Individual and group agreements must contain the following
additional mandatory provisions as applicable:
(1) Certificate. Group agreements must include provisions
that the contract holder must be provided with subscriber certificates
to be delivered to each subscriber, the certificate is a part of the
group contract as if fully incorporated, and any direct conflict between
the group agreement and the certificate will be resolved according
to the terms most favorable to the subscriber. If the same form is
used as both the group contract and the certificate, a copy of the
group contract must be delivered to each subscriber.
(2) New enrollees. Group agreements must include a
provision specifying the conditions under which new enrollees may
be added to those originally covered, including effective date requirements.
For coverage issued to employers, group agreements must include a
provision for special enrollment under 45 C.F.R. §146.117 (concerning
Special Enrollment Periods).
(3) Agreements must comply with the benefit, offer,
coverage, and notice requirements contained in Insurance Code Title
8, Subtitle E, (concerning Benefits Payable Under Health Coverages),
as applicable.
(4) Inability to undergo dental treatment. Group agreements,
except for contracts issued to small employer plans and consumer choice
health benefit plans, may not exclude from coverage under the plan
an enrollee who is unable to undergo dental treatment in an office
setting or under local anesthesia due to a documented physical, mental,
or medical reason as determined by the enrollee's physician or the
dentist providing the dental care. This benefit does not require an
HMO to provide dental services if dental services are not otherwise
scheduled or provided as part of the benefits covered by the agreement.
(5) Agreements, including consumer choice health benefit
plan agreements, providing coverage for children under 18 must define
reconstructive surgery for craniofacial abnormalities as provided
by Insurance Code §1367.153 (concerning Reconstructive Surgery
for Craniofacial Abnormalities; Definition Required).
(6) Group agreements, including consumer choice health
benefit plan agreements, must cover formulas necessary to treat phenylketonuria
or a heritable disease to the same extent that the agreement provides
coverage for drugs that are available only on the orders of a physician,
as required by Insurance Code Chapter 1359 (concerning Formulas for
Individuals With Phenylketonuria or Other Heritable Diseases).
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