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Coverage (Texas)
I.C. Art. 20A.09, including amendment I - HB 1798 & I – HB 1800 - Evidence of Coverage and Charges
(a)(1) Every enrollee residing in this state is entitled to evidence of coverage under a health care plan. If the enrollee obtains coverage under a health care plan through an insurance policy or a contract issued by a group hospital service corporation, whether by option or otherwise, the insurer or the group hospital service corporation shall issue the evidence of coverage. Otherwise, the health maintenance organization shall issue the evidence of coverage. By agreement between the insurer, group hospital service corporation, or health maintenance organization anthe subscriber, or the person entitled to receive the policy, contract, or evidence of coverage, the evidence of coverage required by this section may be delivered by electronic transfer.
(2) No evidence of coverage, or amendment thereto, shall be issued or delivered to any person in this state until a copy of the form of evidence of coverage, or amendment thereto, has been filed with and approved by the commissioner.
(3) An evidence of coverage shall contain:
(A) no provisions or statements which are unjust, unfair, inequitable, misleading, deceptive, which encourage misrepresentation, or which are untrue, misleading, or deceptive as defined in Section 14 of this Act;
(B) a clear and complete statement, if a contract, or a reasonably complete facsimile, if a certificate, of:
(i) the medical, health care services, limited health care services, or single health care service and the issuance of other benefits, if any, to which the enrollee is entitled under the health care plan, limited health care service plan, or single health care service plan;
(ii) any limitation on the services, kinds of services, benefits, or kinds of benefits to be provided, including any deductible or co-payment feature;
(iii) where and in what manner information is available as to how services may be obtained; and
(iv) a clear and understandable description of the health maintenance organization's methods for resolving enrollee complaints, including the enrollee's right to appeal denials of an adverse determination, as that term is defined by Section 12A of this Act, to an independent review organization and the procedures for making an appeal to an independent review organization. Any subsequent changes may be evidenced in a separate document issued to the enrollee;
(C) a provision that, if medically necessary covered services are not available through network physicians or providers, the health maintenance organization must, on the request of a network physician or provider, within a reasonable time period allow referral to a non-network physician or provider and shall fully reimburse the non-network physician or provider at the usual and customary or an agreed rate; each contract must further provide for a review by a specialist of the same, or a similar, specialty as the physician or provider to whom a referral is requested before the health maintenance organization may deny a referral;
(D) a provision to allow enrollees with chronic, disabling, or life-threatening illnesses to apply to the health maintenance organization's medical director to utilize a nonprimary care physician specialist as a primary care physician, provided that:
(i) the request includes information specified by the health maintenance organization, including certification of medical need, and is signed by the enrollee and the nonprimary care physician specialist interested in serving as the primary care physician;
(ii) the nonprimary care physician specialist meets the health maintenance organization's requirements for primary care physician participation; and
(iii) the nonprimary care physician specialist is willing to accept the coordination of all of the enrollee's health care needs;
(E) a provision that if the request for special consideration specified in Paragraph (D) of this subdivision is denied, an enrollee may appeal the decision through the health maintenance organization's established complaint and appeals process; and
(F) a provision that the effective date of the new designation of a nonprimary care physician specialist as set out in Paragraph (D) of this subdivision shall not be retroactive; the health maintenance organization may not reduce the amount of compensation owed to the original primary care physician prior to the date of the new designation.
(4) If an evidence of coverage provides benefits for rehabilitation services and therapies, the provision of those services and therapies that, in the opinion of a physician, are medically necessary may not be denied, limited, or terminated if they meet or exceed treatment goals for the enrollee. For a physically disabled person, treatment goals may include maintenance of functioning or prevention of or slowing of further deterioration.
(5) Any form of the evidence of coverage or group contract to be used in this state, and any amendments thereto, are subject to the filing and approval requirements of Subsection (c) of this section, unless it is subject to the jurisdiction of the commissioner under the laws governing health insurance or group hospital service corporations, in which event the filing and approval provisions of such law shall apply. To the extent, however, that such provisions do not apply to the requirements of Subdivision (3) of this subsection, the requirements of Subdivision (3) shall be applicable.
