| (a) Readability. All health insurance policies, health
benefit plan certificates, endorsements, amendments, applications
or riders are required to be written in a readable and understandable
format that meets the requirements of §3.602 of this chapter
(relating to Plain Language Requirements).
(b) Disclosure of terms and conditions of the policy.
The insurer is required, on request, to provide to a current or prospective
group contract holder or a current or prospective insured an accurate
written description of the terms and conditions of the policy that
allows the current or prospective group contract holder or current
or prospective insured to make comparisons and informed decisions
before selecting among health care plans. An insurer may utilize its
handbook to satisfy this requirement provided that the insurer complies
with all requirements set forth in this subsection including the level
of disclosure required. The written description must be in a readable
and understandable format, by category, and must include a clear,
complete, and accurate description of these items in the following
order:
(1) a statement that the entity providing the coverage
is an insurance company; the name of the insurance company; that,
in the case of a preferred provider benefit plan, the insurance contract
contains preferred provider benefits; and, in the case of an exclusive
provider benefit plan, that the contract only provides benefits for
services received from preferred providers, except as otherwise noted
in the contract and written description or as otherwise required by
law;
(2) a toll-free number, unless exempted by statute
or rule, and address to enable a current or prospective group contract
holder or a current or prospective insured to obtain additional information;
(3) an explanation of the distinction between preferred
and nonpreferred providers;
(4) all covered services and benefits, including payment
for services of a preferred provider and a nonpreferred provider,
and prescription drug coverage, both generic and name brand;
(5) emergency care services and benefits and information
on access to after-hours care;
(6) out-of-area services and benefits;
(7) an explanation of the insured's financial responsibility
for payment for any premiums, deductibles, copayments, coinsurance
or other out-of-pocket expenses for noncovered or nonpreferred services;
(8) any limitations and exclusions, including the existence
of any drug formulary limitations, and any limitations regarding preexisting
conditions;
(9) any authorization requirements, including preauthorization
review, concurrent review, post-service review, and post-payment review;
and any penalties or reductions in benefits resulting from the failure
to obtain any required authorizations;
(10) provisions for continuity of treatment in the
event of termination of a preferred provider's participation in the
plan;
(11) a summary of complaint resolution procedures,
if any, and a statement that the insurer is prohibited from retaliating
against the insured because the insured or another person has filed
a complaint on behalf of the insured, or against a physician or provider
who, on behalf of the insured, has reasonably filed a complaint against
the insurer or appealed a decision of the insurer;
(12) a current list of preferred providers and complete
descriptions of the provider networks, including the name, street
address, location, telephone number, and specialty, if any, of each
physician and health care provider, and a disclosure of whether the
preferred provider is accepting new patients. Both of these items
may be provided electronically, if notice is also provided in the
disclosure required by this subsection regarding how a nonelectronic
copy may be obtained free of charge;
(13) the service area(s); and
(14) information that is updated at least annually
regarding the following network demographics for each service area,
if the preferred provider benefit plan is not offered on a statewide
service area basis, or for each of the 11 regions specified in §3.3711
of this title (relating to Geographic Regions), if the plan is offered
on a statewide service area basis:
(A) the number of insureds in the service area or region;
(B) for each provider area of practice, including at
a minimum internal medicine, family/general practice, pediatric practitioner
practice, obstetrics and gynecology, anesthesiology, psychiatry, and
general surgery, the number of preferred providers, as well as an
indication of whether an active access plan pursuant to §3.3709
of this title (relating to Annual Network Adequacy Report; Access
Plan) applies to the services furnished by that class of provider
in the service area or region and how such access plan may be obtained
or viewed, if applicable; and
(C) for hospitals, the number of preferred provider
hospitals in the service area or region, as well as an indication
of whether an active access plan pursuant to §3.3709 of this
title applies to hospital services in that service area or region
and how the access plan may be obtained or viewed.
(15) information that is updated at least annually
regarding whether any waivers or local market access plans approved
pursuant to §3.3707 of this title (relating to Waiver Due to
Failure to Contract in Local Markets) apply to the plan and that complies
with the following:
(A) if a waiver or a local market access plan applies
to facility services or to internal medicine, family or general practice,
pediatric practitioner practice, obstetrics and gynecology, anesthesiology,
psychiatry, or general surgery services, this must be specifically
noted;
(B) the information may be categorized by service area
or county if the preferred provider benefit plan is not offered on
a statewide service area basis, and, if by county, the aggregate of
counties is not more than those within a region; or for each of the
11 regions specified in §3.3711 of this title (relating to Geographic
Regions), if the plan is offered on a statewide service area basis;
and
(C) the information must identify how to obtain or
view the local market access plan.
(c) Filing required. A copy of the written description
required in subsection (b) of this section must be filed with the
department with the initial filing of the preferred provider benefit
plan and within 60 days of any material changes being made in the
information required in subsection (b) of this section. Submission
of listings of preferred providers as required in subsection (b)(12)
of this section may be made electronically in a format acceptable
to the department or by submitting with the filing the Internet website
address at which the department may view the current provider listing.
