Texas Administrative Code
Title 28 - INSURANCE
Part 1 - TEXAS DEPARTMENT OF INSURANCE
Chapter 26 - EMPLOYER-RELATED HEALTH BENEFIT PLAN REGULATIONS
Subchapter C - LARGE EMPLOYER HEALTH INSURANCE REGULATIONS
Section 26.312 - Point-of-Service Coverage

Universal Citation: 28 TX Admin Code § 26.312

Current through Reg. 50, No. 13; March 28, 2025

(a) A large employer carrier that offers point-of-service coverage must comply, as applicable, with the requirements set forth in either Chapter 11, Subchapter Z of this title (relating to Point-of-Service Riders) or Chapter 21, Subchapter U of this title (relating to Arrangements Between Indemnity Carriers and HMOs for Point-of-Service Coverage).

(b) If an HMO issues coverage to a large employer and eligible employees have access only to in-plan coverage through one or more HMOs, each of the HMOs issuing coverage must offer the eligible employees the option of obtaining coverage that complies with the out-of-plan coverage set forth in either Chapter 11, Subchapter Z of this title or Chapter 21, Subchapter U of this title, and that allows the enrollee to access out-of-plan coverage at the option of the enrollee in compliance with Insurance Code § 1273.052 (concerning Offer of Coverage Through Non-Network Plan Required).

(c) All HMOs offering coverage to eligible employees of a large employer may enter into a written agreement designating one or more of the HMOs to offer the point-of-service option required under this section.

(1) A copy of the agreement must be retained on file by each of the HMOs participating in the agreement and be made available to TDI on request.

(2) If an HMO participating in the agreement ceases to offer coverage to the large employer, a new agreement that complies with all of the requirements of this section must be entered into by all remaining HMOs offering coverage to employees of the large employer.

(3) If for any reason, an agreement is not in existence that ensures that all eligible employees have the option of selecting out-of-plan coverage under this section from at least one of the HMOs offering coverage to the eligible employees, each HMO must offer the eligible employees the option of selecting out-of-plan coverage as required by this section.

(d) Except as otherwise agreed to by the employer, an eligible employee who selects a point-of-service option is responsible for paying all costs, including premiums, coinsurance, copayments, deductibles, and any other cost-sharing provisions imposed by the point-of-service option, including any administrative costs imposed by a large employer as permitted by Insurance Code § 1273.055 (concerning Cost-Sharing Provisions).

(e) The premium for coverage required to be offered under this section must be based on the actuarial value of that coverage and may be different from the premium for the in-plan coverage provided by the HMO through the enrollee's evidence of coverage.

Disclaimer: These regulations may not be the most recent version. Texas may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.