(b) The formula or method for calculating the schedule of charges for enrollee coverage for medical services or health care services must be filed with the commissioner before it is used in conjunction with any health care plan. The formula or method must be established in accordance with actuarial principles for the various categories of enrollees. The charges resulting from the application of the formula or method may not be altered for an individual enrollee based on the status of that enrollee's health. The formula or method must produce charges that are not excessive, inadequate, or unfairly discriminatory, and benefits must be reasonable with respect to the rates produced by the formula or method. A statement by a qualified actuary that certifies the appropriateness of the formula or method must accompany the filing together with supporting information considered adequate by the commissioner.
(c) The commissioner shall, within a reasonable period, approve any form of the evidence of coverage or group contract, or amendment thereto, if the requirements of this section are met. After notice and opportunity for hearing, the commissioner may withdraw previous approval of any form, if the commissioner determines that it violates or does not comply with this Act or a rule adopted by the commissioner. It shall be unlawful to issue such form until approved. If the commissioner disapproves such form, the commissioner shall notify the filer. In the notice, the commissioner shall specify the reason for the disapproval. A hearing shall be granted within 30 days after a request in writing by the person filing. If the commissioner does not disapprove any form within 30 days after the filing of such form it shall be considered approved; provided that the commissioner may by written notice extend the period for approval or disapproval of any filing for such further time, not exceeding an additional 30 days, as necessary for proper consideration of the filing.
(d) The commissioner may require the submission of whatever relevant information he or she deems necessary in determining whether to approve or disapprove a filing made pursuant to this section.
(e) Article 3.74 of the Texas Insurance Code applies to health maintenance organizations other than those health maintenance organizations offering only a single health care service plan.
(f) Article 3.51- 9 of the Texas Insurance Code applies to health maintenance organizations other than those health maintenance organizations offering only a single health care service plan.
(g) Evidence of coverage does not constitute a health insurance policy as that term is defined by the Insurance Code.
(h) Article 3.70- 1(F)(5) of the Insurance Code applies to health maintenance organizations other than those health maintenance organizations offering only a single health care service plan.
(i) Article 3.72 of the Insurance Code applies to health maintenance organizations to the extent that such article is not in conflict with this Act and to the extent that the residential treatment center or crisis stabilization unit is located within the service area of the health maintenance organization and subject to such inspection and review as required by this Act or the rules hereunder.
(j) A health maintenance organization shall comply with Article 21.55 of the Insurance Code with respect to prompt payment to enrollees. A health maintenance organization shall make payment to a physician or provider for covered services rendered to enrollees of the health maintenance organization not later than the 45th day after the date a claim for payment is received with documentation reasonably necessary for the health maintenance organization to process the claim or, if applicable, within the number of calendar days specified by written agreement between the physician or provider and the health maintenance organization. For purposes of this subsection, "covered services" means health care services and benefits to which enrollees are entitled under the terms of an applicable evidence of coverage.
(k) Continuation of Coverage and Conversion. (A) A health maintenance organization shall provide a group continuation privilege as required by this subsection. Any enrollee whose coverage under the group contract has been terminated for any reason except involuntary termination for cause, and who has been continuously insured under the group contract and under any group contract providing similar services and benefits which it replaces for at least three consecutive months immediately prior to termination shall be entitled to such privilege as outlined below. Involuntary termination for cause does not include termination for any health-related cause. Health maintenance organization contracts subject to this section shall provide continuation of group coverage for enrollees subject to the eligibility provisions below:
(1) Continuation of group coverage must be requested in writing within 31 days following the later of: (aa) the date the group coverage would otherwise terminate; or (bb) the date the enrollee is given notice of.the right of continuation by either the employer or the group contract holder.
