Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter X - PREFERRED AND EXCLUSIVE PROVIDER PLANS › Division 1 - GENERAL REQUIREMENTS › Section 3.3705 - Nature of Communications with Insureds; Readability, Mandatory Disclosure Requirements, and Plan Designations

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