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You are here: Home . rules . 2003 . 0510A-059
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Subchapter A. General Provisions

28 TAC §11.2

Subchapter F. Evidence of Coverage

28 TAC §§11.508 and 11.509

The Commissioner of Insurance adopts amendments to §§11.2, 11.508 and 11.509 concerning basic health care services and state-mandated benefits for health maintenance organizations (HMOs). The amendments to §§11.2 and 11.508 are adopted with changes to the proposed text as published in the January 9, 2004 issue of the Texas Register (29 TexReg 293). The amendments to §11.509 are adopted without changes and will not be republished.

These amendments are the result of the enactment of Senate Bill (SB) 541 during the 78 th Regular Legislative Session. That legislation, among other things, provides more flexibility in the health insurance market by authorizing insurers and HMOs to issue health plans that, in whole or in part, do not include state-mandated benefits. These consumer choice plans are the subject of adopted rules published elsewhere in this issue of the Texas Register. In addition, SB 541 amended the definition of "basic health care services" in the HMO Act, Texas Insurance Code Chapter 843, to allow the commissioner to determine those services that an enrolled population might reasonably need to maintain good health, and to delete the requirement that such services include, at a minimum, services designated as basic health care services for federally qualified HMOs under Section 1302, Title XIII, Public Health Service Act (42 U.S.C. Section 300e-1(1)).

The amendments are necessary to comply with SB 541 by identifying basic health care services that are not tied to the specific requirements of federal law. The amendments are also necessary to amend and add definitions consistent with these changes and with the development and issuance of consumer choice plans in the HMO market. In developing a list of basic health care services, the department considered and evaluated the requirements of federal law contained in the existing rule; many of these requirements were retained, although the adopted rule, unlike the existing rule, is comprised primarily of basic services that apply to all persons and removes certain services that are condition-specific. In developing the list, the department also considered the statutes and rules of neighboring states and some of the larger states with populations similar to that of Texas. The department also considered and evaluated those services that were included in evidences of coverage in use in Texas prior to the statutory directive that the federal requirements be considered the minimum standard. Based on the department's analysis of these sources, the department believes the services that are included in the adopted description of basic health care services are those that an enrolled population might reasonably need to maintain good health.

Consistent with SB 541, the amendments also limit the application of some currently required additional mandatory benefit standards for certain group agreements and add coverage requirements for certain services as set forth in §11.508(a)(1)(H)(iv) (cancer screenings as required in Insurance Code Article 3.70-2(H) relating to mammography) and (vi) (cancer screenings as required in Insurance Code Article 21.53S relating to screening for colorectal cancer).

The department received numerous comments relating to the proposed rule. The greatest number of comments concerned the services the department included, and did not include, in the definition of "basic health care services." On the one hand, physician and provider groups, consumer advocates and representatives of various other organizations asserted that the list of basic health care services should include some specific condition- or gender- related services, including diabetes, HIV/AIDS and family planning services for women. Carriers, on the other hand, contended that the list of basic health care services was too broad and was contrary to the legislative intent of providing more choice and flexibility in the market. After considering all comments, the department adopted some changes to the proposed sections as published, as follows: (1) The department changed §11.508(a)(1)(E) to clarify that coverage for prenatal services is required only if maternity benefits are provided. (2) The department changed §11.508(a)(1)(G) to clarify that home health services are covered as "prescribed or directed by the responsible physician or other authority designated by the HMO." (3) The department changed §11.508(a)(1)(H)(vii) to remove the requirement that eye and ear examinations for children be provided annually and instead to require that such examinations be provided "in accordance with established medical guidelines." (4) The department added §11.508(a)(1)(H)(viii) to require immunizations for adults as recommended by the United States Department of Health and Human Services Centers for Disease Control. The department believes the strong public health benefit of immunizations makes them, on a select basis for adults, a service necessary to keep an enrolled population in good health. (5) The department changed §11.508(a)(1)(I) to place a 20-outpatient visit minimum requirement upon the provision of short-term mental health services. (6) The department changed §11.508(b)(2) to clarify t hat maternity benefits includes prenatal, delivery and postdelivery care. (7) The department changed §11.508(d) to clarify that a state-mandated plan must provide coverage for basic health care services without limitation as to time and cost, except for those limitations specifically identified in the rule. This change was necessary to allow for the limitation of required short-term mental health services to 20 outpatient visits. In addition to the foregoing changes, the department also made other changes for purposes of consistency and clarity, including changes necessary to ensure the definitions in §11.2 are in alphabetical order and to correct references to certain statutory provisions that ha ve been revised, as well as to correct clerical and typographical errors.

The amendments to §11.2(b) amend the definition of basic health care service and add definitions for consumer choice plans and state-mandated plans. The amendments in that section also reorganize all of the definitions into alphabetical order and change some of the references to certain provisions of the Insurance Code and other statutory references to reflect recodification and other statutory amendments. The amendments to §11.508 describe basic health care services for group, individual and conversion agreements, including state-mandated plans. The amendments to §11.509 clarify that certain additional mandatory benefit standards must be included in certain group agreements.