Acceptable formats include Microsoft Word and Excel documents. Submit
provider listings as specified on the department's website.
(d) Promotional disclosures required. The preferred
provider benefit plan and all promotional, solicitation, and advertising
material concerning the preferred provider benefit plan must clearly
describe the distinction between preferred and nonpreferred providers.
Any illustration of preferred provider benefits must be in close proximity
to an equally prominent description of basic benefits, except in the
case of an exclusive provider benefit plan.
(e) Internet website disclosures. Insurers that maintain
an Internet website providing information regarding the insurer or
the health insurance policies offered by the insurer for use by current
or prospective insureds or group contract holders must provide:
(1) an internet-based provider listing for use by current
and prospective insureds and group contract holders;
(2) an internet-based listing of the state regions,
counties, or three-digit ZIP Code areas within the insurer's service
area(s), indicating as appropriate for each region, county or ZIP
Code area, as applicable, that the insurer has:
(A) determined that its network meets the network adequacy
requirements of this subchapter; or
(B) determined that its network does not meet the network
adequacy requirements of this subchapter; and
(3) an internet-based listing of the information specified
for disclosure in subsection (b) of this section.
(f) Notice of rights under a network plan required.
An insurer must include the notice specified in Figure: 28 TAC §3.3705(f)(1)
for a preferred provider benefit plan that is not an exclusive provider
benefit plan, or Figure: 28 TAC §3.3705(f)(2) for an exclusive
provider benefit plan, in all policies, certificates, disclosures
of policy terms and conditions provided to comply with subsection
(b) of this section, and outlines of coverage in at least 12-point
font:
(1) Preferred provider benefit plan notice.
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(2) Exclusive provider benefit plan notice.
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(g) Untrue or misleading information prohibited. No
insurer, or agent or representative of an insurer, may cause or permit
the use or distribution of information which is untrue or misleading.
(h) Disclosure concerning access to preferred provider
listing. The insurer must provide notice to all insureds at least
annually describing how the insured may access a current listing of
all preferred providers on a cost-free basis. The notice must include,
at a minimum, information concerning how to obtain a nonelectronic
copy of the listing and a telephone number through which insureds
may obtain assistance during regular business hours to find available
preferred providers.
(i) Required updates of available provider listings.
The insurer must ensure that it updates its listing of preferred providers
on its Internet website at least once a month, as required by Insurance
Code §1451.505. The insurer must ensure that it updates all other
electronic or nonelectronic listings of preferred providers made available
to insureds at least every three months.
(j) Annual provision of provider listing required in
certain cases. If no Internet-based preferred provider listing or
other method of identifying current preferred providers is maintained
for use by insureds, the insurer must distribute a current preferred
provider listing to all insureds no less than annually by mail, or
by an alternative method of delivery if an alternative method is agreed
to by the insured, group policyholder on behalf of the group, or certificate
holder.
(k) Reliance on provider listing in certain cases.
A claim for services rendered by a nonpreferred provider must be paid
in the same manner as if no preferred provider had been available
under §3.3708(b) - (d) of this title (relating to Payment of
Certain Basic Benefit Claims and Related Disclosures) and §3.3725(d)
- (f) of this title (relating to Payment of Certain Out-of-Network
Claims), as applicable, if an insured demonstrates that:
(1) in obtaining services, the insured reasonably relied
upon a statement that a physician or provider was a preferred provider
as specified in:
(A) a provider listing; or
(B) provider information on the insurer's website;
(2) the provider listing or website information was
obtained from the insurer, the insurer's website, or the website of
a third party designated by the insurer to provide such information
for use by its insureds;
(3) the provider listing or website information was
obtained not more than 30 days prior to the date of services; and
(4) the provider listing or website information obtained
indicates that the provider is a preferred provider within the insurer's
network.
(l) Additional listing-specific disclosure requirements.
In all preferred provider listings, including any Internet-based postings
by the insurer to insureds about preferred providers, the insurer
must comply with the requirements in paragraphs (1) - (11) of this
subsection.
(1) The provider information must include a method
for insureds to identify those hospitals that have contractually agreed
with the insurer to facilitate the usage of preferred providers as
specified in subparagraphs (A) and (B) of this paragraph.
(A) The hospital will exercise good-faith efforts to
accommodate requests from insureds to utilize preferred providers.
(B) In those instances in which a particular facility-based
physician or physician group is assigned at least 48 hours prior to
services being rendered, the hospital will provide the insured with
information that is:
(i) furnished at least 24 hours prior to services being
rendered; and
(ii) sufficient to enable the insured to identify the
physician or physician group with enough specificity to permit the
insured to determine, along with preferred provider listings made
available by the insurer, whether the assigned facility-based physician
or physician group is a preferred provider.
(2) The provider information must include a method
for insureds to identify, for each preferred provider hospital, the
percentage of the total dollar amount of claims filed with the insurer
by or on behalf of facility-based physicians that are not under contract
with the insurer. The information must be available by class of facility-based
physician, including radiologists, anesthesiologists, pathologists,
emergency department physicians, neonatologists, and assistant surgeons.
Cont'd... |
