1. (a) Each evidence of coverage providing basic health care services shall provide the following basic health care services when they are provided by network physicians or providers, or by non-network physicians and providers as set forth in §11.506(10) or (15) of this title (relating to Mandatory Contractual Provisions: Group, Individual and Conversion Agreement and Group Certificate):

   1. (1) Outpatient services, including the following:

      1. (A) primary care and specialist physician services;
      2. (B) outpatient services by other providers;
      3. (C) diagnostic services, including laboratory, imaging and radiologic services;
      4. (D) therapeutic radiology services;
      5. (E) prenatal services, if maternity benefits are covered;
      6. (F) outpatient rehabilitation therapies including physical therapy, speech therapy and occupational therapy;
      7. (G) home health services, as prescribed or directed by the responsible physician or other authority designated by the HMO;

      8. (H) preventive services, including:

         1. (i) periodic health examinations for adults as required in the Insurance Code §1271.153;
         2. (ii) immunizations for children as required in the Insurance Code §1367.053;
         3. (iii) well-child care from birth as required in the Insurance Code §1271.154;
         4. (iv) cancer screenings as required in the Insurance Code Chapter 1356 relating to mammography;
         5. (v) cancer screenings as required in the Insurance Code Chapter 1362 relating to screening for prostate cancer;
         6. (vi) cancer screenings as required in the Insurance Code Chapter 1363 relating to screening for colorectal cancer;
         7. (vii) eye and ear examinations for children through age 17, to determine the need for vision and hearing correction in accordance with established medical guidelines; and
         8. (viii) immunizations for adults in accordance with the United States Department of Health and Human Services Centers for Disease Control Recommended Adult Immunization Schedule by Age Group and Medical Conditions, or its successor.
      9. (I) no less than 20 outpatient mental health visits per enrollee per year as may be necessary and appropriate for short-term evaluative or crisis stabilization services, which must have the same cost-sharing and benefit maximum provisions as any physical health services; and
      10. (J) emergency services as required by the Insurance Code §1271.155.
   2. (2) Inpatient hospital services, including 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, administration of whole blood and blood plasma, and short-term rehabilitation therapy services in the acute hospital setting.
   3. (3) Inpatient physician care services, including services performed, prescribed, or supervised by physicians or other health professionals including diagnostic, therapeutic, medical, surgical, preventive, referral and consultative health care services.
   4. (4) Outpatient hospital services, including treatment services; ambulatory surgery services; diagnostic services, including laboratory, radiology, and imaging services; rehabilitation therapy; and radiation therapy.

2. (b) In addition to the basic health care services in subsection (a) of this section, each evidence of coverage shall include coverage for services as follows:

   1. (1) breast reconstruction as required by federal law if the plan provides coverage for mastectomy. 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. (2) prenatal services, delivery and postdelivery care for an enrollee and her newborn child as required by federal law, if the plan provides maternity benefits; and
   3. (3) diabetes self-management training, equipment and supplies as required in the Insurance Code Chapter 1358 Subchapter B.
3. (c) The benefits described in this section that do not apply to small employer plans are not required to be included in such plans.
4. (d) A state-mandated health benefit plan defined in §11.2(b) of this title (relating to Definitions) shall provide coverage for the basic health care services as described in subsection (a) of this section, as well as all state-mandated benefits as described in §§21.3516 - 21.3518 of this title (relating to State-mandated Health Benefits in Individual HMO Plans, State-mandated Health Benefits in Small Employer HMO Plans, and State-mandated Health Benefits in Large Employer HMO Plans), and must provide the services without limitation as to time and cost, other than those limitations specifically prescribed in this subchapter.
5. (e) 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; amended to be effective May 30, 2004, 29 TexReg 5094; amended to be effective February 24, 2005, 30 TexReg 854; amended to be effective November 15, 2006, 31 TexReg 9298.