Texas Administrative Code
Title 28 - INSURANCE
Part 1 - TEXAS DEPARTMENT OF INSURANCE
Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS
Subchapter F - EVIDENCE OF COVERAGE
Section 11.505 - Specifications for Evidence of Coverage Including Insert Pages and Matrix Filings

Universal Citation: 28 TX Admin Code § 11.505

Current through Reg. 50, No. 13; March 28, 2025

(a) The filing and formatting requirements of § 11.301 of this title (relating to Filing Requirements) apply to an evidence of coverage.

(b) The style, arrangement, and overall appearance of documents must give no undue prominence to any portion of the text. The text of the group, individual, and conversion agreements, the certificate, and all amendments include all printed matter except:

(1) the HMO's name, address, website address, and phone number;

(2) the name or title of the form;

(3) the captions and subcaptions; and

(4) any brief introduction to or description of the evidence of coverage.

(c) Each evidence of coverage must indicate by example information that will appear in any blanks with the exception of single-case forms, which must be filed complete and ready for use.

(d) An HMO must identify each form by a unique form number in compliance with § 11.301(2) of this title. Any change in form number is considered a change in the form and requires approval as a new form.

(e) Certain language must not be varied or changed without resubmitting a form for the commissioner's approval. Changeable language must be enclosed in brackets, include the range of variable information or amounts, and include an explanation of how and under what circumstances the information will vary.

(f) Each evidence of coverage must meet the readability standards of § 3.601 of this title (relating to Purpose and Scope, Applicability, and Definitions Used in This Subchapter) and § 3.602 of this title (relating to Plain Language Requirements).

(g) A matrix filing must comply with the filing requirements in this section and § 11.301 of this title. In addition, an HMO submitting a matrix filing:

(1) must identify each provision with a unique form number that is sufficient to distinguish it as a matrix filing; and

(2) may use the same provision filed under one form number for all HMO products, provided that the language is applicable to each HMO product; however, any changes in the language to comply with the requirements for each HMO product will require a unique form number.

(h) Evidences of coverage, agreements, and contracts may be submitted with insert pages, or an insert page may be filed subsequent to the approval of an evidence of coverage, agreement, or contract.

(i) Any HMO submitting an insert page filing:

(1) must identify each insert page with a unique form number located on the lower left hand corner of the page;

(2) may use the same insert page filed under one form number for all plans, provided the language is applicable to each plan type; however, any changes in the language to comply with the requirements for each plan type will require a unique form number;

(3) may use the same insert page to replace an existing page of a previously approved or reviewed evidence of coverage, agreement, or contract. However, if used in this manner, the replaced page, as originally filed, must reflect a unique form number that distinguishes it from the other pages of the form or contract; and

(4) must list the form number for each insert page on the transmittal checklist and provide a statement indicating how the insert page will be used and the type of plan for which the insert page will be used.

(j) In addition to providing the appropriate certification on the transmittal checklist, an HMO submitting a filing as a matrix filing or as an insert page must provide certifications certifying that, when issued, the evidences of coverage, certificates, contracts, riders, or applications created from the forms comply in all respects with all applicable statutes and regulations with regard to the final plan document that will be issued.

Disclaimer: These regulations may not be the most recent version. Texas may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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