SUMMARY OF COMMENTS AND AGENCY´S RESPONSE TO COMMENTS

General

Comment

A commenter testified in favor of the rules and noted that the rules were generally well researched and well thought out.

Agency Response:

The department appreciates the comment.

Comment:

Commenters state that the rules do not address some other provisions contained in the previous rule that are no longer mandated because of the deletion of the federal requirements. One commenter is concerned that restrictions on copayments for HMOs are much more restrictive than are required for other products. These commenters recommend revisions to §11.506(2)(A) to allow both deductible and copayment options and to remove restrictions on copayment and deductible amounts. These changes, the commenters argue, will enable HMOs to be competitive with non-HMO products already available in the market.

Agency Response:

SB 541 changed the definition of "basic health care services," to allow the commissioner to determine those services that an enrolled population might reasonably need to maintain good health and to delete the requirement that such services include, at a minimum, services designated as basic health care services for federally qualified HMOs under Section 1302, Title XII, Public Health Service Act (42 USC Section 300e-1(1)). This was the only statutory change applicable to all HMO plans and this rule implements that statutory requirement. SB 541 also defined "state-mandated health benefits," which may be excluded from a consumer choice plan, to include cost-sharing limitations or restrictions. Therefore, while SB 541 removed restrictions on copayment and deductible amounts for HMO consumer choice plans, it did not remove such restrictions for all HMO plans. The rule implementing SB 541 on consumer choice plans in Chapter 21 clarifies those cost-sharing provisions which may be excluded from an HMO consumer choice plan and the department refers the commenter to that adoption order for greater detail. All HMO plans, including HMO consumer choice plans, must comply with other requirements of the Insurance Code relating to the reasonableness of the cost of coverage, including article 20A.09(k) or 20A.09(b), and §843.082(3).

Comment:

A commenter requests that consideration be given to comments received from medical specialty societies, as they will be highly affected by these rules.

Agency Response:

The department carefully considers comments from all parties, and recognizes the informed perspective medical specialty societies provide to a rule of this nature, as well as the impact the rule will have on their members.

§§11.2(b)(7) & 11.508(a):

A commenter suggests that the list of basic health care services be reviewed periodically. Other commenters suggest that the department revisit the definition and list of basic health care services every two years.

Agency Response:

While the department declines to specify a review period, it continuously monitors adopted rules and will propose changes as necessary.

§§11.2, 11.508, 11.509:

A commenter believes that the rule still includes federal minimum basic health care services that will not allow health plans to continue to be competitive or allow for flexibility and availability of health coverage intended by the legislature. The commenter requests that the proposed rules be changed to more accurately reflect this legislative intent. The commenter believes that TDI should allow market forces to work and enable small employers and individuals to get some level of coverage rather than mandate an amount of coverage that isn´t affordable. Some commenters recommend deleting the provisions that mandate coverage of: annual eye and ear examinations for children; home health services; mental health services for short-term evaluative or crisis stabilization services; and outpatient services by other providers. The commenters believe that the requirement of coverage for outpatient services is overly broad and may force unnecessary contracts and result in premium increases. Other commenters believe that the list of basic health care services is too limited and does not adequately represent the services that an enrolled population may reasonably need to be maintained in good health.

Agency Response:

SB 541 changed the definition of "basic health care services" to allow the commissioner to determine those services that an enrolled population might reasonably need to be maintained in good health and to delete the requirement that such services include, at a minimum, services designated as basic health care services for federally qualified HMOs under Section 1302, Title XII, Public Health Service Act (42 USC Section 300e-1(1)). In developing the list of basic health care services, the department considered many factors, including federally-mandated benefits, laws of states with populations similar to that of Texas, laws of neighboring states, services included in evidences of coverage in Texas prior to adoption of federal requirements as the minimum standard, and comments received during the informal comment period. The rule no longer contains references to certain services that are condition-specific and instead includes those basic services that generally apply to all persons. In developing the list of basic health care services, the department attempted to balance the need for flexible coverage alternatives in the marketplace with the statutory directive to include those services that an enrolled population might reasonably need to maintain good health. While the department declines to remove any additional services from the list of basic health care services, the department notes that it set some guidelines with regard to the provision of certain basic health care services (e.g., prenatal services are required only if maternity benefits are covered, home health services are required but only if prescribed or directed by the responsible physician, eye and ear examinations for children are required in accordance with established medical guidelines rather than annually, and, consistent with the prior rule´s requirement, coverage is required for 20 outpatient mental health visits per member per year).

In addition, HMOs have the flexibility to apply limitations as to time and cost for HMO consumer choice plans. With regard to the provision requiring coverage for outpatient services by other providers, the department notes that the introductory language in §11.508(a) clarifies that these services are only required when they are provided by "network physicians or providers, or by non-network physicians and providers as set forth in §11.506(10) or (15)." In addition, the use of the word"providers" refers to individual or institutional non-physician health care providers as defined in §11.2. Because these terms and their application are limit ed, the department does not believe the provision is overly broad or that it will require any unnecessary contracts.

