Sec. 843.201. DISCLOSURE OF INFORMATION ABOUT HEALTH CARE PLAN TERMS. (a) A health maintenance organization shall provide an accurate written or electronic description of health care plan terms, including restrictions or limitations related to a limited provider network or delegated network within a health care plan, to allow a current or prospective group contract holder or current or prospective enrollee to make comparisons and informed decisions before selecting among health care plans. The written or electronic description must:
(1) be in readable and understandable format prescribed by the commissioner; and
(2) include a current list of physicians and providers, including a delineation of any limited provider network or delegated network.
(b) A health maintenance organization may satisfy the requirement imposed under Subsection (a) through the member handbook provided under Section 843.205 if:
(1) the handbook's contents are substantially similar to and provide the same level of disclosure as the written or electronic description prescribed by the commissioner; and
(2) the current list of physicians and providers is also provided.
(c) If an enrollee designates a primary care physician who practices in a limited provider network or delegated entity, not later than the 30th day after the date of the enrollee's enrollment, the health maintenance organization shall provide the information required under this section to the enrollee with the enrollee's identification card or in a mailing separate from other information.
(d) A health maintenance organization shall provide to an enrollee on request information on:
(1) whether a physician or other health care provider is a participating provider in the health maintenance organization's network;
(2) whether proposed health care services are covered by the health plan; and
(3) what the enrollee's personal responsibility will be for payment of applicable copayment or deductible amounts.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003. Amended by Acts 2003, 78th Leg., ch. 261, Sec. 2, eff. Sept. 1, 2003; Acts 2003, 78th Leg., ch. 1276, Sec. 10A.208(a), eff. Sept. 1, 2003.
Amended by:
Acts 2007, 80th Leg., R.S., Ch. 997 (S.B. 1731), Sec. 12, eff. September 1, 2007.
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