State Codes and Statutes

Statutes > Texas > Insurance-code > Title-8-health-insurance-and-other-health-coverages > Chapter-1273-point-of-service-plans

INSURANCE CODE

TITLE 8. HEALTH INSURANCE AND OTHER HEALTH COVERAGES

SUBTITLE C. MANAGED CARE

CHAPTER 1273. POINT-OF-SERVICE PLANS

SUBCHAPTER A. BLENDED CONTRACTS

Sec. 1273.001. DEFINITIONS. In this subchapter:

(1) "Blended contract" means a single document, including a

single contract policy, certificate, or evidence of coverage,

that provides a combination of indemnity and health maintenance

organization benefits.

(2) "Health maintenance organization" has the meaning assigned

by Section 843.002.

(3) "Insurer" means an insurance company, association, or

organization authorized to engage in business in this state under

Chapter 841, 842, 861, 881, 882, 883, 884, 885, 886, 887, 888,

941, 942, or 982.

(4) "Point-of-service plan" means an arrangement under which:

(A) an enrollee chooses to obtain benefits or services through:

(i) a health maintenance organization delivery network,

including a limited provider network; or

(ii) a non-network delivery system outside the health

maintenance organization delivery network, including a limited

provider network, that is administered under an indemnity benefit

arrangement for the cost of health care services; or

(B) indemnity benefits for the cost of health care services are

provided by an insurer or group hospital service corporation in

conjunction with network benefits arranged or provided by a

health maintenance organization.

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

2005.

Sec. 1273.002. POINT-OF-SERVICE PLAN. An insurer may contract

with a health maintenance organization to provide benefits under

a point-of-service plan, including optional coverage for

out-of-area services or out-of-network care.

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

2005.

Sec. 1273.003. BLENDED CONTRACT. (a) A health maintenance

organization and an insurer may offer a blended contract. The use

of a blended contract is limited to point-of-service arrangements

between a health maintenance organization and an insurer.

(b) A blended contract delivered, issued, or used in this state

is subject to, and must be filed with the department for approval

as provided by, Chapter 1701 and Section 1271.101.

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

2005.

Sec. 1273.004. LIMITED BENEFITS AND SERVICES; COST-SHARING

PROVISIONS. Indemnity benefits and services provided under a

point-of-service plan may be limited to those services described

by the blended contract and may be subject to different

cost-sharing provisions. The cost-sharing provisions for

indemnity benefits may be higher than the cost-sharing provisions

for in-network health maintenance organization coverage. For an

enrollee in a limited provider network, higher cost-sharing may

be imposed only when the enrollee obtains benefits or services

outside the health maintenance organization delivery network.

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

2005.

Sec. 1273.005. RULES. The commissioner may adopt rules to

implement this subchapter.

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

2005.

SUBCHAPTER B. AVAILABILITY OF HEALTH BENEFIT COVERAGE OPTIONS

Sec. 1273.051. DEFINITIONS. In this subchapter:

(1) "Employee" means an individual employed by an employer.

(2) "Health benefit plan" has the meaning assigned by Section

1501.002.

(3) "Non-network plan" means health benefit coverage that

provides an enrollee an opportunity to obtain health care

services through a health delivery system other than a health

maintenance organization delivery network, as defined by Section

843.002.

(4) "Point-of-service plan" means an arrangement under which an

enrollee chooses to obtain benefits or services through:

(A) a health maintenance organization delivery network,

including a limited provider network; or

(B) a non-network delivery system outside the health maintenance

organization delivery network, including a limited provider

network, that is administered under an indemnity benefit

arrangement for the cost of health care services.

(5) "Preferred provider benefit plan" means an insurance policy

issued under Chapter 1301.

(6) "Small employer health benefit plan" has the meaning

assigned by Section 1501.002.

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

2005.

Sec. 1273.052. OFFER OF COVERAGE THROUGH NON-NETWORK PLAN

REQUIRED. (a) Except as provided by Subsection (b), if the only

health benefit coverage offered under an employer's health

benefit plan is a network-based delivery system of coverage

offered by one or more health maintenance organizations, each

health maintenance organization offering coverage must offer to

all eligible employees, at the time of enrollment and at least

annually, the opportunity to obtain coverage through a

non-network plan.

(b) Each health maintenance organization to which Subsection (a)

applies may enter into an agreement designating one or more of

those health maintenance organizations to offer the coverage

required by Subsection (a) for eligible employees of the

employer.

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

2005.

Sec. 1273.053. COVERAGE OPTIONS. The coverage required to be

offered under this subchapter may be provided through:

(1) a point-of-service plan;

(2) a preferred provider benefit plan; or

(3) any coverage arrangement that provides an enrollee with

access to services outside the health maintenance organization's

or limited provider network's delivery network.

