1. (a) Each evidence of coverage providing basic health care services shall contain the basic health care services defined in §11.2(b)(7) of this title (relating to Definitions), and shall provide such services as needed and without limitation as to time and cost, unless such limitation is permitted in this section, including the following:

   1. (1) Diabetes. A provision for the treatment of diabetes and conditions associated with diabetes pursuant to the Insurance Code Article 21.53G.
   2. (2) Diagnostic services. A provision for diagnostic laboratory and diagnostic and therapeutic radiological services in support of basic health services including professional fees.
   3. (3) Home health services. A provision for home health services provided at an enrollee's home by health care personnel, as prescribed or directed by the responsible physician or other authority designated by the HMO.

   4. (4) Inpatient and outpatient services. A provision for inpatient and outpatient services, including the following:

      1. (A) outpatient services, which must include diagnostic services, treatment services and x-ray services, for patients who are ambulatory and may be provided in a non-hospital based health care facility or at a hospital;
      2. (B) inpatient hospital services, which must include but not be limited to, room and board, general nursing care, meals and special diets when medically necessary, use of operating room and related facilities, use of intensive care unit and services, x-ray services, laboratory, and other diagnostic tests, drugs, medications, biologicals, anesthesia and oxygen services, special duty nursing when medically necessary, radiation therapy, inhalation therapy, and administration of whole blood and blood plasma;
      3. (C) outpatient services and inpatient hospital services must include rehabilitative services and physical speech and occupational therapy; if in the opinion of a physician, the provision of those services and therapies are medically necessary, those services and therapies may not be denied, limited, or terminated if they meet or exceed treatment goals for the enrollee. For a person that is physically disabled, treatment goals may include maintenance of functioning or prevention of or slowing of further deterioration.

   5. (5) Breast cancer and related procedures. A provision for coverage for breast cancer including the following:

      1. (A) coverage for mastectomy must provide coverage for breast reconstruction. Breast reconstruction is subject to the same deductible or copayment applicable to mastectomy. Breast reconstruction may not be denied because the mastectomy occurred prior to the effective date of coverage.
      2. (B) coverage for the inpatient care for an enrollee in accordance with the Insurance Code Article 21.52G.
   6. (6) Mental health services. A provision that provides 20 outpatient visits per enrollee per year, as may be necessary and appropriate for short-term evaluative or crisis intervention mental health services, or both.
   7. (7) Mother and newborn child. A provision for maternity benefits must provide care for an enrollee and her newborn child as described in the Insurance Code Article 21.53F.
   8. (8) Physician services. A provision that physician services (including consultant and referral services by a physician) must be provided by a licensed physician, or if a service of a physician may also be provided under applicable state law by other health providers, an HMO may provide the service through these other health providers.

   9. (9) Preventive health services. A provision for preventive health services, which must be made available to enrollees and must include at least the following:

      1. (A) a broad range of voluntary family planning services;
      2. (B) infertility medical services for artificial insemination, including donor-related services, without limitation as to who may be a donor. Such infertility medical services include medical treatment to diagnose and/or treat the medical causes for the infertility of the male or female enrollee. The infertility medical services appearing in §11.512(13) of this title (relating to Optional Benefits) are not considered to be basic health care services;
      3. (C) well-child care from birth;
      4. (D) periodic health evaluations for adults, including health risk assessments not less than once every three years for adults and annual well woman examinations;
      5. (E) a medically recognized diagnostic examination for the detection of prostate cancer in accordance with the Insurance Code Article 21.53F;
      6. (F) annual eye and ear examinations for children through age 17, to determine the need for vision and hearing correction; and
      7. (G) pediatric and adult immunizations, in accord with accepted medical practice, including immunizations for each covered child from birth through the date the child is six years of age, as described in the Insurance Code Article 21.53F and §11.506(2) of this title (relating to Mandatory Contractual Provisions: Group, Individual and Conversion Agreement and Group Certificate). An HMO shall not limit benefits to enrollees for immunizations or vaccinations to circumstances in which an immunization or vaccination is administered by a pharmacist under a physician's written protocol.
   10. (10) Transplants. A provision for benefits for kidney transplants; corneal transplants; liver transplants for children with biliary atresia and other rare congenital abnormalities; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease, and Wiskott-Aldrich syndrome, when medically necessary, including a provision for the payment of the donor's expenses. An HMO may not require an enrollee to travel out-of-state to receive transplant services unless the HMO obtains the informed consent of the enrollee, which explains the benefits and detriments of in-state and out-of-state options.
2. (b) The benefits described in subsection (a)(1), (5) and (9)(E) and (G) of this section do not apply to small employer plans as defined by the Insurance Code Chapter 26.
3. (c) Nothing in this title shall require an HMO, 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 its religious convictions. An HMO that limits or denies health care services under this subsection shall set forth such limitations in its evidence of coverage.

Source Note:The provisions of this §11.508 adopted to be effective November 2, 1998, 23 TexReg 11347.