Section 26.409 - Health Benefit Plans Offered Through Health Group Cooperatives(a) A health benefit plan issued by a health carrier through a health group cooperative is not subject to the following provisions of the Insurance Code or this title: (1) the offer of in vitro fertilization coverage as required by Insurance Code Chapter 1366, Subchapter A (Coverage for In Vitro Fertilization Procedures);(2) coverage of HIV, AIDS, or HIV-related illnesses as required by Insurance Code Chapter 1364, Subchapter A (concerning Exclusion from or Denial of Coverage Prohibited);(3) coverage of chemical dependency and stays in a chemical dependency treatment facility as required by Insurance Code Chapter 1368 (concerning Availability of Chemical Dependency Coverage);(4) coverage or offer of coverage of serious mental illness as required by Insurance Code §§ 1355.001 - 1355.007 (concerning Definitions, Applicability of Subchapter, Exception, Required Coverage for Serious Mental Illness, Managed Care Plan Authorized, Coverage for Certain Conditions Related to Controlled Substance or Marihuana Not Required, Small Employer Coverage);(5) the offer of mental or emotional illness coverage as required by Insurance Code § 1355.106 (concerning Offer of Coverage Required; Alternative Benefits);(6) coverage of inpatient mental health and stays in a psychiatric day treatment facility as required by Insurance Code Chapter 1355, Subchapter C (concerning Psychiatric Day Treatment Facilities);(7) the offer of speech and hearing coverage as required by Insurance Code Chapter 1365 (concerning Loss or Impairment of Speech or Hearing);(8) coverage of mammography screening for the presence of occult breast cancer as required by Insurance Code § 1356.005 (concerning Coverage Required);(9) standards for proof of Alzheimer's disease as required by Insurance Code § 1354.002 (concerning Proof of Organic Disease);(10) coverage of stays in a crisis stabilization unit or residential treatment center for children and adolescents as required by Insurance Code § 1355.055 (concerning Determinations for Treatment in a Residential Treatment Center for Children and Adolescents) and §1355.056 (concerning Determinations for Treatment by a Crisis Stabilization Unit);(11) coverage for formulas necessary for the treatment of phenylketonuria as required by Insurance Code Chapter 1359 (concerning Formulas for Individuals with Phenylketonuria or Other Heritable Diseases);(12) coverage of contraceptive drugs and devices as required by Insurance Code Chapter 1369, Subchapter C (concerning Coverage of Prescription Contraceptive Drugs and Devices and Related Services) and § 21.404(3) of this title (relating to Underwriting);(13) coverage of diagnosis and treatment affecting temporomandibular joint and treatment for a person unable to undergo dental treatment in an office setting or under local anesthesia as required by Insurance Code Chapter 1360 (concerning Diagnosis and Treatment Affecting Temporomandibular Joint);(14) coverage of bone mass measurement for osteoporosis as required by Insurance Code Chapter 1361 (concerning Detection and Prevention of Osteoporosis);(15) coverage of diabetes care as required by Insurance Code Chapter 1358 (concerning Diabetes);(16) coverage of childhood immunizations as required by Insurance Code Chapter 1367, Subchapter B (concerning Childhood Immunizations);(17) coverage for screening tests for hearing loss in children and related diagnostic follow-up care as required by Insurance Code Chapter 1367 Subchapter C (concerning Hearing Test);(18) offer of coverage for therapies for children with developmental delays as required by Insurance Code Chapter 1367, Subchapter E (concerning Developmental Delays);(19) coverage of certain tests for detection of prostate cancer as required by Insurance Code Chapter 1362 (concerning Certain Tests for Detection of Prostate Cancer);(20) coverage of acquired brain injury treatment and services as required by Insurance Code Chapter 1352 (concerning Brain Injury);(21) coverage of certain tests for detection of colorectal cancer as required by Insurance Code Chapter 1363 (concerning Certain Tests for Detection of Colorectal Cancer);(22) coverage for reconstructive surgery for craniofacial abnormalities in a child as required by Insurance Code Chapter 1367, Subchapter D (concerning Childhood Craniofacial Abnormalities);(23) coverage of rehabilitation therapies as required by Insurance Code § 1271.156 (concerning Benefits for Rehabilitation Services and Therapies);(24) limitations on the treatment of complications in pregnancy established by § 21.405 of this title (relating to Policy Terms and Conditions);(25) coverage for services related to immunizations and vaccinations under managed care plans as required by Insurance Code Chapter 1353 (concerning Immunization or Vaccination Protocols under Managed Care Plans);(26) coverage of a minimum stay for maternity as required by Insurance Code Chapter 1366, Subchapter B (concerning Minimum Inpatient Stay Following Birth of Child and Postdelivery Care);(27) coverage of reconstructive surgery incident to mastectomy as required by Insurance Code Chapter 1357, Subchapter A (concerning Reconstructive Surgery Following Mastectomy);(28) coverage of a minimum stay for mastectomy treatment and services as required by Insurance Code Chapter 1357, Subchapter B (concerning Hospital Stay Following Mastectomy and Certain Related Procedures);(29) coverage of autism spectrum disorder as required by the Insurance Code § 1355.015 (concerning Required Coverage for Certain Enrollees);(30) transplant donor coverage, as established by 28 TAC § 3.3040(h) of this title (relating to Prohibited Policy Provisions);(31) coverage for certain tests for detection of human papillomavirus, ovarian cancer, and cervical cancer as required by Insurance Code Chapter 1370 (concerning Certain Tests for Detection of Human Papillomavirus, Ovarian Cancer, and Cervical Cancer);(32) coverage of certain tests for detection of cardiovascular disease as required by Insurance Code Chapter 1376 (concerning Certain Tests for Early Detection of Cardiovascular Disease);(33) coverage of certain amino acid-based elemental formulas as required by Insurance Code Chapter 1377 (concerning Coverage for Certain Amino Acid-Based Elemental Formulas);(34) coverage of prosthetic devices, orthotic devices, and related services as required by Insurance Code Chapter 1371 (concerning Coverage for Certain Prosthetic Devices, Orthotic Devices, and Related Services); and(35) coverage of orally-administered anticancer medications as required by Insurance Code Chapter 1369 (concerning Benefits Related to Prescription Drugs and Devices and Related Services).(b) A health benefit plan issued by an HMO through a health group cooperative must provide for the basic health care services as provided in § 11.508 or § 11.509 of this title (relating to Mandatory Benefit Standards: Group, Individual and Conversion Agreements; and Additional Mandatory Benefit Standards: Group Agreement Only).(c) A health benefit plan offered by an insurer through a health group cooperative is not subject to § 3.3704(a)(6) of this title (relating to Freedom of Choice; Availability of Preferred Providers).28 Tex. Admin. Code § 26.409
The provisions of this §26.409 adopted to be effective August 31, 2004, 29 TexReg 8360; amended to be effective January 31, 2006, 31 TexReg 512; amended to be effective October 4, 2009, 34 TexReg 6656; Amended by Texas Register, Volume 42, Number 19, May 12, 2017, TexReg 2560, eff. 5/17/2017