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CHAPTER 1271. BENEFITS PROVIDED BY HEALTH MAINTENANCE ORGANIZATIONS; EVIDENCE OF COVERAGE; CHARGES

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INSURANCE CODETITLE 8. HEALTH INSURANCE AND OTHER HEALTH COVERAGESSUBTITLE C. MANAGED CARECHAPTER 1271. BENEFITS PROVIDED BY HEALTH MAINTENANCEORGANIZATIONS; EVIDENCE OF COVERAGE; CHARGESSUBCHAPTER A. GENERAL PROVISIONSSec. 1271.001.APPLICABILITY OF DEFINITIONS.In this chapter,terms defined by Section 843.002 have the meanings assigned bythat section.Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,2005.Sec. 1271.002.RIGHT TO EVIDENCE OF COVERAGE; ISSUANCE.(a)Each enrollee residing in this state is entitled to evidence ofcoverage under a health care plan.(b)The health maintenance organization shall issue the evidenceof coverage, except as provided by Subsection (c).(c)If the enrollee obtains coverage under a health care planthrough an insurance policy or a contract issued by a grouphospital service corporation, whether by option or otherwise, theinsurer or the group hospital service corporation shall issue theevidence of coverage.(d)By agreement between the health maintenance organization,insurer, or group hospital service corporation and the subscriberor person entitled to receive the evidence of coverage, policy,or contract, the evidence of coverage required by this sectionmay be delivered electronically.Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,2005.Amended by:Acts 2005, 79th Leg., Ch.728, Sec. 11.032(a), eff. September 1, 2005.Sec. 1271.003.EVIDENCE OF COVERAGE NOT HEALTH INSURANCE POLICY.An evidence of coverage is not a health insurance policy as thatterm is defined by this code.Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,2005.Sec. 1271.004.INDIVIDUAL HEALTH CARE PLAN.(a)In thissection, "individual health care plan" means a health care plan:(1)that provides health care services for individuals and theirdependents;(2)under which an enrollee:(A)pays the premium; and(B)is not covered under the contract in accordance with acontinuation of services or continuation of benefits requirementapplicable under federal or state law; and(3)in which the evidence of coverage meets the requirements ofthe definition of "basic health care services" provided bySection 843.002.(b)A health maintenance organization may provide an individualhealth care plan in accordance with this section and Section1271.307.(c)A health maintenance organization may limit enrollment in anindividual health care plan to individuals who reside or workwithin the service area for the plan's network.(d)The commissioner may adopt rules necessary to implement thissection and to meet the minimum requirements of federal law,including regulations.Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,2005.Sec. 1271.005.APPLICABILITY OF OTHER LAW.(a)Chapters 1368and 1652 apply to a health maintenance organization other than ahealth maintenance organization that offers only a single healthcare service plan.(b)Subchapter B, Chapter 1355, applies to a health maintenanceorganization providing benefits for mental health treatment in aresidential treatment center for children and adolescents orcrisis stabilization unit to the extent that:(1)Subchapter B, Chapter 1355, does not conflict with thischapter, Chapter 843, Subchapter A, Chapter 1452, or SubchapterB, Chapter 1507; and(2)the residential treatment center for children andadolescents or crisis stabilization unit is located within theservice area of the health maintenance organization and issubject to inspection and review as required by this chapter,Chapter 843, Subchapter A, Chapter 1452, or Subchapter B, Chapter1507, or rules adopted under this chapter, Chapter 843,Subchapter A, Chapter 1452, or Subchapter B, Chapter 1507.(c)A health maintenance organization shall comply withSubchapter B, Chapter 542, with respect to prompt payment to anenrollee.(d)Notwithstanding any other law, Subchapter C, Chapter 1355,applies to a group contract issued by a health maintenanceorganization.(e)Notwithstanding any other law, Section 1201.062 applies toan evidence of coverage issued by a health maintenanceorganization.Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,2005.Amended by:Acts 2005, 79th Leg., Ch.728, Sec. 11.074(b), eff. September 1, 2005.Sec. 1271.006.BENEFITS TO DEPENDENT CHILD AND GRANDCHILD.(a)If children are eligible for coverage under the terms of anevidence of coverage, any limiting age applicable to an unmarriedchild of an enrollee, including an unmarried grandchild of anenrollee, is 25 years of age. The limiting age applicable to achild must be stated in the evidence of coverage.(b)A health maintenance organization may provide benefits undera health care plan to an enrollee's dependent grandchild who isliving with and in the household of the enrollee.Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,2005.Sec. 1271.007.RELIGIOUS CONVICTIONS.(a)This chapter,Chapters 843, 1272, and 1367, Subchapter A, Chapter 1452, andSubchapter B, Chapter 1507, do not require a health maintenanceorganization, physician, or provider to recommend, offer adviceconcerning, pay for, provide, assist in, perform, arrange, orparticipate in providing or performing any health care servicethat violates the religious convictions of the health maintenanceorganization, physician, or provider.(b)A health maintenance organization that limits or denieshealth care services under this section shall state thelimitations in the evidence of coverage as required by Section1271.052.Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,2005.Amended by:Acts 2005, 79th Leg., Ch.728, Sec. 11.074(c), eff. September 1, 2005.SUBCHAPTER B. CONTENTS OF EVIDENCE OF COVERAGESec. 1271.051.EVIDENCE OF COVERAGE: CONTRACT AND CERTIFICATEREQUIREMENTS.(a)An evidence of coverage that is a contractmust contain a clear and complete statement of the informationrequired by Sections 1271.052, 1271.053, and 1271.054.(b)An evidence of coverage that is a certificate must contain areasonably complete facsimile of the information required bySections 1271.052, 1271.053, and 1271.054.Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,2005.Sec. 1271.052.INFORMATION ABOUT BENEFITS AND LIMITATIONS.Anevidence of coverage must state:(1)the health care services, limited health care services, orsingle health care service to which the enrollee is entitledunder the health care plan, limited health care service plan, orsingle health care service plan;(2)the issuance of other benefits, if any, to which theenrollee is entitled under the health care plan, limited healthcare service plan, or single health care service plan; and(3)any limitation on the services, kinds of services, benefits,or kinds of benefits to be provided, including any deductible orcopayment feature.Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,2005.Sec. 1271.053.INFORMATION ABOUT OBTAINING SERVICES.Anevidence of coverage must indicate where and in what mannerinformation is available about how to obtain services.Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,2005.Sec. 1271.054.INFORMATION ABOUT COMPLAINTS AND APPEALS.(a)An evidence of coverage must contain a clear and understandabledescription of the health maintenance organization's methods forresolving enrollee complaints, including:(1)the enrollee's right to appeal denial of an adversedetermination to an independent review organization; and(2)the procedures for appealing to an independent revieworganization.(b)A health maintenance organization may indicate a subsequentchange to the methods for resolving enrollee complaints in aseparate document issued to the enrollee.Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,2005.Sec. 1271.055.OUT-OF-NETWORK SERVICES.(a)An evidence ofcoverage must contain a provision regarding non-networkphysicians and providers in accordance with the requirements ofthis section.(b)If medically necessary covered services are not availablethrough network physicians or providers, the health maintenanceorganization, on the request of a network physician or providerand within a reasonable period, shall:(1)allow referral to a non-network physician or provider; and(2)fully reimburse the non-network physician or provider at theusual and customary rate or at an agreed rate.(c)Before denying a request for a referral to a non-networkphysician or provider, a health maintenance organization mustprovide for a review conducted by a specialist of the same orsimilar type of specialty as the physician or provider to whomthe referral is requested.Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,2005.Sec. 1271.056.UNFAIR OR DECEPTIVE PROVISIONS AND STATEMENTSPROHIBITED.An evidence of coverage may not contain a provisionor statement that:(1)is unjust, unfair, inequitable, misleading, or deceptive;(2)encourages misrepresentation; or(3)is untrue, misleading, or deceptive within the meaning ofSection 843.204.Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,2005.SUBCHAPTER C. COMMISSIONER APPROVALSec. 1271.101.APPROVAL OF FORM OF EVIDENCE OF COVERAGE OR GROUPCONTRACT.(a)An evidence of coverage or an amendment of anevidence of coverage may not be issued or delivered to a personin this state until the form of the evidence of coverage oramendment has been filed with and approved by the commissioner.(b)Except as provided by Subsection (c), the form of anevidence of coverage or group contract to be used in this stateor an amendment to one of those forms is subject to the filingand approval requirements of Section 1271.102.(c)If the form of an evidence of coverage or group contract orof an amendment to one of those forms is subject to thejurisdiction of the commissioner under laws governing healthinsurance or group hospital service corporations, the filing andapproval provisions of those laws apply to that form. However,Subchapters B and E apply to that form to the extent that lawsgoverning health insurance or group hospital service corporationsdo not apply to the requirements of Subchapters B and E.Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,2005.Sec. 1271.102.PROCEDURES FOR APPROVAL OF FORM OF EVIDENCE OFCOVERAGE OR GROUP CONTRACT; WITHDRAWAL OF APPROVAL.(a)Thecommissioner shall, within a reasonable period, approve the formof an evidence of coverage or group contract or an amendment toone of those forms if the form meets the requirements of thischapter.(b)If the commissioner does not disapprove a form before the31st day after the date the form is filed, the form is consideredapproved. The commissioner may, by written notice, extend theperiod for approval or disapproval as necessary for properconsideration of the filing for not more than an additional 30days.(c)If the commissioner disapproves a form, the commissionershall notify the person who filed the form of the reason for thedisapproval.(d)A hearing on the disapproval of a form shall be granted notlater than the 30th day after the date the person filing the formmakes a written request for a hearing.Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,2005.Sec. 1271.103.WITHDRAWAL OF APPROVAL OF FORM.(a)Afternotice and opportunity for hearing, the commissioner may withdrawapproval of the form of an evidence of coverage or group contractor an amendment to one of those forms if the commissionerdetermines that the form violates this chapter, Chapter 843,1272, or 1367, Subchapter A, Chapter 1452, or Subchapter B,Chapter 1507, or a rule adopted by the commissioner.(b)If the commissioner withdraws approval of a form under thissection, the form may not be issued until it is approved.Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,2005.Amended by:Acts 2005, 79th Leg., Ch.728, Sec. 11.074(d), eff. September 1, 2005.Sec. 1271.104.INFORMATION REQUIRED BY COMMISSIONER.Thecommissioner may require the submission of any relevantinformation the commissioner considers necessary in determiningwhether to approve or disapprove a filing under this subchapter.Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,2005.SUBCHAPTER D. CERTAIN BENEFITS REQUIREDSec. 1271.151.PROVISION OF BASIC HEALTH CARE SERVICES.Ahealth maintenance organization that offers a basic health careplan shall provide or arrange for basic health care services toits enrollees as needed and without limitation as to time andcost other than any limitation prescribed by rule of thecommissioner.Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,2005.Sec. 1271.152.STANDARDS FOR BASIC HEALTH CARE SERVICES.Thecommissioner may adopt minimum standards relating to basic healthcare services.Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,2005.Sec. 1271.153.PERIODIC HEALTH EVALUATIONS.(a)The basichealth care services provided under an evidence of coverage mustinclude periodic health evaluations for each adult enrollee.(b)The services provided under this section must include ahealth risk assessment at least once every three years and, for afemale enrollee, an annual well-woman examination provided inaccordance with Subchapter F, Chapter 1451.(c)This section does not apply to an evidence of coverage for alimited health care service plan or a single health care serviceplan.Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,2005.Sec. 1271.154.WELL-CHILD CARE FROM BIRTH.