reglab/statecodes huggingface dataset:
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle G - Health Coverage Availability › Chapter 1501 - Health Insurance Portability and Availability Act › Subchapter C. Provision of Coverage › Section 1501.107. Discounts, Rebates, and Reductions

Sec. 1501.107.  DISCOUNTS, REBATES, AND REDUCTIONS.  (a)  A small or large employer health benefit plan issuer may establish premium discounts, rebates, or a reduction in otherwise applicable copayments, coinsurance, or deductibles, or any combination of these incentives, in return for participation in programs promoting disease prevention, wellness, and health.
(b)  A discount, rebate, or reduction established under this section does not violate Section 541.056(a).
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
Amended by:
Acts 2007, 80th Leg., R.S., Ch. 112 (H.B. 2252), Sec. 3, eff. May 17, 2007.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle G - Health Coverage Availability › Chapter 1501 - Health Insurance Portability and Availability Act › Subchapter C. Provision of Coverage › Section 1501.108. Renewability of Coverage; Cancellation

Sec. 1501.108.  RENEWABILITY OF COVERAGE;  CANCELLATION.  (a)  Except as provided by this section and Section 1501.109, a small or large employer health benefit plan issuer shall renew the small or large employer health benefit plan for any covered small or large employer, as applicable, at the employer's option, unless:
(1)  a premium has not been paid as required by the terms of the plan;
(2)  the employer has committed fraud or has intentionally misrepresented a material fact;
(3)  the employer has not complied with the terms of the plan;
(4)  no enrollee in the plan resides or works in the geographic service area of the small or large employer health benefit plan issuer or in the area for which the issuer is authorized to do business;  or
(5)  membership of the employer in an association terminates, but only if coverage is terminated uniformly without regard to a health status related factor of a covered individual.
(b)  A small or large employer health benefit plan issuer may refuse to renew the coverage of a covered employee or dependent for fraud or intentional misrepresentation of a material fact by that individual.
(c)  A small or large employer health benefit plan issuer may not cancel a small or large employer health benefit plan except for a reason specified for refusal to renew under Subsection (a).  A small or large employer health benefit plan issuer may not cancel the coverage of a covered employee or dependent except for a reason specified for refusal to renew under Subsection (b).
(d)  Notwithstanding Subsection (a), a small or large employer health benefit plan issuer may modify a small or large employer health benefit plan in accordance with Section 1369.0541 or if:
(1)  the modification occurs at the time of coverage renewal;
(2)  the modification is effective uniformly among all small or large employers covered by that health benefit plan; and
(3)  the issuer notifies the commissioner and each affected covered small or large employer of the modification not later than the 60th day before the date the modification is effective.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
Amended by:
Acts 2007, 80th Leg., R.S., Ch. 891 (H.B. 2467), Sec. 1, eff. September 1, 2007.
Acts 2011, 82nd Leg., R.S., Ch. 501 (H.B. 1405), Sec. 8, eff. September 1, 2011.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle G - Health Coverage Availability › Chapter 1501 - Health Insurance Portability and Availability Act › Subchapter C. Provision of Coverage › Section 1501.109. Refusal to Renew; Discontinuation of Coverage

Sec. 1501.109.  REFUSAL TO RENEW;  DISCONTINUATION OF COVERAGE.  (a)  A small or large employer health benefit plan issuer may elect to refuse to renew all small or large employer health benefit plans delivered or issued for delivery by the issuer in this state or in a geographic service area.  The issuer shall notify:
(1)  the commissioner of the election not later than the 180th day before the date coverage under the first plan terminates under this subsection; and
(2)  each affected covered small or large employer not later than the 180th day before the date coverage terminates for that employer.
(b)  A small employer health benefit plan issuer that elects under this section to refuse to renew all small employer health benefit plans in this state or in a geographic service area may not write a new small employer health benefit plan in this state or in the geographic service area, as applicable, before the fifth anniversary of the date notice is provided to the commissioner under Subsection (a).
(c)  A large employer health benefit plan issuer that elects under this section to refuse to renew all large employer health benefit plans in this state or in a geographic service area may not write a new large employer health benefit plan in this state or in the geographic service area, as applicable, before the fifth anniversary of the date notice is provided to the commissioner under Subsection (a).
(d)  A small or large employer health benefit plan issuer may elect to discontinue a particular type of small or large employer coverage only if the issuer:
(1)  before the 90th day preceding the date of the discontinuation of the coverage:
(A)  provides notice of the discontinuation to the employer and the commissioner;  and
(B)  offers to each employer the option to purchase other small or large employer coverage offered by the issuer at the time of the discontinuation;  and
(2)  acts uniformly without regard to the claims experience of the employer or any health status related factors of eligible employees, eligible employees' dependents, or new employees or dependents who may become eligible for the coverage.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
Amended by:
Acts 2015, 84th Leg., R.S., Ch. 42 (S.B. 784), Sec. 2.01, eff. September 1, 2015.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle G - Health Coverage Availability › Chapter 1501 - Health Insurance Portability and Availability Act › Subchapter C. Provision of Coverage › Section 1501.110. Notice to Covered Persons

