Current through Reg. 50, No. 13; March 28, 2025
(a)
Readability. All health insurance policies, health benefit plan certificates,
endorsements, amendments, applications, or riders are required to be written in
a readable and understandable format that meets the requirements of §
3.602 of this title (relating to
Plain Language Requirements).
(b)
Plan disclosure. The insurer is required, on request, to provide to a current
or prospective group contract holder or a current or prospective insured an
accurate written description of the terms and conditions of the policy (plan
disclosure) that allows the current or prospective group contract holder or
current or prospective insured to make comparisons and informed decisions
before selecting among health care plans. An insurer may utilize its policy,
certificate, or handbook to satisfy this requirement provided that the insurer
complies with all requirements set forth in this subsection, including the
level of disclosure required. An insurer that is required by federal law to
provide a summary of benefits and coverage (SBC) must include in the SBC a link
to the plan disclosure required in this subsection. The written plan disclosure
must be in a readable and understandable format, by category, and must include
a clear, complete, and accurate description of these items:
(1) a statement that the entity providing the
coverage is an insurance company; the name of the insurance company; that, in
the case of a preferred provider benefit plan, the insurance contract contains
preferred provider benefits; and, in the case of an exclusive provider benefit
plan, that the contract only provides benefits for services received from
preferred providers, except as otherwise noted in the contract and written
description or as otherwise required by law;
(2) a toll-free number, unless exempted by
statute or rule, and website address to enable a current or prospective group
contract holder or a current or prospective insured to obtain additional
information;
(3) an explanation of
the distinction between preferred and nonpreferred providers;
(4) all covered services and benefits,
including payment for services of a preferred provider and a nonpreferred
provider, and, if prescription drug coverage is included, the name of the
formulary used by the plan, a link to the online formulary, and an explanation
regarding how a nonelectronic copy may be obtained free of charge;
(5) emergency care services and benefits and
information on access to after-hours care;
(6) out-of-area services and
benefits;
(7) an explanation of the
insured's financial responsibility for payment for any premiums, deductibles,
copayments, coinsurance, or other out-of-pocket expenses for noncovered or
nonpreferred services;
(8) any
limitations and exclusions, including the existence of any drug formulary
limitations, and any limitations regarding preexisting conditions;
(9) any authorization requirements, including
preauthorization review, concurrent review, post-service review, and
post-payment review; and an explanation that unless a provider obtains
preauthorization, a claim could be denied if a service is not medically
necessary or appropriate, or if a service is experimental or
investigational;
(10) provisions
for continuity of treatment in the event of termination of a preferred
provider's participation in the plan;
(11) a summary of complaint resolution
procedures, if any, and a statement that the insurer is prohibited from
retaliating against the insured because the insured or another person has filed
a complaint on behalf of the insured, or against a physician or provider who,
on behalf of the insured, has reasonably filed a complaint against the insurer
or appealed a decision of the insurer;
(12) the name of the provider network used by
the plan, a link to the online provider listing, and information on how a
nonelectronic copy may be obtained free of charge;
(13) the counties included in the plan's
service area; and
(14) information
that is updated at least annually regarding the following network demographics
for each county:
(A) the number of insureds in
the service area or region; and
(B)
for each preferred provider area of practice and applicable network adequacy
standard, the number of preferred providers, as well as an indication of
whether an active waiver and access plan under §
3.3707 of this title (relating to
Waiver Due to Failure to Contract in Local Markets) applies to the services
furnished by that class of provider in the county and how such access plan may
be obtained or viewed, if applicable.
(c) Filing required. A copy of the plan
disclosure required in subsection (b) of this section must be filed with the
department with the initial filing of the preferred provider benefit plan and
within 60 days of any material changes being made in the information required
in subsection (b) of this section.
(d) Promotional disclosures required.
(1) The preferred provider benefit plan and
all promotional, solicitation, and advertising material concerning the
preferred provider benefit plan must clearly describe the distinction between
preferred and nonpreferred providers. Any illustration of preferred provider
benefits must be in close proximity to an equally prominent description of
out-of-network benefits, except in the case of an exclusive provider benefit
plan.
