28 Tex. Admin. Code § 11.2206 - Mandatory Disclosure Statements; Certification of Compliance

(a) Each point-of-service group enrollment application and, if the employer, association, or private group arrangement elects to offer the point-of-service option, each enrollment form, must include a disclosure statement written in a readable and understandable format that includes the following information:

(1) a statement that the dental indemnity benefits are provided through an insurer and that the dental care services are offered or arranged by the HMO;

(2) the name of the insurer and the name of the HMO offering the benefits; and

(3) an explanation that, in order to receive benefits:

(A) under the HMO, an enrollee must use only network providers, except for emergency dental care, and pay the copayments specified in the evidence of coverage;

(B) under the indemnity plan, an enrollee may use any provider but before receiving reimbursement, the enrollee must meet the required deductible and is responsible for the coinsurance amount specified in the policy or certificate.

(b) Each HMO offering a point-of-service plan must retain on file a certification by an HMO officer that the point-of-service plan includes dental indemnity benefits that correspond to the benefits contained in the HMO evidence of coverage. The HMO may enter into agreement with the insurer or a qualified actuary to prepare the certification, provided that the HMO retains responsibility for obtaining the certification and must keep the certification in its possession.

Notes

28 Tex. Admin. Code § 11.2206

The provisions of this §11.2206 adopted to be effective May 13, 1999, 24 TexReg 3525; Adopted by Texas Register, Volume 42, Number 16, April 21, 2017, TexReg 2263, eff. 8/1/2017