Texas Administrative Code
Title 28 - INSURANCE
Part 1 - TEXAS DEPARTMENT OF INSURANCE
Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS
Subchapter F - EVIDENCE OF COVERAGE
Section 11.512 - Optional Benefits
Current through Reg. 50, No. 13; March 28, 2025
An HMO may provide health services to its enrollees in addition to the services required in § 11.508 of this title (relating to Basic Health Care Services and Mandatory Benefit Standards: Group, Individual and Conversion Agreements). An HMO may limit these optional health services as to time and cost. Evidences of coverage may contain optional benefits, including:
(1) corrective appliances and artificial aids;
(2) cosmetic surgery;
(3) care for military service-connected disabilities for which the enrollee is legally entitled to services and for which facilities are reasonably available to the enrollee;
(4) care for conditions that state or local law requires be treated in a public facility;
(5) dental services, except as otherwise required;
(6) vision care;
(7) custodial or domiciliary care;
(8) experimental and investigational medical, surgical, or other experimental or investigational health care procedures, unless approved as a basic health care service by the policymaking body of the HMO, provided that:
(9) personal or comfort items and private rooms, unless medically necessary during inpatient hospitalization;
(10) durable medical equipment for home use (such as wheelchairs, surgical beds, ventilators, or dialysis machines);
(11) infertility medical services, including gamete intrafallopian transfer (GIFT), zygote intrafallopian transfer (ZIFT), and outpatient infertility drugs;
(12) reversal of voluntary sterilization;
(13) prescribed drugs and medicines incident to outpatient care; and
(14) noninsurance benefits, provided that the HMO complies with Chapter 21, Subchapter NN, of this title (relating to Noninsurance Benefits and Features).
