Current through Reg. 50, No. 13; March 28, 2025
(a) Prescribed
mandatory benefit notices consist of the following:
(1) For a health benefit plan that provides
coverage or benefits for the treatment of breast cancer, a carrier must issue a
notice that includes the language provided in Figure 1 of §
21.2106(b) of
this title (relating to Forms).
(2)
For a health benefit plan that provides coverage or benefits for a mastectomy,
a carrier must issue:
(A) an enrollment
notice that includes the language provided in Figure 2 of §
21.2106(b) of
this title; and
(B) an annual
notice that includes either:
(i) the language
provided in Figure 3 §
21.2106(b) of
this title; or
(ii) the language
provided in Figure 2 §
21.2106(b) of
this title.
(3) For a health benefit plan that provides
coverage or benefits for diagnostic medical procedures, a carrier must issue a
notice that includes the language provided in Figure 4 §
21.2106(b) of
this title.
(4) For a health
benefit plan that provides coverage or benefits for maternity, including
benefits for childbirth, a carrier must issue a notice that includes the
language provided in Figure 5 §
21.2106(b) of
this title.
(5) If the health
benefit plan described in paragraph (4) of this subsection includes benefits or
coverage for in-home postdelivery care, the following language, or
substantially similar language, must be inserted immediately before the
"Prohibitions" portion of the notice language in Figure 5 §
21.2106(b) of
this title: "Since we provide in-home postdelivery care, we are not required to
provide the minimum number of hours outlined above unless (a) the mother's or
child's physician determines the inpatient care is medically necessary, or (b)
the mother requests the inpatient stay."
(6) For a health benefit plan that provides
coverage or benefits for medical screening procedures, a carrier must issue a
notice that includes the language provided in Figure 6 §
21.2106(b) of
this title.
(7) For a health
benefit plan that provides coverage or benefits for medical screening
procedures, a carrier must issue a notice that includes the language provided
in Figure 7 §
21.2106(b) of
this title. If a plan is not required to provide a benefit for ovarian cancer
screening due to the exception in Insurance Code §
1370.002(b)
(concerning Exceptions), the notice may be modified to omit the references to
ovarian cancer and the CA 125 blood test.
(b) Instead of the prescribed notices
outlined in subsection (a) of this section, a carrier may opt to provide
notices with substantially similar language rather than the notices contained
in §
21.2106(b) of
this title. A form that includes substantially similar language under this
subsection must be filed for review and approval by the commissioner prior to
use, in accordance with Insurance Code Chapters 843 (concerning Health
Maintenance Organizations), 1271 (concerning Benefits Provided by Health
Maintenance Organizations; Evidence of Coverage; Charges), and 1701 (concerning
Policy Forms), except that a form already in use may not be used after March 1,
2017, unless approved by the commissioner. The substantially similar language
must be in a readable and understandable format, and must include a clear,
complete, and accurate description of these items in the following order:
(1) a heading in bold print and all capital
letters indicating the information in the notice relates to mandated
benefits;
(2) a statement that the
notice is being provided to advise the enrollee of the appropriate coverage or
benefits, including the carrier's complete licensed name;
(3) a heading in bold print describing the
coverage or benefits being provided; for example, Examinations for Detection of
Prostate Cancer;
(4) a description
of the coverage or benefits for which the notice is being provided;
(5) for a carrier who issues a health benefit
plan that provides coverage or benefits for a mastectomy, the following
requirements apply:
(A) the enrollment notice
required by subsection (a)(2)(A) of this section must disclose that the
coverage or benefits must be provided in a manner determined to be appropriate,
in consultation with the attending physician and the enrollee, and state the
specific deductibles, copayments, and coinsurance, which may not be greater
than the deductibles, copayments, and coinsurance applicable to other benefits
under the health benefit plan; and
(B) the annual notice required by subsection
(a)(2)(B) of this section must, at a minimum, describe that the health benefit
plan provides coverage or benefits for reconstructive surgery after mastectomy,
surgery and reconstruction of the other breast for symmetry, prostheses, and
treatment of complications resulting from a mastectomy (including
lymphedema);
(6) for the
notice required by subsection (a)(1), (2)(A), and (4) of this section, the
heading "Prohibitions" in bold, followed by a summary of the prohibited acts by
a carrier in providing the coverage or benefits for which the notice is being
provided; and
(7) a statement
identifying the carrier, and providing a phone number and address to which an
enrollee may direct questions regarding the coverage or benefits for which the
notice is being provided.
(c) If a health benefit plan provides
coverage or benefits of more than one of the required notices described in
subsection (a) of this section, the carrier may combine the language of the
required notices into one notice.
(d) The notices must be printed in no less
than 10-point type.