Sec. 1501.110.  NOTICE TO COVERED PERSONS.  (a)  A small or large employer health benefit plan issuer that cancels or refuses to renew coverage under a small or large employer health benefit plan under Section 1501.108 or 1501.109 shall, not later than the 30th day before the date termination of coverage is effective, notify the small or large employer of the cancellation of or refusal to renew coverage.  The employer is responsible for notifying enrollees in the plan of the cancellation of or refusal to renew coverage.
(b)  The notice provided to a small or large employer by a small or large employer health benefit plan issuer under this section is in addition to any other notice required by Section 1501.109.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle G - Health Coverage Availability › Chapter 1501 - Health Insurance Portability and Availability Act › Subchapter C. Provision of Coverage › Section 1501.111. Written Statement of Denial, Cancellation, or Refusal to Renew Required

Sec. 1501.111.  WRITTEN STATEMENT OF DENIAL, CANCELLATION, OR REFUSAL TO RENEW REQUIRED.  Denial by a small or large employer health benefit plan issuer of an application from a small or large employer for coverage from the issuer or cancellation of or refusal to renew coverage by a small or large employer health benefit plan issuer must:
(1)  be in writing;  and
(2)  state the reason or reasons for the denial, cancellation, or refusal to renew.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle G - Health Coverage Availability › Chapter 1501 - Health Insurance Portability and Availability Act › Subchapter D. Guaranteed Issue of Small Employer Health Benefit Plans; Continuation of Coverage › Section 1501.151. Guaranteed Issue

Sec. 1501.151.  GUARANTEED ISSUE.  (a)  A small employer health benefit plan issuer shall issue the small employer health benefit plan chosen by the small employer to each small employer that elects to be covered under the plan and agrees to satisfy the other requirements of the plan.
(b)  A small employer health benefit plan issuer shall provide small employer health benefit plans without regard to health status related factors.
(c)  This chapter does not require a small employer to purchase health coverage for the employer's employees.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle G - Health Coverage Availability › Chapter 1501 - Health Insurance Portability and Availability Act › Subchapter D. Guaranteed Issue of Small Employer Health Benefit Plans; Continuation of Coverage › Section 1501.152. Exclusion of Eligible Employee or Dependent Prohibited

Sec. 1501.152.  EXCLUSION OF ELIGIBLE EMPLOYEE OR DEPENDENT PROHIBITED.  A small employer health benefit plan issuer may not exclude an eligible employee or dependent, including a late enrollee, who would otherwise be covered under a small employer group.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle G - Health Coverage Availability › Chapter 1501 - Health Insurance Portability and Availability Act › Subchapter D. Guaranteed Issue of Small Employer Health Benefit Plans; Continuation of Coverage › Section 1501.153. Employer Contribution

Sec. 1501.153.  EMPLOYER CONTRIBUTION.  (a)  This chapter does not require a small employer to make an employer contribution to the premium paid to a small employer health benefit plan issuer, but the issuer may require an employer contribution in accordance with the issuer's usual and customary practices applicable to the issuer's employer group health benefit plans in this state.  The issuer shall apply the employer contribution level uniformly to each small employer offered or issued coverage by the issuer in this state.
(a-1)  Notwithstanding Subsection (a), a small employer health benefit plan issuer may offer a small employer the option of a small employer health benefit plan for which the employer is required to contribute 100 percent of the premium paid.  A plan offered under this subsection may be offered in addition to a plan offered by the issuer in accordance with Subsection (a) that requires a lower percentage of the premium paid to be contributed by the employer.  A plan issued under this subsection must require the employer to contribute 100 percent of the premium paid for each eligible participating employee.
(b)  If two or more small employer health benefit plan issuers participate in a purchasing cooperative established under Section 1501.056, each participating issuer may use the employer contribution requirement established by the cooperative for policies marketed by the cooperative.
(c)  A small employer that elects to make an employer contribution to the premium paid to a small employer health benefit plan issuer is not required to pay any amount with respect to an employee who elects not to be covered.
(d)  A small employer may elect to pay the premium for additional coverage.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
Amended by:
Acts 2009, 81st Leg., R.S., Ch. 462 (S.B. 80), Sec. 1, eff. September 1, 2009.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle G - Health Coverage Availability › Chapter 1501 - Health Insurance Portability and Availability Act › Subchapter D. Guaranteed Issue of Small Employer Health Benefit Plans; Continuation of Coverage › Section 1501.154. Minimum Participation Requirement