§11.2(b)(59):A commenter finds referencing the lists in adopted §§21.3515-21.3518 in the definition of "state-mandated plan" to be confusing, and questions whether the benefits listed in these sections are required in the state-mandated plan.

Agency Response:

A "state-mandated plan" must include all benefits required by law, including those benefits which a health carrier may exclude from a consumer choice health benefit plan. Accordingly, a state-mandated plan must include the benefits listed in §§21.3515-21.3518, as appropriate for the type of plan issued.

§11.508

Comment:

A commenter asks if an analysis has been done of what the inclusion of certain basic health care services will do to the cost of the premium and encourages the department to consider the increased costs of benefit and administrative requirements in this analysis.

Agency Response:

The department´s obligations under SB 541 are to identify, and require coverage for, those services that an enrolled population might reasonably need to maintain good health. In performing this task, the department was mindful of the goals of the legislation, and accordingly, has not added any additional basic health care services that are not necessary to achieve this purpose. The department has, in fact, removed some of those services, especially some that were condition-specific. Because the department has limited or deleted some of the previous basic health care services, and because HMOs have the flexibility to apply limitations as to time and cost for HMO consumer choice plans, the department anticipates that the adopted rule should not result in any increased costs.

Comment:

A commenter is concerned that the definition of "basic health care services" for HMOs is not limited as to time and cost, and recommends that these limitations be included.

Agency Response:

The department disagrees that general limitations as to time and cost should be allowed for all basic health care services, since Insurance Code Article 20A.09(l) (regarding the provision of basic health care services without limitation as to time and cost) still applies to HMO plans, other than HMO consumer choice plans. However, the rule identifies certain limitations that may apply with respect to coverage for a particular service within the definition of "basic health care services." Specifically, the rule limits the required coverage of short-term mental health services to 20 outpatient visits. Otherwise, the rule requires coverage of basic health care services without limitation as to time and cost for all HMO plans, except HMO consumer choice plans. In addition, the adopted rule on consumer choice plans in Chapter 21 allows the provision of basic health care services in HMO consumer choice plans to be limited by time and cost through deductibles, benefit maximums, and copayments. However, all HMO plans, including HMO consumer choice plans, must comply with other requirements of the Insurance Code relating to the reasonableness of the cost of coverage, including Article 20A.09(k) or 20A.09(b), and §843.082(3).

§11.508(a)

Comment:

Commenters suggest that the following types of services are "basic" and should be included in the list of basic health care services: treatment of diabetes; treatment of HIV/AIDS; the full range of voluntary family planning services for women; screening for cervical cancer for women; and basic infertility diagnosis and limited treatment for infertility for women. One commenter requests that if coverage is required for specific conditions, TDI make this clear in the final rule.

Agency Response:

The department declines to make the requested changes. The legislature in SB 541 recognized the need for individuals and employers to have the opportunity to choose health maintenance organization plans that are more affordable and flexible than existing market health care plans. Accordingly, in developing the new list of basic health care services, the department sought to focus more specifically on the "services" an HMO would have to provide, as opposed to the conditions it would have to cover. The department has thus removed some references to coverages that are condition-specific. A basic service HMO is still required to provide these coverages as required by state or federal law. The difference is that the authority stems from specific statutory or regulatory requirements, instead of from the list of basic services. For example, the previous list of basic health care services required that "a provision of maternity benefits must provide care for an enrollee and her newborn child as described in the Insurance Code Article 21.53F." While the new list of basic health care services no longer includes this specific requirement, a basic service HMO must still provide it in accordance with the statute. The new list is intended to outline the structure and type of required services that apply to all persons covered by an HMO, and allow market forces and other specific legal requirements determine which conditions are covered.

As the department has eliminated specific references to coverages from the previous list of basic health care services, it would not be appropriate to add to the list any new specific coverages, such as treatment for AIDS/HIV. The department notes, however, that Article 3.51-6, §3C forbids a group HMO health plan, other than a consumer choice plan, to exclude or deny coverage for AIDS/HIV.

While the list of basic health care services does not specifically include diabetes care, the rule does require an evidence of coverage to include coverage for diabetes care as required by Insurance Code Article 21.53G. Certain HMO plans would also have to comply with Article 21.53D.

While the Texas Insurance and Administrative Codes are the primary sources for other laws requiring an HMO to cover specific conditions and treatments, the TDI website also contains a mandated benefit chart to provide guidance in this area. Where there is no specific legal direction, the group or individual purchaser and the HMO can decide whether a particular condition-specific service/treatment will be limited or available. For example, while specialty physician services and hospital services are basic health care services, they may not be covered benefits for cosmetic procedures if such procedures are excluded under the plan.

