(a) Each enrollee residing in Texas is entitled to an evidence of coverage under a health care plan. An HMO may deliver the evidence of coverage electronically but must provide a paper copy on request.     
      (b) Each group, individual, and conversion contract and group certificate must contain the following provisions:      
        (1) Face page. Where applicable, the name, address, website address, and phone number of the HMO must appear. The toll-free number referred to in Insurance Code §521.102 (concerning Health Maintenance Organization or Insurer Toll-Free Number for Information and Complaints) must appear on the face page.                  (A) The face page of an agreement is the first page that contains any written material.                   (B) If the agreements or certificates are in booklet form, the first page inside the cover is considered the face page.                   (C) The HMO must provide the information regarding the toll-free number referred to in Insurance Code Chapter 521, Subchapter C, (concerning Health Maintenance Organization or Insurer Toll-Free Number for Information and Complaints), in compliance with §1.601 of this title (relating to Notice of Toll-Free Telephone Numbers and Information and Complaint Procedures).         
        (2) Benefits. A schedule of all health care services that are available to enrollees under the basic, limited, or single service plan must be included, together with any copayments or deductibles and a description of where and how to obtain services. An HMO may use a variable copayment or deductible schedule. The schedule must clearly indicate the benefit to which it applies.                  (A) Copayments. An HMO may require copayments to supplement payment for health care services.                      (i) Each basic health care service HMO may establish one or more reasonable copayment options. A reasonable copayment option may not exceed 50 percent of the total cost of services provided.                       (ii) A basic health care service HMO may not impose copayment charges on any enrollee in any calendar year, when the copayments made by the enrollee in that calendar year total 200 percent of the total annual premium cost which is required to be paid by or on behalf of that enrollee. This limitation applies only if the enrollee demonstrates that copayments in that amount have been paid in that year.                       (iii) The HMO must state the copayment, the limit on enrollee copayments, and the enrollee reporting responsibility in the group, individual, or conversion agreement and group certificate.                     (B) Deductibles. A deductible must be for a specific dollar amount of the cost of the basic, limited, or single health care service. Except for a consumer choice benefit plan authorized by Insurance Code Chapter 1507 (concerning Consumer Choice of Benefits Plans), an HMO may not charge a deductible for services received in the HMO's delivery network. Except in cases involving emergency care and services that are not available in the HMO's delivery network, as described in §11.1611, an HMO may charge an out-of-network deductible for services performed out of the HMO's service area or for services performed by a physician or provider who is not in the HMO's delivery network.                   (C) Facility-based Physicians. In compliance with Insurance Code §1456.003 (concerning Required Disclosure: Health Benefit Plan), a statement that:                      (i) a facility-based physician or other health care practitioner may not be included in the health benefit plan's provider network;                       (ii) the non-network facility-based physician or other health care practitioner may balance bill the enrollee for amounts not paid by the health benefit plan; and                       (iii) if the enrollee receives a balance bill, the enrollee should contact the HMO.                     (D) Immunizations. An HMO may not charge a copayment or deductible for immunizations as described in Insurance Code Chapter 1367, Subchapter B, (concerning Childhood Immunizations) for a child from birth through the date the child is six years of age, except that a small employer health benefit plan as defined by Insurance Code §1501.002 (concerning Definitions) that covers the immunizations may charge a copayment, and a consumer choice benefit plan under Insurance Code Chapter 1507 may charge a copayment and a deductible.         
        (3) Cancellation and nonrenewal. A statement specifying the following grounds for cancellation and nonrenewal of coverage and the minimum notice period that will apply.                  (A) Unless otherwise prohibited by law, an HMO may cancel coverage of a subscriber in a group and the subscriber's enrolled dependents under circumstances described in this subparagraph, so long as the circumstances do not include health status-related factors:                      (i) for nonpayment of amounts due under the contract, after not less than 30-days written notice, except no additional written notice will be required for failure to pay premium;                       (ii) after not less than 15-days written notice, in the case of fraud or intentional misrepresentation of a material fact, except as described in paragraph (13) of this subsection;                       (iii) after not less than 15-days written notice, in the case of fraud in the use of services or facilities;                       (iv) immediately, subject to continuation of coverage and conversion privilege provisions, if applicable, for failure to meet eligibility requirements other than the requirement that the subscriber reside, live, or work in the service area; and                       (v) after not less than 30-days written notice, where the subscriber does not reside, live, or work in the service area of the HMO or area for which the HMO is authorized to do business, but only if the HMO terminates coverage uniformly without regard to any health status-related factor of enrollees, except that an HMO may not cancel coverage for a child who is the subject of a medical support order because the child does not reside, live, or work in the service area.                     (B) An HMO may cancel a group under circumstances described below, unless otherwise prohibited by law:                      (i) for nonpayment of premium, at the end of the grace period as described in paragraph (12) of this subsection;                       (ii) in the case of fraud on the part of the group, after 15-days written notice;                       (iii) for employer groups, for violation of participation or contribution rules, under §26.8(h) of this title (relating to Guaranteed Issue; Contribution and Participation Requirements) and §26.303(j) of this title (relating to Coverage Requirements);                       (iv) for employer groups, under §26.16 of this title (relating to Refusal to Renew and Application to Reenter Small Employer Market) and §26.309 of this title (relating to Refusal to Renew and Application to Reenter Large Employer Market) on discontinuance of:                          (I) each of its small or large employer coverages; or                           (II) a particular type of small or large employer coverage;                         (v) where no enrollee resides, lives, or works in the service area of the HMO or area for which the HMO is authorized to do business, but only if the coverage is terminated uniformly without regard to any health status-related factor of enrollees after 30-days written notice; and                       (vi) if membership of an employer in an association ceases, and if coverage is terminated uniformly without regard to the health status of an enrollee, after 30-days written notice.                     (C) A group or individual contract holder may cancel a contract in the case of a material change by the HMO to any provisions required to be disclosed to contract holders or enrollees under this chapter or other law after not less than 30-days written notice to the HMO.                   (D) An HMO may cancel an individual contract under circumstances described below, unless otherwise prohibited by law:                      (i) for nonpayment of premiums under the terms of the contract, including any timeliness provisions, without written notice, subject to paragraph (12) of this subsection;                       (ii) in the case of fraud or intentional material misrepresentation, except as described in paragraph (13) of this subsection, after not less than 15-days written notice;                       (iii) in the case of fraud in the use of services or facilities, after not less than 15-days written notice;                       (iv) after not less than 30-days written notice where the subscriber does not reside, live, or work in the service area of the HMO or area in which the HMO is authorized to do business, but only if coverage is terminated uniformly without regard to any health status-related factor of enrollees, except that an HMO may not cancel coverage for a child who is the subject of a medical support order because the child does not reside, live, or work in the service area;                       (v) in case of termination by discontinuance of a particular type of individual coverage by the HMO in that service area, but only if coverage is discontinued uniformly without regard to health status-related factors of enrollees and dependents of enrollees who may become eligible for coverage, after 90-days written notice, in which case the HMO must offer to each enrollee on a guaranteed-issue basis any other individual basic health care coverage offered by the HMO in that service area; and                       (vi) in case of termination by discontinuance of all individual basic health care coverage by the HMO in that service area, but only if coverage is discontinued uniformly without regard to health status-related factors of enrollees and dependents of enrollees who may become eligible for coverage, after 180-days written notice to the commissioner and the enrollees, in which case the HMO may not re-enter the individual market in that service area for five years beginning on the date of discontinuance at the last coverage not renewed.           
        (4) Claim payment procedure. A provision that sets forth the procedure for paying claims, including any time frame for payment of claims that must comply with Insurance Code Chapter 542, Subchapter B, (concerning Prompt Payment of Claims); Insurance Code §1271.005 (concerning Applicability of Other Law); and rules adopted under these Insurance Code provisions.       
        (5) Complaint and appeal procedures. A description of the HMO's complaint and appeal process available to complainants, including internal adverse determination appeal and independent review procedures under Insurance Code Chapter 4201 (concerning Utilization Review Agents) and Chapter 19, Subchapter R, of this title (relating to Utilization Reviews for Health Care Provided Under a Health Benefit Plan or Health Insurance Policy).       
        (6) Definitions. A provision defining any words in the evidence of coverage that have other than the usual meaning. Definitions must be in alphabetical order.       
        (7) Effective date. A statement of the effective date requirements of various kinds of enrollees.       
        (8) Eligibility. A statement of the eligibility requirements for membership.                  (A) The statement must provide that the subscriber must reside, live, or work in the service area and the legal residence of any enrolled dependents must be the same as the subscriber, or the subscriber must reside, live, or work in the service area and the residence of any enrolled dependents must be:                      (i) in the service area with the person having temporary or permanent conservatorship or guardianship of the dependents, including adoptees or children who have become the subject of a suit for adoption by the enrollee, where the subscriber has legal responsibility for the health care of the dependents;                       (ii) in the service area under other circumstances where the subscriber is legally responsible for the health care of the dependents;                       (iii) in the service area with the subscriber's spouse; or                       (iv) anywhere in the United States for a child whose coverage under a plan is required by a medical support order.                     (B) The statement must provide the conditions under which dependent enrollees may be added to those originally covered.                   (C) The statement must describe any limiting age for subscriber and dependents.                   (D) The statement must provide a clear statement regarding the coverage of newborn children.                      (i) No evidence of coverage may contain any provision excluding or limiting coverage for a newborn child of the subscriber or the subscriber's spouse.                       (ii) Congenital defects must be treated the same as any other illness or injury for which coverage is provided.                       (iii) The HMO may require that the subscriber notify the HMO during the initial 31 days after the birth of the child and pay any premium required to continue coverage for the newborn child.                       (iv) The HMO may not require that a newborn child receive health care services only from network physicians or providers after the birth if the newborn child is born outside the HMO service area due to an emergency or born in a non-network facility to a mother who does not have HMO coverage, but may require that the newborn be transferred to a network facility at the HMO's expense and, if applicable, to a network provider when the transfer is medically appropriate as determined by the newborn's treating physician.                      Cont'd...