Availability of Plan Information

(a) Criteria for medical necessity determinations. The criteria for medical necessity determinations made under a health benefit plan with respect to mental health or substance use disorder benefits must be made available by the issuer to any enrollee or contracting provider upon request, consistent with Insurance Code Chapters 843 and 1301.

(b) Reason for denial. The reason for any denial under a health benefit plan with respect to mental health or substance use disorder benefits in the case of any enrollee must be made available by the issuer in a form and manner consistent with Insurance Code §4201.303, concerning Adverse Determination: Contents of Notice.

(c) Provisions of other law. Compliance with the disclosure requirements in subsections (a) and (b) of this section is not determinative of compliance with any other provision of applicable federal or state law.

Source Note: The provisions of this §21.2411 adopted to be effective September 7, 2021, 46 TexReg 5571.