28 Tex. Admin. Code § 11.512

Current through Reg. 50, No. 1; January 3, 2025

Section 11.512 - Optional Benefits

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).

28 Tex. Admin. Code § 11.512

The provisions of this §11.512 adopted to be effective November 2, 1998, 23 TexReg 11347; amended to be effective February 24, 2005, 30 TexReg 854; Adopted by Texas Register, Volume 42, Number 16, April 21, 2017, TexReg 2232, eff. 8/1/2017