A qualifying health benefit plan may cover only in-plan services and benefits, with limited exceptions, and must include certain hospital, physician, and prescription drug benefits.
Sec. 1508.104. CERTAIN COVERAGE PROHIBITED OR REQUIRED. (a) A qualifying health benefit plan may only provide coverage for in-plan services and benefits, except for: (1) emergency care; or (2) other services not available through a plan provider. (b) In-plan services and benefits provided under a qualifying health benefit plan must include the following: (1) inpatient hospital services; (2) outpatient hospital services; (3) physician services; and (4) prescription drug benefits. (c) The commissioner may approve in-plan benefits other than those required under Subsection (b) or emergency care or other services not available through a plan provider if the commissioner determines the inclusion to be essential to achieve the purposes of this chapter. (d) The commissioner may, with respect to the categories of services and benefits described by Subsections (b) and (c): (1) prepare specifications for a coverage provided under this chapter; (2) determine the methods and procedures of claims administration; (3) establish procedures to decide contested cases arising from coverage provided under this chapter; (4) study, on an ongoing basis, the operation of all coverages provided under this chapter, including gross and net costs, administration costs, benefits, utilization of benefits, and claims administration; (5) administer the healthy Texas small employer premium stabilization fund established under Subchapter F; (6) provide the beginning and ending dates of coverages for enrollees in a qualifying health benefit plan; (7) develop basic group coverage plans applicable to all individuals eligible to participate in the program; (8) provide for optional group coverage plans in addition to the basic group coverage plans described by Subdivision (7); (9) provide, as determined to be appropriate by the commissioner, additional statewide optional coverage plans; (10) develop specific health benefit plans that permit access to high-quality, cost-effective health care; (11) design, implement, and monitor health benefit plan features intended to discourage excessive utilization, promote efficiency, and contain costs for qualifying health benefit plans; (12) develop and refine, on an ongoing basis, a health benefit strategy for the program that is consistent with evolving benefits delivery systems; (13) develop a funding strategy that efficiently uses employer contributions to achieve the purposes of this chapter; and (14) modify the copayment and deductible amounts for prescription drug benefits under a qualifying health benefit plan, if the commissioner determines that the modification is necessary to achieve the purposes of this chapter. Added by Acts 2009, 81st Leg., R.S., Ch. 721 (S.B. 78), Sec. 2.01, eff. September 1, 2009. SUBCHAPTER D. PROGRAM ADMINISTRATION