With regard to cervical cancer screenings for women, the department included in the list of basic services only those cancer screenings required by statute, and no statute requires cervical cancer screening for women. The department notes, however, that coverage of this screening is universal among HMOs, as are many other condition-specific coverages not required by law. The statute empowers the commissioner to define basic health care services, and the department will continue to monitor the conditions basic service HMOs cover and consider amending the list as necessary to require coverage of specific conditions as necessary to keep an enrolled population in good health.

The final requested coverages, family planning services for women and infertility treatment and diagnosis, are utilized by a broad segment of the population to varying degrees. As set forth in response to a previous comment, the department considered various factors in developing the list of basic health care services, including federally-mandated benefits, laws of states with populations similar to that of Texas, laws of neighboring states, services included in evidences of coverage in Texas prior to adoption of federal requirements as the minimum standard, and comments received during the informal comment period. The department determined through its review and analysis of these sources, however, that the level and scope of required coverage of the requested services varied greatly among the states, with a significant number requiring neither family planning nor infertility coverage. Moreover, as mentioned above, SB 541 aims to provide more affordable and flexible health care plans. Consistent with the aims of SB 541, allowing the parties to the coverage contract to determine the level of coverage for family planning/infertility services provides a broader spectrum of plan design and cost-sharing options than is currently available under the federal mandate to cover a broad range of voluntary family planning services. Plans, of course, may continue to offer coverage for services that the rule does not include as basic health care services.

Comment:

A commenter suggests that immunizations, in accordance with the U.S. Centers for Disease Control recommended schedule for adults with medical conditions, should be a basic health care service and should be included in the list of basic health care services. Other commenters recommend deletion of the provision that mandates preventive health services including adult immunizations in accord with accepted medical practices. Another commenter requests that if coverage is required for immunizations, TDI make this clear in the final rule.

Agency Response:

The previous rule included, as a basic health care service, a broad requirement of immunizations for adults "in accordance with medical practices." The proposed rule deleted this requirement, but, based on comments received, the department has reinstated adult immunizations as a basic health care service. The amended requirement is, however, narrowly drawn to include only immunizations recognized by the United States Department of Health and Human Services Centers for Disease Control Recommended Adult Immunization Schedule by Age Group and Medical Conditions. Immunizations prevent development of communicable diseases in, and transmission of such diseases to, otherwise healthy individuals. Consequently, the department believes the strong public health benefit of immunizations makes them, on a select basis for adults, a necessary and cost-effective service to keep an enrolled population in good health.

Comment:

A commenter recommends the list of basic health care services continue to include the language "Diabetes, A provision for the treatment of diabetes, and conditions associated with diabetes pursuant to the Insurance Code Article 21.53G." Another commenter requests that enrollees in plans subject to these rules be assured of services for the prevention and appropriate treatment of diabetes and related conditions.

Agency Response: As set forth in response to previous comments, the department removed condition-related services from the list of basic health care services and whether coverage is available or limited for certain conditions will depend upon various factors, including applicable statutory and regulatory provisions. Because Insurance Code Article 21.53G requires coverage for supplies and services associated with the treatment of diabetes, such coverage does not need to be included as a basic health care service. The department notes, however, that the rule at §11.508(b)(3) requires coverage for "diabetes self-management training, equipment and supplies as required in Insurance Code Article 21.53G." Thus, this coverage is required for all HMO plans, including HMO consumer choice plans. In addition, Insurance Code Article 21.53D requires coverage for diabetes care under certain HMO plans, other than HMO consumer choice plans.

§11.508(a)(1)(F):

Commenters request that physical therapy be included as a basic health care service. Other commenters recommend deleting the outpatient rehabilitation therapies mandate, and note that the federal requirements limit this to short-term rehabilitation therapy. Another commenter suggests that distinguishing between outpatient and inpatient services is not an appropriate distinction for physical therapy. Another commenter is concerned that deleting the previous rule´s clarifying language that treatment goals may include maintenance of function or slowing of further deterioration from the reference to rehabilitative services may result in the exclusion of that kind of rehabilitative therapy from basic health care services. The commenter asks that the rule make clear that such therapies are basic health care services, and offers proposed language.

Agency Response:

As set forth in response to previous comments, the department considered numerous sources in determining what constitutes a basic health care service. Based upon the department´s review of these sources, the department concluded that outpatient rehabilitation therapies and inpatient short-term rehabilitation therapy services in an acute hospital setting are necessary to maintain an enrolled population in good health. The department determined that such therapies may be necessary to achieve, for example, successful and cost-effective surgical outcomes, to avoid costly procedures, and to return ill or injured patients to a functional and productive state. Consequently, the department declines to remove these rehabilitation therapies from the list of basic health care services. However, in consumer choice plans an HMO may limit these therapies by time and cost through deductibles, benefit maximums, and copayments. The department recognizes that physical therapy services provided in the outpatient and inpatient settings may be very similar or the same; however the therapies are listed in both locations to clarify that therapy provided in both settings must be covered. While language regarding treatment goals was removed from the rule, the language remains in Texas Insurance Code Article 20A.09(a)(4). Thus, HMO plans, except HMO consumer choice plans, must still provide coverage for such therapies.

