(a) A health maintenance organization may offer and issue health benefit plans that reimburse or arrange for covered healthcare services to covered persons through a limited network plan if:
(1) The health maintenance organization provides itself, or arranges through an insurance company, for an annual option for covered persons to choose a health benefit plan or a point-of-service plan that reimburses or arranges for the covered healthcare services from any healthcare provider qualified to render the covered healthcare services;
(2) The difference in the benefit level of the optional health benefit plan or point-of-service plan shall not exceed twenty-five percent (25%) of the benefit level under the limited benefit plan;
(3) The employer or other group contract holder contracting with the health maintenance organization for a health benefit plan shall provide an equal contribution per covered person regardless of which option the covered person chooses pursuant to the provisions of this subchapter; and
(4) Under the optional health benefit plan or point-of-service plan, the rate of reimbursement for healthcare providers out of the network shall be no higher than the normal and usual and customary rate charged by those out-of-network providers on a regular basis, provided that copayment, coinsurance, and other cost-sharing features may be different for out-of-network providers and in-network providers.
(b)
(1) The pricing of the optional health benefit plan or point-of-service plan must provide an expected incurred loss ratio of not less than eighty percent (80%).
(2) The Insurance Commissioner shall promulgate rules as may be necessary to implement the provisions of this subchapter and to ensure that the price of the option provided in this section bears a reasonable relationship to the costs and benefits of the limited network plan.
(c) This subchapter shall apply to any health benefit plan issued or renewed on or after January 1, 2000.