Section 3.3705 - Nature of Communications with Insureds; Readability, Mandatory Disclosure Requirements, and Plan Designations(a) Readability. All health insurance policies, health benefit plan certificates, endorsements, amendments, applications, or riders are required to be written in a readable and understandable format that meets the requirements of § 3.602 of this title (relating to Plain Language Requirements).(b) Plan disclosure. The insurer is required, on request, to provide to a current or prospective group contract holder or a current or prospective insured an accurate written description of the terms and conditions of the policy (plan disclosure) that allows the current or prospective group contract holder or current or prospective insured to make comparisons and informed decisions before selecting among health care plans. An insurer may utilize its policy, certificate, or handbook to satisfy this requirement provided that the insurer complies with all requirements set forth in this subsection, including the level of disclosure required. An insurer that is required by federal law to provide a summary of benefits and coverage (SBC) must include in the SBC a link to the plan disclosure required in this subsection. The written plan disclosure must be in a readable and understandable format, by category, and must include a clear, complete, and accurate description of these items: (1) a statement that the entity providing the coverage is an insurance company; the name of the insurance company; that, in the case of a preferred provider benefit plan, the insurance contract contains preferred provider benefits; and, in the case of an exclusive provider benefit plan, that the contract only provides benefits for services received from preferred providers, except as otherwise noted in the contract and written description or as otherwise required by law;(2) a toll-free number, unless exempted by statute or rule, and website address to enable a current or prospective group contract holder or a current or prospective insured to obtain additional information;(3) an explanation of the distinction between preferred and nonpreferred providers;(4) all covered services and benefits, including payment for services of a preferred provider and a nonpreferred provider, and, if prescription drug coverage is included, the name of the formulary used by the plan, a link to the online formulary, and an explanation regarding how a nonelectronic copy may be obtained free of charge;(5) emergency care services and benefits and information on access to after-hours care;(6) out-of-area services and benefits;(7) an explanation of the insured's financial responsibility for payment for any premiums, deductibles, copayments, coinsurance, or other out-of-pocket expenses for noncovered or nonpreferred services;(8) any limitations and exclusions, including the existence of any drug formulary limitations, and any limitations regarding preexisting conditions;(9) any authorization requirements, including preauthorization review, concurrent review, post-service review, and post-payment review; and an explanation that unless a provider obtains preauthorization, a claim could be denied if a service is not medically necessary or appropriate, or if a service is experimental or investigational;(10) provisions for continuity of treatment in the event of termination of a preferred provider's participation in the plan;(11) a summary of complaint resolution procedures, if any, and a statement that the insurer is prohibited from retaliating against the insured because the insured or another person has filed a complaint on behalf of the insured, or against a physician or provider who, on behalf of the insured, has reasonably filed a complaint against the insurer or appealed a decision of the insurer;(12) the name of the provider network used by the plan, a link to the online provider listing, and information on how a nonelectronic copy may be obtained free of charge;(13) the counties included in the plan's service area; and(14) information that is updated at least annually regarding the following network demographics for each county:(A) the number of insureds in the service area or region; and(B) for each preferred provider area of practice and applicable network adequacy standard, the number of preferred providers, as well as an indication of whether an active waiver and access plan under § 3.3707 of this title (relating to Waiver Due to Failure to Contract in Local Markets) applies to the services furnished by that class of provider in the county and how such access plan may be obtained or viewed, if applicable.(c) Filing required. A copy of the plan disclosure required in subsection (b) of this section must be filed with the department with the initial filing of the preferred provider benefit plan and within 60 days of any material changes being made in the information required in subsection (b) of this section.(d) Promotional disclosures required. (1) The preferred provider benefit plan and all promotional, solicitation, and advertising material concerning the preferred provider benefit plan must clearly describe the distinction between preferred and nonpreferred providers. Any illustration of preferred provider benefits must be in close proximity to an equally prominent description of out-of-network benefits, except in the case of an exclusive provider benefit plan.