28 Tex. Admin. Code § 11.505 - Specifications for Evidence of Coverage Including Insert Pages and Matrix Filings
(a) The filing and
formatting requirements of §
11.301 of this title (relating to
Filing Requirements) apply to an evidence of coverage.
(b) The style, arrangement, and overall
appearance of documents must give no undue prominence to any portion of the
text. The text of the group, individual, and conversion agreements, the
certificate, and all amendments include all printed matter except:
(1) the HMO's name, address, website address,
and phone number;
(2) the name or
title of the form;
(3) the captions
and subcaptions; and
(4) any brief
introduction to or description of the evidence of coverage.
(c) Each evidence of coverage must
indicate by example information that will appear in any blanks with the
exception of single-case forms, which must be filed complete and ready for
use.
(d) An HMO must identify each
form by a unique form number in compliance with §
11.301(2) of
this title. Any change in form number is considered a change in the form and
requires approval as a new form.
(e) Certain language must not be varied or
changed without resubmitting a form for the commissioner's approval. Changeable
language must be enclosed in brackets, include the range of variable
information or amounts, and include an explanation of how and under what
circumstances the information will vary.
(f) Each evidence of coverage must meet the
readability standards of §
3.601 of this title (relating to
Purpose and Scope, Applicability, and Definitions Used in This Subchapter) and
§
3.602 of this title (relating to
Plain Language Requirements).
(g) A
matrix filing must comply with the filing requirements in this section and §
11.301 of this title. In addition,
an HMO submitting a matrix filing:
(1) must
identify each provision with a unique form number that is sufficient to
distinguish it as a matrix filing; and
(2) may use the same provision filed under
one form number for all HMO products, provided that the language is applicable
to each HMO product; however, any changes in the language to comply with the
requirements for each HMO product will require a unique form number.
(h) Evidences of coverage,
agreements, and contracts may be submitted with insert pages, or an insert page
may be filed subsequent to the approval of an evidence of coverage, agreement,
or contract.
(i) Any HMO submitting
an insert page filing:
(1) must identify each
insert page with a unique form number located on the lower left hand corner of
the page;
(2) may use the same
insert page filed under one form number for all plans, provided the language is
applicable to each plan type; however, any changes in the language to comply
with the requirements for each plan type will require a unique form
number;
(3) may use the same insert
page to replace an existing page of a previously approved or reviewed evidence
of coverage, agreement, or contract. However, if used in this manner, the
replaced page, as originally filed, must reflect a unique form number that
distinguishes it from the other pages of the form or contract; and
(4) must list the form number for each insert
page on the transmittal checklist and provide a statement indicating how the
insert page will be used and the type of plan for which the insert page will be
used.
(j) In addition to
providing the appropriate certification on the transmittal checklist, an HMO
submitting a filing as a matrix filing or as an insert page must provide
certifications certifying that, when issued, the evidences of coverage,
certificates, contracts, riders, or applications created from the forms comply
in all respects with all applicable statutes and regulations with regard to the
final plan document that will be issued.
Notes
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