(a)In thissection, "well-child care from birth" has the meaning used underSection 1302, Public Health Service Act (42 U.S.C. Section300e-1), and its subsequent amendments. The term includes newbornscreening required by the Texas Department of Health.(b)A health maintenance organization shall ensure that eachhealth care plan provided by the health maintenance organizationincludes well-child care from birth that complies with:(1)federal requirements adopted under Chapter XI, Public HealthService Act (42 U.S.C. Section 300e et seq.), and its subsequentamendments; and(2)the rules adopted by the Texas Department of Health toimplement those requirements.Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,2005.Sec. 1271.155.EMERGENCY CARE.(a)A health maintenanceorganization shall pay for emergency care performed bynon-network physicians or providers at the usual and customaryrate or at an agreed rate.(b)A health care plan of a health maintenance organization mustprovide the following coverage of emergency care:(1)a medical screening examination or other evaluation requiredby state or federal law necessary to determine whether anemergency medical condition exists shall be provided to coveredenrollees in a hospital emergency facility or comparablefacility;(2)necessary emergency care shall be provided to coveredenrollees, including the treatment and stabilization of anemergency medical condition; and(3)services originated in a hospital emergency facility,freestanding emergency medical care facility, or comparableemergency facility following treatment or stabilization of anemergency medical condition shall be provided to coveredenrollees as approved by the health maintenance organization,subject to Subsections (c) and (d).(c)A health maintenance organization shall approve or denycoverage of poststabilization care as requested by a treatingphysician or provider within the time appropriate to thecircumstances relating to the delivery of the services and thecondition of the patient, but not to exceed one hour from thetime of the request.(d)A health maintenance organization shall respond to inquiriesfrom a treating physician or provider in compliance with thisprovision in the health care plan of the health maintenanceorganization.(e)A health care plan of a health maintenance organizationshall comply with this section regardless of whether thephysician or provider furnishing the emergency care has acontractual or other arrangement with the health maintenanceorganization to provide items or services to covered enrollees.Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,2005.Amended by:Acts 2009, 81st Leg., R.S., Ch.1273, Sec. 3, eff. March 1, 2010.Sec. 1271.156.BENEFITS FOR REHABILITATION SERVICES ANDTHERAPIES.(a)If benefits are provided for rehabilitationservices and therapies under an evidence of coverage, theprovision of a rehabilitation service or therapy that, in theopinion of a physician, is medically necessary may not be denied,limited, or terminated if the service or therapy meets or exceedstreatment goals for the enrollee.(b)For an enrollee with a physical disability, treatment goalsmay include maintenance of functioning or prevention of orslowing of further deterioration.Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,2005.SUBCHAPTER E. CHOICE OF PRIMARY CARE PHYSICIAN FOR CERTAINENROLLEESSec. 1271.201.DESIGNATION OF SPECIALIST AS PRIMARY CAREPHYSICIAN.(a)An evidence of coverage must provide that anenrollee with a chronic, disabling, or life-threatening illnessmay apply to the health maintenance organization's medicaldirector to use a nonprimary care physician specialist as theenrollee's primary care physician.(b)The application must:(1)include information specified by the health maintenanceorganization, including certification of the medical need; and(2)be signed by the enrollee and the nonprimary care physicianspecialist interested in serving as the enrollee's primary carephysician.(c)To be eligible to serve as the enrollee's primary carephysician, a physician specialist must:(1)meet the health maintenance organization's requirements forprimary care physician participation; and(2)agree to accept the responsibility to coordinate all of theenrollee's health care needs.Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,2005.Sec. 1271.202.APPEAL.If a health maintenance organizationdenies a request under Section 1271.201, the enrollee may appealthe decision through the health maintenance organization'sestablished complaint and appeals process.Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,2005.Sec. 1271.203.EFFECTIVE DATE OF DESIGNATION.(a)Theeffective date of the designation of a nonprimary care physicianspecialist as an enrollee's primary care physician under Section1271.201 may not be applied retroactively.(b)A health maintenance organization may not reduce the amountof compensation owed to the original primary care physician forservices provided before the date of the new designation.Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,2005.SUBCHAPTER F. SCHEDULE OF CHARGESSec. 1271.251.APPROVAL OF FORMULA OR METHOD FOR COMPUTINGSCHEDULE OF CHARGES.(a)The formula or method for computingthe schedule of charges for enrollee coverage for health careservices must be filed with the commissioner before the formulaor method is used in conjunction with a health care plan.(b)The formula or method must be established in accordance withactuarial principles for the various categories of enrollees. Thefiling of the method or formula must contain:(1)a statement by a qualified actuary that certifies that theformula or method is appropriate; and(2)supporting information that the commissioner considersadequate.(c)The formula or method must produce charges that are notexcessive, inadequate, or unfairly discriminatory. Benefits mustbe reasonable with respect to the rates produced by the formulaor method.Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,2005.Sec. 1271.252.CONSIDERATION OF INDIVIDUAL HEALTH STATUSPROHIBITED.The charges resulting from the application of aformula or method described by Section 1271.251 may not bealtered for an individual enrollee based on the status of thatenrollee's health.Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,2005.Sec. 1271.253.INFORMATION REQUIRED BY COMMISSIONER.Thecommissioner may require the submission of any relevantinformation the commissioner considers necessary in determiningwhether to approve or disapprove a filing under this subchapter.Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,2005.SUBCHAPTER G. CONTINUATION OF COVERAGE, CONVERSION CONTRACTS, ANDRENEWALSec. 