Group agreements must contain the following additional mandatory provisions.

1. (1) Certificate. Provisions that the contract holder must be provided with subscriber certificates to be delivered to each subscriber; that the certificate is a part of the group contract as if fully incorporated therein; and that any direct conflict between the group agreement and the certificate will be resolved according to the terms which are most favorable to the subscriber. If the same form is used as both the group contract and the certificate, a copy of the group contract must be delivered to each subscriber.
2. (2) New members. A provision specifying the conditions under which new members may be added to those originally covered, including effective date requirements. For coverage issued to employers, a provision for special enrollment in accordance with 45 C.F.R. 146.117 (Health Insurance Portability and Accessibility Act).

3. (3) Chemical dependency. A provision to provide benefits for the necessary care and treatment of chemical dependency that are not less favorable than for physical illness generally, subject to the same durational limits, dollar limits, deductibles and coinsurance factors. Dollar or durational limits which are less favorable than for physical illness generally may be set only if such limits are sufficient to provide appropriate care and treatment under the guidelines and standards adopted under the Insurance Code Article 3.51-9, §2A(d), including §§3.8001-3.8022 of this title (relating to Standards for Reasonable Cost Control and Utilization Review for Chemical Dependency Treatment Centers).

   1. (A) Coverage for chemical dependency may be limited to a lifetime maximum of three separate series of treatment for each covered individual as described by the Insurance Code Article 3.51-9, §2A(b).
   2. (B) Benefits provided shall be determined as if necessary care and treatment in a chemical dependency treatment center were care and treatment in a hospital.
4. (4) Osteoporosis. A provision that provides coverage to a qualified individual as defined in the Insurance Code Article 21.53C for medically accepted bone mass measurement for the detection of low bone mass and to determine the person's risk of osteoporosis and fractures associated with osteoporosis.
5. (5) Serious mental illness. Group agreements, except for contracts issued to small employer plans, must include a provision for the treatment of serious mental illness, as required in the Insurance Code Article 3.51-14. Small employer plans must be offered coverage for serious mental illness as required in the Insurance Code Article 3.51-14. Serious mental illness benefits are also subject to the provisions of the Insurance Code Articles 3.70-2(F) and 3.72.
6. (6) Conditions affecting the temporomandibular joint. Group agreements, except for contracts issued to small employer plans must include a provision that provides coverage for a condition affecting the temporomandibular joint as required by the Insurance Code Article 21.53A.
7. (7) Inability to undergo dental treatment. Group agreements, except for contracts issued to small employer plans, may not exclude from coverage under the plan an enrollee who is unable to undergo dental treatment in an office setting or under local anesthesia due to a documented physical, mental, or medical reason as determined by the enrollee's physician or the dentist providing the dental care. This benefit does not require an HMO to provide dental services if dental services are not otherwise scheduled or provided as part of the benefits covered by the agreement.

Source Note:The provisions of this §11.509 adopted to be effective November 2, 1998, 23 TexReg 11347.