28 Tex. Admin. Code § 3.9203 - Policy and Premium Rates
(a) Disclosure of
complaint system. An EPP policy or certificate must contain the Complaints and
Appeals Process found in this subchapter. This information must include a clear
and understandable description of the issuer's methods for resolving
complaints. An issuer must provide any subsequent changes to the complaint
system to insureds, which it may include in a separate document issued to the
insured.
(b) Medically necessary
covered services. If medically necessary covered services are not available
through exclusive providers, the issuer, on the request of an exclusive
provider, must allow referral within a reasonable period to a non-network
health care provider and must fully reimburse the non-network health care
provider at the usual and customary or an agreed rate. The policy must provide
for a review by a health care provider of the same specialty or a similar
specialty as the type of health care provider to whom a referral is requested
before the issuer may deny a referral.
(c) Schedule of premiums. An issuer must file
the schedule of premium rates and formula or method for calculating the
schedule of premium rates for covered health care services along with
supporting documentation with the commissioner before it is used in conjunction
with any EPP. The issuer must establish the formula or method in accordance
with accepted actuarial principles and must produce premium rates that are not
excessive, inadequate, or unfairly discriminatory, as well as premium rates
that are reasonable with respect to benefits. An issuer may not alter the
premium rates resulting from the application of the formula or method for an
individual insured based on the status of that insured's health.
(1) An issuer must accompany each schedule of
premium rates and formula or method for calculating the schedule of premium
rates with the certification of a qualified actuary that, based on reasonable
assumptions, the formula is appropriate to produce premium rates that are not
excessive, inadequate, or unfairly discriminatory. An actuary is considered
qualified if he or she:
(A) is a member of the
American Academy of Actuaries; or
(B) is a Fellow of the Society of
Actuaries.
(2) An issuer
must accompany each formula or method for calculating the schedule of premium
rates with adequate detail including assumptions to justify that the premium
rates produced by the formula or method are not excessive, inadequate, or
unfairly discriminatory.
(3) If the
formula or method for calculating the schedule of premium rates and the
resulting rates are to be continued beyond a one-year period, the issuer must
file with the commissioner, no later than the anniversary of the effective date
of the original filing, an actuarial statement stating that the issuer has
applied the previously filed formula or method consistently, and that the rates
charged have proven and are expected to continue to be adequate, not excessive,
nor unfairly discriminatory. The issuer must include with this filing a
reconciliation of actual benefits to a schedule of premium rates.
(4) To the extent that an entity contracting
with the insured predetermines the schedule of premium rates, the issuer must
submit the information described in this subsection and demonstrate that the
issuer is able to provide the services for the contracted rates.
Notes
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No prior version found.