Section 21.2010 - Prohibition on Service Area Restrictions(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 must either: (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) provide coverage through the use of alternative delivery systems, such as reciprocal agreements with indemnity insurers or HMOs.(b) If the policy contains preferred provider provisions for the purposes of offering a network of preferred providers as defined in Insurance Code Chapter 1301 , 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 must be provided at the preferred provider level of benefits.(c) If the insurer provides coverage under subsection (a)(2) of this section, the coverage must 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.(d) If the coverage is provided under subsection (a)(2) of this section, the insurer must submit a certification to the Texas Department of Insurance. The certification must be filed with the Texas Department of Insurance, Life and Health Division by email to MCQA@tdi.texas.gov, signed by an officer of the insurer and include: (1) the insurer's full name;(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) 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 Chapter 1701, and Insurance Code § 1504.002 and § 1504.052 or § 11.301 of this title (relating to Filing Requirements);(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) if the coverage is not identical, the certification must 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 must take into account plan design (e.g., copayments, coinsurance, deductibles, etc.) and scope of benefits. The certification must identify any other variables considered in the analysis relating to the actuarial equivalence of the coverages.28 Tex. Admin. Code § 21.2010
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; Amended by Texas Register, Volume 46, Number 44, October 29, 2021, TexReg 7418, eff. 11/7/2021