| (a) An HMO may not consider an in-plan covered service
to be a benefit provided under the point-of-service rider.
(b) An HMO may not require an enrollee to use either
the point-of-service rider benefits or in-plan covered services first.
(c) An HMO that includes limited provider networks:
(1) may not limit the access, under the point-of-service
rider, of an enrollee whose in-plan covered services are restricted
to the limited provider network, to either participating physicians
and providers or nonparticipating physicians and providers;
(2) may not impose cost-sharing arrangements for an
enrollee whose in-plan covered services are restricted to a limited
provider network, and who, through the point-of-service rider, accesses
a participating physician or provider outside the limited provider
network, that differ from the cost-sharing arrangements for in-plan
covered services obtained by the enrollee from a physician or provider
in the limited provider network; and
(3) may provide for cost-sharing arrangements for benefits
obtained from nonparticipating physicians and providers that are different
from the cost sharing arrangements for in-plan covered services, provided
that coinsurance required under a point-of-service rider must never
exceed 50 percent of the total amount to be covered.
(d) An HMO that issues or offers to issue a point-of-service
rider plan is subject, to the same extent as the HMO is subject in
issuing any other health plan product, to all applicable provisions
of Insurance Code Chapters 541 (concerning Unfair Methods of Competition
and Unfair or Deceptive Acts or Practices), 542 (concerning Processing
and Settlement of Claims), 543 (concerning Prohibited Practices Related
to Policy or Certificate of Membership), 544 (concerning Prohibited
Discrimination), 547 (concerning False Advertising by Unauthorized
Insurers), 843 (concerning Health Maintenance Organizations), and
1273 (concerning Point-Of-Service Plans).
(e) A point-of-service rider plan offered under this
subchapter must contain:
(1) a point-of-service rider that:
(A) includes coverage that corresponds to all in-plan
covered services provided in the evidence of coverage as well as coverage
that is provided to an enrollee as part of the enrollee's in-plan
coverage through separate riders attached to the evidence of coverage;
(B) may include benefits in addition to in-plan covered
services;
(C) may limit or exclude coverage for benefits that
do not correspond to in-plan covered services;
(D) may not limit coverage for benefits that correspond
to in-plan covered services except as provided in subparagraphs (E),
(F), and (G) of this paragraph;
(E) may include reasonable out-of-pocket limits and
annual and lifetime benefit allowances that differ from limits or
allowances on in-plan covered services provided under other riders
attached to the evidence of coverage so long as the allowances and
limits comply with applicable federal and state laws;
(F) may provide for cost-sharing arrangements that
are different from the cost-sharing arrangements for in-plan covered
services, provided that coinsurance required under a point-of-service
rider must never exceed 50 percent of the total amount to be covered;
(G) may be reduced by benefits obtained as in-plan
covered services;
(H) may not reduce or limit in-plan covered services
in any way by coverage for benefits obtained by an enrollee under
the point-of-service rider;
(I) if applicable, must disclose:
(i) how the point-of-service rider cost-sharing arrangements
differ from those in the evidence of coverage;
(ii) any reduction of benefits as set forth in subparagraph
(G) of this paragraph;
(iii) any deductible that must be met by the enrollee
under the point-of-service rider; and
(iv) whether copayments made for in-plan covered services
apply toward the point-of-service rider deductible;
(J) must provide coverage for services obtained without
the HMO's authorization from a participating physician or provider,
but the enrollee must comply with any precertification requirements
as set forth in subparagraph (L) of this paragraph that are applicable
to the point-of-service rider;
(K) must include a description of how an enrollee may
access out-of-plan covered benefits under the point-of-service rider,
including coverage contained in other riders attached to the evidence
of coverage;
(L) must disclose all precertification requirements
for coverage under the point-of-service rider including any penalties
for failure to comply with any precertification or cost containment
provisions, provided that the penalties will not reduce benefits more
than 50 percent in the aggregate;
(M) if it is issued to a group, must contain provisions
that comply with Insurance Code Chapter 1251, Subchapter C, (concerning
Partnership for Long-Term Care Program); and
(N) if it is issued to an individual, must contain
provisions that comply with Insurance Code §§1201.211 -
1201.217 (concerning Policy Provision: Notice of Claim, Policy Provision:
Claim Forms, Policy Provision: Proof of Loss, Policy Provision: Time
of Payment of Claims, Policy Provision: Payment of Claims, Policy
Provision: Physical Examinations and Autopsy, Policy Provision: Legal
Actions);
(2) an evidence of coverage that includes a description
and reference to the point-of-service rider sufficient to notify a
prospective or current enrollee that the plan provides the option
of accessing participating physicians and providers as well as nonparticipating
physicians and providers for out-of-plan covered benefits, and that
accessing these benefits through the point-of-service rider may involve
greater costs than accessing corresponding in-plan covered services;
and
(3) a side-by-side summary of the schedule of the corresponding
coverage for services, benefits, and supplies available under the
point-of-service rider and services, benefits, and supplies available
in the evidence of coverage that together constitute the point-of-service
rider plan.
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