Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter F - EVIDENCE OF COVERAGE › Section 11.508 - Basic Health Care Services and Mandatory Benefit Standards: Group, Individual, and Conversion Agreements

Current through Reg. 49, No. 28; July 12, 2024
(a) Each evidence
				  of coverage providing basic health care services must provide the following
				  basic health care services when they are provided by network physicians or
				  providers, or by non-network physicians and providers as set out in §
										11.506(b)(9)
				  or §
										11.506(b)(14)
				  of this title (relating to Mandatory Contractual Provisions: Group, Individual,
				  and Conversion Agreement and Group Certificate):
(1) outpatient services, including the
				  following:
(A) primary care and specialist
				  physician services;
(B) outpatient
				  services by other providers;
(C)
				  diagnostic services, including laboratory, imaging, and radiologic
				  services;
(D) therapeutic radiology
				  services;
(E) prenatal services, if
				  maternity benefits are covered;
(F)
				  outpatient rehabilitation therapies including physical therapy, speech therapy,
				  and occupational therapy;
(G) home
				  health services, as prescribed or directed by the responsible physician or
				  other authority designated by the HMO;
(H) preventive services, including:
(i) periodic health examinations for adults
				  as required by Insurance Code §
													1271.153
				  (concerning Periodic Health Evaluations);
(ii) immunizations for children as required
				  by Insurance Code §
													1367.053
				  (concerning Coverage Required);
(iii) well-child care from birth as required
				  by Insurance Code §
													1271.154
				  (concerning Well-Child Care From Birth);
(iv) cancer screenings as required by
				  Insurance Code Chapters 1356 (concerning Low-Dose Mammography), 1362
				  (concerning Certain Tests for Detection of Prostate Cancer), and 1363
				  (concerning Certain Tests for Detection of Colorectal Cancer);
(v) eye and ear examinations for children
				  through age 17, to determine the need for vision and hearing correction
				  complying with established medical guidelines; and
(vi) immunizations for adults under the
				  United States Department of Health and Human Services Centers for Disease
				  Control Recommended Adult Immunization Schedule by Age Group and Medical
				  Conditions, or its successor;
(I) coverage for outpatient mental health
				  services complying with the mental health parity requirements in Chapter 21,
				  Subchapter P, of this title (relating to Mental Health Parity); and
(J) emergency services as required by
				  Insurance Code §
												1271.155
				  (concerning Emergency Care), including emergency transport in an emergency
				  medical services vehicle licensed under Health and Safety Code Chapter 773
				  (concerning Emergency Medical Services), which is considered emergency care if
				  it is provided as part of the evaluation and stabilization of medical
				  conditions of a recent onset and severity, including severe pain, that would
				  lead a prudent layperson possessing an average knowledge of medicine and health
				  to believe that the individual's condition, sickness, or injury is of such a
				  nature that failure to get immediate care through emergency transport could
				  place the individual's health in serious jeopardy, result in serious impairment
				  to bodily functions, result in serious dysfunction of a bodily organ or part,
				  result in serious disfigurement, or for a pregnant woman, result in serious
				  jeopardy to the health of the fetus;