§11.508(a)(1)(H)(iv) ­ (vi):A commenter suggests that the department broaden these references to cancer screenings to allow for advances in medical technology allowing improved and less expensive screening.

Agency Response:

The rule´s references to cancer screenings are tied to specific statutory requirements. HMOs are free to include in their plans additional types or methods of screening, and as medical science advances, the department expects that plans will include improved and less expensive screening methods. In addition, the department will periodically continue to review the list of basic health care services and update as necessary.

§11.508(b)(2):Commenters recommend that the rule mandate prenatal services only if the policy covers pregnancy.

Agency Response: The department agrees with this comment and has revised the rule accordingly.

NAMES OF THOSE COMMENTING FOR AND AGAINST THE SECTIONS

For With Changes:

Advocacy, Incorporated; American Diabetes Association; Blue Cross Blue Shield of Texas; Coalition for Texans with Disabilities; Consumers Union; National Multiple Sclerosis Society of Texas; NEXT; Office of Public Insurance Counsel; TFE Company; Texas Association of Businesses; Texas Association of Health Plans; Texas Association of Life and Health Insurers; Texas Medical Association; Texas Physical Therapy Association; and Women´s Health and Family Planning Association of Texas.

The amendments are adopted under the Insurance Code Article 20A.09N(j) and §§843.002(2), 843.151 and 36.001. Insurance Code Article 20A.09N(j) requires the commissioner to adopt rules as necessary to implement the statutes creating consumer choice plans. Section 843.002(2) provides that basic health care services are those the commissioner determines an enrolled population might reasonably require in order to be maintained in good health. Section 843.151 provides that the commissioner may adopt reasonable rules as necessary and proper to carry out the provisions of Chapters 843 and 20A. Section 36.001 provides that the commissioner may adopt any rules necessary and appropriate to implement the powers and duties of the Texas Department of Insurance under the Insurance Code and other laws of this state.

Subchapter A. General Provisions

§11.2. Definitions.

(a) The definitions found in the Texas Health Maintenance Organization Act, Texas Insurance Code §843.002 are hereby incorporated into this chapter.

(b) The following words and terms, when used in this chapter, shall have the following meanings unless the context clearly indicates otherwise.

(1) Act--The Texas Health Maintenance Organization Act, codified as the Texas Insurance Code Chapters 20A and 843.

(2) Admitted assets--All assets as defined by statutory accounting principles, as permitted and valued in accordance with §11.803 of this title (relating to Investments, Loans, and Other Assets).

(3) Adverse determination--A determination upon utilization review that the health care services furnished or adopted to be furnished to a patient are not medically necessary or not appropriate.

(4) Affiliate--A person that directly, or indirectly through one or more intermediaries, controls, or is controlled by, or is under common control with, the person specified.

(5) Agent--As defined in the Insurance Code Article 21.07-1, §1(b) , unless the context of the rule clearly indicates applicability to any agents licensed under one specific article.

(6) ANHC or approved nonprofit health corporation--A nonprofit health corporation certified under §162.001 of the Occupations Code.

(7) Annual financial statement--The annual statement to be used by HMOs, as promulgated by the NAIC and as adopted by the commissioner under Insurance Code Article 1.11 and §§802.001, 802.003 and 843.155.

(8) Authorized control level--The number determined under the RBC formula in accordance with the RBC instructions.

(9) Basic health care service--Health care services which an enrolled population might reasonably require to maintain good health, as prescribed in §§11.508 and 11.509 of this title (relating to Mandatory Benefit Standards: Group, Individual and Conversion Agreements, and Additional Mandatory Benefit Standards: Group Agreement Only).

(10) Code--The Texas Insurance Code.

(11) Consumer choice plan--A health plan offered by an HMO, as described in Subchapter AA of Chapter 21 of this title (relating to Consumer Choice Health Benefit Plans);

(12) Contract holder--An individual, association, employer, trust or organization to which an individual or group contract for health care services has been issued.

(13) Control--As defined in the Insurance Code §§823.005 and 823.151.

(14) Controlled HMO--An HMO controlled directly or indirectly by a holding company.

(15) Controlled person--Any person, other than an HMO, who is controlled directly or indirectly by a holding company.

(16) Copayment--A charge in addition to premium to an enrollee for a service which is not fully prepaid.

(17) Credentialing--The process of collecting, assessing, and validating qualifications and other relevant information pertaining to a physician or provider to determine eligibility to deliver health care services.

(18) Dentist--An individual provider licensed to practice dentistry by the Texas State Board of Dental Examiners.

