Current through Reg. 50, No. 13; March 28, 2025
(a) With respect to a child who lives outside
the insurer's service area but inside the United States whose coverage under
the policy is required by a medical support order, an insurer must either:
(1) cover the child under coverage for which
the parent who has been ordered to provide the coverage is eligible and not
enforce otherwise applicable policy provisions that would deny, limit, or
reduce payment for claims for such child; or
(2) provide coverage through the use of
alternative delivery systems, such as reciprocal agreements with indemnity
insurers or HMOs.
(b) If
the policy contains preferred provider provisions for the purposes of offering
a network of preferred providers as defined in Insurance Code Chapter 1301, and
the insurer does not provide coverage under subsection (a)(2) of this section,
reimbursement for services for a child who is the subject of a medical support
order and lives outside the insurer's service area must be provided at the
preferred provider level of benefits.
(c) If the insurer provides coverage under
subsection (a)(2) of this section, the coverage must include benefits identical
to, greater than, or comparable to those provided to other dependent children
covered by the policy under which coverage is required by a medical support
order.
(d) If the coverage is
provided under subsection (a)(2) of this section, the insurer must submit a
certification to the Texas Department of Insurance. The certification must be
filed with the Texas Department of Insurance, Life and Health Division by email
to MCQA@tdi.texas.gov, signed by an officer of the insurer and include:
(1) the insurer's full name;
(2) a statement that the insurer has elected
to utilize an alternative delivery system to provide coverage for children who
are the subject of a medical support order;
(3) the name of the HMO or indemnity carrier
with which the insurer has contracted to provide coverage to children who are
the subject of a medical support order and a statement, if applicable, that the
HMO or indemnity carrier has filed the applicable forms providing the coverage
as required by Insurance Code Chapter 1701, and Insurance Code §
1504.002 and §
1504.052 or §
11.301 of this title (relating to
Filing Requirements);
(4) a
statement that the coverage provided by the alternative delivery system is
either identical, greater or comparable to the coverage provided other
dependent children under the policy under which coverage is required by a
medical support order; and
(5) if
the coverage is not identical, the certification must also be signed by a
qualified actuary or an officer of the insurer who attests that the coverage
provided is at least actuarially equivalent to or greater than the coverage
provided to other dependent children under the policy under which coverage is
required by a medical support order. The determination of actuarial equivalence
of the coverages must take into account plan design (e.g., copayments,
coinsurance, deductibles, etc.) and scope of benefits. The certification must
identify any other variables considered in the analysis relating to the
actuarial equivalence of the coverages.
