Texas Health plan benefits

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Health Plan Benefits
                                              provided by Texas Department of Insurance (link here)  please see page for updates

Benefits vary from one plan to another. Health plans are classified as either “state-mandated plans” or “consumer choice plans.” A state-mandated plan provides certain required minimum features and coverages. To make health coverage more affordable, Texas law allows carriers to also offer consumer choice plans that do not include all of the state-mandated benefits. Consumer choice plans are required to provide members with a disclosure statement and a list describing the benefits that are not covered. To be certain of the coverages you have with any plan, you should refer to your policy or explanation of coverage.

Although consumer choice plans also may be called “standard plans,” be careful not to interpret the term to mean that the coverages provided are “standardized.”  Each carrier’s consumer choice plan may be different – and, in fact, a carrier may offer several different consumer choice plans.

The following charts show the minimum required benefits for consumer choice and state-mandated health plans. The requirements are different according to whether the plan is an individual, small-employer, or large-employer plan, and whether it is administered by an insurer or an HMO.

Notes: “SMP” denotes a state-mandated plan; “CCP” denotes a consumer choice plan. Benefits labeled “Yes” must be included as part of the plan; benefits labeled “No” are not required; benefits labeled “Offer” must be offered, but you may decline any or all of them if you wish.

Minimum required benefits in individual health plans
Benefit	Fee for Service Plan		HMO
	SMP	CCP	SMP	CCP
Mammography	Yes	Yes	Yes	Yes
Emergency care	Yes, if PPO	Yes, if PPO	Yes	Yes
Alzheimer’s disease (certain requirements if coverage for Alzheimer’s disease is provided)	Yes	Yes	Yes	Yes
Contraceptive drugs and devices (if prescription drugs are covered)	Yes	No	Yes	No
Diabetes equipment, supplies, and training	Yes	Yes	Yes	Yes
Guidelines for diabetes care	Yes	No	Yes	No
Childhood immunizations	Yes	Yes	Yes	Yes
Telehealth and telemedecine	Yes	No	Yes	No
Hearing screenings	Yes	Yes	Yes	Yes
Certain therapies for children with developmental delays	Offer	No	Yes	No
Maternity minimum stay (if maternity is covered)	Yes	Yes, federal	Yes	Yes, federal
Prostate testing	Yes	Yes	Yes	Yes
Reconstructive surgery incident to mastectomy	Yes	Yes, federal	Yes	Yes, federal
Mastectomy minimum stay	Yes	No	Yes	No
Off-label drug use	Yes	No	Yes	No
Acquired brain injury	Yes	No	Yes	No
Detection of colorectal cancer	Yes	Yes	Yes	Yes
Reconstructive surgery for craniofacial abnormalities in a child	Yes	Yes	Yes	Yes
Mental/nervous disorders with demonstrable organic disease	Yes	No	No	No
Transplant donor coverage (certain requirements if transplant coverage is provided)	Yes	No	No	No
Complications of pregnancy	Yes	Yes	Yes	Yes

 

Minimum required benefits in small-employer health plans
Benefit	Fee for Service Plan		HMO
	SMP	CCP	SMP	CCP
In vitro fertilization	Offer	No	Offer	No
HIV, AIDS, or related infection	Yes	No	Yes	No
Chemical dependency, chemical dependency treatment facility	Yes	No	Yes	No
Serious mental illness	Offer	No	Offer	No
Treatment of mental or emotional illness	Yes	No	Yes	Yes
Inpatient mental health, psychiatric day treatment facility	Yes	No	Yes	No
Speech and hearing	Offer	No	Offer	No
Mammography	Yes	Yes	Yes	Yes
Home health care	Offer	No	Yes	Yes
Emergency care (only stabilization)	Yes, if PPO	Yes, if PPO	Yes	Yes
Crisis stabilization unit and residential treatment center for children and adolescents	Yes	No	Yes	No
Alzheimer’s disease (certain requirements if coverage for Alzheimer’s disease is provided)	Yes	Yes	Yes	Yes
PKU treatment (if prescription drugs are covered)	Yes	Yes	Yes	Yes
Contraceptive drugs and devices (if prescription drugs are covered)	Yes	No	Yes	No
Bone mass measurement for osteoporosis	Yes	No	Yes	No
Maternity minimum stay (if maternity is covered)	Yes, state & federal	Yes, federal	Yes, state & federal	Yes, federal
Prostate testing	No	No	No	No
Reconstructive surgery incident to mastectomy	Yes, state & federal	Yes, federal	Yes, state & federal	Yes, federal
Acquired brain injury	Yes	No	Yes	No
Complications of pregnancy	Yes	Yes	Yes	Yes