(19) General hospital--A licensed establishment that:

(A) offers services, facilities, and beds for use for more than 24 hours for two or more unrelated individuals requiring diagnosis, treatment, or care for illness, injury, deformity, abnormality, or pregnancy; and

(B) regularly maintains, at a minimum, clinical laboratory services, diagnostic X-ray services, treatment facilities including surgery or obstetrical care or both, and other definitive medical or surgical treatment of similar extent.

(20) HMO--A health maintenance organization as defined in Insurance Code §843.002(14).

(21) Health status related factor--Any of the following in relation to an individual:

(A) health status;

(B) medical condition (including both physical and mental illnesses);

(C) claims experience;

(D) receipt of health care;

(E) medical history;

(F) genetic information;

(G) evidence of insurability (including conditions arising out of acts of domestic violence, including family violence as defined by the Insurance Code Article 21.21-5); or

(H) disability.

(22) Individual provider--Any person, other than a physician or institutional provider, who is licensed or otherwise authorized to provide a health care service. Includes, but is not limited to, licensed doctor of chiropractic, dentist, registered nurse, advanced practice nurse, physician assistant, pharmacist, optometrist, registered optician, and acupuncturist.

(23) Institutional provider--A provider that is not an individual. Includes any medical or health related service facility caring for the sick or injured or providing care or supplies for other coverage which may be provided by the HMO. Includes but is not limited to:

(A) General hospitals,

(B) Psychiatric hospitals,

(C) Special hospitals,

(D) Nursing homes,

(E) Skilled nursing facilities,

(F) Home health agencies,

(G) Rehabilitation facilities,

(H) Dialysis centers,

(I) Free-standing surgical centers,

(J) Diagnostic imaging centers,

(K) Laboratories,

(L) Hospice facilities,

(M) Infusion services centers,

(N) Residential treatment centers,

(O) Community mental health centers,

(P) Urgent care centers, and

(Q) Pharmacies.

(24) Limited provider network--A subnetwork within an HMO delivery network in which contractual relationships exist between physicians, certain providers, independent physician associations and/or physician groups which limit the enrollees' access to only the physicians and providers in the subnetwork.

(25) Limited service HMO--An HMO which has been issued a certificate of authority to issue a limited health care service plan as defined in the Insurance Code §843.002.

(26) NAIC--National Association of Insurance Commissioners.

(27) Out of area benefits--Benefits that the HMO covers when its enrollees are outside the geographical limits of the HMO service area.

(28) Pathology services--Services provided by a licensed laboratory which has the capability of evaluating tissue specimens for diagnoses in histopathology, oral pathology, or cytology.

(29) Pharmaceutical services--Services, including dispensing prescription drugs, under the Pharmacy Act, Occupations Code, Chapter 551, that are ordinarily and customarily rendered by a pharmacy or pharmacist.

(30) Pharmacist--An individual provider licensed to practice pharmacy under the Pharmacy Act, Occupations Code, Chapter 551.

(31) Pharmacy--A facility licensed under the Pharmacy Act, Occupations Code, Chapter 551.

(32) Premium--The prospectively determined rate that is paid by or on behalf of an enrollee for specified health services.

(33) Primary care physician or primary care provider--A physician or individual provider who is responsible for providing initial and primary care to patients, maintaining the continuity of patient care, and initiating referral for care.

(34) Primary HMO--An HMO that contracts directly with, and issues an evidence of coverage to, individuals or organizations to arrange for or provide a basic, limited, or single health care service plan to enrollees on a prepaid basis.

(35) Provider HMO--An HMO that contracts directly with a primary HMO to provide or arrange to provide health care services on behalf of the primary HMO within the primary HMO's defined service area.

(36) Psychiatric hospital--A licensed hospital which offers inpatient services, including treatment, facilities and beds for use beyond 24 hours, for the primary purpose of providing psychiatric assessment and diagnostic services and psychiatric inpatient care and treatment for mental illness. Such services must be more intensive than room, board, personal services, and general medical and nursing care. Although substance abuse services may be offered, a majority of beds must be dedicated to the treatment of mental illness in adults and/or children.

(37) Qualified HMO--An HMO which has been federally approved under Title XIII of the Public Health Service Act, Public Law 93-222, as amended.

(38) Quality improvement--A system to continuously examine, monitor and revise processes and systems that support and improve administrative and clinical functions.

(39) RBC--Risk-based capital.

(40) RBC formula--NAIC risk-based capital formula.

(41) RBC Report--Health Risk-Based Capital Report including Overview and Instructions for Companies published by the NAIC and adopted by reference in §11.809 of this title (relating to Risk-Based Capital for HMOs and Insurers Filing the NAIC Health Blank).

(42) Recredentialing--The periodic process by which:

(A) qualifications of physicians and providers are reassessed;

(B) performance indicators, including utilization and quality indicators, are evaluated; and

(C) continued eligibility to provide services is determined.

(43) Reference laboratory--A licensed laboratory that accepts specimens for testing from outside sources and depends on referrals from other laboratories or entities. HMOs may contract with a reference laboratory to provide clinical diagnostic services to their enrollees.

