Source: http://www.tdi.texas.gov/rules/2005/1229-059.html
Timestamp: 2018-03-24 10:11:06
Document Index: 550451441

Matched Legal Cases: ['§21', '§21', '§1370', '§21', '§21', '§21', '§21', '§21', '§1370', '§21', '§21', '§21', '§21', '§21', '§21', '§21', '§21', '§21', '§21', '§21', '§21', '§21', '§21', '§21', '§21']

28 TAC §§21.2101 - 21.2103, 21.2105, and 21.2106
1. INTRODUCTION. The Commissioner of Insurance adopts amendments to §§21.2101 - 21.2103, 21.2105 and 21.2106, concerning mandatory notice of coverage of certain tests for the detection of human papillomavirus and cervical cancer. The sections are adopted without changes to the proposed text published in the November 11, 2005 issue of the Texas Register (30 TexReg 7360).
2. REASONED JUSTIFICATION. These amendments are necessary to implement HB 1485 enacted by the 79th Texas Legislature, Regular Session, which added Chapter 1370 to the Texas Insurance Code, mandating certain benefits related to the detection of human papillomavirus and cervical cancer. Chapter 1370 also contains mandatory notice requirements. This adoption amends the notice provisions in 28 Texas Administrative Code, Subchapter M to implement the statutory notice requirement in §1370.004. The adoption also updates statutory references changed by the Texas Legislature's enactment of nonsubstantive revision of the Insurance Code.
3. HOW THE SECTIONS WILL FUNCTION. The amendments to §21.2101 expand the scope of the subchapter to include the notice requirements for coverage of benefits related to the detection of human papillomavirus and cervical cancer and set an effective date for the notice requirements. The amendments to §21.2102 revise the definitions of "carrier" and "health benefit plan" to implement the provisions of HB 1485. The amendments to §21.2103 require a carrier to issue the notice related to the detection of human papillomavirus and cervical cancer and revise subsection (d) to provide that if the mandated notice is issued prior to the effective date of these amendments, the notice is deemed compliant with the subchapter's notice requirements. The amendments to §21.2105 recognize statutory changes permitting electronic distribution of notices and address requirements relating to delivery of the notice. The amendment to §21.2106 adopts a new form, number LHL391, which carriers may use to satisfy the notice requirement. The adoption also includes corrective editorial and grammatical changes for clarity as well as to update statutory references.
4. SUMMARY OF COMMENTS. The department received no comments.
5. STATUTORY AUTHORITY. The amendments are adopted under Insurance Code §§1370.004, 1251.201, 1251.008, 1271.002, 843.151, and 36.001. Section 1370.004 requires health benefit plan issuers to provide written notice of coverage related to the detection of human papillomavirus and cervical cancer to each woman 18 years of age or older enrolled in the plan in accordance with rules adopted by the Commissioner. Section 1251.201 authorizes an insurer, by agreement between the insurer and the policyholder, to deliver certificates of insurance electronically. Section 1251.008 authorizes the commissioner to adopt rules necessary to administer Chapter 1251. Section 1271.002 authorizes an insurer, group hospital service corporation, or health maintenance organization, by agreement between it and the subscriber or other person entitled to receive the policy, contract, or evidence of coverage, to deliver evidences of coverage electronically. Section 843.151 authorizes the commissioner to adopt reasonable rules as necessary and proper to implement Chapter 1271. Section 36.001 provides that the Commissioner of Insurance may adopt any rules necessary and appropriate to implement the powers and duties of the Texas Department of Insurance under the Insurance Code and other laws of this state.
