| (a) A large employer carrier that offers point-of-service
coverage must comply, as applicable, with the requirements set forth
in either Chapter 11, Subchapter Z of this title (relating to Point-of-Service
Riders) or Chapter 21, Subchapter U of this title (relating to Arrangements
Between Indemnity Carriers and HMOs for Point-of-Service Coverage).
(b) If an HMO issues coverage to a large employer and
eligible employees have access only to in-plan coverage through one
or more HMOs, each of the HMOs issuing coverage must offer the eligible
employees the option of obtaining coverage that complies with the
out-of-plan coverage set forth in either Chapter 11, Subchapter Z
of this title or Chapter 21, Subchapter U of this title, and that
allows the enrollee to access out-of-plan coverage at the option of
the enrollee in compliance with Insurance Code §1273.052 (concerning
Offer of Coverage Through Non-Network Plan Required).
(c) All HMOs offering coverage to eligible employees
of a large employer may enter into a written agreement designating
one or more of the HMOs to offer the point-of-service option required
under this section.
(1) A copy of the agreement must be retained on file
by each of the HMOs participating in the agreement and be made available
to TDI on request.
(2) If an HMO participating in the agreement ceases
to offer coverage to the large employer, a new agreement that complies
with all of the requirements of this section must be entered into
by all remaining HMOs offering coverage to employees of the large
employer.
(3) If for any reason, an agreement is not in existence
that ensures that all eligible employees have the option of selecting
out-of-plan coverage under this section from at least one of the HMOs
offering coverage to the eligible employees, each HMO must offer the
eligible employees the option of selecting out-of-plan coverage as
required by this section.
(d) Except as otherwise agreed to by the employer,
an eligible employee who selects a point-of-service option is responsible
for paying all costs, including premiums, coinsurance, copayments,
deductibles, and any other cost-sharing provisions imposed by the
point-of-service option, including any administrative costs imposed
by a large employer as permitted by Insurance Code §1273.055
(concerning Cost-Sharing Provisions).
(e) The premium for coverage required to be offered
under this section must be based on the actuarial value of that coverage
and may be different from the premium for the in-plan coverage provided
by the HMO through the enrollee's evidence of coverage.
|
| Source Note: The provisions of this §26.312 adopted to be effective July 10, 2001, 26 TexReg 5017; amended to be effective April 6, 2005, 30 TexReg 1931; amended to be effective May 17, 2017, 42 TexReg 2539 |
