Current through Reg. 50, No. 13; March 28, 2025
(a) Written agreement between the HMO and the
indemnity carrier. A POS plan offered under this subchapter must be evidenced
by a written agreement between the HMO and indemnity carrier that must be filed
with the department as a plan document and must provide the following:
(1) the identity of each entity, including
the HMO, the indemnity carrier, or any third-party administrator (TPA) that
will administer the coverages offered under the POS plan;
(2) all duties of the HMO and indemnity
carrier to each other relating to the POS plan issued under this
subchapter;
(3) all costs allocable
to the HMO or the indemnity carrier relating to the POS plan;
(4) the HMO's network of providers and, if
the POS indemnity coverage includes preferred provider benefits, as allowed by
Insurance Code Chapter 1301 and applicable rules, the indemnity carrier's list
of preferred providers, which may not be identical; and
(5) the respective premium rates for the POS
HMO coverage and for the POS indemnity coverage must be derived separately by
the HMO and the indemnity carrier and must be separately identified in each POS
plan contract; however, the agreement may provide that for a POS plan offered
by the entities under this subchapter:
(A) the
HMO, the indemnity carrier or a TPA may collect the premiums for both
coverages;
(B) the purchaser may
issue one payment for both coverages; and
(C) the entity delegated to collect the
premium will then disburse the appropriate premium to the other party or
parties;
(6) premium
rates charged by the HMO must be based on the actuarial value of the POS HMO
coverage and may be different from the premium rates charged by the indemnity
carrier, which must be based on the actuarial value of the POS indemnity
coverage offered by the indemnity carrier;
(7) the HMO and indemnity carrier must
maintain separate books and records for the POS plan, including but not limited
to information regarding premiums, lists of covered persons, claim payment
data, complaint records, maintenance tax records, and all other books and
records required to be maintained by law or rule;
(8) neither entity may use the other to
perform functions or duties that are its own responsibility by law or rule,
including but not limited to making all reports and filings required by law or
rule;
(9) the entities may delegate
those functions or duties permitted by law or rule to be delegated to another
party to perform, including but not limited to contracting with providers,
administering claims, and conducting grievance procedures, provided that the
delegating entity remains responsible for ensuring that all delegated functions
are conducted in compliance with all applicable laws and rules;
(10) the agreement between the indemnity
carrier and the HMO may not be canceled or terminated until the coverage for
each enrollee in a POS plan issued by both the indemnity carrier and HMO is
terminated or canceled according to the provisions of this subchapter;
and
(11) the arrangements to be
made in the event of insolvency, loss of certification or any other
circumstances affecting the ability of the indemnity carrier, the HMO, or both
to comply with this subchapter.
(b) Basic requirements. In addition to
complying with all of the requirements listed in subsection (a) of this
section, a contract creating a POS blended contract plan and contracts that
together create a POS dual contracts plan must provide the following:
(1) enrollees may not be required to first
use either the POS indemnity coverage or POS HMO coverage;
(2) if the premiums necessary to maintain
both the POS HMO coverage and the POS indemnity coverage are not paid, both
coverages will be cancelled simultaneously, and any premium the enrollee has
remitted to maintain coverage will be returned to the enrollee;
(3) the POS HMO evidence of coverage must
include all mandatory HMO coverages and the POS indemnity coverage must contain
all mandatory indemnity coverages;
(4) corresponding coverage for a POS plan
must include the following:
(A) all mandatory
benefit offers required by the Insurance Code that are accepted or rejected by
the purchaser must also be accepted or rejected in the same manner with respect
to both the POS HMO and the POS indemnity coverage;
(B) benefits under the POS HMO coverage may
not be reduced by the benefits received under the POS indemnity coverage;
and
(C) benefits for POS indemnity
coverage under the plan may be reduced by benefits received under the POS HMO
coverage.
(5) if
medically necessary covered services, benefits, and supplies are not available
through the HMO's participating physicians or providers, the HMO is not
relieved of its obligation to provide out-of-network services under Insurance
Code Chapter 1271 on the basis that the same services are available to an
enrollee through POS indemnity coverage; and
(6) each POS contract must identify the
respective premium rates for the POS HMO coverage and for the POS indemnity
coverage, as well as the name and address of the entity to whom the premiums
must be paid.
(c) POS
blended contracts. Contracts for POS blended contract plans must:
(1) list all POS HMO coverage;
(2) specify how services, benefits and
supplies under the POS HMO coverage are accessed;
(3) list all POS indemnity
coverage;
(4) specify how claims
are made for POS indemnity coverage;
(5) disclose all copayments
required;
(6) disclose all
coinsurance required for POS indemnity coverage, which must never exceed 50% of
the total amount to be covered;
(7)
disclose all deductibles required;
(8) disclose all precertification
requirements for POS indemnity coverage under the plan including any penalties
for failing to comply with any precertification or cost containment provisions,
provided that any such penalties do not reduce benefits by more than 50% in the
aggregate;
(9) disclose how the
enrollee may complain about a denial of coverage and appeal an adverse
determination rendered concerning the coverage under the POS plan and disclose
any rights the enrollee may have to an independent review of an adverse
determination under Insurance Code Chapter 4201;
(10) POS indemnity coverage issued to a group
must contain provisions that comply with Insurance Code §§
1251.111 -
1251.116(1);
and
(11) POS indemnity coverage
issued to an individual must contain provisions that comply with Insurance Code
§§ 1201.111 -
1201.217.
(d) POS dual contracts. Contracts
comprising a POS dual contract plan must comply with the following:
(1) The contract issued by the indemnity
carrier must comply with all applicable requirements for indemnity carriers and
must:
(A) list all indemnity
coverage;
(B) specify how claims
are made;
(C) disclose all
applicable copayments and coinsurance, which must never exceed 50% of the total
amount to be covered;
(D) disclose
all applicable deductibles;
(E)
disclose all precertification requirements for POS indemnity coverage under the
plan, including any penalties for failing to comply with any precertification
or cost containment provisions, provided that any such penalties must not
reduce benefits more than 50% in the aggregate;
(F) disclose how the enrollee may complain
about a denial of coverage and appeal an adverse determination rendered
concerning the coverage under the POS indemnity coverage and disclose any
rights the enrollee may have to an independent review of an adverse
determination under Insurance Code Chapter 4201, if applicable;
(G) POS indemnity coverage issued to a group
must contain provisions that comply with Insurance Code §§
1251.111 -
1251.116;
(H) POS indemnity coverage issued to an
individual must contain provisions that comply with Insurance Code §§
1201.111 -
1201.217.
(2) The contract issued by the HMO
must comply with all requirements for an HMO evidence of coverage and must:
(A) list all covered services, benefits and
supplies;
(B) specify how covered
services, benefits and supplies are accessed by the enrollee; and
(C) disclose all applicable
copayments.
(e) Filings. All plan documents for a POS
plan offered under this subchapter must be submitted to the department in
accordance with:
(1) Insurance Code Chapter
1271 and Chapter 11 of this title (relating to Health Maintenance
Organizations), including the filing fee requirements; and
(2) Insurance Code Chapter 1701 and Chapter
3, Subchapter A, of this title (relating to Submission Requirements for Filings
and Departmental Actions Related to Such Filings), including the filing fee
requirements.