(1) to require notice to enrollees in a health benefit plan of coverage and/or benefits for prostate cancer examinations; minimum inpatient stays for maternity and childbirth; minimum inpatient stays for mastectomy or lymph node dissection; reconstructive surgery after mastectomy; certain diagnostic screening tests for early detection of human papillomavirus and cervical cancer, and certain tests for the detection of colorectal cancer. With the exception of notice for reconstructive surgery after mastectomy, notice for certain diagnostic screening tests for early detection of human papillomavirus and cervical cancer, and notice for colorectal cancer detection, §§21.2102 - 21.2106 of this subchapter apply to all carriers issuing, delivering, or renewing health benefit plans as defined in this subchapter as of January 1, 1998. For state notice requirements pertaining to reconstructive surgery after mastectomy, §§21.2102 - 21.2106 of this subchapter apply to all carriers issuing, delivering, or renewing health benefit plans as defined in this subchapter as of June 18, 1999. For notice requirements pertaining to tests for colorectal cancer detection, §§21.2102 - 21.2106 of this subchapter apply to all carriers issuing, delivering, or renewing health benefit plans as defined in this subchapter as of January 1, 2002. For notice requirements pertaining to diagnostic screening tests for early detection of human papillomavirus and cervical cancer, §§21.2102 - 21.2106 of this subchapter apply on or after January 1, 2006, to all carriers issuing, delivering, or renewing health benefit plans as defined in this subchapter.
(1) Carrier--An insurance company, a group hospital service corporation, a fraternal benefit society, a stipulated premium insurance company, a health maintenance organization, a multiple employer welfare arrangement that holds a certificate of authority under Insurance Code Chapter 846, or an approved nonprofit health corporation that holds a certificate of authority issued by the commissioner under Insurance Code Chapter 844. In addition, for the purposes of paragraph (3)(B) and (F) of this section, the term also includes a reciprocal exchange operating under Insurance Code Chapter 942; for purposes of paragraph (3)(E) and (F) of this section, the term also includes a Lloyd´s plan operating under Insurance Code, Chapter 941; and for purposes of paragraph (3)(E) of this section, the term also includes a risk pool created under Chapter 172, Local Government Code.
(3) Health benefit plan--Subject to subparagraphs (A), (B), (C), (D), (E), and (F) of this paragraph, a plan that is offered by a carrier and provides benefits for medical or surgical expenses incurred as a result of a health condition, accident, or sickness including an individual, group, blanket or franchise insurance policy or insurance agreement, a group hospital service contract, an individual or group evidence of coverage, or any similar coverage document. The term does not include a plan that provides coverage only for accidental death or dismemberment, disability income, supplement to liability insurance, Medicare supplement, workers´ compensation, medical payment insurance issued as a part of a motor vehicle insurance policy or a long-term care policy.
(A) For the inpatient mastectomy coverage notice required by subsection (a)(1) of §21.2103 of this title (relating to Mandatory Benefit Notices), the definition of health benefit plan includes a plan that provides coverage only for a specific disease or condition for the treatment of breast cancer or for hospitalization. The term does not include a small employer health benefit plan issued under the Insurance Code Chapter 1501, Subchapters A - H.
(C) For the prostate cancer examination notice required by subsection (a)(3) of §21.2103 of this title, the definition of health benefit plan does not include a small employer health benefit plan written under the Insurance Code Chapter 1501, Subchapters A - H, a plan that provides coverage only for a specified disease or other limited benefit, or only for indemnity for hospital confinement.
(D) For the inpatient maternity and childbirth coverage notice required by subsection (a)(4) and (5) of §21.2103 of this title, the definition of health benefit plan does not include a plan that provides only credit insurance, a plan that provides coverage only for a specified disease or other limited benefit, only for dental or vision care, or only for indemnity for hospital confinement.
(E) For the detection of colorectal cancer screening coverage notice required by subsection (a)(6) of §21.2103 of this title, the definition of health benefit plan does not include a small employer health benefit plan written under the Insurance Code Chapter 1501, Subchapters A - H, or a plan that provides coverage only for a specified disease or other limited benefit or only for indemnity for hospital confinement.
(v) a limited benefit policy that does not provide coverage for physical examinations or wellness exams.