(2) All promotion and advertisement of the preferred provider benefit plan for which a waiver has been granted must contain a statement that the plan received a waiver for a departure from network adequacy requirements and a website link where the following information about the waiver may be obtained: (A) the name of the plan and the insurer offering the plan;(B) the specific network adequacy standards waived;(C) each county affected by the waiver; and(D) the access plan procedures the insurer will use to assist insureds in obtaining medically necessary services, consistent with § 3.3707(j) of this title.(e) Website disclosures. Insurers that maintain a website providing information regarding the insurer or the health insurance policies offered by the insurer for use by current or prospective insureds or group contract holders must provide on their website a:(1) preferred provider listing for use by current and prospective insureds and group contract holders;(2) listing of the counties within the insurer's service area, indicating as appropriate for each county that the insurer has:(A) determined that its network meets the network adequacy requirements of this subchapter; or(B) determined that its network does not meet the network adequacy requirements of this subchapter; and(3) listing of the information specified for disclosure in subsection (b) of this section.(f) Notice of rights under a network plan required. An insurer must include the notice specified in Figure: 28 TAC § 3.3705(f)(1) for a preferred provider benefit plan that provides major medical insurance and is not an exclusive provider benefit plan, or Figure: 28 TAC § 3.3705(f)(2) for an exclusive provider benefit plan that provides major medical insurance, in all policies, certificates, plan disclosures provided to comply with subsection (b) of this section, and outlines of coverage in at least 12-point font: (g) Untrue or misleading information prohibited. No insurer, or agent or representative of an insurer, may cause or permit the use or distribution of information which is untrue or misleading.(h) Disclosure concerning access to preferred provider listing. The insurer must provide notice to all insureds at least annually describing how the insured may access a current listing of all preferred providers on a cost-free basis. The notice must include, at a minimum, information concerning how to obtain a nonelectronic copy of the listing and a telephone number through which insureds may obtain assistance during regular business hours to find available preferred providers.(i) Required updates of available preferred provider listings. The insurer must ensure that it updates its listing of preferred providers on its website at least once a month, as required by Insurance Code § 1451.505, concerning Physician and Health Care Provider Directory on Internet Website. The insurer must ensure that it updates all other electronic or nonelectronic listings of preferred providers made available to insureds at least every three months.(j) Annual provision of preferred provider listing required in certain cases. If no preferred provider website listing or other method of identifying current preferred providers is maintained for use by insureds, the insurer must distribute a current preferred provider listing to all insureds no less than annually by mail, or by an alternative method of delivery if an alternative method is agreed to by the insured, group policyholder on behalf of the group, or certificate holder.(k) Reliance on preferred provider listing in certain cases. A claim for services rendered by a nonpreferred provider must be paid in the same manner as if no preferred provider had been available under § 3.3708(a)(5) of this title (relating to Payment of Certain Out-of-Network Claims), and the insurer must take responsibility for any balance bill amount the nonpreferred provider may charge in excess of the insurer's payment if an insured demonstrates that:(1) in obtaining services, the insured reasonably relied upon a statement that a physician or provider was a preferred provider as specified in:(A) a preferred provider listing; or(B) preferred provider information on the insurer's website;(2) the preferred provider listing or website information was obtained from the insurer, the insurer's website, or the website of a third party designated by the insurer to provide such information for use by its insureds;(3) the preferred provider listing or website information was obtained not more than 30 days prior to the date of services; and(4) the preferred provider listing or website information obtained indicates that the provider is a preferred provider within the insurer's network.(l) Additional listing-specific disclosure requirements. In all preferred provider listings, including any website postings by the insurer to insureds about preferred providers, the insurer must comply with the requirements in paragraphs (1) - (11) of this subsection. (1) The preferred provider information must include a method for insureds to identify those hospitals that have contractually agreed with the insurer to facilitate the usage of preferred providers as specified in subparagraphs (A) and (B) of this paragraph. (A) The hospital will exercise good-faith efforts to accommodate requests from insureds to utilize preferred providers.