1. (a) With respect to a child who lives outside the insurer's service area but inside the United States whose coverage under the policy is required by a medical support order, an insurer shall either:

   1. (1) cover the child under coverage for which the parent who has been ordered to provide the coverage is eligible and not enforce otherwise applicable policy provisions that would deny, limit, or reduce payment for claims for such child; or
   2. (2) provide coverage through the use of alternative delivery systems, such as reciprocal agreements with indemnity insurers or HMOs.
2. (b) If the policy contains preferred provider provisions for the purposes of offering a network of preferred providers as defined in the Insurance Code Article 3.70-3C, and the insurer does not provide coverage under subsection (a)(2) of this section, reimbursement for services for a child who is the subject of a medical support order and lives outside the insurer's service area shall be provided at the preferred provider level of benefits.
3. (c) If the insurer provides coverage under subsection (a)(2), the coverage shall include benefits identical to, greater than, or comparable to those provided to other dependent children covered by the policy under which coverage is required by a medical support order.

4. (d) If the coverage is provided under subsection (a)(2) of this section, the insurer shall submit a certification to the Texas Department of Insurance. The certification shall be filed with the Life/Health/HMO Intake Unit, Mail Code 106-1E, Texas Department of Insurance, P.O. Box 149104, Austin, Texas 78714-9104 or 333 Guadalupe, Austin, Texas 78701, signed by an officer of the insurer and include:

   1. (1) the insurer's full name;
   2. (2) a statement that the insurer has elected to utilize an alternative delivery system to provide coverage for children who are the subject of a medical support order;
   3. (3) the name of the HMO or indemnity carrier with which the insurer has contracted to provide coverage to children who are the subject of a medical support order and a statement, if applicable, that the HMO or indemnity carrier has filed the applicable forms providing the coverage as required by Insurance Code Articles 3.42 and 3.96-8 or §11.301 of this title (relating to Filing Requirements for HMOs);
   4. (4) a statement that the coverage provided by the alternative delivery system is either identical, greater or comparable to the coverage provided other dependent children under the policy under which coverage is required by a medical support order; and
   5. (5) if the coverage is not identical, the certification shall also be signed by a qualified actuary or an officer of the insurer who attests that the coverage provided is at least actuarially equivalent to or greater than the coverage provided to other dependent children under the policy under which coverage is required by a medical support order. The determination of actuarial equivalence of the coverages shall take into account plan design (e.g., copayments, coinsurance, deductibles, etc.) and scope of benefits. The certification shall identify any other variables considered in the analysis relating to the actuarial equivalence of the coverages.

Source Note:The provisions of this §21.2010 adopted to be effective May 8, 1997, 22 TexReg 3799; amended to be effective January 31, 1999, 24 TexReg 388.