SECTION 3.3603. Purpose and Scope

(a) The purpose and scope of these sections is to codify the notice requirements for the content and format of seven disclosure statements which must be provided to inform prospective buyers of health insurance policies about the extent to which benefits under such policies duplicate Medicare benefits. The disclosure statements in these sections have been developed by the National Association of Insurance Commissioners and approved by the U.S. Secretary of Health and Human Services. Health insurance policy issuers subject to the requirements to provide such disclosure must comply with such requirements on and after August 11, 1995. These sections in no way impact the effective date on which issuers must provide affirmative disclosure of Medicare duplication to prospective insureds.

(b) On and after the effective date set out by federal requirements, issuers of the policies that duplicate Medicare benefits must display the applicable statement in a prominent manner as part of, or together with, the application for the policy.

(c) Each of the statements applies to one of seven different types of health insurance policy identified as needing a disclosure based on its potential to duplicate Medicare benefits, even if only incidentally.

(d) Issuers who fail to provide the duplication notice are in violation of both federal and state law, and subject to both federal and state penalties.

(e) The seven separate types of health insurance policies which must be accompanied by an individualized statement of the extent to which the policy duplicates Medicare are listed in paragraphs (1)-(7) of this subsection. Each of these listed policy types must contain the disclosure statement, which may not vary from the statements set out in sections 3.3604-3.3309 and 3.3613 of this title (relating to Required Disclosure Statements for Policies That Duplicate Medicare) in terms of language or format, including type size, spacing, boldfacing, line spacing, and use of boxes to surround text. The specific policy types are:

(1) policies that provide benefits for expenses incurred for an accidental injury only;

(2) policies that provide benefits for specified limited services;

(3) policies that reimburse expenses incurred for specified disease or other specified impairments (including cancer policies, specified disease policies and other policies that limit reimbursement to named medical conditions);

(4) policies that pay fixed dollar amounts for specified disease or other specified impairments (including cancer, specified disease policies and other policies that pay a scheduled benefit or specified payment based on diagnosis of the conditions named in the policy);

(5) indemnity policies and other policies that pay a fixed dollar amount per day, excluding long-term care policies;

(6) policies that provide benefits for both expenses incurred and fixed indemnity;

(7) other health insurance policies not specifically identified in paragraphs (1)-(6) of this subsection.

(f) Providing the notice and disclosure addressed in these sections has no impact on the continuing application and effectiveness of §21.113(l) of this title (relating to Acknowledgment of Nonduplication and Provision of Notice to Consumer).

Source Note: The provisions of this §3.3603 adopted to be effective April 25, 1996, 21 TexReg 3370; amended to be effective April 14, 1999, 24 TexReg 3353