Sec. 1501.154.  MINIMUM PARTICIPATION REQUIREMENT.  (a)  Except as provided by Section 1501.155, coverage is available under a small employer health benefit plan if at least 75 percent of a small employer's eligible employees elect to participate in the plan.
(b)  If a small employer offers multiple health benefit plans, the collective participation in those plans must be at least:
(1)  75 percent of the employer's eligible employees;  or
(2)  if applicable, the lower participation level offered by the small employer health benefit plan issuer under Section 1501.155.
(c)  A small employer health benefit plan issuer may elect not to offer a health benefit plan to a small employer that offers multiple health benefit plans if:
(1)  the plans are provided by more than one issuer; and
(2)  the issuer would have less than 75 percent of the employer's eligible employees enrolled in the issuer's plan.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
Amended by:
Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.054(a), eff. September 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle G - Health Coverage Availability › Chapter 1501 - Health Insurance Portability and Availability Act › Subchapter D. Guaranteed Issue of Small Employer Health Benefit Plans; Continuation of Coverage › Section 1501.155. Exception to Minimum Participation Requirement

Sec. 1501.155.  EXCEPTION TO MINIMUM PARTICIPATION REQUIREMENT.  (a)  A small employer health benefit plan issuer may offer a small employer health benefit plan to a small employer with a participation level of less than 75 percent of the employer's eligible employees if the issuer permits the same qualifying participation level for each small employer health benefit plan offered by the issuer in this state.
(b)  A small employer health benefit plan issuer may offer a small employer health benefit plan to a small employer even if the employer's participation level is less than the issuer's qualifying participation level established in accordance with Subsection (a) if:
(1)  the employer obtains a written waiver from each eligible employee who declines coverage under a health benefit plan offered to the employer stating that the employee was not induced or pressured to decline coverage because of the employee's risk characteristics;  and
(2)  the issuer accepts or rejects the entire group of eligible employees who choose to participate and excludes only those employees who have declined coverage.
(c)  A small employer health benefit plan issuer may underwrite the group of eligible employees who do not decline coverage under Subsection (b).
(d)  A small employer health benefit plan issuer may not provide coverage to a small employer or the employer's employees under Subsection (b) if the issuer or an agent for the issuer knows that the employer has induced or pressured an eligible employee or a dependent of the employee to decline coverage because of the individual's risk characteristics.
(e)  A small employer health benefit plan issuer, a small employer, or an agent may not use the exception provided by Subsection (b) to circumvent the requirements of this chapter.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle G - Health Coverage Availability › Chapter 1501 - Health Insurance Portability and Availability Act › Subchapter D. Guaranteed Issue of Small Employer Health Benefit Plans; Continuation of Coverage › Section 1501.156. Employee Enrollment; Waiting Period

Sec. 1501.156.  EMPLOYEE ENROLLMENT;  WAITING PERIOD.  (a)  The initial enrollment period under a small employer health benefit plan for employees and dependents must be at least 31 days, with a 31-day open enrollment period provided annually.
(b)  A small employer may establish a waiting period not to exceed 90 days from the first day of employment.
(c)  A small employer health benefit plan issuer may not deny coverage to a new employee of a covered small employer or the employee's dependents if the issuer receives an application for coverage not later than the 31st day after the date employment begins or on completion of a waiting period established under Subsection (b).
(d)  A small employer health benefit plan issuer may deny coverage to a late enrollee until the next annual open enrollment period and may subject the enrollee to a one-year preexisting condition provision as described by Section 1501.102.  The period during which the preexisting condition provision applies may not exceed 18 months from the date of the initial application.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle G - Health Coverage Availability › Chapter 1501 - Health Insurance Portability and Availability Act › Subchapter D. Guaranteed Issue of Small Employer Health Benefit Plans; Continuation of Coverage › Section 1501.157. Coverage for Newborn Children