(B) In those instances in which a particular facility-based physician or provider or physician group is assigned at least 48 hours prior to services being rendered, the hospital will provide the insured with information that is: (i) furnished at least 24 hours prior to services being rendered; and(ii) sufficient to enable the insured to identify the physician or physician group with enough specificity to permit the insured to determine, along with preferred provider listings made available by the insurer, whether the assigned facility-based physician or provider or physician group is a preferred provider.(2) The preferred provider information must include a method for insureds to identify, for each preferred provider hospital, the percentage of the total dollar amount of claims filed with the insurer by or on behalf of facility-based physicians that are not under contract with the insurer. The information must be available by class of facility-based physician, including radiologists, anesthesiologists, pathologists, emergency department physicians, and neonatologists.(3) In determining the percentages specified in paragraph (2) of this subsection, an insurer may consider claims filed in a 12-month period designated by the insurer ending not more than 12 months before the date the information specified in paragraph (2) of this subsection is provided to the insured.(4) The preferred provider information must indicate whether each preferred provider is accepting new patients.(5) The preferred provider information must provide a method by which insureds may notify the insurer of inaccurate information in the listing, with specific reference to: (A) information about the provider's contract status; and(B) whether the provider is accepting new patients.(6) The preferred provider information must provide a method by which insureds may identify preferred provider facility-based physicians or providers able to provide services at preferred provider facilities, if applicable.(7) The preferred provider information must be provided in at least 10-point type.(8) The preferred provider information must specifically identify those facilities at which the insurer has no contracts with a class of facility-based provider, specifying the applicable provider class.(9) The preferred provider information must be dated.(10) Consistent with Insurance Code Chapter 1451, Subchapter K, concerning Health Care Provider Directories, for each health care provider that is a facility included in the listing, the insurer must:(A) create separate headings under the facility name for radiologists, anesthesiologists, anesthesiologist assistants, nurse anesthetists, nurse midwives, pathologists, emergency department physicians, neonatologists, physical therapists, occupational therapists, speech-language pathologists, and surgical assistants, except that a physician or health care provider who is employed by the facility is not required to be listed;(B) under each heading described by subparagraph (A) of this paragraph, list each preferred facility-based physician or provider practicing in the specialty corresponding with that heading;(C) for the facility and each facility-based physician or provider described by subparagraph (B) of this paragraph, clearly indicate each health benefit plan issued by the insurer that may provide coverage for the services provided by that facility, physician or provider, or facility-based physician or provider group;(D) for each facility-based physician or provider described by subparagraph (B) of this paragraph, include the name, street address, telephone number, and any physician or provider group in which the facility-based physician or provider practices; and(E) include the facility in a listing of all facilities and indicate:(i) the name of the facility;(ii) the municipality in which the facility is located or county in which the facility is located if the facility is in the unincorporated area of the county; and(iii) each health benefit plan issued by the insurer that may provide coverage for the services provided by the facility.(11) Consistent with Insurance Code Chapter 1451, Subchapter K, the listing must list each facility-based physician or provider individually and, if a physician or provider belongs to a physician or provider group, also as part of the physician or provider group.(m) Annual policyholder notice concerning use of an access plan. An insurer operating a preferred provider benefit plan that relies on an access plan as specified in § 3.3707 of this title (relating to Waiver Due to Failure to Contract in Local Markets) must provide notice of this fact to each individual and group policyholder participating in the plan at policy issuance and at least 30 days prior to renewal of an existing policy. The notice must include:(1) a link to any webpage listing of information on network waivers and access plans disclosed under subsection (d)(2) of this section and made available under subsection (e) of this section;(2) information on how to obtain or view any access plan or plans the insurer uses; and(3) a link to the department's website where the department posts information relevant to the grant of waivers.