(a) Each evidence
of coverage providing basic health care services must 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 out in §
11.506(b)(9) or
§
11.506(b)(14) 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 laboratory, 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 by Insurance Code §
1271.153 (concerning
Periodic Health Evaluations);
(ii)
immunizations for children as required by Insurance Code §
1367.053 (concerning
Coverage Required);
(iii)
well-child care from birth as required by Insurance Code §
1271.154 (concerning
Well-Child Care From Birth);
(iv)
cancer screenings as required by Insurance Code Chapters 1356 (concerning
Low-Dose Mammography), 1362 (concerning Certain Tests for Detection of Prostate
Cancer), and 1363 (concerning Certain Tests for Detection of Colorectal
Cancer);
(v) eye and ear
examinations for children through age 17, to determine the need for vision and
hearing correction complying with established medical guidelines; and
(vi) immunizations for adults under 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) coverage for outpatient mental health
services complying with the mental health parity requirements in Chapter 21,
Subchapter P, of this title (relating to Mental Health Parity); and
(J) emergency services as required by
Insurance Code §
1271.155 (concerning
Emergency Care), including emergency transport in an emergency medical services
vehicle licensed under Health and Safety Code Chapter 773 (concerning Emergency
Medical Services), which is considered emergency care if it is provided as part
of the evaluation and stabilization of medical conditions of a recent onset and
severity, including severe pain, that would lead a prudent layperson possessing
an average knowledge of medicine and health to believe that the individual's
condition, sickness, or injury is of such a nature that failure to get
immediate care through emergency transport could place the individual's health
in serious jeopardy, result in serious impairment to bodily functions, result
in serious dysfunction of a bodily organ or part, result in serious
disfigurement, or for a pregnant woman, result in serious jeopardy to the
health of the fetus;
(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; private duty nursing when medically necessary;
radiation therapy; inhalation therapy; whole blood including cost of blood,
blood plasma, and blood plasma expanders, that are not replaced by or for the
enrollee; 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; and
(4) outpatient hospital services, including
treatment services; ambulatory surgery services; diagnostic services, including
laboratory, radiology, and imaging services; rehabilitation therapy; and
radiation therapy.