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

2005.

Sec. 1273.054. PREMIUM FOR COVERAGE OPTIONS. The premium for

coverage required to be offered under this subchapter must be

based on the actuarial value of that coverage and may be

different from the premium for coverage otherwise offered by the

health maintenance organization.

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

2005.

Sec. 1273.055. COST-SHARING PROVISIONS. (a) Different

cost-sharing provisions may be imposed for a point-of-service

plan offered under this subchapter, and those provisions may be

higher than the cost-sharing provisions for in-network health

maintenance organization coverage. For an enrollee in a limited

provider network, higher cost-sharing may be imposed only when

the enrollee obtains benefits or services outside the health

maintenance organization delivery network.

(b) An employee who chooses the non-network plan is responsible

for any additional costs for the non-network plan, and the

employer may impose a reasonable administrative fee for providing

the non-network plan.

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

2005.

Sec. 1273.056. EXCEPTIONS. This subchapter does not apply to:

(1) a small employer health benefit plan; or

(2) a group model health maintenance organization that is a

nonprofit, state-certified health maintenance organization that:

(A) provides the majority of its professional services through a

single group medical practice that is governed by a board

composed entirely of physicians; and

(B) educates medical students or resident physicians through a

contract with the medical school component of a Texas

state-supported college or university accredited by the

Accreditation Council on Graduate Medical Education or the

American Osteopathic Association.

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

2005.

Sec. 1273.057. RULES. The commissioner shall adopt rules

necessary to administer this subchapter.

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

2005.

State Codes and Statutes

Statutes > Texas > Insurance-code > Title-8-health-insurance-and-other-health-coverages > Chapter-1273-point-of-service-plans

INSURANCE CODE

TITLE 8. HEALTH INSURANCE AND OTHER HEALTH COVERAGES

SUBTITLE C. MANAGED CARE

CHAPTER 1273. POINT-OF-SERVICE PLANS

SUBCHAPTER A. BLENDED CONTRACTS

Sec. 1273.001. DEFINITIONS. In this subchapter:

(1) "Blended contract" means a single document, including a

single contract policy, certificate, or evidence of coverage,

that provides a combination of indemnity and health maintenance

organization benefits.

(2) "Health maintenance organization" has the meaning assigned

by Section 843.002.

(3) "Insurer" means an insurance company, association, or

organization authorized to engage in business in this state under

Chapter 841, 842, 861, 881, 882, 883, 884, 885, 886, 887, 888,

941, 942, or 982.

(4) "Point-of-service plan" means an arrangement under which:

(A) an enrollee chooses to obtain benefits or services through:

(i) a health maintenance organization delivery network,

including a limited provider network; or

(ii) a non-network delivery system outside the health

maintenance organization delivery network, including a limited

provider network, that is administered under an indemnity benefit

arrangement for the cost of health care services; or

(B) indemnity benefits for the cost of health care services are

provided by an insurer or group hospital service corporation in

conjunction with network benefits arranged or provided by a

health maintenance organization.

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

2005.

Sec. 1273.002. POINT-OF-SERVICE PLAN. An insurer may contract

with a health maintenance organization to provide benefits under

a point-of-service plan, including optional coverage for

out-of-area services or out-of-network care.

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

2005.

Sec. 1273.003. BLENDED CONTRACT. (a) A health maintenance

organization and an insurer may offer a blended contract. The use

of a blended contract is limited to point-of-service arrangements

between a health maintenance organization and an insurer.

(b) A blended contract delivered, issued, or used in this state

is subject to, and must be filed with the department for approval

as provided by, Chapter 1701 and Section 1271.101.

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

2005.

Sec. 1273.004. LIMITED BENEFITS AND SERVICES; COST-SHARING

PROVISIONS. Indemnity benefits and services provided under a

point-of-service plan may be limited to those services described

by the blended contract and may be subject to different

cost-sharing provisions. The cost-sharing provisions for

indemnity benefits may be higher than the cost-sharing provisions

for in-network health maintenance organization coverage. For an

enrollee in a limited provider network, higher cost-sharing may

be imposed only when the enrollee obtains benefits or services

outside the health maintenance organization delivery network.

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

2005.

Sec. 1273.005. RULES. The commissioner may adopt rules to

implement this subchapter.

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

2005.

SUBCHAPTER B. AVAILABILITY OF HEALTH BENEFIT COVERAGE OPTIONS

Sec. 1273.051. DEFINITIONS. In this subchapter:

(1) "Employee" means an individual employed by an employer.

(2) "Health benefit plan" has the meaning assigned by Section

1501.002.