(6) For a health benefit plan that provides coverage and/or benefits for medical screening procedures, a carrier shall issue a notice which includes the language provided in Figure 6 of subsection (b) of §21.2106 of this title (relating to Forms, Form Number 1467 Colorectal Cancer Screening).
(d) If, before the effective date of the amendments to this subchapter relating to a notice listed in paragraphs (1) - (3) of this subsection, a carrier has provided to its enrollees notice(s) that contains the information concerning the required coverage or benefit, such notice(s) shall be deemed to comply with the requirements of this subchapter as to those enrollees;
(3) tests for detection of human papillomavirus and cervical cancer as required by subsection (a)(7) or (b) of this section.
(2) Except as specified in paragraph (6) of this subsection, a carrier shall deliver the notices to enrollees through the U.S. Postal Service or, as permitted by state law, electronically.
(c) A carrier shall issue the notices required by §21.2103(a)(6) and (7) of this title to enrollees of a health benefit plan, and subsections (a)(2) - (6) of this section shall also apply to the notices, except for the timeline requirements of subsection (a)(1) of this section.
Figure: 28 TAC §21.2106(b)(1):
This notice is to advise you of certain coverage and/or benefits provided by your
contract with [name of carrier].
The minimum number of inpatient hours is not required if the covered person receiving
the treatment and the attending physician determine that a shorter period of inpatient
care is appropriate.
If any person covered by this plan has questions concerning the above, please call [name of carrier] at [customer service or related department phone number], or write us at [carrier's customer service or related department address].
(2) Figure Number 2: Form Number 1764 Reconstructive Surgery After Mastectomy-Enrollment:
Figure: 28 TAC §21.2106(b)(2):
Prohibitions: We may not (a) offer the covered person a financial incentive to forego breast reconstruction or waive the coverage and/or benefits shown above; (b) condition, limit, or deny any covered person's eligibility or continued eligibility to enroll in the plan or fail to renew this plan solely to avoid providing the coverage and/or benefits shown above; or (c) reduce or limit the amount paid to the physician or provider, nor otherwise penalize, or provide a financial incentive to induce the physician or provider to provide care to a covered person in a manner inconsistent with the coverage and/or benefits shown above.
Figure: 28 TAC §21.2106(b)(3):
Your contract, as required by the federal Women's Health and Cancer Rights Act of 1998, provides benefits for mastectomy-related services including reconstruction and surgery to achieve symmetry between the breasts, prostheses, and complications resulting from a mastectomy (including lymphedema).
Figure: 28 TAC §21.2106(b)(4):
Figure: 28 TAC §21.2106(b)(5):
If a covered mother or her newborn child is discharged before the 48 or 96 hours has expired, we will provide coverage for postdelivery care. Postdelivery care includes parent education, assistance and training in breast-feeding and bottle-feeding and the performance of any necessary and appropriate clinical tests. Care will be provided by a physician, registered nurse or other appropriate licensed health care provider, and the mother will have the option of receiving the care at her home, the health care provider's office or a health care facility.
Prohibitions. We may not (a) modify the terms of this coverage based on any covered person requesting less than the minimum coverage required; (b) offer the mother financial incentives or other compensation for waiver of the minimum number of hours required; (c) refuse to accept a physician's recommendation for a specified period of inpatient care made in consultation with the mother if the period recommended by the physician does not exceed guidelines for prenatal care developed by nationally recognized professional associations of obstetricians and gynecologists or pediatricians; (d) reduce payments or reimbursements below the usual and customary rate; or (f) penalize a physician for recommending inpatient care for the mother and/or the newborn child.
Figure: 28 TAC §21.2106(b)(6):
Benefits are provided, for each person enrolled in the plan who is 50 years of age or older and at normal risk for developing colon cancer, for expenses incurred in conducting a medically recognized screening examination for the detection of colorectal cancer. Benefits include the covered person's choice of: