Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter KK - EXCLUSIVE PROVIDER BENEFIT PLAN › Section 3.9209 - Mandatory Disclosure Requirements

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  An issuer must write all policies, health benefit plan certificates,
				  endorsements, amendments, applications, and riders in plain language, in a
				  readable and understandable format, and in compliance with all applicable
				  requirements relating to minimum readability requirements as found in §
										3.602
				  of this title (relating to Plain Language Requirements).
(b) The issuer shall provide to current or
				  prospective insureds on request an accurate written description of the terms
				  and conditions of the policy to allow current or prospective insureds to make
				  comparisons and informed decisions before selecting among health care plans.
				  The written description must be in a readable and understandable format as
				  prescribed by the commissioner and must include a current list of exclusive
				  providers. The issuer's handbook may satisfy this requirement if it is
				  substantively similar to and achieves the same level of disclosure as the
				  written description prescribed by subsection (e) of this section and it
				  contains the current list of health care providers.
(c) An issuer shall furnish a current list of
				  exclusive providers to all insureds no less frequently than annually.
(d) No issuer, or agent or representative of
				  an issuer, may cause or permit the use or distribution to prospective insureds
				  of information which is untrue or misleading.
(e) The written plan description must be in a
				  readable and understandable format that includes a clear, complete and accurate
				  description of paragraphs (1) - (11) of this subsection in the following order:
(1) a statement that the plan providing the
				  coverage is an EPP;
(2) a toll-free
				  number, unless exempted by statute or rule, and address for the prospective or
				  current group contract holder or prospective or current enrollee to obtain
				  additional information, including provider information;
(3) all covered services and benefits,
				  including a description of the options (if any) for prescription drug coverage,
				  both generic and brand name;
(4)
				  emergency care services and benefits, including coverage for out-of-area
				  emergency care services and information on access to after-hours
				  care;
(5) out-of-area services and
				  benefits (if any);
(6) an
				  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 exclusive providers have agreed
				  to look only to the issuer and not to its insureds for payment of covered
				  services, except as set forth in the description of the plan;
(7) any limitations or exclusions, including
				  the existence of any drug formulary limitations;
(8) any description of prior authorization
				  requirements, including limitations or restrictions thereon, and a summary of
				  procedures to obtain approval for referrals to providers other than primary
				  care physicians or dentists, and other review requirements, including
				  preauthorization review, concurrent review, post service review, and post
				  payment review, and the consequences resulting from the failure to obtain any
				  required authorizations;
(9)
				  provision for continuity of treatment in the event of the termination of a
				  primary care physician or dentist in those instances where an insured has
				  selected one;
(10) a summary of the
				  complaint and appeal procedures of the EPP, a statement of the availability of
				  the independent review process as applicable, and a statement that the EPP is
				  prohibited from retaliating against insureds because the group contract holder
				  or insured has filed a complaint against the EPP or appealed a decision of the
				  EPP, and is prohibited from retaliating against a health care provider because
				  the health care provider has, on behalf of an insured, reasonably filed a
				  complaint against the EPP or appealed a decision of the EPP; and
(11) a statement that female insureds shall
				  have direct access to an OB/GYN (who is an exclusive provider) for female
				  services.