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SUBCHAPTER M. Mandatory Notice Requirements 28 TAC §§ 21.2101 21.2103 , 21.2105 and 21.2106

The Texas Department of Insurance proposes amendments to §§21.2101 21.2103, 21.2105 and 21.2106 concerning mandatory notice of coverage of certain tests for the detection of colorectal cancer. The 77 th Texas Legislature enacted Senate Bill 1467 which added new Article 21.53S to the Texas Insurance Code mandating certain benefits related to the detection of colorectal cancer. Article 21.53S also contains mandatory notice requirements. The department proposes the amendments to the notice provisions in subchapter M to implement the notice requirements in Article 21.53S.

Kim Stokes, Senior Associate Commissioner, Life, Health and Licensing Division, has determined that for each year of the first five years the proposed sections will be in effect, there will be no fiscal impact to state and local governments as a result of the enforcement or administration of the rule. There will be no measurable effect on local employment or the local economy as a result of the proposal.

Ms. Stokes has determined that for each year of the first five years the sections are in effect, the public benefit anticipated as a result of the proposed sections will be that affected enrollees are notified on a timely basis of available benefits related to tests for the detection of colorectal cancer. The costs to comply with the proposed amendments are the result of the legislative enactment of SB 1467, which created Article 21.53S. In an effort to minimize costs, carriers may, in a fashion similar to other notices required under this subchapter, deliver the required notice along with other plan documents rather than in a separate mailing. It is the department´s position that the proposed amendments will not have an adverse economic effect on small businesses or micro-businesses and it is neither legal nor feasible to waive these requirements for small or micro businesses because to do so would have an adverse health impact on those entities' enrollees.

To be considered, written comments on the proposal must be submitted no later than 5:00 p.m. on January 28, 2002 to Lynda H. Nesenholtz, General Counsel and Chief Clerk, Mail Code 113-2A, Texas Department of Insurance, P. O. Box 149104, Austin, Texas 78714-9104. An additional copy of the comment must be simultaneously submitted to Diane Moellenberg, Mail Code 107-2A, Texas Department of Insurance, P.O. Box 149104, Austin, Texas 78714-9104. A request for a public hearing should be submitted separately to the Office of the Chief Clerk.

The amendments are proposed under the Insurance Code Article 21.53S and Section 36.001. Article 21.53S provides rulemaking authority to the Commissioner of Insurance for the purpose of administering the statute and directs the Commissioner to adopt rules for the provision of a notice under the statute. Section 36.001 provides that the Commissioner of Insurance may adopt rules and regulations to execute the duties and functions of the Texas Department of Insurance only as authorized by statute.

The following articles are affected by this proposal: Insurance Code Article 21.53S

§21.2101. Scope. The purpose of this subchapter is:

(1) to require notice to enrollees in a health benefit plan of coverage and/or benefits for prostate cancer examinations; minimum inpatient stays for maternity and childbirth; minimum inpatient stays for mastectomy or lymph node dissection; [ and] reconstructive surgery after mastectomy ; and certain tests for the detection of colorectal cancer. With the exception of notice for reconstructive surgery after mastectomy and notice for colorectal cancer detection, §§21.2102 through 21.2106 of this subchapter apply to all carriers issuing, delivering, or renewing health benefit plans as defined in this subchapter as of January 1, 1998. For state notice requirements pertaining to reconstructive surgery after mastectomy, §§21.2102 - 21.2106 of this subchapter apply to all carriers issuing, delivering, or renewing health benefit plans as defined in this subchapter as of June 18, 1999. For notice requirements pertaining to tests for colorectal cancer detection, §§21.2102-21.2106 of this subchapter apply to all carriers issuing, delivering, or renewing health benefit plans as defined in this subchapter as of January 1, 2002.

(2) (No change.)

§21.2102. Definitions. The following words and terms, when used in this subchapter shall have the following meanings, unless the context clearly indicates otherwise.

(1) Carrier--An insurance company, a group hospital service corporation, a fraternal benefit society, a stipulated premium insurance company, a health maintenance organization, a multiple employer welfare arrangement that holds a certificate of authority under Insurance Code Article 3.95-2, or an approved nonprofit health corporation that holds a certificate of authority issued by the commissioner under Insurance Code Article 21.52F. In addition, for the purposes of paragraph (3)(B) of this section, the term also includes a reciprocal exchange operating under Insurance Code Chapter 19 and for purposes of paragraph (3)(E) of this section, the term also includes a Lloyd´s plan operating under Insurance Code, Chapter 18 and a risk pool created under Chapter 172, Local Government Code.

(2) Enrollee--A person enrolled in and entitled to coverage under a health benefit plan, including covered dependents.