Sec. 1501.157.  COVERAGE FOR NEWBORN CHILDREN.  (a)  A small employer health benefit plan may not limit or exclude initial coverage of a newborn child of a covered employee.
(b)  Coverage of a newborn child of a covered employee under this section ends on the 32nd day after the date of the child's birth unless, not later than the 31st day after the date of birth, the small employer health benefit plan issuer receives:
(1)  notice of the birth;  and
(2)  any required additional premium.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle G - Health Coverage Availability › Chapter 1501 - Health Insurance Portability and Availability Act › Subchapter D. Guaranteed Issue of Small Employer Health Benefit Plans; Continuation of Coverage › Section 1501.158. Coverage for Adopted Children

Sec. 1501.158.  COVERAGE FOR ADOPTED CHILDREN.  (a)  A small employer health benefit plan may not limit or exclude initial coverage of an adopted child of an insured.  A child is considered to be the child of an insured if the insured is a party to a suit in which the insured seeks to adopt the child.
(b)  An adopted child of an insured may be enrolled, at the insured's option, not later than the 31st day after:
(1)  the date the insured becomes a party to a suit in which the insured seeks to adopt the child;  or
(2)  the date the adoption becomes final.
(c)  Coverage of an adopted child of an insured under this section ends unless the small employer health benefit plan issuer receives notice of the adoption and any required additional premium not later than the 31st day after:
(1)  the date the insured becomes a party to a suit in which the insured seeks to adopt the child;  or
(2)  the date the adoption becomes final.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle G - Health Coverage Availability › Chapter 1501 - Health Insurance Portability and Availability Act › Subchapter D. Guaranteed Issue of Small Employer Health Benefit Plans; Continuation of Coverage › Section 1501.159. Continuation of Coverage for Certain Dependents

Sec. 1501.159.  CONTINUATION OF COVERAGE FOR CERTAIN DEPENDENTS.  An employee's dependent may choose to continue coverage under a small employer health benefit plan if:
(1)  the dependent:
(A)  is under one year of age;  or
(B)  has been covered by the small employer under a plan for at least one year;
(2)  the dependent loses eligibility for coverage because of the death, divorce, or retirement of the employee, as provided by Subchapter G, Chapter 1251;  and
(3)  the Consolidated Omnibus Budget Reconciliation Act of 1985 (Pub. L. No. 99-272) does not require continuation or conversion coverage for dependents of an employee.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle G - Health Coverage Availability › Chapter 1501 - Health Insurance Portability and Availability Act › Subchapter E. Underwriting and Rating of Small Employer Health Benefit Plans › Section 1501.201. Definitions

Sec. 1501.201.  DEFINITIONS.  In this subchapter:
(1)  "Base premium rate" means, for each class of business and for a specific rating period, the lowest premium rate that is charged or that could be charged under a rating system for that class of business by a small employer health benefit plan issuer to small employers with similar case characteristics for small employer health benefit plans that provide the same or similar coverage.
(2)  "Case characteristics" means, with respect to a small employer, the geographic area in which the employer's employees reside, the age and gender of the individual employees and their dependents, the number of employees and dependents, the appropriate industry classification as determined by the small employer health benefit plan issuer, and other objective criteria established by the issuer that are considered by the issuer in setting premium rates for the employer.  The term does not include:
(A)  health status related factors;
(B)  duration of coverage since the date of issuance of a health benefit plan;  or
(C)  whether a covered individual is or may become pregnant.
(3)  "Class of business" means all small employers or a separate grouping of small employers established under this subchapter.
(4)  "Index rate" means, for each class of business and for a specific rating period for small employers with similar case characteristics, the arithmetic average of the applicable base premium rate and corresponding highest premium rate.
(5)  "New business premium rate" means, for each class of business and for a specific rating period, the lowest premium rate that is charged or offered or that could be charged or offered by a small employer health benefit plan issuer to small employers with similar case characteristics for newly issued small employer health benefit plans that provide the same or similar coverage.
(6)  "Rating period" means a calendar period during which premium rates established by a small employer health benefit plan issuer are assumed to be in effect.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle G - Health Coverage Availability › Chapter 1501 - Health Insurance Portability and Availability Act › Subchapter E. Underwriting and Rating of Small Employer Health Benefit Plans › Section 1501.202. Establishment of Classes of Business