(2) All promotion and
advertisement of the preferred provider benefit plan for which a waiver has
been granted must contain a statement that the plan received a waiver for a
departure from network adequacy requirements and a website link where the
following information about the waiver may be obtained:
(A) the name of the plan and the insurer
offering the plan;
(B) the specific
network adequacy standards waived;
(C) each county affected by the waiver;
and
(D) the access plan procedures
the insurer will use to assist insureds in obtaining medically necessary
services, consistent with §
3.3707(j) of
this title.
(e)
Website disclosures. Insurers that maintain a website providing information
regarding the insurer or the health insurance policies offered by the insurer
for use by current or prospective insureds or group contract holders must
provide on their website a:
(1) preferred
provider listing for use by current and prospective insureds and group contract
holders;
(2) listing of the
counties within the insurer's service area, indicating as appropriate for each
county that the insurer has:
(A) determined
that its network meets the network adequacy requirements of this subchapter;
or
(B) determined that its network
does not meet the network adequacy requirements of this subchapter;
and
(3) listing of the
information specified for disclosure in subsection (b) of this
section.
(f) Notice of
rights under a network plan required. An insurer must include the notice
specified in Figure: 28 TAC §
3.3705(f)(1) for
a preferred provider benefit plan that provides major medical insurance and is
not an exclusive provider benefit plan, or Figure: 28 TAC §
3.3705(f)(2) for
an exclusive provider benefit plan that provides major medical insurance, in
all policies, certificates, plan disclosures provided to comply with subsection
(b) of this section, and outlines of coverage in at least 12-point font:
(1) Preferred provider benefit plan notice.
Attached Graphic
(2) Exclusive provider benefit
plan notice.
Attached Graphic
(g) Untrue or misleading
information prohibited. No insurer, or agent or representative of an insurer,
may cause or permit the use or distribution of information which is untrue or
misleading.
(h) Disclosure
concerning access to preferred provider listing. The insurer must provide
notice to all insureds at least annually describing how the insured may access
a current listing of all preferred providers on a cost-free basis. The notice
must include, at a minimum, information concerning how to obtain a
nonelectronic copy of the listing and a telephone number through which insureds
may obtain assistance during regular business hours to find available preferred
providers.
(i) Required updates of
available preferred provider listings. The insurer must ensure that it updates
its listing of preferred providers on its website at least once a month, as
required by Insurance Code §
1451.505, concerning
Physician and Health Care Provider Directory on Internet Website. The insurer
must ensure that it updates all other electronic or nonelectronic listings of
preferred providers made available to insureds at least every three
months.
(j) Annual provision of
preferred provider listing required in certain cases. If no preferred provider
website listing or other method of identifying current preferred providers is
maintained for use by insureds, the insurer must distribute a current preferred
provider listing to all insureds no less than annually by mail, or by an
alternative method of delivery if an alternative method is agreed to by the
insured, group policyholder on behalf of the group, or certificate
holder.
(k) Reliance on preferred
provider listing in certain cases. A claim for services rendered by a
nonpreferred provider must be paid in the same manner as if no preferred
provider had been available under §
3.3708(a)(5) of
this title (relating to Payment of Certain Out-of-Network Claims), and the
insurer must take responsibility for any balance bill amount the nonpreferred
provider may charge in excess of the insurer's payment if an insured
demonstrates that:
(1) in obtaining services,
the insured reasonably relied upon a statement that a physician or provider was
a preferred provider as specified in:
(A) a
preferred provider listing; or
(B)
preferred provider information on the insurer's website;
(2) the preferred provider listing or website
information was obtained from the insurer, the insurer's website, or the
website of a third party designated by the insurer to provide such information
for use by its insureds;
(3) the
preferred provider listing or website information was obtained not more than 30
days prior to the date of services; and
(4) the preferred provider listing or website
information obtained indicates that the provider is a preferred provider within
the insurer's network.
(l) Additional listing-specific disclosure
requirements. In all preferred provider listings, including any website
postings by the insurer to insureds about preferred providers, the insurer must
comply with the requirements in paragraphs (1) - (11) of this subsection.
