Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter Q - OTHER REQUIREMENTS › Section 11.1600 - Information to Prospective and Current Contract Holders and Enrollees

Current through Reg. 49, No. 28; July 12, 2024
(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.