Sec. 1501.202.  ESTABLISHMENT OF CLASSES OF BUSINESS.  (a)  Except as otherwise provided by this subchapter, a small employer health benefit plan issuer may not establish a separate class or classes of business for small employers.
(b)  A small employer health benefit plan issuer may establish a separate class of business only to reflect substantial differences in expected claims experience or administrative costs related to the following reasons:
(1)  the issuer uses more than one type of system to market and sell small employer health benefit plans to small employers;
(2)  the issuer has acquired a class of business from another small employer health benefit plan issuer;  or
(3)  the issuer provides coverage to one or more employer-based association groups.
(c)  Except as provided by Subsection (e), a small employer health benefit plan issuer may not establish more than nine separate classes of business under this section.
(d)  The commissioner may adopt rules to provide for a transition period to permit a small employer health benefit plan issuer to comply with Subsection (c) after acquiring an additional class of business from another small employer health benefit plan issuer.
(e)  On application to the commissioner, the commissioner may approve the establishment of additional classes of business if the commissioner finds that the establishment of additional classes would enhance the efficiency and fairness of the health coverage market for small employers.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle G - Health Coverage Availability › Chapter 1501 - Health Insurance Portability and Availability Act › Subchapter E. Underwriting and Rating of Small Employer Health Benefit Plans › Section 1501.203. Establishment of Classes of Business on Certain Bases Prohibited

Sec. 1501.203.  ESTABLISHMENT OF CLASSES OF BUSINESS ON CERTAIN BASES PROHIBITED.  (a)  A small employer health benefit plan issuer may not establish a separate class of business based on:
(1)  participation requirements;  or
(2)  whether the coverage provided to a small employer group is provided on a guaranteed issue basis or is subject to underwriting or proof of insurability.
(b)  A small employer health benefit plan issuer may not directly or indirectly use as a criterion for establishing a separate class of business:
(1)  the number of employees and dependents of a small employer;  or
(2)  except as provided by Section 1501.202(b)(3), the trade or occupation of the employees of a small employer or the industry or type of business of the small employer.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle G - Health Coverage Availability › Chapter 1501 - Health Insurance Portability and Availability Act › Subchapter E. Underwriting and Rating of Small Employer Health Benefit Plans › Section 1501.204. Index Rates

Sec. 1501.204.  INDEX RATES.  Under a small employer health benefit plan:
(1)  the index rate for a class of business may not exceed the index rate for any other class of business by more than 20 percent;  and
(2)  premium rates charged during a rating period to small employers in a class of business with similar case characteristics for the same or similar coverage, or premium rates that could be charged to those employers under the rating system for that class of business, may not vary from the index rate by more than 25 percent.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle G - Health Coverage Availability › Chapter 1501 - Health Insurance Portability and Availability Act › Subchapter E. Underwriting and Rating of Small Employer Health Benefit Plans › Section 1501.205. Premium Rates: Establishment

Sec. 1501.205.  PREMIUM RATES:  ESTABLISHMENT.  (a)  In this section:
(1)  "Risk characteristic" means:
(A)  a health status related factor;
(B)  the duration of coverage;  or
(C)  any characteristic similar to a characteristic described by Paragraph (A) or (B) that is related to the health status or experience of a small employer group or of any member of a small employer group.
(2)  "Risk load" means the percentage above the applicable base premium rate a small employer health benefit plan issuer charges to a small employer to reflect the risk characteristics associated with that particular small employer group.
(b)  Small employer health benefit plan issuers shall develop premium rates for each small employer group in a two-step process.  In the first step, the small employer health benefit plan issuer shall develop a base premium rate for each small employer group without regard to any risk characteristic of the group.  In the second step, the small employer health benefit plan issuer may adjust the resulting base premium rate by the risk load of the group, subject to this subchapter, to reflect the risk characteristics of the group.
(c)  The risk load assessed to a particular group shall reflect the risk characteristics of the particular group.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle G - Health Coverage Availability › Chapter 1501 - Health Insurance Portability and Availability Act › Subchapter E. Underwriting and Rating of Small Employer Health Benefit Plans › Section 1501.206. Premium Rates: Adjustments

Sec. 1501.206.  PREMIUM RATES:  ADJUSTMENTS.  (a)  The percentage increase in the premium rate charged to a small employer for a new rating period may not exceed the sum of:
(1)  the percentage change in the new business premium rate, measured from the first day of the preceding rating period to the first day of the new rating period;
(2)  any adjustment, not to exceed 15 percent annually and adjusted pro rata for a rating period of less than one year, due to the claims experience, health status, or duration of coverage of the employees or dependents of employees of the small employer, as determined under the small employer health benefit plan issuer's rate manual for the class of business;  and
(3)  any adjustment due to change in coverage or change in the case characteristics of the small employer, as determined under the issuer's rate manual for the class of business.
(b)  An adjustment in the premium rate for claims experience, health status, or duration of coverage:
(1)  may not be charged to individual employees or dependents;  and
(2)  must be applied uniformly to the rates charged for all employees and dependents of employees of the small employer.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle G - Health Coverage Availability › Chapter 1501 - Health Insurance Portability and Availability Act › Subchapter E. Underwriting and Rating of Small Employer Health Benefit Plans › Section 1501.207. Premium Rate Adjustment in Closed Plan