(2) An enrollee electing continuation must pay to the group contract holder or employer on a monthly basis, in advance, the amount of contribution required by the contract holder or employer, plus two percent of the group rate for the coverage being continued under the group contract, on the due date of each payment.
(3) The enrollee's written election of continuation, together with the first contribution required to establish contributions on a monthly basis, in advance, must be given to the contract holder or employer within 31 days following the later of: (aa) the date the group coverage would otherwise terminate; or (bb) the date the enrollee is given notice of the right of continuation by either the employer or the group contract holder.
(4) Continuation may not terminate until the earliest of: (aa) six months after the date the election is made; (bb) the date on which failure to make timely payments would terminate coverage; (cc) the date on which the covered person is covered for similar services and benefits by another hospital, surgical, medical, or major medical expense insurance policy or hospital or medical service subscriber contract or medical practice or other prepayment plan or any other plan or program; or (dd) the date on which the group coverage terminates in its entirety.
(5) Not less than 30 days before the end of the six months after the date the enrollee elects continuation of the contract, the health maintenance organization shall notify the enrollee that he/she may be eligible for coverage under the Texas Health Insurance Risk Pool, as provided under Article 3.77, Insurance Code, and the health maintenance organization shall provide the address for applying to such pool to the enrollee.
(B) A health maintenance organization may offer to each enrollee a conversion contract. Such conversion contract shall be issued without evidence of insurability if written application for and payment of the first premium is made not later than the 31st day after the date of termination. The conversion contract shall meet the minimum standards for services and benefits for conversion contracts. The commissioner shall issue rules and regulations to establish minimum standards for services and benefits under contracts issued pursuant to this subdivision.
(C) The premium for a conversion contract issued under this Act shall be determined in accordance with the health maintenance organization's premium rates for coverage that were provided under the group contract or plan. The premium may be based on geographic location of each person to be covered and the type of conversion contract and coverage provided. The premium for the same coverage under a conversion contract may not exceed 200 percent of the premium determined in accordance with this subdivision. The premium must be based on the type of conversion contract and the coverage provided by contract.
(l) Individual Health Care Plan. A health maintenance organization may provide an individual health care plan as required by this subsection.
(A) For purposes of this subsection, an "individual health care plan" means:
(1) a health care plan providing health care services for individuals and their dependents;
(2) a health care plan in which an enrollee pays the premium and is not being covered under the contract pursuant to continuation of services and benefits provisions applicable under federal or state law; and
(3) a plan in which the evidence of coverage meets the requirements of Section 2(a) of this Act.
(B) A health maintenance organization may limit its enrollees to those who live, reside, or work within the service area for such network plan.
(C) Renewability of Coverage. An individual health care plan or a conversion contract providing health care services shall be renewable with respect to an enrollee at the option of the enrollee, and may be nonrenewed based only on one or more of the following reasons:
(1) failure to pay premiums or contributions in accordance with the terms of the plan or the issuer has not received timely premium payments;
(2) fraud or intentional misrepresentation;
(3) the health maintenance organization is ceasing to offer coverage in the individual market in accordance with rules established by the commissioner;
(4) enrollee no longer resides, lives, or works in the area in which the health maintenance organization is authorized to provide coverage, but only if such coverage is terminated under this paragraph uniformly without regard to any health-status-related factor of covered enrollees; or
(5) in accordance with applicable federal law and regulations.
(D) The commissioner may adopt rules necessary to implement this subsection and to meet in the minimum requirements of federal law and regulations.
(l) A health maintenance organization that offers a basic health care plan shall provide or arrange for the provision of basic health care services to its enrollees as needed and without limitations as to time and cost other than limitations prescribed by rule of the commissioner.
(m) Nothing in this Act shall require a health maintenance organization, 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. A health maintenance organization that limits or denies health care services under this subsection shall set forth such limitations in the evidence of coverage as required by Section 9(a)(3) of this Act.
(n) The commissioner may adopt minimum standards relating to basic health care services.
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