| (a) An HMO must provide an accurate written description
of health care plan terms and conditions to allow any prospective
contract holder or enrollee or current contract holder or enrollee
to make comparisons and informed decisions before selecting among
health care plans. The HMO may deliver the written description of
health care plan terms and conditions electronically but must provide
a paper copy on request.
(b) The written or electronic plan description must
be filed for approval in compliance with §11.301 of this title
(relating to Filing Requirements); be in a readable and understandable
format that meets the requirements of §3.602 of this title (relating
to Plain Language Requirements), by category; and include these items
in the following order:
(1) a statement that the entity providing the coverage
is an HMO;
(2) a toll-free number, unless exempted by statute
or rule, and address for obtaining additional information, including
physician and provider information;
(3) a clear, complete, and accurate description of
all covered services and benefits, including a description of the
options, if any, for prescription drug coverage, both generic and
brand name, and if applicable, an explanation of how to access formulary
information consistent with §21.3031(b) of this title (relating
to Formulary Information on Issuer's Website);
(4) a clear, complete, and accurate description of
emergency care services and benefits, including coverage for out-of-area
emergency care services and information on access to after-hours care;
(5) a clear, complete, and accurate description of
out-of-area services and benefits (if any);
(6) as provided in Insurance Code §1456.003 (concerning
Required Disclosure: Health Benefit Plan), statements that:
(A) a facility-based physician or other health care
practitioner may not be included in the health benefit plan's physician
and provider network;
(B) the facility-based physician or other health care
practitioner may balance bill the enrollee for amounts not paid by
the health benefit plan; and
(C) if the enrollee receives a balance bill, the enrollee
should contact the HMO;
(7) a clear, complete, and accurate explanation of
enrollee financial responsibility for payment of premiums, copayments,
deductibles, and any other out-of-pocket expenses for noncovered or
out-of-plan services, and an explanation that network physicians and
providers have agreed to look only to the HMO and not to its enrollees
for payment of covered services, except as set forth in this description
of the plan;
(8) a clear, complete, and accurate description of
any limitations or exclusions, including the existence of any drug
formulary limitations;
(9) information regarding preauthorization requirements
as required by Insurance Code §843.3481 (concerning Posting of
Preauthorization Requirements) and Chapter 19, Subchapter R, of this
title (relating to Utilization Reviews for Health Care Provided Under
a Health Benefit Plan or Health Insurance Policy);
(10) a provision for continuity of treatment in the
event of the termination of a primary care physician or dentist;
(11) a clear, complete, and accurate summary of the
HMO's complaint and appeal procedures, a statement of the availability
of the independent review process, and a statement that the HMO is
prohibited from retaliating against a group contract holder or enrollee
because the group contract holder or enrollee has filed a complaint
against the HMO or appealed a decision of the HMO, and is prohibited
from retaliating against a physician or provider because the physician
or provider has, on behalf of an enrollee, reasonably filed a complaint
against the HMO or appealed a decision of the HMO;
(12) a current list of physicians and providers, including
behavioral health providers and substance abuse treatment providers,
if applicable, with the information necessary to fully inform prospective
or current enrollees about the network, including the information
required by §11.1612 of this title (relating to Mandatory Disclosure
Requirements), together with a link to the online directory required
under §11.1612(a) of this title;
(13) a clear, complete, and accurate description of
the service area;
(14) when the HMO product includes point-of-service
coverage, including when such coverage is provided by an insurer,
or when the product is explicitly marketed with the option of purchasing
point-of-service coverage, a clear, complete, and accurate explanation
of the point-of-service coverage, including:
(A) an explanation of how any deductible is calculated,
clearly explaining if multiple deductibles may be applied under the
plan as a whole;
(B) a method to obtain a real-time estimate of the
amount of reimbursement that will be paid to a non-network provider
for a particular service;
(C) a clear, complete, and accurate explanation of
how reimbursements of non-network point-of-service services will be
determined subject to §11.2503 of this title (relating to Coverage
Relating to Point-of-Service Rider Plans) for point-of-service riders
or §21.2902 of this title (relating to Arrangements between Indemnity
Carriers and HMOs to Provide Coverage) for dual and blended point-of-service
arrangements;
(D) if point-of-service coverage is provided under
a dual or blended point-of-service arrangement, a clear, complete,
and accurate explanation of how the coverage will be coordinated and
who the enrollee should contact for common issues, including;
(i) the identity and contact information for each entity,
the HMO, the indemnity carrier, or any third-party administrator (TPA)
that will administer the coverages offered under the point-of-service
plan;
(ii) a clear, complete, and accurate description of
all duties of the HMO and other carrier to each other relating to
the point-of-service plan issued under this subchapter; and
(iii) as applicable, a clear, complete, and accurate
explanation of out-of-plan coverage for point-of-service coverage
offered in conjunction with plans subject to Insurance Code Chapter
1301 (concerning Preferred Provider Benefit Plans);
(E) a clear, complete, and accurate explanation that
for an enrollee in a limited provider network, higher cost-sharing
may be imposed only when the enrollee obtains benefits or services
outside the HMO delivery network.
(c) An HMO may use its member handbook to satisfy the
requirements of this section if the information contained in the handbook
is substantially similar to and provides the same level of disclosure
as the written or electronic description prescribed by the Commissioner
and contains all the information required under this section.
(d) An HMO offering a Children's Health Insurance Program
plan that files its plan description in the form of its member handbook
in compliance with §11.301 of this title (relating to Filing
Requirements), for information only, together with a certification
from the HMO that the handbook has been approved by the Texas Health
and Human Services Commission and a copy of the document approving
the handbook is exempt from the filing and approval requirements of
subsection (b) of this section.
(e) If an HMO limits enrollees' access to health care
to a limited provider network, then it must provide a notice in substantially
the following form to prospective and current group contract holders:
"Choosing Your Physician--Now that you have chosen (Name of HMO),
your next choice will be deciding who will provide the majority of
your health care services. Your Primary Care Physician or Primary
Care Provider (PCP) will be the one you call when you need medical
advice, when you are sick, and when you need preventive care such
as immunizations. Your PCP is also part of a 'network' or association
of health professionals who work together to provide a full range
of health care services. That means when you choose your PCP, you
are also choosing a network and in most instances you are not allowed
to receive services from any physician or health care professional,
including your obstetrician-gynecologist (OB-GYN), that is not also
part of your PCP's network. You will not be able to select any physician
or health care professional outside of your PCP's network, even though
that physician or health care provider is listed with your health
plan. The network to which your PCP belongs will provide or arrange
for all of your care, so make sure that your PCP's network includes
the specialists and hospitals that you prefer."
(f) If an HMO does not limit an enrollee's selection
of an obstetrician or gynecologist to the limited provider network
to which that enrollee's primary care physician or provider belongs,
then it must provide a notice in compliance with Insurance Code Chapter
1451, Subchapter F, (concerning Access to Obstetrical or Gynecological
Care) in substantially the following form to current or prospective
enrollees: "ATTENTION FEMALE ENROLLEES: You have the right to select
and visit an obstetrician-gynecologist Cont'd... |