(3) Health benefit plan--Subject to subparagraphs (A), (B), (C), [ and] (D) and (E) of this paragraph, a plan that is offered by a carrier and provides benefits for medical or surgical expenses incurred as a result of a health condition, accident, or sickness including an individual, group, blanket or franchise insurance policy or insurance agreement, a group hospital service contract, an individual or group evidence of coverage, or any similar coverage document. The term does not include a plan that provides coverage only for accidental death or dismemberment, disability income, supplement to liability insurance, Medicare supplement, workers´ compensation, medical payment insurance issued as a part of a motor vehicle insurance policy or a long-term care policy.

(A) For the inpatient mastectomy coverage notice required by subsection (a)(1) of §21.2103 of this title (relating to Mandatory Benefit Notices), the definition of health benefit plan includes a plan that provides coverage only for a specific disease or condition for the treatment of breast cancer or for hospitalization. The term does not include a small employer health benefit plan issued under the Insurance Code Chapter 26, Subchapters A-G.

(B) For the reconstructive surgery after mastectomy notices required by subsection (a)(2) of §21.2103 of this title, the definition of health benefit plan does not include a plan that provides coverage for a specified disease or other limited benefit except for cancer, a plan that provides only credit insurance, a plan that provides coverage only for dental or vision care, or only for indemnity for hospital confinement.

(C) For the prostate cancer examination notice required by subsection (a)(3) of §21.2103 of this title, the definition of health benefit plan does not include a small employer health benefit plan written under the Insurance Code Chapter 26, Subchapters A-G, a plan that provides coverage only for a specified disease or other limited benefit, or only for indemnity for hospital confinement.

(D) For the inpatient maternity and childbirth coverage notice required by subsections (a)(4) and (5) of §21.2103 of this title, the definition of health benefit plan does not include a plan that provides only credit insurance, a plan that provides coverage only for a specified disease or other limited benefit, only for dental or vision care, or only for indemnity for hospital confinement.

(E) For the detection of colorectal cancer screening coverage notice required by subsection (a)(6) of §21.2103 of this title, the definition of health benefit plan does not include a small employer health benefit plan written under the Insurance Code Chapter 26, Subchapters A-G, or a plan that provides coverage only for a specified disease or other limited benefit or only for indemnity for hospital confinement

.

(4) Other limited benefit--A plan that provides coverage singularly or in combination, for benefits for a specifically named disease, accident or combination of diseases or accidents, including but not limited to heart attack, stroke, AIDS, and travel, farm or occupational accident.

(5) Primary Enrollee--For group coverage, the covered member or employee of the group. For individual coverage, the person first named on the application and/or enrollment form.

§21.2103. Mandatory Benefit Notices.

(a) Prescribed mandatory benefit notices consist of the following:

(1) (5) (No change.)

(6) For a health benefit plan that provides coverage and/or benefits for screening medical procedures, a carrier shall issue a notice which includes the language provided in Figure 6 of subsection (b) of §21.2106 of this title (relating to Forms, Form Number 1467 Colorectal Cancer Screening).

(b) (d) (No change.)

(e) If, before the effective date of the amendments to this subchapter relating to tests for the detection of colorectal cancer, a carrier has provided to its enrollees a notice that contains the information concerning colorectal cancer screening tests as required by §21.2103 (a)(6) or (b) of this subchapter, such notice shall be deemed to comply with the requirements of this subchapter as to those enrollees.

§21.2105. Delivery of Mandatory Benefit Notices.

(a) (b) (No change.)

(c) The notice required by §21.2103(a)(6) of this title shall be issued to enrollees of a health benefit plan and Subsections (a)(2)-(6) of this section shall also apply to the notice, except for the timeline requirements of subsection (a)(1) of this section.

§21.2106. Forms.

(a) The forms identified in §21.2103 of this title (relating to Mandatory Benefit Notices) for notices of mandatory benefits are included in subsection (b) of this section in their entirety and have been filed with the Office of the Secretary of State. The forms can be obtained from the Texas Department of Insurance, Life/Health Division, MC 106-1A, P.O. Box 149104, Austin, Texas 78714-9104, or from the department´s Web site, www.tdi.state.tx.us.

(b) The forms referenced in this chapter are as follow:

(1) (5) (No change.)

(6) Figure Number 6: Form Number 1467 Colorectal Cancer Screening:

Figure Number 6: 28 TAC §21.2106(b)(6)

NOTICE OF CERTAIN MANDATORY BENEFITS

This notice is to advise you of certain coverage and/or benefits provided by your contract with [name of carrier].

Coverage for Tests for Detection of Colorectal Cancer

Benefits are provided, for each person enrolled in the plan who is 50 years of age or older and at normal risk for developing colon cancer, for expenses incurred in conducting a medically recognized screening examination for the detection of colorectal cancer. Benefits include the choice of:

(a) a fecal occult blood test performed annually and a flexible sigmoidoscopy performed every five years, or

(b) a colonoscopy performed every 10 years. If any person covered by this plan has questions concerning the above, please call [name of carrier] at [customer service or related department phone number], or write us at [carrier´s customer service or related department address]. Form Number 1467 Colorectal Cancer Screening



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