1271.301.ENTITLEMENT TO CONTINUATION OF GROUP COVERAGE.(a)In this section, "involuntary termination for cause" doesnot include termination for any health-related reason.(b)A health maintenance organization shall provide a groupcoverage continuation privilege as required by and subject to theeligibility provisions of this subchapter.(c)An enrollee is entitled to continue group coverage asprovided by this subchapter if:(1)the enrollee's coverage under a group contract is terminatedfor any reason except involuntary termination for cause; and(2)the enrollee for at least three consecutive monthsimmediately before the termination of coverage has beencontinuously covered under the group contract and under anyprevious group contract providing similar services and benefitsthat the current group contract replaced.Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,2005.Sec. 1271.302.REQUEST FOR CONTINUED COVERAGE; DEADLINE.Anenrollee must provide to the employer or group contract holder awritten notice of election to continue group coverage under thissubchapter not later than the 60th day after the later of:(1)the date the group coverage would otherwise terminate; or(2)the date the enrollee is given notice of the right ofcontinuation by the employer or group contract holder.Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,2005.Amended by:Acts 2009, 81st Leg., R.S., Ch.550, Sec. 5, eff. June 19, 2009.Sec. 1271.303.PAYMENT FOR CONTINUED COVERAGE.(a)An enrolleeelecting continuation of group coverage must pay to the employeror group contract holder the amount of contribution required bythe employer or group contract holder, plus an amount equal totwo percent of the group rate for the coverage being continuedunder the group contract.(b)The enrollee must make the payment not later than the 45thday after the initial election for coverage and on the due dateof each payment thereafter.Following the first payment madeafter the initial election for coverage, the payment of any otherpremium shall be considered timely if made by the 30th day afterthe date on which payment is due.Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,2005.Amended by:Acts 2009, 81st Leg., R.S., Ch.550, Sec. 6, eff. June 19, 2009.Sec. 1271.304.TERMINATION OF CONTINUED COVERAGE.Groupcontinued coverage under this subchapter may not terminate untilthe earliest of:(1)the date the maximum continuation period provided by lawwould end, which is:(A)for any enrollee not eligible for continuation coverageunder Title X, Consolidated Omnibus Budget Reconciliation Act of1985 (29 U.S.C. Section 1161 et seq.) (COBRA), the end of thenine-month period after the date the election to continuecoverage is made; or(B)for any enrollee eligible for continuation coverage underCOBRA, six additional months following any period of continuationprovided under that statute;(2)the date on which failure to make timely payments terminatescoverage;(3)the date on which the enrollee is covered for similarservices and benefits by any other plan or program, including ahospital, surgical, medical, or major medical expense insurancepolicy, hospital or medical service subscriber contract, ormedical practice or other prepayment plan; or(4)the date on which the group coverage terminates in itsentirety.Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,2005.Amended by:Acts 2009, 81st Leg., R.S., Ch.550, Sec. 7, eff. June 19, 2009.Sec. 1271.305.NOTIFICATION OF RISK POOL ELIGIBILITY.(a)Atleast 30 days before the end of the continuation period describedby Section 1271.304(1) that is applicable to the enrollee, thehealth maintenance organization shall notify the enrollee thatthe enrollee may be eligible for coverage under the Texas HealthInsurance Risk Pool as provided by Chapter 1506.(b)The health maintenance organization shall provide to theenrollee the address for applying to the pool for coverage.Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,2005.Amended by:Acts 2009, 81st Leg., R.S., Ch.550, Sec. 8, eff. June 19, 2009.Sec. 1271.306.CONVERSION CONTRACTS.(a)A health maintenanceorganization may offer to each enrollee a conversion contract.(b)A health maintenance organization shall issue the conversioncontract without evidence of insurability if written applicationfor the contract and payment of the first premium are made notlater than the 31st day after the date of termination ofcoverage.(c)A conversion contract must meet the minimum standards forservices and benefits for conversion contracts. The commissionershall adopt rules to prescribe the minimum standards for servicesand benefits applicable to conversion contracts.(d)The premium for a conversion contract shall be determined inaccordance with the health maintenance organization's premiumrates for coverage provided under the group contract or plan. Thepremium may be based on the geographic location of each person tobe covered and must be based on the type of conversion contractand the coverage provided by the contract. The premium may notexceed 200 percent of the premium rates for the same coverageprovided under a group contract or plan.Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,2005.Sec. 1271.307.RENEWABILITY OF COVERAGE: INDIVIDUAL HEALTH CAREPLANS AND CONVERSION CONTRACTS.(a)In this section,"individual health care plan" has the meaning assigned by Section1271.004.(b)An individual health care plan or a conversion contract thatprovides health care services to an enrollee is renewable at theoption of the enrollee. A health maintenance organization maydecline to renew an individual health care plan or conversioncontract only:(1)for failure to pay premiums or contributions in accordancewith the terms of the plan or because the issuer of the plan hasnot received timely premium payments;(2)for fraud or intentional misrepresentation;(3)because the health maintenance organization ceases to offercoverage in the individual market in accordance with rulesestablished by the commissioner;(4)because the enrollee no longer resides or works in the areain which the health maintenance organization is authorized toprovide coverage, if coverage under the plan is terminateduniformly for this reason without regard to any factor related tothe health status of a covered enrollee; or(5)in accordance with applicable federal law, includingregulations.(c)The commissioner may adopt rules necessary to implement thissection and to meet the minimum requirements of federal law,including regulations.Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,2005.
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  • INSURANCE CODE