Sec. 1501.207.  PREMIUM RATE ADJUSTMENT IN CLOSED PLAN.  For a closed health benefit plan under which a small employer health benefit plan issuer is no longer enrolling new small employers, the issuer shall use the percentage change in the base premium rate to adjust premium rates under Section 1501.206(a)(1).  The portion of change in premium rates computed under that subdivision may not exceed, on a percentage basis, the change in the new business premium rate for the most similar health benefit plan under which the issuer is enrolling new small employers.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle G - Health Coverage Availability › Chapter 1501 - Health Insurance Portability and Availability Act › Subchapter E. Underwriting and Rating of Small Employer Health Benefit Plans › Section 1501.208. Premium Rates: Industry Classification

Sec. 1501.208.  PREMIUM RATES:  INDUSTRY CLASSIFICATION.  A small employer health benefit plan issuer may use the industry classification to which a small employer belongs as a case characteristic in establishing the premium rate, but the highest rate factor associated with any industry classification may not exceed by more than 15 percent the lowest rate factor associated with any industry classification.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle G - Health Coverage Availability › Chapter 1501 - Health Insurance Portability and Availability Act › Subchapter E. Underwriting and Rating of Small Employer Health Benefit Plans › Section 1501.209. Premium Rates: Number of Employees

Sec. 1501.209.  PREMIUM RATES:  NUMBER OF EMPLOYEES.  A small employer health benefit plan issuer may use the number of employees and dependents of a small employer as a case characteristic in establishing premium rates for the group.  The highest rate factor associated with a classification based on the number of employees and dependents of a small employer may not exceed by more than 20 percent the lowest rate factor associated with a classification based on the number of employees and dependents of a small employer.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle G - Health Coverage Availability › Chapter 1501 - Health Insurance Portability and Availability Act › Subchapter E. Underwriting and Rating of Small Employer Health Benefit Plans › Section 1501.210. Premium Rates: Nondiscrimination

Sec. 1501.210.  PREMIUM RATES:  NONDISCRIMINATION.  (a)  A small employer health benefit plan issuer shall apply rating factors, including case characteristics, consistently with respect to all small employers in a class of business.  Rating factors must produce premium rates for identical groups that:
(1)  differ only by the amounts attributable to health benefit plan design;  and
(2)  do not reflect differences because of the nature of the groups assumed to select particular health benefit plans.
(b)  A small employer health benefit plan issuer shall treat each health benefit plan issued or renewed in the same calendar month as having the same rating period.
(c)  Without the prior approval of the commissioner, a small employer health benefit plan issuer may not use case characteristics other than:
(1)  the geographic area in which the small employer's employees reside;
(2)  the age and gender of the individual employees and their dependents;
(3)  the number of employees and dependents;  and
(4)  the appropriate industry classification.
(d)  Premium rates for a small employer health benefit plan must comply with the requirements of this chapter, notwithstanding any assessment paid or payable by a small employer health benefit plan issuer.
(e)  A small employer health benefit plan issuer may not transfer a small employer involuntarily into or out of a class of business.  The issuer may not offer to transfer a small employer into or out of a class of business unless the offer is made to transfer all other small employers in the employer's class of business without regard to case characteristics, claims experience, health status, or duration of coverage since the issuance of the health benefit plan.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle G - Health Coverage Availability › Chapter 1501 - Health Insurance Portability and Availability Act › Subchapter E. Underwriting and Rating of Small Employer Health Benefit Plans › Section 1501.211. Rules Concerning Premium Rates

Sec. 1501.211.  RULES CONCERNING PREMIUM RATES.  Rules adopted under Section 1501.010 may ensure that:
(1)  rating practices used by small employer health benefit plan issuers are consistent with the purposes of this chapter;  and
(2)  differences in premium rates charged for each small employer health benefit plan are reasonable and reflect objective differences in plan design.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle G - Health Coverage Availability › Chapter 1501 - Health Insurance Portability and Availability Act › Subchapter E. Underwriting and Rating of Small Employer Health Benefit Plans › Section 1501.212. Restricted Provider Network

Sec. 1501.212.  RESTRICTED PROVIDER NETWORK.  (a)  A small employer health benefit plan may use a restricted provider network to provide benefits under the plan.
(b)  A small employer health benefit plan that uses a restricted provider network does not provide similar coverage to a plan that does not use a restricted provider network if the use of the network results in reduced premium rates charged to the small employer or substantial differences in claim costs.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle G - Health Coverage Availability › Chapter 1501 - Health Insurance Portability and Availability Act › Subchapter E. Underwriting and Rating of Small Employer Health Benefit Plans › Section 1501.213. Premium Rates: Health Maintenance Organization Health Benefit Plan

