| (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 title (relating
to Plain Language Requirements).
(b) Plan disclosure. 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 (plan disclosure) 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 policy, certificate,
or handbook to satisfy this requirement provided that the insurer
complies with all requirements set forth in this subsection, including
the level of disclosure required. An insurer that is required by federal
law to provide a summary of benefits and coverage (SBC) must include
in the SBC a link to the plan disclosure required in this subsection.
The written plan disclosure must be in a readable and understandable
format, by category, and must include a clear, complete, and accurate
description of these items:
(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 website 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, if prescription drug coverage is included, the name of the formulary
used by the plan, a link to the online formulary, and an explanation
regarding how a nonelectronic copy may be obtained free of charge;
(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 an explanation that unless a provider obtains preauthorization,
a claim could be denied if a service is not medically necessary or
appropriate, or if a service is experimental or investigational;
(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) the name of the provider network used by the plan,
a link to the online provider listing, and information on how a nonelectronic
copy may be obtained free of charge;
(13) the counties included in the plan's service area;
and
(14) information that is updated at least annually
regarding the following network demographics for each county:
(A) the number of insureds in the service area or region;
and
(B) for each preferred provider area of practice and
applicable network adequacy standard, the number of preferred providers,
as well as an indication of whether an active waiver and access plan
under §3.3707 of this title (relating to Waiver Due to Failure
to Contract in Local Markets) applies to the services furnished by
that class of provider in the county and how such access plan may
be obtained or viewed, if applicable.
(c) Filing required. A copy of the plan disclosure
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.
(d) Promotional disclosures required.
(1) 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 out-of-network benefits, except in the case of an exclusive provider
benefit plan.
(2) All promotion and advertisement of the preferred
provider benefit plan for which a waiver has been granted must contain
a statement that the plan received a waiver for a departure from network
adequacy requirements and a website link where the following information
about the waiver may be obtained:
(A) the name of the plan and the insurer offering the
plan;
(B) the specific network adequacy standards waived;
(C) each county affected by the waiver; and
(D) the access plan procedures the insurer will use
to assist insureds in obtaining medically necessary services, consistent
with §3.3707(j) of this title.
(e) Website disclosures. Insurers that maintain a 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 on their website a:
(1) preferred provider listing for use by current and
prospective insureds and group contract holders;
(2) listing of the counties within the insurer's service
area, indicating as appropriate for each county 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) 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 provides major medical
insurance and is not an exclusive provider benefit plan, or Figure:
28 TAC §3.3705(f)(2) for an exclusive provider benefit plan that
provides major medical insurance, in all policies, certificates, plan
disclosures 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 preferred provider
listings. The insurer must ensure that it updates its listing of preferred
providers on its website at least once a month, as required by Insurance
Code §1451.505, concerning Physician and Health Care Provider
Directory on Internet Website. 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.
Cont'd... |