(1) The preferred provider information must
include a method for insureds to identify those hospitals that have
contractually agreed with the insurer to facilitate the usage of preferred
providers as specified in subparagraphs (A) and (B) of this paragraph.
(A) The hospital will exercise good-faith
efforts to accommodate requests from insureds to utilize preferred
providers.
(B) In those instances
in which a particular facility-based physician or provider or physician group
is assigned at least 48 hours prior to services being rendered, the hospital
will provide the insured with information that is:
(i) furnished at least 24 hours prior to
services being rendered; and
(ii)
sufficient to enable the insured to identify the physician or physician group
with enough specificity to permit the insured to determine, along with
preferred provider listings made available by the insurer, whether the assigned
facility-based physician or provider or physician group is a preferred
provider.
(2)
The preferred provider information must include a method for insureds to
identify, for each preferred provider hospital, the percentage of the total
dollar amount of claims filed with the insurer by or on behalf of
facility-based physicians that are not under contract with the insurer. The
information must be available by class of facility-based physician, including
radiologists, anesthesiologists, pathologists, emergency department physicians,
and neonatologists.
(3) In
determining the percentages specified in paragraph (2) of this subsection, an
insurer may consider claims filed in a 12-month period designated by the
insurer ending not more than 12 months before the date the information
specified in paragraph (2) of this subsection is provided to the
insured.
(4) The preferred provider
information must indicate whether each preferred provider is accepting new
patients.
(5) The preferred
provider information must provide a method by which insureds may notify the
insurer of inaccurate information in the listing, with specific reference to:
(A) information about the provider's contract
status; and
(B) whether the
provider is accepting new patients.
(6) The preferred provider information must
provide a method by which insureds may identify preferred provider
facility-based physicians or providers able to provide services at preferred
provider facilities, if applicable.
(7) The preferred provider information must
be provided in at least 10-point type.
(8) The preferred provider information must
specifically identify those facilities at which the insurer has no contracts
with a class of facility-based provider, specifying the applicable provider
class.
(9) The preferred provider
information must be dated.
(10)
Consistent with Insurance Code Chapter 1451, Subchapter K, concerning Health
Care Provider Directories, for each health care provider that is a facility
included in the listing, the insurer must:
(A)
create separate headings under the facility name for radiologists,
anesthesiologists, anesthesiologist assistants, nurse anesthetists, nurse
midwives, pathologists, emergency department physicians, neonatologists,
physical therapists, occupational therapists, speech-language pathologists, and
surgical assistants, except that a physician or health care provider who is
employed by the facility is not required to be listed;
(B) under each heading described by
subparagraph (A) of this paragraph, list each preferred facility-based
physician or provider practicing in the specialty corresponding with that
heading;
(C) for the facility and
each facility-based physician or provider described by subparagraph (B) of this
paragraph, clearly indicate each health benefit plan issued by the insurer that
may provide coverage for the services provided by that facility, physician or
provider, or facility-based physician or provider group;
(D) for each facility-based physician or
provider described by subparagraph (B) of this paragraph, include the name,
street address, telephone number, and any physician or provider group in which
the facility-based physician or provider practices; and
(E) include the facility in a listing of all
facilities and indicate:
(i) the name of the
facility;
(ii) the municipality in
which the facility is located or county in which the facility is located if the
facility is in the unincorporated area of the county; and
(iii) each health benefit plan issued by the
insurer that may provide coverage for the services provided by the
facility.
(11)
Consistent with Insurance Code Chapter 1451, Subchapter K, the listing must
list each facility-based physician or provider individually and, if a physician
or provider belongs to a physician or provider group, also as part of the
physician or provider group.
(m) Annual policyholder notice concerning use
of an access plan. An insurer operating a preferred provider benefit plan that
relies on an access plan as specified in §
3.3707 of this title (relating to
Waiver Due to Failure to Contract in Local Markets) must provide notice of this
fact to each individual and group policyholder participating in the plan at
policy issuance and at least 30 days prior to renewal of an existing policy.