Sec. 1501.213.  PREMIUM RATES:  HEALTH MAINTENANCE ORGANIZATION HEALTH BENEFIT PLAN.  (a)  The premium rates for a state-approved health benefit plan offered by a health maintenance organization under Section 1501.255 must be established in accordance with formulas or schedules of charges filed with the department.
(b)  A health maintenance organization that participates in a purchasing cooperative that provides employees of small employers a choice of health benefit plans may use rating methods in accordance with this subchapter that are used by other small employer health benefit plan issuers participating in the same cooperative, including rating by age and gender, if the health maintenance organization has established:
(1)  a separate class of business, as provided by Section 1501.202; and
(2)  a separate line of business, as provided under Section 1501.255(b).
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
Amended by:
Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.055(a), eff. September 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle G - Health Coverage Availability › Chapter 1501 - Health Insurance Portability and Availability Act › Subchapter E. Underwriting and Rating of Small Employer Health Benefit Plans › Section 1501.214. Enforcement

Sec. 1501.214.  ENFORCEMENT.  If the commissioner determines that a small employer health benefit plan issuer subject to this chapter exceeds the applicable premium rate established under this subchapter, the commissioner may order restitution and assess penalties as provided by Chapter 82.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle G - Health Coverage Availability › Chapter 1501 - Health Insurance Portability and Availability Act › Subchapter E. Underwriting and Rating of Small Employer Health Benefit Plans › Section 1501.215. Reporting Requirements

Sec. 1501.215.  REPORTING REQUIREMENTS.  (a)  Annually, each small employer health benefit plan issuer that offers a small employer health benefit plan shall file with the commissioner an actuarial certification stating that the issuer's underwriting and rating methods:
(1)  comply with accepted actuarial practices;
(2)  are uniformly applied to each small employer health benefit plan covering a small employer;  and
(3)  comply with this subchapter.
(b)  Each small employer health benefit plan issuer shall maintain at its principal place of business a complete and detailed description of its rating practices and renewal underwriting practices, including information and documentation that demonstrate that its rating methods and practices are based on commonly accepted actuarial assumptions and are in accordance with sound actuarial principles.
(c)  A small employer health benefit plan issuer shall make the information and documentation described in Subsection (b) available to the commissioner on request.  Unless the information or documentation relates to a violation of this chapter, the information or documentation is considered proprietary and trade secret information and is not subject to disclosure by the commissioner to a person outside the department except as agreed to by the issuer or as ordered by a court.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle G - Health Coverage Availability › Chapter 1501 - Health Insurance Portability and Availability Act › Subchapter E. Underwriting and Rating of Small Employer Health Benefit Plans › Section 1501.216. Premium Rates: Notice of Increase

Sec. 1501.216.  PREMIUM RATES: NOTICE OF INCREASE.  (a)  Not less than 60 days before the date on which a premium rate increase takes effect on a small employer health benefit plan delivered or issued for delivery in this state by an insurer, the insurer shall:
(1)  give written notice to the small employer of the effective date of the increase; and
(2)  provide the small employer a table that clearly lists:
(A)  the actual dollar amount of the premium on the date of the notice;
(B)  the actual dollar amount of the premium after the premium rate increase; and
(C)  the percentage change between the amounts described by Paragraphs (A) and (B).
(b)  The notice required by this section must be based on coverage in effect on the date of the notice.
(c)  This section may not be construed to prevent an insurer, at the request of a small employer, from negotiating a change in benefits or rates after delivery of the notice required by this section.
(d)  An insurer may not require a small employer entitled to notice under this section to respond to the insurer to renew the policy or take other action relating to the renewal or extension of the policy before the 45th day after the date the notice described by Subsection (a) is given.
(e)  The notice required by this section must include:
(1)  contact information for the department, including information concerning how to file a complaint with the department;
(2)  contact information for the Texas Consumer Health Assistance Program, including information concerning how to request from the program consumer protection information or assistance with filing a complaint; and
(3)  the addresses of Internet websites that provide consumer information related to rate increase justifications, including the websites of the department and the United States Department of Health and Human Services.
Added by Acts 2011, 82nd Leg., R.S., Ch. 1147 (H.B. 1951), Sec. 3.003, eff. September 1, 2011.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle G - Health Coverage Availability › Chapter 1501 - Health Insurance Portability and Availability Act › Subchapter F. Coverage Under Small Employer Health Benefit Plans › Section 1501.251. Exception From Certain Mandated Benefit Requirements