(n) Disclosure of substantial decrease in the availability of certain preferred providers. An insurer is required to provide notice as specified in this subsection of a substantial decrease in the availability of preferred facility-based physicians or providers at a preferred provider facility. (1) A decrease is substantial if: (A) the contract between the insurer and any facility-based physician or provider group that comprises 75% or more of the preferred providers for that specialty at the facility terminates; or(B) the contract between the facility and any facility-based physician or provider group that comprises 75% or more of the preferred providers for that specialty at the facility terminates, and the insurer receives notice as required under § 3.3703(a)(26) of this title (relating to Contracting Requirements).(2) For purposes of this subsection, decreases in numbers of physicians and other providers must be assessed separately, but no notice of a substantial decrease is required if the requirements specified in either subparagraph (A) or (B) of this paragraph are met:(A) alternative preferred providers of the same specialty as the physician or provider group that terminates a contract as specified in paragraph (1) of this subsection are made available to insureds at the facility so the percentage level of preferred providers of that specialty at the facility is returned to a level equal to or greater than the percentage level that was available prior to the substantial decrease; or(B) the insurer determines that the termination of the provider contract has not caused the preferred provider service delivery network for any plan supported by the network to be noncompliant with the adequacy standards specified in § 3.3704 of this title (relating to Freedom of Choice; Availability of Preferred Providers) as those standards apply to the applicable provider specialty.(3) An insurer must prominently post notice of any contract termination specified in paragraph (1)(A) or (B) of this subsection and the resulting decrease in availability of preferred providers on the portion of the insurer's website where its provider listing is available to insureds.(4) Notice of any contract termination specified in paragraph (1)(A) or (B) of this subsection and of the decrease in availability of providers must be maintained on the insurer's website until the earlier of:(A) the date on which adequate preferred providers of the same specialty become available to insureds at the facility at the percentage level specified in paragraph (2)(A) of this subsection; or(B) six months from the date that the insurer initially posts the notice.(5) An insurer must post notice as specified in paragraph (3) of this subsection and update its website preferred provider listing as soon as practicable and in no case later than two business days after:(A) the effective date of the contract termination as specified in paragraph (1)(A) of this subsection; or(B) the later of: (i) the date on which an insurer receives notice of a contract termination as specified in paragraph (1)(B) of this subsection; or(ii) the effective date of the contract termination as specified in paragraph (1)(B) of this subsection.(o) Disclosures concerning reimbursement of out-of-network services. An insurer must make disclosures in all insurance policies, certificates, and outlines of coverage concerning the reimbursement of out-of-network services as specified in this subsection. (1) An insurer must disclose how reimbursements of nonpreferred providers will be determined.(2) An insurer must disclose how the plan will cover out-of-network services received when medically necessary covered services are not reasonably available through a preferred provider, consistent with § 3.3708 of this title and how an enrollee can obtain assistance with accessing care in these circumstances, consistent with § 3.3707(k) of this title.(3) Except in an exclusive provider benefit plan, if an insurer bases reimbursement of nonpreferred providers on any amount other than full billed charges, the insurer must: (A) disclose that the insurer's reimbursement of claims for nonpreferred providers may be less than the billed charge for the service;(B) disclose that the insured may be liable to the nonpreferred provider for any amounts not paid by the insurer, unless balance billing protections apply, as specified in §3.3708(a)(1) - (4) of this title;(C) provide a description of the methodology by which the reimbursement amount for nonpreferred providers is calculated; and(D) provide to insureds a method to obtain a real-time estimate of the amount of reimbursement that will be paid to a nonpreferred provider for a particular service.28 Tex. Admin. Code § 3.3705
The provisions of this §3.3705 adopted to be effective July 15, 1999, 24 TexReg 5204; amended to be effective December 6, 2011, 36 TexReg 3411; amended to be effective February 21, 2013, 38 TexReg 827; Amended by Texas Register, Volume 41, Number 44, October 28, 2016, TexReg 8605, eff. 11/3/2016; Amended by Texas Register, Volume 42, Number 19, May 12, 2017, TexReg 2537, eff. 5/16/2017; Amended by Texas Register, Volume 46, Number 13, March 26, 2021, TexReg 2029, eff. 3/30/2021; Amended by Texas Register, Volume 49, Number 16, April 19, 2024, TexReg 2518, eff. 4/25/2024