The notice must include:
(1) a link to any
webpage listing of information on network waivers and access plans disclosed
under subsection (d)(2) of this section and made available under subsection (e)
of this section;
(2) information on
how to obtain or view any access plan or plans the insurer uses; and
(3) a link to the department's website where
the department posts information relevant to the grant of waivers.
(n) Disclosure of substantial
decrease in the availability of certain preferred providers. An insurer is
required to provide notice as specified in this subsection of a substantial
decrease in the availability of preferred facility-based physicians or
providers at a preferred provider facility.
(1) A decrease is substantial if:
(A) the contract between the insurer and any
facility-based physician or provider group that comprises 75% or more of the
preferred providers for that specialty at the facility terminates; or
(B) the contract between the facility and any
facility-based physician or provider group that comprises 75% or more of the
preferred providers for that specialty at the facility terminates, and the
insurer receives notice as required under §
3.3703(a)(26) of
this title (relating to Contracting Requirements).
(2) For purposes of this subsection,
decreases in numbers of physicians and other providers must be assessed
separately, but no notice of a substantial decrease is required if the
requirements specified in either subparagraph (A) or (B) of this paragraph are
met:
(A) alternative preferred providers of
the same specialty as the physician or provider group that terminates a
contract as specified in paragraph (1) of this subsection are made available to
insureds at the facility so the percentage level of preferred providers of that
specialty at the facility is returned to a level equal to or greater than the
percentage level that was available prior to the substantial decrease;
or
(B) the insurer determines that
the termination of the provider contract has not caused the preferred provider
service delivery network for any plan supported by the network to be
noncompliant with the adequacy standards specified in §
3.3704 of this title (relating to
Freedom of Choice; Availability of Preferred Providers) as those standards
apply to the applicable provider specialty.
(3) An insurer must prominently post notice
of any contract termination specified in paragraph (1)(A) or (B) of this
subsection and the resulting decrease in availability of preferred providers on
the portion of the insurer's website where its provider listing is available to
insureds.
(4) Notice of any
contract termination specified in paragraph (1)(A) or (B) of this subsection
and of the decrease in availability of providers must be maintained on the
insurer's website until the earlier of:
(A)
the date on which adequate preferred providers of the same specialty become
available to insureds at the facility at the percentage level specified in
paragraph (2)(A) of this subsection; or
(B) six months from the date that the insurer
initially posts the notice.
(5) An insurer must post notice as specified
in paragraph (3) of this subsection and update its website preferred provider
listing as soon as practicable and in no case later than two business days
after:
(A) the effective date of the contract
termination as specified in paragraph (1)(A) of this subsection; or
(B) the later of:
(i) the date on which an insurer receives
notice of a contract termination as specified in paragraph (1)(B) of this
subsection; or
(ii) the effective
date of the contract termination as specified in paragraph (1)(B) of this
subsection.
(o) Disclosures concerning reimbursement of
out-of-network services. An insurer must make disclosures in all insurance
policies, certificates, and outlines of coverage concerning the reimbursement
of out-of-network services as specified in this subsection.
(1) An insurer must disclose how
reimbursements of nonpreferred providers will be determined.
(2) An insurer must disclose how the plan
will cover out-of-network services received when medically necessary covered
services are not reasonably available through a preferred provider, consistent
with §
3.3708 of this title and how an
enrollee can obtain assistance with accessing care in these circumstances,
consistent with §
3.3707(k) of
this title.
(3) Except in an
exclusive provider benefit plan, if an insurer bases reimbursement of
nonpreferred providers on any amount other than full billed charges, the
insurer must:
(A) disclose that the insurer's
reimbursement of claims for nonpreferred providers may be less than the billed
charge for the service;
(B)
disclose that the insured may be liable to the nonpreferred provider for any
amounts not paid by the insurer, unless balance billing protections apply, as
specified in §
3.3708(a)(1) -
(4) of this title;
(C) provide a description of the methodology
by which the reimbursement amount for nonpreferred providers is calculated;
and
(D) provide to insureds a
method to obtain a real-time estimate of the amount of reimbursement that will
be paid to a nonpreferred provider for a particular service.