SECTION 11.511. Optional Provisions

Evidences of coverage may contain optional provisions, including, but not limited to, the following:

(1) Coordination of benefits. Plans may contain a provision that the value of any benefits or services provided by the HMO may be coordinated with any other type of insurance plan or coverage under governmental programs so no more than 100 percent of eligible expenses incurred is paid. The coordination of benefits provision applies to the plan when an enrollee has health care coverage under more than one plan. This provision will only apply for the duration of the enrollee's coverage in a plan.

(A) If benefits are covered by more than one plan, any plan or plans that do not have a coordination of benefits provision are primary.

(B) Group plans issued or renewed on or before March 25, 2014, may not coordinate benefits with any type of individual or conversion plan.

(C) Group plans issued or renewed on or after March 25, 2014, may coordinate benefits with other plans subject to the requirements of Insurance Code Chapter 1203 (concerning Coordination of Benefits Provisions) and Chapter 3, Subchapter V, of this title (relating to Coordination of Benefits).

(2) Subrogation. Plans may contain a provision that the HMO is subrogated to and has a right to reimbursement from an individual's recovery for a personal injury for payments made or costs of benefits provided by the HMO as a result of that injury, subject to and limited by the provisions of Civil Practice and Remedies Code Chapter 140 (concerning Contractual Subrogation Rights of Payors of Certain Benefits), as added by Acts 2013, 83rd Leg., R.S., Ch. 180, §1 (HB 1869).

(3) Sale of substitutes to workers' compensation insurance. If the HMO chooses to market a product that provides coverage for on-the-job injuries or illness, it must comply with §5.6302 of this title (relating to Sale of Substitutes to Workers' Compensation Insurance).

(4) Conversion privilege. Group agreements and certificates for an HMO may, at the HMO's option, contain a conversion privilege. If an HMO elects to offer a conversion privilege, it must provide that, on termination of coverage, each enrollee who resides, lives, or works in the service area who has been covered under the group contract for a period of at least three months, or in the case of a court-ordered dependent, lives outside the service area but within the United States, has the right to convert within 31 days to a conversion agreement without presenting evidence of insurability. A single service or limited service HMO must offer a conversion contract without requiring evidence of insurability. Charges must comply with §11.704 of this title (relating to Conversion Rates).

(5) Arbitration. Plans may contain a statement of any arbitration procedure. If enrollee complaints and grievances are resolved through a specified arbitration agreement, the arbitration must be conducted under Texas Civil Practice and Remedies Code Chapter 171 (concerning General Arbitration).

Source Note: The provisions of this §11.511 adopted to be effective August 1, 2017, 42 TexReg 2169