(3) "Non-network plan" means health benefit coverage that

provides an enrollee an opportunity to obtain health care

services through a health delivery system other than a health

maintenance organization delivery network, as defined by Section

843.002.

(4) "Point-of-service plan" means an arrangement under which an

enrollee chooses to obtain benefits or services through:

(A) a health maintenance organization delivery network,

including a limited provider network; or

(B) a non-network delivery system outside the health maintenance

organization delivery network, including a limited provider

network, that is administered under an indemnity benefit

arrangement for the cost of health care services.

(5) "Preferred provider benefit plan" means an insurance policy

issued under Chapter 1301.

(6) "Small employer health benefit plan" has the meaning

assigned by Section 1501.002.

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

2005.

Sec. 1273.052. OFFER OF COVERAGE THROUGH NON-NETWORK PLAN

REQUIRED. (a) Except as provided by Subsection (b), if the only

health benefit coverage offered under an employer's health

benefit plan is a network-based delivery system of coverage

offered by one or more health maintenance organizations, each

health maintenance organization offering coverage must offer to

all eligible employees, at the time of enrollment and at least

annually, the opportunity to obtain coverage through a

non-network plan.

(b) Each health maintenance organization to which Subsection (a)

applies may enter into an agreement designating one or more of

those health maintenance organizations to offer the coverage

required by Subsection (a) for eligible employees of the

employer.

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

2005.

Sec. 1273.053. COVERAGE OPTIONS. The coverage required to be

offered under this subchapter may be provided through:

(1) a point-of-service plan;

(2) a preferred provider benefit plan; or

(3) any coverage arrangement that provides an enrollee with

access to services outside the health maintenance organization's

or limited provider network's delivery network.

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

2005.

Sec. 1273.054. PREMIUM FOR COVERAGE OPTIONS. The premium for

coverage required to be offered under this subchapter must be

based on the actuarial value of that coverage and may be

different from the premium for coverage otherwise offered by the

health maintenance organization.

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

2005.

Sec. 1273.055. COST-SHARING PROVISIONS. (a) Different

cost-sharing provisions may be imposed for a point-of-service

plan offered under this subchapter, and those provisions may be

higher than the cost-sharing provisions for in-network health

maintenance organization coverage. For an enrollee in a limited

provider network, higher cost-sharing may be imposed only when

the enrollee obtains benefits or services outside the health

maintenance organization delivery network.

(b) An employee who chooses the non-network plan is responsible

for any additional costs for the non-network plan, and the

employer may impose a reasonable administrative fee for providing

the non-network plan.

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

2005.

Sec. 1273.056. EXCEPTIONS. This subchapter does not apply to:

(1) a small employer health benefit plan; or

(2) a group model health maintenance organization that is a

nonprofit, state-certified health maintenance organization that:

(A) provides the majority of its professional services through a

single group medical practice that is governed by a board

composed entirely of physicians; and

(B) educates medical students or resident physicians through a

contract with the medical school component of a Texas

state-supported college or university accredited by the

Accreditation Council on Graduate Medical Education or the

American Osteopathic Association.

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

2005.

Sec. 1273.057. RULES. The commissioner shall adopt rules

necessary to administer this subchapter.

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

2005.


State Codes and Statutes

State Codes and Statutes

Statutes > Texas > Insurance-code > Title-8-health-insurance-and-other-health-coverages > Chapter-1273-point-of-service-plans

INSURANCE CODE

TITLE 8. HEALTH INSURANCE AND OTHER HEALTH COVERAGES

SUBTITLE C. MANAGED CARE

CHAPTER 1273. POINT-OF-SERVICE PLANS

SUBCHAPTER A. BLENDED CONTRACTS

Sec. 1273.001. DEFINITIONS. In this subchapter:

(1) "Blended contract" means a single document, including a

single contract policy, certificate, or evidence of coverage,

that provides a combination of indemnity and health maintenance

organization benefits.

(2) "Health maintenance organization" has the meaning assigned

by Section 843.002.

(3) "Insurer" means an insurance company, association, or

organization authorized to engage in business in this state under

Chapter 841, 842, 861, 881, 882, 883, 884, 885, 886, 887, 888,

941, 942, or 982.

(4) "Point-of-service plan" means an arrangement under which:

(A) an enrollee chooses to obtain benefits or services through:

(i) a health maintenance organization delivery network,

including a limited provider network; or

(ii) a non-network delivery system outside the health

maintenance organization delivery network, including a limited

provider network, that is administered under an indemnity benefit

arrangement for the cost of health care services; or

(B) indemnity benefits for the cost of health care services are

provided by an insurer or group hospital service corporation in

conjunction with network benefits arranged or provided by a

health maintenance organization.

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

2005.