    TITLE 8. HEALTH INSURANCE AND OTHER HEALTH COVERAGES

    SUBTITLE C. MANAGED CARE

    CHAPTER 1271. BENEFITS PROVIDED BY HEALTH MAINTENANCE

    ORGANIZATIONS; EVIDENCE OF COVERAGE; CHARGES

    SUBCHAPTER A. GENERAL PROVISIONS

    Sec. 1271.001. APPLICABILITY OF DEFINITIONS. In this chapter,

    terms defined by Section 843.002 have the meanings assigned by

    that section.

    Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

    2005.

    Sec. 1271.002. RIGHT TO EVIDENCE OF COVERAGE; ISSUANCE. (a)

    Each enrollee residing in this state is entitled to evidence of

    coverage under a health care plan.

    (b) The health maintenance organization shall issue the evidence

    of coverage, except as provided by Subsection (c).

    (c) If the enrollee obtains coverage under a health care plan

    through an insurance policy or a contract issued by a group

    hospital service corporation, whether by option or otherwise, the

    insurer or the group hospital service corporation shall issue the

    evidence of coverage.

    (d) By agreement between the health maintenance organization,

    insurer, or group hospital service corporation and the subscriber

    or person entitled to receive the evidence of coverage, policy,

    or contract, the evidence of coverage required by this section

    may be delivered electronically.

    Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

    2005.

    Amended by:

    Acts 2005, 79th Leg., Ch.

    728, Sec. 11.032(a), eff. September 1, 2005.

    Sec. 1271.003. EVIDENCE OF COVERAGE NOT HEALTH INSURANCE POLICY.

    An evidence of coverage is not a health insurance policy as that

    term is defined by this code.

    Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

    2005.

    Sec. 1271.004. INDIVIDUAL HEALTH CARE PLAN. (a) In this

    section, "individual health care plan" means a health care plan:

    (1) that provides health care services for individuals and their

    dependents;

    (2) under which an enrollee:

    (A) pays the premium; and

    (B) is not covered under the contract in accordance with a

    continuation of services or continuation of benefits requirement

    applicable under federal or state law; and

    (3) in which the evidence of coverage meets the requirements of

    the definition of "basic health care services" provided by

    Section 843.002.

    (b) A health maintenance organization may provide an individual

    health care plan in accordance with this section and Section

    1271.307.

    (c) A health maintenance organization may limit enrollment in an

    individual health care plan to individuals who reside or work

    within the service area for the plan's network.

    (d) The commissioner may adopt rules necessary to implement this

    section and to meet the minimum requirements of federal law,

    including regulations.

    Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

    2005.

    Sec. 1271.005. APPLICABILITY OF OTHER LAW. (a) Chapters 1368

    and 1652 apply to a health maintenance organization other than a

    health maintenance organization that offers only a single health

    care service plan.

    (b) Subchapter B, Chapter 1355, applies to a health maintenance

    organization providing benefits for mental health treatment in a

    residential treatment center for children and adolescents or

    crisis stabilization unit to the extent that:

    (1) Subchapter B, Chapter 1355, does not conflict with this

    chapter, Chapter 843, Subchapter A, Chapter 1452, or Subchapter

    B, Chapter 1507; and

    (2) the residential treatment center for children and

    adolescents or crisis stabilization unit is located within the

    service area of the health maintenance organization and is

    subject to inspection and review as required by this chapter,

    Chapter 843, Subchapter A, Chapter 1452, or Subchapter B, Chapter

    1507, or rules adopted under this chapter, Chapter 843,

    Subchapter A, Chapter 1452, or Subchapter B, Chapter 1507.

    (c) A health maintenance organization shall comply with

    Subchapter B, Chapter 542, with respect to prompt payment to an

    enrollee.

    (d) Notwithstanding any other law, Subchapter C, Chapter 1355,

    applies to a group contract issued by a health maintenance

    organization.

    (e) Notwithstanding any other law, Section 1201.062 applies to

    an evidence of coverage issued by a health maintenance

    organization.

    Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

    2005.

    Amended by:

    Acts 2005, 79th Leg., Ch.

    728, Sec. 11.074(b), eff. September 1, 2005.

    Sec. 1271.006. BENEFITS TO DEPENDENT CHILD AND GRANDCHILD. (a)

    If children are eligible for coverage under the terms of an

    evidence of coverage, any limiting age applicable to an unmarried

    child of an enrollee, including an unmarried grandchild of an

    enrollee, is 25 years of age. The limiting age applicable to a

    child must be stated in the evidence of coverage.

    (b) A health maintenance organization may provide benefits under

    a health care plan to an enrollee's dependent grandchild who is

    living with and in the household of the enrollee.

    Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

    2005.

    Sec. 1271.007. RELIGIOUS CONVICTIONS. (a) This chapter,

    Chapters 843, 1272, and 1367, Subchapter A, Chapter 1452, and

    Subchapter B, Chapter 1507, do not require a health maintenance

    organization, physician, or provider to recommend, offer advice

    concerning, pay for, provide, assist in, perform, arrange, or

    participate in providing or performing any health care service

    that violates the religious convictions of the health maintenance

    organization, physician, or provider.

    (b) A health maintenance organization that limits or denies

    health care services under this section shall state the

    limitations in the evidence of coverage as required by Section

    1271.052.

    Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

    2005.

    Amended by:

    Acts 2005, 79th Leg., Ch.

    728, Sec. 11.074(c), eff. September 1, 2005.

    SUBCHAPTER B. CONTENTS OF EVIDENCE OF COVERAGE

    Sec. 1271.051. EVIDENCE OF COVERAGE: CONTRACT AND CERTIFICATE

    REQUIREMENTS. (a) An evidence of coverage that is a contract

    must contain a clear and complete statement of the information

    required by Sections 1271.052, 1271.053, and 1271.054.

    (b) An evidence of coverage that is a certificate must contain a

    reasonably complete facsimile of the information required by

    Sections 1271.052, 1271.053, and 1271.054.

    Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

    2005.

    Sec. 1271.052. INFORMATION ABOUT BENEFITS AND LIMITATIONS. An

    evidence of coverage must state:

    (1) the health care services, limited health care services, or

    single health care service to which the enrollee is entitled

    under the health care plan, limited health care service plan, or

    single health care service plan;

    (2) the issuance of other benefits, if any, to which the

    enrollee is entitled under the health care plan, limited health

    care service plan, or single health care service plan; and

    (3) any limitation on the services, kinds of services, benefits,

    or kinds of benefits to be provided, including any deductible or

    copayment feature.

    Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

    2005.

    Sec. 1271.053. INFORMATION ABOUT OBTAINING SERVICES. An

    evidence of coverage must indicate where and in what manner

    information is available about how to obtain services.

    Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

    2005.

    Sec. 1271.054. INFORMATION ABOUT COMPLAINTS AND APPEALS. (a)

    An evidence of coverage must contain a clear and understandable

    description of the health maintenance organization's methods for

    resolving enrollee complaints, including:

    (1) the enrollee's right to appeal denial of an adverse

    determination to an independent review organization; and

    (2) the procedures for appealing to an independent review

    organization.

    (b) A health maintenance organization may indicate a subsequent

    change to the methods for resolving enrollee complaints in a

    separate document issued to the enrollee.

    Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

    2005.

    Sec. 1271.055. OUT-OF-NETWORK SERVICES. (a) An evidence of

    coverage must contain a provision regarding non-network

    physicians and providers in accordance with the requirements of

    this section.

    (b) If medically necessary covered services are not available

    through network physicians or providers, the health maintenance

    organization, on the request of a network physician or provider

    and within a reasonable period, shall:

    (1) allow referral to a non-network physician or provider; and

    (2) fully reimburse the non-network physician or provider at the

    usual and customary rate or at an agreed rate.

    (c) Before denying a request for a referral to a non-network

    physician or provider, a health maintenance organization must

    provide for a review conducted by a specialist of the same or

    similar type of specialty as the physician or provider to whom

    the referral is requested.

    Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

    2005.

    Sec. 1271.056. UNFAIR OR DECEPTIVE PROVISIONS AND STATEMENTS

    PROHIBITED. An evidence of coverage may not contain a provision

    or statement that:

    (1) is unjust, unfair, inequitable, misleading, or deceptive;

    (2) encourages misrepresentation; or

    (3) is untrue, misleading, or deceptive within the meaning of

    Section 843.204.

    Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

    2005.

    SUBCHAPTER C. COMMISSIONER APPROVAL

    Sec. 1271.101. APPROVAL OF FORM OF EVIDENCE OF COVERAGE OR GROUP

    CONTRACT. (a) An evidence of coverage or an amendment of an

    evidence of coverage may not be issued or delivered to a person

    in this state until the form of the evidence of coverage or

    amendment has been filed with and approved by the commissioner.

    (b) Except as provided by Subsection (c), the form of an

    evidence of coverage or group contract to be used in this state

    or an amendment to one of those forms is subject to the filing

    and approval requirements of Section 1271.102.

    (c) If the form of an evidence of coverage or group contract or

    of an amendment to one of those forms is subject to the

    jurisdiction of the commissioner under laws governing health

    insurance or group hospital service corporations, the filing and

    approval provisions of those laws apply to that form. However,

    Subchapters B and E apply to that form to the extent that laws

    governing health insurance or group hospital service corporations

    do not apply to the requirements of Subchapters B and E.

    Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

    2005.

    Sec. 1271.102. PROCEDURES FOR APPROVAL OF FORM OF EVIDENCE OF

    COVERAGE OR GROUP CONTRACT; WITHDRAWAL OF APPROVAL. (a) The

    commissioner shall, within a reasonable period, approve the form

    of an evidence of coverage or group contract or an amendment to

    one of those forms if the form meets the requirements of this

    chapter.

    (b) If the commissioner does not disapprove a form before the

    31st day after the date the form is filed, the form is considered

    approved. The commissioner may, by written notice, extend the

    period for approval or disapproval as necessary for proper

    consideration of the filing for not more than an additional 30

    days.

    (c) If the commissioner disapproves a form, the commissioner

    shall notify the person who filed the form of the reason for the

    disapproval.

    (d) A hearing on the disapproval of a form shall be granted not

    later than the 30th day after the date the person filing the form

    makes a written request for a hearing.

    Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

    2005.

    Sec. 1271.103. WITHDRAWAL OF APPROVAL OF FORM. (a) After

    notice and opportunity for hearing, the commissioner may withdraw

    approval of the form of an evidence of coverage or group contract

    or an amendment to one of those forms if the commissioner

    determines that the form violates this chapter, Chapter 843,

    1272, or 1367, Subchapter A, Chapter 1452, or Subchapter B,

    Chapter 1507, or a rule adopted by the commissioner.

    (b) If the commissioner withdraws approval of a form under this

    section, the form may not be issued until it is approved.

    Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

    2005.

    Amended by:

    Acts 2005, 79th Leg., Ch.

    728, Sec. 11.074(d), eff. September 1, 2005.

    Sec. 1271.104. INFORMATION REQUIRED BY COMMISSIONER. The

    commissioner may require the submission of any relevant

    information the commissioner considers necessary in determining

    whether to approve or disapprove a filing under this subchapter.

    Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

    2005.

    SUBCHAPTER D. CERTAIN BENEFITS REQUIRED

    Sec. 1271.151. PROVISION OF BASIC HEALTH CARE SERVICES. A

    health maintenance organization that offers a basic health care

    plan shall provide or arrange for basic health care services to

    its enrollees as needed and without limitation as to time and

    cost other than any limitation prescribed by rule of the

    commissioner.

    Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

    2005.

    Sec. 1271.152. STANDARDS FOR BASIC HEALTH CARE SERVICES. The

    commissioner may adopt minimum standards relating to basic health

    care services.

    Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

    2005.

    Sec. 1271.153. PERIODIC HEALTH EVALUATIONS. (a) The basic

    health care services provided under an evidence of coverage must

    include periodic health evaluations for each adult enrollee.

    (b) The services provided under this section must include a

    health risk assessment at least once every three years and, for a

    female enrollee, an annual well-woman examination provided in

    accordance with Subchapter F, Chapter 1451.

    (c) This section does not apply to an evidence of coverage for a

    limited health care service plan or a single health care service

    plan.

    Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

    2005.

    Sec. 1271.154. WELL-CHILD CARE FROM BIRTH. (a) In this

    section, "well-child care from birth" has the meaning used under

    Section 1302, Public Health Service Act (42 U.S.C. Section

    300e-1), and its subsequent amendments. The term includes newborn

    screening required by the Texas Department of Health.