 

Minimum required benefits in large-employer health plans
Benefit	Fee for Service Plan		HMO
	SMP	CCP	SMP	CCP
In vitro fertilization	Yes	No	Yes	No
HIV, AIDS, or related infections	Yes	No	Yes	No
Chemical dependency, chemical dependency treatment facility	Yes	No	Yes	No
Serious mental illness	Yes	Yes	Yes	Yes
Outpatient treatment of mental or emotional illness	Offer	No	Yes	Yes
Inpatient mental health, psychiatric day treatment facility	Yes	No	Yes	No
Speech and hearing	Offer	No	Yes	No
Mammography	Yes	Yes	Yes	Yes
Home health care	Yes	No	Yes	Yes
Emergency care	Yes, if PPO	Yes, if PPO	Yes	Yes
Crisis stabilization unit and residential treatment center for children and adolescents	Yes	No	Yes	No
Alzheimer’s disease (certain requirements if coverage for Alzheimer’s disease is provided)	Yes	Yes	Yes	Yes
PKU treatment	Yes	Yes	Yes	Yes
Mastectomy minimum stay	Yes	No	Yes	No
Drug formulary, continuation of benefits	Yes	No	Yes	No
Contraceptive drugs and devices (if prescription drugs are covered)	Yes	No	Yes	No
TMJ, coverage for person unable to undergo dental treatment in an office setting or under local anesthesia	Yes	No	Yes	No
Bone mass measurement for osteoporosis	Yes	No	Yes	No
Childhood immunizations	Yes	Yes	Yes	Yes
Telehealth and telemedecine	Yes	No	Yes	No
Hearing screenings	Yes	Yes	Yes	Yes
Certain therapies for children with developmental delays	Offer	No	Yes	No
Maternity minimum stay, if maternity is covered	Yes	Yes, federal	Yes	Yes, federal
Prostate testing	Yes	Yes	Yes	Yes
Diabetes equipment, supplies, and training	Yes	Yes	Yes	Yes
Guidelines for diabetes care	Yes	No	Yes	No
Reconstructive surgery incident to mastectomy	Yes	Yes, federal	Yes	Yes, federal
Off-label drug use	Yes	No	Yes	No
Acquired brain injury	Yes	No	Yes	No
Detection of colorectal cancer	Yes	Yes	Yes	Yes
Reconstructive surgery for craniofacial abnormalities in a child	Yes	Yes	Yes	Yes
Point of service coverage	No	No	Yes	Yes
Complications of pregnancy	Yes	Yes	Yes	Yes

Federally mandated benefits

In addition, the following benefits are required by federal law:

• Maternity and newborn coverage
  
  If maternity benefits are covered, a group health plan with more than 15 employees must provide for a minimum hospital stay of 48 hours after an uncomplicated vaginal delivery, and a minimum stay of 96 hours after an uncomplicated cesarean birth.
  
  A carrier may not deny benefits on the grounds that a pregnancy is a “pre-existing condition.”
  
  Plans that have maternity benefits must automatically extend coverage to the newborn for 31 days. To continue coverage beyond 31 days, you must notify your plan administrator during this period and pay any additional required premiums.
  
  A carrier may not exclude or limit initial coverage of a newborn child because of premature birth, accident, illness, or congenital medical conditions. This includes providing reconstructive surgery for craniofacial abnormalities for a child younger than 18 who has been continually covered by a health plan.
  
  A benefit covering “complications of pregnancy” may help if your plan does not include a maternity benefit. Miscarriages or non-elective cesarean births are considered complications. In most cases, management of a difficult birth is not considered a complication, and is only covered by plans with maternity benefits.
• Mastectomy benefits
  
  Plans that offer mastectomy coverage must also provide for reconstructive surgery of the breast on which the operation was performed, as well as the other breast if needed for a symmetrical appearance. This coverage may be subject to deductibles, copayments, and coinsurance that are consistent with other benefits under the plan. The benefit must also cover prosthesis and treatment of complications at all stages of mastectomy, including lymphedemas.