Sec. 1273.002. POINT-OF-SERVICE PLAN. An insurer may contract

with a health maintenance organization to provide benefits under

a point-of-service plan, including optional coverage for

out-of-area services or out-of-network care.

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

2005.

Sec. 1273.003. BLENDED CONTRACT. (a) A health maintenance

organization and an insurer may offer a blended contract. The use

of a blended contract is limited to point-of-service arrangements

between a health maintenance organization and an insurer.

(b) A blended contract delivered, issued, or used in this state

is subject to, and must be filed with the department for approval

as provided by, Chapter 1701 and Section 1271.101.

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

2005.

Sec. 1273.004. LIMITED BENEFITS AND SERVICES; COST-SHARING

PROVISIONS. Indemnity benefits and services provided under a

point-of-service plan may be limited to those services described

by the blended contract and may be subject to different

cost-sharing provisions. The cost-sharing provisions for

indemnity benefits may be higher than the cost-sharing provisions

for in-network health maintenance organization coverage. For an

enrollee in a limited provider network, higher cost-sharing may

be imposed only when the enrollee obtains benefits or services

outside the health maintenance organization delivery network.

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

2005.

Sec. 1273.005. RULES. The commissioner may adopt rules to

implement this subchapter.

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

2005.

SUBCHAPTER B. AVAILABILITY OF HEALTH BENEFIT COVERAGE OPTIONS

Sec. 1273.051. DEFINITIONS. In this subchapter:

(1) "Employee" means an individual employed by an employer.

(2) "Health benefit plan" has the meaning assigned by Section

1501.002.

(3) "Non-network plan" means health benefit coverage that

provides an enrollee an opportunity to obtain health care

services through a health delivery system other than a health

maintenance organization delivery network, as defined by Section

843.002.

(4) "Point-of-service plan" means an arrangement under which an

enrollee chooses to obtain benefits or services through:

(A) a health maintenance organization delivery network,

including a limited provider network; or

(B) a non-network delivery system outside the health maintenance

organization delivery network, including a limited provider

network, that is administered under an indemnity benefit

arrangement for the cost of health care services.

(5) "Preferred provider benefit plan" means an insurance policy

issued under Chapter 1301.

(6) "Small employer health benefit plan" has the meaning

assigned by Section 1501.002.

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

2005.

Sec. 1273.052. OFFER OF COVERAGE THROUGH NON-NETWORK PLAN

REQUIRED. (a) Except as provided by Subsection (b), if the only

health benefit coverage offered under an employer's health

benefit plan is a network-based delivery system of coverage

offered by one or more health maintenance organizations, each

health maintenance organization offering coverage must offer to

all eligible employees, at the time of enrollment and at least

annually, the opportunity to obtain coverage through a

non-network plan.

(b) Each health maintenance organization to which Subsection (a)

applies may enter into an agreement designating one or more of

those health maintenance organizations to offer the coverage

required by Subsection (a) for eligible employees of the

employer.

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

2005.

Sec. 1273.053. COVERAGE OPTIONS. The coverage required to be

offered under this subchapter may be provided through:

(1) a point-of-service plan;

(2) a preferred provider benefit plan; or

(3) any coverage arrangement that provides an enrollee with

access to services outside the health maintenance organization's

or limited provider network's delivery network.

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

2005.

Sec. 1273.054. PREMIUM FOR COVERAGE OPTIONS. The premium for

coverage required to be offered under this subchapter must be

based on the actuarial value of that coverage and may be

different from the premium for coverage otherwise offered by the

health maintenance organization.

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

2005.

Sec. 1273.055. COST-SHARING PROVISIONS. (a) Different

cost-sharing provisions may be imposed for a point-of-service

plan offered under this subchapter, and those provisions may be

higher than the cost-sharing provisions for in-network health

maintenance organization coverage. For an enrollee in a limited

provider network, higher cost-sharing may be imposed only when

the enrollee obtains benefits or services outside the health

maintenance organization delivery network.

(b) An employee who chooses the non-network plan is responsible

for any additional costs for the non-network plan, and the

employer may impose a reasonable administrative fee for providing

the non-network plan.

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

2005.

Sec. 1273.056. EXCEPTIONS. This subchapter does not apply to:

(1) a small employer health benefit plan; or

(2) a group model health maintenance organization that is a

nonprofit, state-certified health maintenance organization that:

(A) provides the majority of its professional services through a

single group medical practice that is governed by a board

composed entirely of physicians; and

(B) educates medical students or resident physicians through a

contract with the medical school component of a Texas

state-supported college or university accredited by the

Accreditation Council on Graduate Medical Education or the

American Osteopathic Association.

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

2005.

Sec. 1273.057. RULES. The commissioner shall adopt rules

necessary to administer this subchapter.

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

2005.