning Benefits
Provided by Health Maintenance Evidence of Coverage; Charges) or other
applicable laws, the remaining provisions and parts of provisions
that can be given effect without the invalid provision or part of
a provision are not rendered invalid but must be construed and applied
as if they were in full compliance with Insurance Code Chapter 1271
and other applicable laws.
(20) Conformity with Medicare supplement minimum standards
and long-term care minimum standards. Each group, individual, and
conversion agreement, and group certificate must comply with Chapter
3, Subchapter T, of this title (relating to Minimum Standards for
Medicare Supplement Policies), referred to in this paragraph as Medicare
supplement rules, and Chapter 3, Subchapter Y, of this title (relating
to Standards for Long-Term Care Insurance, Non-Partnership and Partnership
Long-Term Care Insurance Coverage Under Individual and Group Policies
and Annuity Contracts, and Life Insurance Policies That Provide Long-Term
Care Benefits Within the Policy), referred to in this paragraph as
long-term care rules, where applicable. If there is a conflict between
the Medicare supplement or long-term care rules, or both, and the
HMO rules, the Medicare supplement or long-term care rules will govern
to the exclusion of the conflicting provisions of the HMO rules. Where
there is no conflict, an HMO must follow the Medicare supplement,
the long-term care rules, and the HMO rules where applicable.
(21) Nonprimary care physician specialist as primary
care physician. A provision that allows enrollees with chronic, disabling,
or life threatening illnesses to apply to the HMO's medical director
to use a nonprimary care physician specialist as a primary care physician
as set out in Insurance Code §1271.201 (concerning Designation
of Specialist as Primary Care Physician).
(22) Selected obstetrician or gynecologist. Group,
individual, and conversion agreements, and group certificates, except
small employer health benefit plans as defined by Insurance Code §1501.002
(concerning Definitions), must contain a provision that permits an
enrollee to select, in addition to a primary care physician, an obstetrician
or gynecologist to provide health care services within the scope of
the professional specialty practice of a properly credentialed obstetrician
or gynecologist, and subject to the provisions of Insurance Code Chapter
1451, Subchapter F,(concerning Access to Obstetrical or Gynecological
Care). An HMO may not prevent an enrollee from selecting a family
physician, internal medicine physician, or other qualified physician
to provide obstetrical or gynecological care.
(A) An HMO must permit an enrollee who selects an obstetrician
or gynecologist direct access to the health care services of the selected
obstetrician or gynecologist without a referral by the enrollee's
primary care physician or prior authorization or precertification
from the HMO.
(B) Access to the health care services of an obstetrician
or gynecologist includes:
(i) one well-woman examination per year;
(ii) care related to pregnancy;
(iii) care for all active gynecological conditions;
and
(iv) diagnosis, treatment, and referral to a specialist
within the HMO's network for any disease or condition within the scope
of the selected professional practice of a properly credentialed obstetrician
or gynecologist, including treatment of medical conditions concerning
breasts.
(C) An HMO may require an enrollee who selects an obstetrician
or gynecologist to select the obstetrician or gynecologist from within
the limited provider network to which the enrollee's primary care
physician belongs.
(D) An HMO may require a selected obstetrician or gynecologist
to forward information concerning the medical care of the patient
to the primary care physician. However, the HMO may not impose any
penalty, financial or otherwise, on the obstetrician or gynecologist
for failure to provide this information if the obstetrician or gynecologist
has made a reasonable and good-faith effort to provide the information
to the primary care physician.
Cont'd... |