(44) Reference laboratory specimen procurement services--The operation utilized by the reference laboratory to pick up the lab specimens from the client offices or referring labs, etc. for delivery to the reference laboratory for testing and reporting.

(45) Referral specialists (other than primary care)--Physicians or individual providers who set themselves apart from the primary care physician or primary care provider through specialized training and education in a health care discipline.

(46) Schedule of charges--Specific rates or premiums to be charged for enrollee and dependent coverages.

(47) Service area--A geographic area within which direct service benefits are available and accessible to HMO enrollees who live, reside or work within that geographic area and which complies with §11.1606 of this title (relating to Organization of an HMO).

(48) Single service HMO--An HMO which has been issued a certificate of authority to issue a single health care service plan as defined in the Insurance Code §843.002.

(49) Special hospital--A licensed establishment that:

(A) offers services, facilities and beds for use for more than 24 hours for two or more unrelated individuals who are regularly admitted, treated and discharged and who require services more intensive than room, board, personal services, and general nursing care;

(B) has clinical laboratory facilities, diagnostic X-ray facilities, treatment facilities or other definitive medical treatment;

(C) has a medical staff in regular attendance; and

(D) maintains records of the clinical work performed for each patient.

(50) State-mandated plan--A health plan offered by an HMO, that contains coverage for all state-mandated benefits, including those as described in §§21.3515 ­ 21.3518 of this title (relating to State-mandated Health Benefits in Individual HMO Plans, State-mandated Health Benefits in Group HMO Plans, State-mandated Health Benefits in Small Employer HMO Plans, and State-mandated Health Benefits in Large Employer HMO Plans) and offers basic health care services without limitation as to time and cost.

(51) Statutory surplus--Admitted assets minus accrued uncovered liabilities.

(52) Subscriber--If conversion or individual coverage, the individual who is the contract holder and is responsible for payment of premiums to the HMO; or if group coverage, the individual who is the certificate holder and whose employment or other membership status, except for family dependency, is the basis for eligibility for enrollment in the HMO.

(53) Subsidiary--An affiliate controlled by a specified person directly or indirectly through one or more intermediaries.

(54) Telehealth service--As defined in Section 57.042, Utilities Code.

(55) Telemedicine medical service--As defined in Section 57.042, Utilities Code.

(56) Total adjusted capital--An HMO's statutory capital and surplus/total net worth as determined in accordance with the statutory accounting applicable to the annual financial statements required to be filed pursuant to the Insurance Code, and such other items, if any, as the RBC instructions provide.

(57) Urgent care--Health care services provided in a situation other than an emergency which are typically provided in a setting such as a physician or individual provider's office or urgent care center, as a result of an acute injury or illness that is severe or painful enough to lead a prudent layperson, possessing an average knowledge of medicine and health, to believe that his or her condition, illness, or injury is of such a nature that failure to obtain treatment within a reasonable period of time would result in serious deterioration of the condition of his or her health.

(58) Utilization review--A system for prospective or concurrent review of the medical necessity and appropriateness of health care services being provided or proposed to be provided to an individual within this state. Utilization review shall not include elective requests for clarification of coverage.

(59) Voting security--As defined in the Insurance Code §823.007, including any security convertible into or evidencing a right to acquire such security.

SUBCHAPTER F. EVIDENCE OF COVERAGE

§11.508. Mandatory Benefit Standards: Group, Individual and Conversion Agreements.

(a) Each evidence of coverage providing basic health care services shall 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 forth in §11.506(10) or (15) 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 labora tory, 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 in Insurance Code Article 20A.09B;

(ii) immunizations for children as required in Insurance Code Article 21.53F §3;

(iii) well-child care from birth as required in Insurance Code Article 20A.09E;

(iv) cancer screenings as required in Insurance Code Article 3.70-2(H) relating to mammography;

(v) cancer screenings as required in Insurance Code Article 21.53F relating to screening for prostate cancer;

(vi) cancer screenings as required in Insurance Code Article 21.53S relating to screening for colorectal cancer;

(vii) eye and ear examinations for children through age 17, to determine the need for vision and hearing correction in accordance with established medical guidelines; and

(viii) immunizations for adults in accordance with 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) no less than 20 outpatient mental health visits per enrollee per year as may be necessary and appropriate for short-term evaluative or crisis stabilization services, which must have the same cost-sharing and benefit maximum provisions as any physical health services ; and

(J) emergency services as required by Insurance Code Article 20A.09Y.

(2) Inpatient hospital services, including room and board, general nursing care, meals and special diets when medically necessary, use of operating room and related facilities, use of intensive care unit and services, x-ray services, laboratory and other diagnostic tests, drugs, medications, biologicals, anesthesia and oxygen services, special duty nursing when medically necessary, radiation therapy, inhalation therapy, administration of whole blood and blood plasma, and short-term rehabilitation therapy services in the acute hospital setting.

(3) Inpatient physician care services, including services performed, prescribed, or supervised by physicians or other health professionals including diagnostic, therapeutic, medical, surgical, preventive, referral and consultative health care services.

