1. (a) An HMO shall provide an accurate written description of health care plan terms and conditions to allow any prospective contract holder or enrollee or current contract holder or enrollee to make comparisons and informed decisions before selecting among health care plans. By agreement, the HMO may deliver the required description of health care plan terms required by this section electronically.

2. (b) The written or electronic 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 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 and substance abuse treatment providers, if applicable, updated on at least a quarterly basis. The list shall include the information necessary to fully inform prospective or current enrollees about the network, 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.

       1. (A) If an HMO limits enrollees' access to a limited provider network, it shall provide to prospective and current group contract holders and enrollees 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, including your obstetrician-gynecologist (OB-GYN), 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. The network to which your PCP belongs will provide or arrange for all of your care, so make sure that your PCP's network includes the specialists and hospitals that you prefer."
       2. (B) If an HMO does not limit an enrollee's selection of an obstetrician or gynecologist to the limited provider network to which that enrollee's primary care physician or provider belongs, it shall provide to current or prospective enrollees a notice in compliance with Insurance Code Article 21.53D in substantially the following form: "ATTENTION FEMALE ENROLLEES: You have the right to select 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 select an OB-GYN. You may elect to receive your OB-GYN services from your PCP."
       3. (C) An HMO shall clearly differentiate limited provider networks and open networks within its service area by providing a separate listing of its limited provider networks and an alphabetical listing of all the physicians and providers, including specialists, available in the limited provider network. An HMO shall include an index of the alphabetical listing of all physicians and providers, including behavioral health providers and substance abuse treatment providers, if applicable, within the HMO's service area, and shall indicate 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.
       4. (D) An HMO shall provide notice to enrollees informing them to contact the HMO upon receipt of a bill for covered services from any physician or provider. The notice shall inform enrollees of the method(s) for contacting the HMO for this purpose.
       5. (E) An HMO that maintains an internet site shall include on its internet site the information as required in subparagraphs (A) - (D) of this paragraph.
   12. (12) the service area.
3. (c) No HMO, or representatives thereof, may cause or knowingly permit the use or distribution of 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 is substantially similar to and provides the same level of disclosure as the written or electronic description prescribed by the commissioner and contains all the information required under subsection (b) of this section.
5. (e) If an HMO or limited provider network provides for an enrollee's care by a physician other than the enrollee's primary care physician while the enrollee is in an inpatient facility (e.g., hospital or skilled nursing facility), the plan description must disclose that upon admission to the inpatient facility, a physician other than the primary care physician may direct and oversee the enrollee's care.
6. (f) An HMO that maintains an internet site shall list the information as required by subsection (b)(11) of this section and Insurance Code §843.2015 on its internet site. Such information shall be easily accessible from the home page of the site.

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; amended to be effective February 24, 2005, 30 TexReg 854.