    (b) A health maintenance organization shall ensure that each

    health care plan provided by the health maintenance organization

    includes well-child care from birth that complies with:

    (1) federal requirements adopted under Chapter XI, Public Health

    Service Act (42 U.S.C. Section 300e et seq.), and its subsequent

    amendments; and

    (2) the rules adopted by the Texas Department of Health to

    implement those requirements.

    Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

    2005.

    Sec. 1271.155. EMERGENCY CARE. (a) A health maintenance

    organization shall pay for emergency care performed by

    non-network physicians or providers at the usual and customary

    rate or at an agreed rate.

    (b) A health care plan of a health maintenance organization must

    provide the following coverage of emergency care:

    (1) a medical screening examination or other evaluation required

    by state or federal law necessary to determine whether an

    emergency medical condition exists shall be provided to covered

    enrollees in a hospital emergency facility or comparable

    facility;

    (2) necessary emergency care shall be provided to covered

    enrollees, including the treatment and stabilization of an

    emergency medical condition; and

    (3) services originated in a hospital emergency facility,

    freestanding emergency medical care facility, or comparable

    emergency facility following treatment or stabilization of an

    emergency medical condition shall be provided to covered

    enrollees as approved by the health maintenance organization,

    subject to Subsections (c) and (d).

    (c) A health maintenance organization shall approve or deny

    coverage of poststabilization care as requested by a treating

    physician or provider within the time appropriate to the

    circumstances relating to the delivery of the services and the

    condition of the patient, but not to exceed one hour from the

    time of the request.

    (d) A health maintenance organization shall respond to inquiries

    from a treating physician or provider in compliance with this

    provision in the health care plan of the health maintenance

    organization.

    (e) A health care plan of a health maintenance organization

    shall comply with this section regardless of whether the

    physician or provider furnishing the emergency care has a

    contractual or other arrangement with the health maintenance

    organization to provide items or services to covered enrollees.

    Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

    2005.

    Amended by:

    Acts 2009, 81st Leg., R.S., Ch.

    1273, Sec. 3, eff. March 1, 2010.

    Sec. 1271.156. BENEFITS FOR REHABILITATION SERVICES AND

    THERAPIES. (a) If benefits are provided for rehabilitation

    services and therapies under an evidence of coverage, the

    provision of a rehabilitation service or therapy that, in the

    opinion of a physician, is medically necessary may not be denied,

    limited, or terminated if the service or therapy meets or exceeds

    treatment goals for the enrollee.

    (b) For an enrollee with a physical disability, treatment goals

    may include maintenance of functioning or prevention of or

    slowing of further deterioration.

    Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

    2005.

    SUBCHAPTER E. CHOICE OF PRIMARY CARE PHYSICIAN FOR CERTAIN

    ENROLLEES

    Sec. 1271.201. DESIGNATION OF SPECIALIST AS PRIMARY CARE

    PHYSICIAN. (a) An evidence of coverage must provide that an

    enrollee with a chronic, disabling, or life-threatening illness

    may apply to the health maintenance organization's medical

    director to use a nonprimary care physician specialist as the

    enrollee's primary care physician.

    (b) The application must:

    (1) include information specified by the health maintenance

    organization, including certification of the medical need; and

    (2) be signed by the enrollee and the nonprimary care physician

    specialist interested in serving as the enrollee's primary care

    physician.

    (c) To be eligible to serve as the enrollee's primary care

    physician, a physician specialist must:

    (1) meet the health maintenance organization's requirements for

    primary care physician participation; and

    (2) agree to accept the responsibility to coordinate all of the

    enrollee's health care needs.

    Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

    2005.

    Sec. 1271.202. APPEAL. If a health maintenance organization

    denies a request under Section 1271.201, the enrollee may appeal

    the decision through the health maintenance organization's

    established complaint and appeals process.

    Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

    2005.

    Sec. 1271.203. EFFECTIVE DATE OF DESIGNATION. (a) The

    effective date of the designation of a nonprimary care physician

    specialist as an enrollee's primary care physician under Section

    1271.201 may not be applied retroactively.

    (b) A health maintenance organization may not reduce the amount

    of compensation owed to the original primary care physician for

    services provided before the date of the new designation.

    Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

    2005.

    SUBCHAPTER F. SCHEDULE OF CHARGES

    Sec. 1271.251. APPROVAL OF FORMULA OR METHOD FOR COMPUTING

    SCHEDULE OF CHARGES. (a) The formula or method for computing

    the schedule of charges for enrollee coverage for health care

    services must be filed with the commissioner before the formula

    or method is used in conjunction with a health care plan.

    (b) The formula or method must be established in accordance with

    actuarial principles for the various categories of enrollees. The

    filing of the method or formula must contain:

    (1) a statement by a qualified actuary that certifies that the

    formula or method is appropriate; and

    (2) supporting information that the commissioner considers

    adequate.

    (c) The formula or method must produce charges that are not

    excessive, inadequate, or unfairly discriminatory. Benefits must

    be reasonable with respect to the rates produced by the formula

    or method.

    Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

    2005.

    Sec. 1271.252. CONSIDERATION OF INDIVIDUAL HEALTH STATUS

    PROHIBITED. The charges resulting from the application of a

    formula or method described by Section 1271.251 may not be

    altered for an individual enrollee based on the status of that

    enrollee's health.

    Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

    2005.

    Sec. 1271.253. INFORMATION REQUIRED BY COMMISSIONER. The

    commissioner may require the submission of any relevant

    information the commissioner considers necessary in determining

    whether to approve or disapprove a filing under this subchapter.

    Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

    2005.

    SUBCHAPTER G. CONTINUATION OF COVERAGE, CONVERSION CONTRACTS, AND

    RENEWAL

    Sec. 1271.301. ENTITLEMENT TO CONTINUATION OF GROUP COVERAGE.

