CHAPTER 1273. POINT-OF-SERVICE PLANS
INSURANCE CODE
TITLE 8. HEALTH INSURANCE AND OTHER HEALTH COVERAGES
SUBTITLE C. MANAGED CARE
CHAPTER 1273. POINT-OF-SERVICE PLANS
SUBCHAPTER A. BLENDED CONTRACTS
Sec. 1273.001. DEFINITIONS. In this subchapter:
(1) "Blended contract" means a single document, including a
single contract policy, certificate, or evidence of coverage,
that provides a combination of indemnity and health maintenance
organization benefits.
(2) "Health maintenance organization" has the meaning assigned
by Section 843.002.
(3) "Insurer" means an insurance company, association, or
organization authorized to engage in business in this state under
Chapter 841, 842, 861, 881, 882, 883, 884, 885, 886, 887, 888,
941, 942, or 982.
(4) "Point-of-service plan" means an arrangement under which:
(A) an enrollee chooses to obtain benefits or services through:
(i) a health maintenance organization delivery network,
including a limited provider network; or
(ii) a non-network delivery system outside the health
maintenance organization delivery network, including a limited
provider network, that is administered under an indemnity benefit
arrangement for the cost of health care services; or
(B) indemnity benefits for the cost of health care services are
provided by an insurer or group hospital service corporation in
conjunction with network benefits arranged or provided by a
health maintenance organization.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1273.002. POINT-OF-SERVICE PLAN. An insurer may contract
with a health maintenance organization to provide benefits under
a point-of-service plan, including optional coverage for
out-of-area services or out-of-network care.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1273.003. BLENDED CONTRACT. (a) A health maintenance
organization and an insurer may offer a blended contract. The use
of a blended contract is limited to point-of-service arrangements
between a health maintenance organization and an insurer.
(b) A blended contract delivered, issued, or used in this state
is subject to, and must be filed with the department for approval
as provided by, Chapter 1701 and Section 1271.101.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1273.004. LIMITED BENEFITS AND SERVICES; COST-SHARING
PROVISIONS. Indemnity benefits and services provided under a
point-of-service plan may be limited to those services described
by the blended contract and may be subject to different
cost-sharing provisions. The cost-sharing provisions for
indemnity benefits may be higher than the cost-sharing provisions
for in-network health maintenance organization coverage. For an
enrollee in a limited provider network, higher cost-sharing may
be imposed only when the enrollee obtains benefits or services
outside the health maintenance organization delivery network.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1273.005. RULES. The commissioner may adopt rules to
implement this subchapter.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
SUBCHAPTER B. AVAILABILITY OF HEALTH BENEFIT COVERAGE OPTIONS
Sec. 1273.051. DEFINITIONS. In this subchapter:
(1) "Employee" means an individual employed by an employer.
(2) "Health benefit plan" has the meaning assigned by Section
1501.002.
(3) "Non-network plan" means health benefit coverage that
provides an enrollee an opportunity to obtain health care
services through a health delivery system other than a health
maintenance organization delivery network, as defined by Section
843.002.
(4) "Point-of-service plan" means an arrangement under which an
enrollee chooses to obtain benefits or services through:
(A) a health maintenance organization delivery network,
including a limited provider network; or
(B) a non-network delivery system outside the health maintenance
organization delivery network, including a limited provider
network, that is administered under an indemnity benefit
arrangement for the cost of health care services.
(5) "Preferred provider benefit plan" means an insurance policy
issued under Chapter 1301.
(6) "Small employer health benefit plan" has the meaning
assigned by Section 1501.002.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1273.052. OFFER OF COVERAGE THROUGH NON-NETWORK PLAN
REQUIRED. (a) Except as provided by Subsection (b), if the only
health benefit coverage offered under an employer's health
benefit plan is a network-based delivery system of coverage
offered by one or more health maintenance organizations, each
health maintenance organization offering coverage must offer to
all eligible employees, at the time of enrollment and at least
annually, the opportunity to obtain coverage through a
non-network plan.
(b) Each health maintenance organization to which Subsection (a)
applies may enter into an agreement designating one or more of
those health maintenance organizations to offer the coverage
required by Subsection (a) for eligible employees of the
employer.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1273.053. COVERAGE OPTIONS. The coverage required to be
offered under this subchapter may be provided through:
(1) a point-of-service plan;
(2) a preferred provider benefit plan; or
(3) any coverage arrangement that provides an enrollee with
access to services outside the health maintenance organization's
or limited provider network's delivery network.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1273.054. PREMIUM FOR COVERAGE OPTIONS. The premium for
coverage required to be offered under this subchapter must be
based on the actuarial value of that coverage and may be
different from the premium for coverage otherwise offered by the
health maintenance organization.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1273.055. COST-SHARING PROVISIONS. (a) Different
cost-sharing provisions may be imposed for a point-of-service
plan offered under this subchapter, and those provisions may be
higher than the cost-sharing provisions for in-network health
maintenance organization coverage. For an enrollee in a limited
provider network, higher cost-sharing may be imposed only when
the enrollee obtains benefits or services outside the health
maintenance organization delivery network.
(b) An employee who chooses the non-network plan is responsible
for any additional costs for the non-network plan, and the
employer may impose a reasonable administrative fee for providing
the non-network plan.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1273.056. EXCEPTIONS. This subchapter does not apply to:
(1) a small employer health benefit plan; or
(2) a group model health maintenance organization that is a
nonprofit, state-certified health maintenance organization that:
(A) provides the majority of its professional services through a
single group medical practice that is governed by a board
composed entirely of physicians; and
(B) educates medical students or resident physicians through a
contract with the medical school component of a Texas
state-supported college or university accredited by the
Accreditation Council on Graduate Medical Education or the
American Osteopathic Association.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1273.057. RULES. The commissioner shall adopt rules
necessary to administer this subchapter.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.