SECTION 3.9209. Mandatory Disclosure Requirements

(a) An issuer must write all policies, health benefit plan certificates, endorsements, amendments, applications, and riders in plain language, in a readable and understandable format, and in compliance with all applicable requirements relating to minimum readability requirements as found in §3.602 of this title (relating to Plain Language Requirements).

(b) The issuer shall provide to current or prospective insureds on request an accurate written description of the terms and conditions of the policy to allow current or prospective insureds to make comparisons and informed decisions before selecting among health care plans. The written description must be in a readable and understandable format as prescribed by the commissioner and must include a current list of exclusive providers. The issuer's handbook may satisfy this requirement if it is substantively similar to and achieves the same level of disclosure as the written description prescribed by subsection (e) of this section and it contains the current list of health care providers.

(c) An issuer shall furnish a current list of exclusive providers to all insureds no less frequently than annually.

(d) No issuer, or agent or representative of an issuer, may cause or permit the use or distribution to prospective insureds of information which is untrue or misleading.

(e) The written plan description must be in a readable and understandable format that includes a clear, complete and accurate description of paragraphs (1) - (11) of this subsection in the following order:

(1) a statement that the plan providing the coverage is an EPP;

(2) a toll-free number, unless exempted by statute or rule, and address for the prospective or current group contract holder or prospective or current enrollee to obtain additional information, including provider information;

(3) all covered services and benefits, including a description of the options (if any) for prescription drug coverage, both generic and brand name;

(4) emergency care services and benefits, including coverage for out-of-area emergency care services and information on access to after-hours care;

(5) out-of-area services and benefits (if any);

(6) an explanation of enrollee financial responsibility for payment of premiums, copayments, deductibles, and any other out-of-pocket expenses for noncovered or out-of-plan services, and an explanation that exclusive providers have agreed to look only to the issuer and not to its insureds for payment of covered services, except as set forth in the description of the plan;

(7) any limitations or exclusions, including the existence of any drug formulary limitations;

(8) any description of prior authorization requirements, including limitations or restrictions thereon, and a summary of procedures to obtain approval for referrals to providers other than primary care physicians or dentists, and other review requirements, including preauthorization review, concurrent review, post service review, and post payment review, and the consequences resulting from the failure to obtain any required authorizations;

(9) provision for continuity of treatment in the event of the termination of a primary care physician or dentist in those instances where an insured has selected one;

(10) a summary of the complaint and appeal procedures of the EPP, a statement of the availability of the independent review process as applicable, and a statement that the EPP is prohibited from retaliating against insureds because the group contract holder or insured has filed a complaint against the EPP or appealed a decision of the EPP, and is prohibited from retaliating against a health care provider because the health care provider has, on behalf of an insured, reasonably filed a complaint against the EPP or appealed a decision of the EPP; and

(11) a statement that female insureds shall have direct access to an OB/GYN (who is an exclusive provider) for female services.

Source Note: The provisions of this §3.9209 adopted to be effective September 17, 2003, 28 TexReg 7993