An HMO may provide health services to its enrollees in addition to the services required in §11.508 of this title (relating to Basic Health Care Services and Mandatory Benefit Standards: Group, Individual and Conversion Agreements). An HMO may limit these optional health services as to time and cost. Evidences of coverage may contain optional benefits, including:
  (1) corrective appliances and artificial aids;
  (2) cosmetic surgery;
  (3) care for military service-connected disabilities for which the enrollee is legally entitled to services and for which facilities are reasonably available to the enrollee;
  (4) care for conditions that state or local law requires be treated in a public facility;
  (5) dental services, except as otherwise required;
  (6) vision care;
  (7) custodial or domiciliary care;
  (8) experimental and investigational medical, surgical, or other experimental or investigational health care procedures, unless approved as a basic health care service by the policymaking body of the HMO, provided that:
    (A) a denial of a request for experimental or investigational services is an adverse determination; and
    (B) an HMO must comply with Chapter 19, Subchapter R, of this title (relating to Utilization Reviews for Health Care Provided Under a Health Benefit Plan or Health Insurance Policy) if the HMO denies requested services because the HMO determines that the requested services are experimental and investigational;
  (9) personal or comfort items and private rooms, unless medically necessary during inpatient hospitalization;
  (10) durable medical equipment for home use (such as wheelchairs, surgical beds, ventilators, or dialysis machines);
  (11) infertility medical services, including gamete intrafallopian transfer (GIFT), zygote intrafallopian transfer (ZIFT), and outpatient infertility drugs;
  (12) reversal of voluntary sterilization;
  (13) prescribed drugs and medicines incident to outpatient care; and
  (14) noninsurance benefits, provided that the HMO complies with Chapter 21, Subchapter NN, of this title (relating to Noninsurance Benefits and Features).

Source Note: The provisions of this §11.512 adopted to be effective August 1, 2017, 42 TexReg 2169