| (a) Prescribed mandatory benefit notices consist of
the following:
(1) For a health benefit plan that provides coverage
or benefits for the treatment of breast cancer, a carrier must issue
a notice that includes the language provided in Figure 1 of §21.2106(b)
of this title (relating to Forms).
(2) For a health benefit plan that provides coverage
or benefits for a mastectomy, a carrier must issue:
(A) an enrollment notice that includes the language
provided in Figure 2 of §21.2106(b) of this title; and
(B) an annual notice that includes either:
(i) the language provided in Figure 3 §21.2106(b)
of this title; or
(ii) the language provided in Figure 2 §21.2106(b)
of this title.
(3) For a health benefit plan that provides coverage
or benefits for diagnostic medical procedures, a carrier must issue
a notice that includes the language provided in Figure 4 §21.2106(b)
of this title.
(4) For a health benefit plan that provides coverage
or benefits for maternity, including benefits for childbirth, a carrier
must issue a notice that includes the language provided in Figure
5 §21.2106(b) of this title.
(5) If the health benefit plan described in paragraph
(4) of this subsection includes benefits or coverage for in-home postdelivery
care, the following language, or substantially similar language, must
be inserted immediately before the "Prohibitions" portion of the notice
language in Figure 5 §21.2106(b) of this title: "Since we provide
in-home postdelivery care, we are not required to provide the minimum
number of hours outlined above unless (a) the mother's or child's
physician determines the inpatient care is medically necessary, or
(b) the mother requests the inpatient stay."
(6) For a health benefit plan that provides coverage
or benefits for medical screening procedures, a carrier must issue
a notice that includes the language provided in Figure 6 §21.2106(b)
of this title.
(7) For a health benefit plan that provides coverage
or benefits for medical screening procedures, a carrier must issue
a notice that includes the language provided in Figure 7 §21.2106(b)
of this title. If a plan is not required to provide a benefit for
ovarian cancer screening due to the exception in Insurance Code §1370.002(b)
(concerning Exceptions), the notice may be modified to omit the references
to ovarian cancer and the CA 125 blood test.
(b) Instead of the prescribed notices outlined in subsection
(a) of this section, a carrier may opt to provide notices with substantially
similar language rather than the notices contained in §21.2106(b)
of this title. A form that includes substantially similar language
under this subsection must be filed for review and approval by the
commissioner prior to use, in accordance with Insurance Code Chapters
843 (concerning Health Maintenance Organizations), 1271 (concerning
Benefits Provided by Health Maintenance Organizations; Evidence of
Coverage; Charges), and 1701 (concerning Policy Forms), except that
a form already in use may not be used after March 1, 2017, unless
approved by the commissioner. The substantially similar language must
be in a readable and understandable format, and must include a clear,
complete, and accurate description of these items in the following
order:
(1) a heading in bold print and all capital letters
indicating the information in the notice relates to mandated benefits;
(2) a statement that the notice is being provided to
advise the enrollee of the appropriate coverage or benefits, including
the carrier's complete licensed name;
(3) a heading in bold print describing the coverage
or benefits being provided; for example, Examinations for Detection
of Prostate Cancer;
(4) a description of the coverage or benefits for which
the notice is being provided;
(5) for a carrier who issues a health benefit plan
that provides coverage or benefits for a mastectomy, the following
requirements apply:
(A) the enrollment notice required by subsection (a)(2)(A)
of this section must disclose that the coverage or benefits must be
provided in a manner determined to be appropriate, in consultation
with the attending physician and the enrollee, and state the specific
deductibles, copayments, and coinsurance, which may not be greater
than the deductibles, copayments, and coinsurance applicable to other
benefits under the health benefit plan; and
(B) the annual notice required by subsection (a)(2)(B)
of this section must, at a minimum, describe that the health benefit
plan provides coverage or benefits for reconstructive surgery after
mastectomy, surgery and reconstruction of the other breast for symmetry,
prostheses, and treatment of complications resulting from a mastectomy
(including lymphedema);
(6) for the notice required by subsection (a)(1), (2)(A),
and (4) of this section, the heading "Prohibitions" in bold, followed
by a summary of the prohibited acts by a carrier in providing the
coverage or benefits for which the notice is being provided; and
(7) a statement identifying the carrier, and providing
a phone number and address to which an enrollee may direct questions
regarding the coverage or benefits for which the notice is being provided.
(c) If a health benefit plan provides coverage or benefits
of more than one of the required notices described in subsection (a)
of this section, the carrier may combine the language of the required
notices into one notice.
(d) The notices must be printed in no less than 10-point
type.
|
| Source Note: The provisions of this §21.2103 adopted to be effective March 29, 1998, 23 TexReg 3009; amended to be effective April 14, 1999, 24 TexReg 3356; amended to be effective January 8, 2001, 26 TexReg 202; amended to be effective April 2, 2002, 27 TexReg 2506; amended to be effective January 19, 2006, 31 TexReg 295; amended to be effective November 2, 2016, 41 TexReg 8609 |
