28 Tex. Admin. Code § 11.1600 - Information to Prospective and Current Contract Holders and Enrollees
(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.
(c) An HMO may use its member handbook to
satisfy the requirements of this section if the information contained in the
handbook is substantially similar to and provides the same level of disclosure
as the written or electronic description prescribed by the Commissioner and
contains all the information required under this section.
(d) An HMO offering a Children's Health
Insurance Program plan that files its plan description in the form of its
member handbook in compliance with §
11.301 of this title (relating to
Filing Requirements), for information only, together with a certification from
the HMO that the handbook has been approved by the Texas Health and Human
Services Commission and a copy of the document approving the handbook is exempt
from the filing and approval requirements of subsection (b) of this
section.
(e) If an HMO limits
enrollees' access to health care to a limited provider network, then it must
provide a notice in substantially the following form to prospective and current
group contract holders: "Choosing Your Physician--Now that you have chosen
(Name of HMO), your next choice will be deciding who will provide the majority
of your health care services. Your Primary Care Physician or Primary Care
Provider (PCP) will be the one you call when you need medical advice, when you
are sick, and when you need preventive care such as immunizations. Your PCP is
also part of a 'network' or association of health professionals who work
together to provide a full range of health care services. That means when you
choose your PCP, you are also choosing a network and in most instances you are
not allowed to receive services from any physician or health care professional,
including your obstetrician-gynecologist (OB-GYN), that is not also part of
your PCP's network. You will not be able to select any physician or health care
professional outside of your PCP's network, even though that physician or
health care provider is listed with your health plan. The network to which your
PCP belongs will provide or arrange for all of your care, so make sure that
your PCP's network includes the specialists and hospitals that you
prefer."
(f) If an HMO does not
limit an enrollee's selection of an obstetrician or gynecologist to the limited
provider network to which that enrollee's primary care physician or provider
belongs, then it must provide a notice in compliance with Insurance Code
Chapter 1451, Subchapter F, (concerning Access to Obstetrical or Gynecological
Care) in substantially the following form to current or prospective enrollees:
"ATTENTION FEMALE ENROLLEES: You have the right to select and visit an
obstetrician-gynecologist (OB-GYN) without first obtaining a referral from your
PCP. (Name of HMO) has opted not to limit your selection of an OB-GYN to your
PCP's network. You are not required to select an OB-GYN. You may elect to
receive your OB-GYN services from your PCP."
(g) An HMO must clearly identify limited
provider networks within its service area by providing a separate listing of
its limited provider networks and an alphabetical listing of all the physicians
and providers, including specialists, available in each limited provider
network. An HMO must include an index of the alphabetical listing of all
contracted physicians and providers, including behavioral health providers and
substance abuse treatment providers, if applicable, within the HMO's service
area, and must indicate the limited provider network(s) to which the physician
or provider belongs and the page number where the physician or provider's name
can be found.
(h) An HMO must
provide notice to enrollees informing them to contact the HMO on receipt of a
bill for covered services from any physician or provider, including a
facility-based physician or other health care practitioner. The notice must
inform enrollees of the method(s) for contacting the HMO for this
purpose.
(i) If an HMO or limited
provider network provides for an enrollee's care by a physician other than the
enrollee's primary care physician while the enrollee is in an inpatient
facility (for example, a hospital or skilled nursing facility), the plan
description must disclose that on admission to the inpatient facility, a
physician other than the primary care physician may direct and oversee the
enrollee's care.
(j) An HMO that
maintains a website must list the information on its website as required by
subsections (b) - (g) of this section and Insurance Code §
843.2015 (concerning
Information Available Through Internet Site) and §1456.003 (concerning Required
Disclosure: Health Benefit Plan). The information must be easily accessible
from the home page of the HMO's website.
Notes
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No prior version found.