This is a clone of the Texas Administrative Code (TAC) for educational purposes. It is not the official version and should not be used for legal purposes. Site created Wed, 21 May 2025 21:16:49 GMT

TITLE 28 - INSURANCE
PART 1 - TEXAS DEPARTMENT OF INSURANCE
CHAPTER 11 - HEALTH MAINTENANCE ORGANIZATIONS
SUBCHAPTER F - EVIDENCE OF COVERAGE
SECTION/RULE §11.509 - Additional Mandatory Benefit Standards: Individual and Group Agreements
Chapter Review Date 05/05/2022

Individual and group agreements must contain the following additional mandatory provisions as applicable:(1) Certificate. Group agreements must include provisions that the contract holder must be provided with subscriber certificates to be delivered to each subscriber, the certificate is a part of the group contract as if fully incorporated, and any direct conflict between the group agreement and the certificate will be resolved according to the terms most favorable to the subscriber. If the same form is used as both the group contract and the certificate, a copy of the group contract must be delivered to each subscriber.(2) New enrollees. Group agreements must include a provision specifying the conditions under which new enrollees may be added to those originally covered, including effective date requirements. For coverage issued to employers, group agreements must include a provision for special enrollment under 45 C.F.R. §146.117 (concerning Special Enrollment Periods).(3) Agreements must comply with the benefit, offer, coverage, and notice requirements contained in Insurance Code