Tex.
Ins. Code Section 1456.003
Required Disclosure: Health Benefit Plan
(a)
Each health benefit plan that provides health care through a provider network shall provide notice to its enrollees that:(1)
a facility-based physician or other health care practitioner may not be included in the health benefit plan’s provider network; and(2)
a health care practitioner described by Subdivision (1) may balance bill the enrollee for amounts not paid by the health benefit plan unless the health care or medical service or supply provided to the enrollee is subject to a law prohibiting balance billing.(b)
The health benefit plan shall provide the disclosure in writing to each enrollee:(1)
in any materials sent to the enrollee in conjunction with issuance or renewal of the plan’s insurance policy or evidence of coverage;(2)
in an explanation of payment summary provided to the enrollee or in any other analogous document that describes the enrollee’s benefits under the plan; and(3)
conspicuously displayed, on any health benefit plan website that an enrollee is reasonably expected to access.(c)
A health benefit plan must clearly identify any health care facilities within the provider network in which facility-based physicians do not participate in the health benefit plan’s provider network. Health care facilities identified under this subsection must be identified in a separate and conspicuous manner in any provider network directory or website directory.(d)
Along with any explanation of benefits sent to an enrollee that contains a remark code indicating a payment made to a non-network physician has been paid at the health benefit plan’s allowable or usual and customary amount, a health benefit plan must also include the number for the department’s consumer protection division for complaints regarding payment.
Source:
Section 1456.003 — Required Disclosure: Health Benefit Plan, https://statutes.capitol.texas.gov/Docs/IN/htm/IN.1456.htm#1456.003 (accessed Jun. 5, 2024).