    (a) In this section, "involuntary termination for cause" does

    not include termination for any health-related reason.

    (b) A health maintenance organization shall provide a group

    coverage continuation privilege as required by and subject to the

    eligibility provisions of this subchapter.

    (c) An enrollee is entitled to continue group coverage as

    provided by this subchapter if:

    (1) the enrollee's coverage under a group contract is terminated

    for any reason except involuntary termination for cause; and

    (2) the enrollee for at least three consecutive months

    immediately before the termination of coverage has been

    continuously covered under the group contract and under any

    previous group contract providing similar services and benefits

    that the current group contract replaced.

    Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

    2005.

    Sec. 1271.302. REQUEST FOR CONTINUED COVERAGE; DEADLINE. An

    enrollee must provide to the employer or group contract holder a

    written notice of election to continue group coverage under this

    subchapter not later than the 60th day after the later of:

    (1) the date the group coverage would otherwise terminate; or

    (2) the date the enrollee is given notice of the right of

    continuation by the employer or group contract holder.

    Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

    2005.

    Amended by:

    Acts 2009, 81st Leg., R.S., Ch.

    550, Sec. 5, eff. June 19, 2009.

    Sec. 1271.303. PAYMENT FOR CONTINUED COVERAGE. (a) An enrollee

    electing continuation of group coverage must pay to the employer

    or group contract holder the amount of contribution required by

    the employer or group contract holder, plus an amount equal to

    two percent of the group rate for the coverage being continued

    under the group contract.

    (b) The enrollee must make the payment not later than the 45th

    day after the initial election for coverage and on the due date

    of each payment thereafter. Following the first payment made

    after the initial election for coverage, the payment of any other

    premium shall be considered timely if made by the 30th day after

    the date on which payment is due.

    Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

    2005.

    Amended by:

    Acts 2009, 81st Leg., R.S., Ch.

    550, Sec. 6, eff. June 19, 2009.

    Sec. 1271.304. TERMINATION OF CONTINUED COVERAGE. Group

    continued coverage under this subchapter may not terminate until

    the earliest of:

    (1) the date the maximum continuation period provided by law

    would end, which is:

    (A) for any enrollee not eligible for continuation coverage

    under Title X, Consolidated Omnibus Budget Reconciliation Act of

    1985 (29 U.S.C. Section 1161 et seq.) (COBRA), the end of the

    nine-month period after the date the election to continue

    coverage is made; or

    (B) for any enrollee eligible for continuation coverage under

    COBRA, six additional months following any period of continuation

    provided under that statute;

    (2) the date on which failure to make timely payments terminates

    coverage;

    (3) the date on which the enrollee is covered for similar

    services and benefits by any other plan or program, including a

    hospital, surgical, medical, or major medical expense insurance

    policy, hospital or medical service subscriber contract, or

    medical practice or other prepayment plan; or

    (4) the date on which the group coverage terminates in its

    entirety.

    Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

    2005.

    Amended by:

    Acts 2009, 81st Leg., R.S., Ch.

    550, Sec. 7, eff. June 19, 2009.

    Sec. 1271.305. NOTIFICATION OF RISK POOL ELIGIBILITY. (a) At

    least 30 days before the end of the continuation period described

    by Section 1271.304(1) that is applicable to the enrollee, the

    health maintenance organization shall notify the enrollee that

    the enrollee may be eligible for coverage under the Texas Health

    Insurance Risk Pool as provided by Chapter 1506.

    (b) The health maintenance organization shall provide to the

    enrollee the address for applying to the pool for coverage.

    Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

    2005.

    Amended by:

    Acts 2009, 81st Leg., R.S., Ch.

    550, Sec. 8, eff. June 19, 2009.

    Sec. 1271.306. CONVERSION CONTRACTS. (a) A health maintenance

    organization may offer to each enrollee a conversion contract.

    (b) A health maintenance organization shall issue the conversion

    contract without evidence of insurability if written application

    for the contract and payment of the first premium are made not

    later than the 31st day after the date of termination of

    coverage.

    (c) A conversion contract must meet the minimum standards for

    services and benefits for conversion contracts. The commissioner

    shall adopt rules to prescribe the minimum standards for services

    and benefits applicable to conversion contracts.

    (d) The premium for a conversion contract shall be determined in

    accordance with the health maintenance organization's premium

    rates for coverage provided under the group contract or plan. The

    premium may be based on the geographic location of each person to

    be covered and must be based on the type of conversion contract

    and the coverage provided by the contract. The premium may not

    exceed 200 percent of the premium rates for the same coverage

    provided under a group contract or plan.

    Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

    2005.

    Sec. 1271.307. RENEWABILITY OF COVERAGE: INDIVIDUAL HEALTH CARE

    PLANS AND CONVERSION CONTRACTS. (a) In this section,

    "individual health care plan" has the meaning assigned by Section

    1271.004.

    (b) An individual health care plan or a conversion contract that

    provides health care services to an enrollee is renewable at the

    option of the enrollee. A health maintenance organization may

    decline to renew an individual health care plan or conversion

    contract only:

    (1) for failure to pay premiums or contributions in accordance

    with the terms of the plan or because the issuer of the plan has

    not received timely premium payments;

    (2) for fraud or intentional misrepresentation;

    (3) because the health maintenance organization ceases to offer

    coverage in the individual market in accordance with rules

    established by the commissioner;

    (4) because the enrollee no longer resides or works in the area

    in which the health maintenance organization is authorized to

    provide coverage, if coverage under the plan is terminated

    uniformly for this reason without regard to any factor related to

    the health status of a covered enrollee; or

    (5) in accordance with applicable federal law, including

    regulations.

    (c) The commissioner may adopt rules necessary to implement this

    section and to meet the minimum requirements of federal law,

    including regulations.

    Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

    2005.

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