Evidences of coverage may contain optional provisions, including,
but not limited to, the following:
(1) Coordination of benefits. Plans may contain a provision
that the value of any benefits or services provided by the HMO may
be coordinated with any other type of insurance plan or coverage under
governmental programs so no more than 100 percent of eligible expenses
incurred is paid. The coordination of benefits provision applies to
the plan when an enrollee has health care coverage under more than
one plan. This provision will only apply for the duration of the enrollee's
coverage in a plan.
(A) If benefits are covered by more than one plan,
any plan or plans that do not have a coordination of benefits provision
are primary.
(B) Group plans issued or renewed on or before March
25, 2014, may not coordinate benefits with any type of individual
or conversion plan.
(C) Group plans issued or renewed on or after March
25, 2014, may coordinate benefits with other plans subject to the
requirements of Insurance Code Chapter 1203 (concerning Coordination
of Benefits Provisions) and Chapter 3, Subchapter V, of this title
(relating to Coordination of Benefits).
(2) Subrogation. Plans may contain a provision that
the HMO is subrogated to and has a right to reimbursement from an
individual's recovery for a personal injury for payments made or costs
of benefits provided by the HMO as a result of that injury, subject
to and limited by the provisions of Civil Practice and Remedies Code
Chapter 140 (concerning Contractual Subrogation Rights of Payors of
Certain Benefits), as added by Acts 2013, 83rd Leg., R.S., Ch. 180,
§1 (HB 1869).
(3) Sale of substitutes to workers' compensation insurance.
If the HMO chooses to market a product that provides coverage for
on-the-job injuries or illness, it must comply with §5.6302 of
this title (relating to Sale of Substitutes to Workers' Compensation
Insurance).
(4) Conversion privilege. Group agreements and certificates
for an HMO may, at the HMO's option, contain a conversion privilege.
If an HMO elects to offer a conversion privilege, it must provide
that, on termination of coverage, each enrollee who resides, lives,
or works in the service area who has been covered under the group
contract for a period of at least three months, or in the case of
a court-ordered dependent, lives outside the service area but within
the United States, has the right to convert within 31 days to a conversion
agreement without presenting evidence of insurability. A single service
or limited service HMO must offer a conversion contract without requiring
evidence of insurability. Charges must comply with §11.704 of
this title (relating to Conversion Rates).
(5) Arbitration. Plans may contain a statement of any
arbitration procedure. If enrollee complaints and grievances are resolved
through a specified arbitration agreement, the arbitration must be
conducted under Texas Civil Practice and Remedies Code Chapter 171
(concerning General Arbitration).
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