1. (a) An HMO shall provide an accurate written description of health care plan terms and conditions; to allow any prospective or current group contract holder and prospective enrollee eligible for enrollment in a health care plan or a current enrollee to make comparisons and informed decisions before selecting among health care plans.

2. (b) The written plan description must be in a readable and understandable format that meets the requirements of §3.602 of this title (relating to Plain Language Requirements), by category, and must include a clear, complete and accurate description of these items in the following order:

   1. (1) a statement that the entity providing the coverage is an HMO;
   2. (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 for obtaining additional information, including provider information;
   3. (3) all covered services and benefits, including a description of the options (if any) for prescription drug coverage, both generic and brand name;
   4. (4) emergency care services and benefits, including coverage for out-of-area emergency care services and information on access to after-hours care;
   5. (5) out-of-area services and benefits (if any);
   6. (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 network physicians and providers have agreed to look only to the HMO and not to its enrollees for payment of covered services, except as set forth in this description of the plan;
   7. (7) any limitations or exclusions, including the existence of any drug formulary limitations;
   8. (8) any 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. (9) provision for continuity of treatment in the event of the termination of a primary care physician or dentist;
   10. (10) a summary of the complaint and appeal procedures of the HMO, a statement of the availability of the independent review process, and a statement that the HMO is prohibited from retaliating against a group contract holder or enrollee because the group contract holder or enrollee has filed a complaint against the HMO or appealed a decision of the HMO, and is prohibited from retaliating against a physician or provider because the physician or provider has, on behalf of an enrollee, reasonably filed a complaint against the HMO or appealed a decision of the HMO;

   11. (11) a current list of physicians and providers, including behavioral health providers, updated on at least a quarterly basis, including names and locations of physicians and providers, a statement of limitations of accessibility and referrals to specialists, including any limitations imposed by a limited provider network, and a disclosure of which physicians and providers will not accept new enrollees or participate in closed provider networks serving only certain enrollees. If an HMO limits enrollees' access to a limited provider network, it shall provide the following information to prospective and current group contract holders and enrollees:

       1. (A) a notice in substantially the following form: "Choosing Your Physician--Now that you have chosen XYZ Health Plan, your next choice will be deciding who will provide the majority of your health care services. Your Primary Care Physician or Primary Care Provider (PCP) will be the one you call when you need medical advice, when you are sick and when you need preventive care such as immunizations. Your PCP is also part of a "network" or association of health professionals who work together to provide a full range of health care services. That means when you choose your PCP, you are also choosing a network and in most instances you are not allowed to receive services from any physician or health care professional that is not also part of your PCP's network. You will not be able to select any physician or health care professional outside of your PCP's network, even though that physician or health care provider is listed with your health plan. All of your care will be provided by or arranged for within the network to which your PCP belongs, so make sure that your PCP's network includes the specialists and hospitals that you prefer."
       2. (B) If an HMO opts to limit a female enrollee's designation of an obstetrician or gynecologist to the limited provider network to which that enrollee's primary care physician or primary care provider belongs, a notice in substantially the following form: "ATTENTION FEMALE ENROLLEES: Your Choice of Physician or Provider Affects your Choice of OB/GYN--In selecting your Primary Care Physician or Primary Care Provider (PCP), remember that your PCP's network affects your choice of an OB/GYN. You have the right to designate an OB/GYN to whom you have access without first obtaining a referral from your PCP. However, if you choose to designate an OB/GYN, the OB/GYN you designate must belong to the same network as your PCP. This is another reason to make certain that your PCP's network includes the specialists, particularly the OB/GYN and hospitals that you prefer. You are not required to designate an OB/GYN; you may elect to receive your OB/GYN services from your PCP."
       3. (C) If an HMO does not limit an enrollee's designation of an obstetrician or gynecologist to the limited provider network to which that enrollee's primary care physician or primary care provider belongs, a notice in substantially the following form: "ATTENTION FEMALE ENROLLEES: Although your choice of Primary Care Physician or Primary Care Provider (PCP) in most cases limits your selection of specialists and hospitals to those specialists and hospitals that belong to your PCP's network, such is not the case in your choice of an OB/GYN. You have the right to designate an OB/GYN to whom you have access without first obtaining a referral from your PCP. (Name of HMO) has opted not to limit your selection of an OB/GYN to your PCP's network. You are not required to designate an OB/GYN; you may elect to receive your OB/GYN services from your PCP."
       4. (D) An HMO shall clearly differentiate limited provider networks and open networks within its service area by assigning different colors, symbols, or other distinguishing marks to each network. An HMO shall provide a separate listing of its limited provider networks and an alphabetical listing of all the physicians and providers available in the limited provider network. Specialists shall be listed by city in alphabetical order by specialty. An index of the alphabetical listing of all physicians and providers, including behavioral health providers, within the HMO's service area shall be included, and shall include the name, the color, symbol or other distinguishing mark indicating the limited provider network(s) to which the physician or provider belongs, and the page number where the physician or provider's name can be found.
   12. (12) the service area.
3. (c) No HMO, or representatives thereof, may cause or knowingly permit the use or distribution of prospective enrollee information which is untrue or misleading.
4. (d) An HMO may utilize its handbook to satisfy the requirements of this section if the information contained in the handbook contains all the information required under subsection (b) of this section.

Source Note:The provisions of this §11.1600 adopted to be effective December 6, 1995, 20 TexReg 9698; amended to be effective June 1, 1996, 21 TexReg 2467; amended to be effective November 2, 1998, 23 TexReg 11347.