Sec. 1501.251.  EXCEPTION FROM CERTAIN MANDATED BENEFIT REQUIREMENTS.  Except as expressly provided by this chapter, a small employer health benefit plan is not subject to a law that requires coverage or the offer of coverage of a health care service or benefit.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle G - Health Coverage Availability › Chapter 1501 - Health Insurance Portability and Availability Act › Subchapter F. Coverage Under Small Employer Health Benefit Plans › Section 1501.252. Health Benefit Plans

Sec. 1501.252.  HEALTH BENEFIT PLANS.  (a)  A small employer health benefit plan issuer shall offer a standard health benefit plan as authorized by Chapter 1507.
(b)  A small employer health benefit plan issuer may offer to a small employer additional benefit riders to the standard health benefit plan or may design and offer standard health benefit plans with additional mandatory benefits.
(c)  Subject to this chapter, a small employer health benefit plan issuer shall also offer to a small employer at least one other health benefit plan authorized under this code that provides state-mandated health benefits.  Section 1501.251 does not apply to a health benefit plan offered to a small employer under this subsection.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
Amended by:
Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.056(a), eff. September 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle G - Health Coverage Availability › Chapter 1501 - Health Insurance Portability and Availability Act › Subchapter F. Coverage Under Small Employer Health Benefit Plans › Section 1501.254. Alcohol and Substance Abuse Benefits

Sec. 1501.254.  ALCOHOL AND SUBSTANCE ABUSE BENEFITS.  (a)  This section applies only if the basic coverage health benefit plan developed by the commissioner under Section 1501.253 includes coverage for alcohol and substance abuse benefits.
(b)  A small employer health benefit plan issuer may offer and the employees of a small employer group may accept a basic coverage health benefit plan without coverage for alcohol and substance abuse benefits if:
(1)  at least 50 percent of the employees in writing:
(A)  waive the benefits;  and
(B)  indicate that they have undergone alcoholism or substance abuse treatment or counseling within the preceding three years;  and
(2)  the exclusion of those benefits applies only to those employees.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle G - Health Coverage Availability › Chapter 1501 - Health Insurance Portability and Availability Act › Subchapter F. Coverage Under Small Employer Health Benefit Plans › Section 1501.255. Health Maintenance Organization Plans

Sec. 1501.255.  HEALTH MAINTENANCE ORGANIZATION PLANS.  (a)  In this section, "point-of-service contract" means a health benefit plan offered through a health maintenance organization that:
(1)  includes corresponding indemnity benefits in addition to benefits relating to out-of-area or emergency services provided through insurers or group hospital service corporations;  and
(2)  permits the covered individual to obtain coverage under either the health maintenance organization conventional plan or the indemnity plan as determined in accordance with the terms of the contract.
(b)  A health maintenance organization:
(1)  shall offer at least one state-approved basic health care plan that complies with this chapter, Chapters 843, 1271, 1272, and 1367, Subchapter A, Chapter 1452, Subchapter B, Chapter 1507, Title XIII, Public Health Service Act (42 U.S.C. Section 300e et seq.), and its subsequent amendments, and rules adopted under those laws and may offer additional such plans;
(2)  shall offer a standard health benefit plan under Subchapter B, Chapter 1507, and may offer additional benefit riders to the standard health benefit plan or offer standard health benefit plans with additional mandatory benefits; and
(3)  may offer a point-of-service contract in connection with an insurer that includes optional coverage for out-of-area services, emergency care, or out-of-network care.
(c)  A point-of-service contract offered under Subsection (b)(3) is subject to this chapter unless specifically exempted.  The insurer with which the health maintenance organization offers a point-of-service contract is not required to otherwise make available the health benefit plans adopted under this subchapter if the insurer's small employer products are limited to the point-of-service contract.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
Amended by:
Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.057(a), eff. September 1, 2005.
Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.074(i), eff. September 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle G - Health Coverage Availability › Chapter 1501 - Health Insurance Portability and Availability Act › Subchapter F. Coverage Under Small Employer Health Benefit Plans › Section 1501.256. Coordination With Federal Law

Sec. 1501.256.  COORDINATION WITH FEDERAL LAW.  (a)  To the extent required to comply with federal law applicable to a small employer health benefit plan described by this subchapter, the commissioner by rule may:
(1)  modify the plan;  or
(2)  adopt a substitute for the plan.
(b)  The commissioner shall use the Texas Health Benefits Purchasing Cooperative in implementing this section.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.