(4) Outpatient hospital services, including treatment services; ambulatory surgery services; diagnostic services, including laboratory, radiology, and imaging services; rehabilitation therapy; and radiation therapy.

(b) In addition to the basic health care services in subsection (a) of this section, each evidence of coverage shall include coverage for the following:

(1) breast reconstruction as required by federal law if the plan provides coverage for mastectomy. Breast reconstruction is subject to the same deductible or copayment applicable to mastectomy. Breast reconstruction may not be denied because the mastectomy occurred prior to the effective date of coverage;

(2) prenatal services, delivery and postdelivery care for an enrollee and her newborn child as required by federal law, if the plan provides maternity benefits; and

(3) diabetes self-management training, equipment and supplies as required in Insurance Code Article 21.53G.

(c) The benefits described in subsection (a)(1)(F) and (1)(H)(ii) and (vi) of this section do not apply to small employer plans as defined by the Insurance Code Chapter 26.

(d) A state-mandated plan defined in §11.2(b) of this title (relating to Definitions) shall provide coverage for the basic health care services as described in subsection (a) of this section, as well as all state-mandated benefits as described in §§21.3516 ­ 21.3518 of this title (relating to State-mandated Health Benefits in Individual HMO Plans, State-mandated Health Benefits in Small Employer HMO Plans, and State-mandated Health Benefits in Large Employer HMO Plans) , and must provide the services without limitation as to time and cost, other than those limitations specifically prescribed in this section.

(e) Nothing in this title shall require an HMO, physician, or provider to recommend, offer advice concerning, pay for, provide, assist in, perform, arrange, or participate in providing or performing any health care service that violates its religious convictions. An HMO that limits or denies health care services under this subsection shall set forth such limitations in its evidence of coverage.

§11.509. Additional Mandatory Benefit Standards: Group Agreement Only. Group agreements must contain the following additional mandatory provisions.

(1) Certificate. Provisions that the contract holder must be provided with subscriber certificates to be delivered to each subscriber; that the certificate is a part of the group contract as if fully incorporated therein; and that any direct conflict between the group agreement and the certificate will be resolved according to the terms which are most favorable to the subscriber. If the same form is used as both the group contract and the certificate, a copy of the group contract must be delivered to each subscriber.

(2) New members. A provision specifying the conditions under which new members may be added to those originally covered, including effective date requirements. For coverage issued to employers, a provision for special enrollment in accordance with 45 C.F.R. 146.117 (Health Insurance Portability and Accessibility Act).

(3) Chemical dependency. A provision to provide benefits for the necessary care and treatment of chemical dependency that are not less favorable than for physical illness generally, subject to the same durational limits, dollar limits, deductibles and coinsurance factors is required for state-mandated plans defined in §11.2(b) of this title (relating to Definitions). Dollar or durational limits which are less favorable than for physical illness generally may be set only if such limits are sufficient to provide appropriate care and treatment under the guidelines and standards adopted under the Insurance Code Article 3.51-9, §2A(d), including §§3.8001 - 3.8022 of this title (relating to Standards for Reasonable Cost Control and Utilization Review for Chemical Dependency Treatment Centers).

(A) Coverage for chemical dependency may be limited to a lifetime maximum of three separate series of treatment for each covered individual as described by the Insurance Code Article 3.51-9, §2A(b).

(B) Benefits provided shall be determined as if necessary care and treatment in a chemical dependency treatment center were care and treatment in a hospital.

(4) Osteoporosis. A provision that provides coverage to a qualified individual as defined in the Insurance Code Article 21.53C for medically accepted bone mass measurement for the detection of low bone mass and to determine the person's risk of osteoporosis and fractures associated with osteoporosis is required for state-mandated plans defined in §11.2(b) of this title.

(5) Serious mental illness. Group agreements, except for contracts issued to small employer plans, must include a provision for the treatment of serious mental illness, as required in the Insurance Code Article 3.51-14. Small employer plans must be offered coverage for serious mental illness as required in the Insurance Code Article 3.51-14. Serious mental illness benefits are also subject to the provisions of the Insurance Code Articles 3.70-2(F) and 3.72.

(6) Conditions affecting the temporomandibular joint. Group agreements, except for contracts issued to small employer plans and consumer choice plans defined in §11.2(b) of this title must include a provision that provides coverage for a condition affecting the temporomandibular joint as required by the Insurance Code Article 21.53A.

(7) Inability to undergo dental treatment. Group agreements, except for contracts issued to small employer plans and consumer choice plans defined in §11.2(b) of this title, may not exclude from coverage under the plan an enrollee who is unable to undergo dental treatment in an office setting or under local anesthesia due to a documented physical, mental, or medical reason as determined by the enrollee's physician or the dentist providing the dental care. This benefit does not require an HMO to provide dental services if dental services are not otherwise scheduled or provided as part of the benefits covered by the agreement.



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