| (v) in case of termination by discontinuance of a particular
type of individual coverage by the HMO in that service area, but only
if coverage is discontinued uniformly without regard to health status-related
factors of enrollees and dependents of enrollees who may become eligible
for coverage, after 90-days written notice, in which case the HMO
must offer to each enrollee on a guaranteed-issue basis any other
individual basic health care coverage offered by the HMO in that service
area; and
(vi) in case of termination by discontinuance of all
individual basic health care coverage by the HMO in that service area,
but only if coverage is discontinued uniformly without regard to health
status-related factors of enrollees and dependents of enrollees who
may become eligible for coverage, after 180-days written notice to
the commissioner and the enrollees, in which case the HMO may not
re-enter the individual market in that service area for five years
beginning on the date of discontinuance at the last coverage not renewed.
(4) Claim payment procedure. A provision that sets
forth the procedure for paying claims, including any time frame for
payment of claims that must comply with Insurance Code Chapter 542,
Subchapter B, (concerning Prompt Payment of Claims); Insurance Code
§1271.005 (concerning Applicability of Other Law); and rules
adopted under these Insurance Code provisions.
(5) Complaint and appeal procedures. A description
of the HMO's complaint and appeal process available to complainants,
including internal adverse determination appeal and independent review
procedures under Insurance Code Chapter 4201 (concerning Utilization
Review Agents) and Chapter 19, Subchapter R, of this title (relating
to Utilization Reviews for Health Care Provided Under a Health Benefit
Plan or Health Insurance Policy).
(6) Definitions. A provision defining any words in
the evidence of coverage that have other than the usual meaning. Definitions
must be in alphabetical order.
(7) Effective date. A statement of the effective date
requirements of various kinds of enrollees.
(8) Eligibility. A statement of the eligibility requirements
for membership.
(A) The statement must provide that the subscriber
must reside, live, or work in the service area and the legal residence
of any enrolled dependents must be the same as the subscriber, or
the subscriber must reside, live, or work in the service area and
the residence of any enrolled dependents must be:
(i) in the service area with the person having temporary
or permanent conservatorship or guardianship of the dependents, including
adoptees or children who have become the subject of a suit for adoption
by the enrollee, where the subscriber has legal responsibility for
the health care of the dependents;
(ii) in the service area under other circumstances
where the subscriber is legally responsible for the health care of
the dependents;
(iii) in the service area with the subscriber's spouse;
or
(iv) anywhere in the United States for a child whose
coverage under a plan is required by a medical support order.
(B) The statement must provide the conditions under
which dependent enrollees may be added to those originally covered.
(C) The statement must describe any limiting age for
subscriber and dependents.
(D) The statement must provide a clear statement regarding
the coverage of newborn children.
(i) No evidence of coverage may contain any provision
excluding or limiting coverage for a newborn child of the subscriber
or the subscriber's spouse.
(ii) Congenital defects must be treated the same as
any other illness or injury for which coverage is provided.
(iii) The HMO may require that the subscriber notify
the HMO during the initial 31 days after the birth of the child and
pay any premium required to continue coverage for the newborn child.
(iv) The HMO may not require that a newborn child receive
health care services only from network physicians or providers after
the birth if the newborn child is born outside the HMO service area
due to an emergency or born in a non-network facility to a mother
who does not have HMO coverage, but may require that the newborn be
transferred to a network facility at the HMO's expense and, if applicable,
to a network provider when the transfer is medically appropriate as
determined by the newborn's treating physician.
(v) A newborn child of the subscriber or subscriber's
spouse is entitled to coverage during the initial 31 days following
birth. The HMO must allow an enrollee 31 days after the birth of the
child to notify the HMO, either verbally or in writing, of the addition
of the newborn as a covered dependent.
(E) The statement must include a clear statement regarding
the coverage of the enrollee's grandchildren that complies with Insurance
Code §1201.062 (concerning Coverage for Certain Children in Individual
or Group Policy or in Plan or Program) and §1271.006 (concerning
Benefits to Dependent Child and Grandchild).
(9) Emergency services. A description of how to obtain
services in emergency situations including:
(A) what to do in case of an emergency occurring outside
or inside the service area;
(B) a statement of any restrictions or limitations
on out-of-area services;
(C) a statement that the HMO will provide for any medical
screening examination or other evaluation required by state or federal
law that is necessary to determine whether an emergency medical condition
exists in a hospital emergency facility or comparable facility;
(D) a statement that necessary emergency care services
will be provided, including the treatment and stabilization of an
emergency medical condition;
(E) a statement that where stabilization of an emergency
condition originated in a hospital emergency facility or in a comparable
facility, as defined in subparagraph (F) of this paragraph, treatment
subject to stabilization must be provided to enrollees as approved
by the HMO, provided that:
(i) the HMO must approve or deny coverage of poststabilization
care as requested by a treating physician or provider; and
(ii) the HMO must approve or deny the treatment within
the time appropriate to the circumstances relating to the delivery
of the services and the condition of the patient, but in no case may
approval or denial exceed one hour from the time of the request; and
(F) for purposes of this paragraph, "comparable facility"
includes the following:
(i) any stationary or mobile facility, including, but
not limited to, Level V Trauma Facilities and Rural Health Clinics
that have licensed or certified or both licensed and certified personnel
and equipment to provide Advanced Cardiac Life Support consistent
with American Heart Association and American Trauma Society standards
of care and a free-standing emergency medical care facility as that
term is defined in Insurance Code §843.002 (concerning Definitions);
(ii) for purposes of emergency care related to mental
illness, a mental health facility that can provide 24-hour residential
and psychiatric services and that is:
(I) a facility operated by the Texas Department of
State Health Services;
(II) a private mental hospital licensed by the Texas
Department of State Health Services;
(III) a community center as defined by Texas Health
and Safety Code §534.001 (concerning Establishment);
(IV) a facility operated by a community center or other
entity the Texas Department of State Health Services designates to
provide mental health services;
(V) an identifiable part of a general hospital in which
diagnosis, treatment, and care for persons with mental illness is
provided and that is licensed by the Texas Department of State Health
Services; or
(VI) a hospital operated by a federal agency.
(10) Entire contract, amendments. A provision stating
that the form, applications, if any, and any attachments constitute
the entire contract between the parties and that, to be valid, any
change in the form must be approved by an officer of the HMO and attached
to the affected form and that no agent has the authority to change
the form or waive any of the provisions.
(11) Exclusions and limitations. A provision setting
forth any exclusions and limitations on basic, limited, or single
health care services.
(12) Grace period. A provision for a grace period of
at least 30 days for the payment of any premium due after the first
premium payment during which the coverage remains in effect. An HMO
may add a charge to the premium for late payments received within
the grace period.
Cont'd... |
