| (a) With respect to a child who lives outside the insurer's
service area but inside the United States whose coverage under the
policy is required by a medical support order, an insurer must either:
(1) cover the child under coverage for which the parent
who has been ordered to provide the coverage is eligible and not enforce
otherwise applicable policy provisions that would deny, limit, or
reduce payment for claims for such child; or
(2) provide coverage through the use of alternative
delivery systems, such as reciprocal agreements with indemnity insurers
or HMOs.
(b) If the policy contains preferred provider provisions
for the purposes of offering a network of preferred providers as defined
in Insurance Code Chapter 1301, and the insurer does not provide coverage
under subsection (a)(2) of this section, reimbursement for services
for a child who is the subject of a medical support order and lives
outside the insurer's service area must be provided at the preferred
provider level of benefits.
(c) If the insurer provides coverage under subsection
(a)(2) of this section, the coverage must include benefits identical
to, greater than, or comparable to those provided to other dependent
children covered by the policy under which coverage is required by
a medical support order.
(d) If the coverage is provided under subsection (a)(2)
of this section, the insurer must submit a certification to the Texas
Department of Insurance. The certification must be filed with the
Texas Department of Insurance, Life and Health Division by email to
MCQA@tdi.texas.gov, signed by an officer of the insurer and include:
(1) the insurer's full name;
(2) a statement that the insurer has elected to utilize
an alternative delivery system to provide coverage for children who
are the subject of a medical support order;
(3) the name of the HMO or indemnity carrier with which
the insurer has contracted to provide coverage to children who are
the subject of a medical support order and a statement, if applicable,
that the HMO or indemnity carrier has filed the applicable forms providing
the coverage as required by Insurance Code Chapter 1701, and Insurance
Code §1504.002 and §1504.052 or §11.301 of this title
(relating to Filing Requirements);
(4) a statement that the coverage provided by the alternative
delivery system is either identical, greater or comparable to the
coverage provided other dependent children under the policy under
which coverage is required by a medical support order; and
(5) if the coverage is not identical, the certification
must also be signed by a qualified actuary or an officer of the insurer
who attests that the coverage provided is at least actuarially equivalent
to or greater than the coverage provided to other dependent children
under the policy under which coverage is required by a medical support
order. The determination of actuarial equivalence of the coverages
must take into account plan design (e.g., copayments, coinsurance,
deductibles, etc.) and scope of benefits. The certification must identify
any other variables considered in the analysis relating to the actuarial
equivalence of the coverages.
|
| Source Note: The provisions of this §21.2010 adopted to be effective May 8, 1997, 22 TexReg 3799; amended to be effective January 31, 1999, 24 TexReg 388; amended to be effective November 7, 2021, 46 TexReg 7408 |
