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 F. Coverage Under Small Employer Health Benefit Plans › Section 1501.2561. Waiver of Certain Federal Requirements

Sec. 1501.2561.  WAIVER OF CERTAIN FEDERAL REQUIREMENTS.  The commissioner may apply to and negotiate with the United States secretary of health and human services to obtain a waiver under 42 U.S.C. Section 18052 for small employer health benefit plans of the actuarial value requirements and related levels of health plan coverage requirements imposed under 42 U.S.C. Section 18022(d)(3).
Added by Acts 2017, 85th Leg., R.S., Ch. 106 (S.B. 1406), Sec. 1, eff. May 23, 2017.
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 1501.257. Cost Containment

Sec. 1501.257.  COST CONTAINMENT.  (a)  A small employer health benefit plan issuer may use cost containment and managed care features in a small employer health benefit plan, including:
(1)  utilization review of health care services, including review of the medical necessity of hospital and physician services;
(2)  case management, including discharge planning and review of stays in hospitals or other health care facilities;
(3)  selective contracting with hospitals, physicians, and other health care providers;
(4)  reasonable benefit differentials applicable to health care providers that participate or do not participate in restricted network arrangements;
(5)  precertification or preauthorization for certain covered services;  and
(6)  coordination of benefits.
(b)  A provision of a small employer health benefit plan that provides for coordination of benefits must comply with this chapter and guidelines established by the commissioner.
(c)  Utilization review performed for any cost containment, case management, or managed care arrangement must comply with Chapter 4201.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
Amended by:
Acts 2007, 80th Leg., R.S., Ch. 730 (H.B. 2636), Sec. 2G.015, eff. April 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 F. Coverage Under Small Employer Health Benefit Plans › Section 1501.258. Forms

Sec. 1501.258.  FORMS.  (a)  A small employer health benefit plan issuer shall comply with:
(1)  Chapter 1701 as it relates to policy form approval; and
(2)  Chapter 1271 as it relates to evidence of coverage approval.
(b)  A small employer health benefit plan issuer may not offer benefit plans through a policy form or evidence of coverage that does not comply with this chapter.
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. 11.058(b), 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 1501.259. Riders; Filing With Commissioner

Sec. 1501.259.  RIDERS;  FILING WITH COMMISSIONER.  (a)  A small employer health benefit plan issuer shall file with the commissioner, in a form and manner prescribed by the commissioner, each rider to a small employer health benefit plan to be used by the issuer, as authorized by Section 1501.252.
(b)  A small employer health benefit plan issuer may use a rider filed under this section after the 30th day after the date the rider is filed unless the commissioner disapproves its use.
(c)  The commissioner, after notice and an opportunity for a hearing, may disapprove the continued use of a rider by a small employer health benefit plan issuer if the rider does not meet the requirements of this chapter and other applicable statutes.
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 1501.260. Plain Language Required

Sec. 1501.260.  PLAIN LANGUAGE REQUIRED.  (a)  A health benefit plan issuer may not issue and the commissioner may not approve a health benefit plan certificate or policy or a rider to a health benefit plan certificate or policy unless it is written in plain language.
(b)  Each provision of a health benefit plan certificate or policy or a rider to a health benefit plan certificate or policy relating to renewal of coverage, conditions of coverage, or per occurrence or aggregate dollar limitations on coverage must be clearly explained in plain language.
(c)  A health benefit plan issuer may not use and the commissioner may not approve a health benefit plan application form unless it is written in plain language.
(d)  Subsections (a)-(c) do not apply if the specific language to be used is required by federal law or state statute or by rules implementing federal law.
(e)  For purposes of Subsections (a)-(d), a health benefit plan certificate or policy, a rider to or a provision of a health benefit plan certificate or policy, or a health benefit plan application form is written in plain language if it achieves the minimum score established by the commissioner on the Flesch reading ease test or an equivalent test selected by the commissioner.
(f)  This section does not apply to:
(1)  a health benefit plan group master policy;  or
(2)  a policy application or enrollment form for a health benefit plan group master policy.
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 G. Reinsurance for Small Employer Health Benefit Plans › Section 1501.301. Definitions

Sec. 1501.301.  DEFINITIONS.  In this subchapter:
(1)  "Board" means the board of directors of the Texas Health Reinsurance System.
(2)  "Plan of operation" means the plan of operation of the system established under Section 1501.306.
(3)  "Reinsured health benefit plan issuer" means a small employer health benefit plan issuer that participates in the system.
(4)  "Risk-assuming health benefit plan issuer" means a small employer health benefit plan issuer that does not participate in the system.
(5)  "System" means the Texas Health Reinsurance System established under this subchapter.
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 G. Reinsurance for Small Employer Health Benefit Plans › Section 1501.302. Texas Health Reinsurance System

Sec. 1501.302.  TEXAS HEALTH REINSURANCE SYSTEM.  (a)  The Texas Health Reinsurance System is a nonprofit entity administered by a board of directors and subject to the supervision and control of the commissioner.
(b)  The system may operate only during the period an order authorizing operation of the system under Section 1501.3021 is in effect.  The system may not operate after the effective date of an order of suspension of operation of the system under Section 1501.3022 until a subsequent order authorizing the operation of the system under Section 1501.3021, if any, is effective.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
Amended by:
Acts 2017, 85th Leg., R.S., Ch. 105 (S.B. 1171), Sec. 1, eff. May 23, 2017.
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 G. Reinsurance for Small Employer Health Benefit Plans › Section 1501.3021. Authorization of Operation

Sec. 1501.3021.  AUTHORIZATION OF OPERATION.  (a)  The commissioner shall hold a hearing if:
(1)  the commissioner believes small employer health benefit plan issuers in this state are threatened with the inability to secure reinsurance coverage in the open market; or
(2)  the commissioner receives a petition requesting the hearing from an association of health benefit plan issuers in this state or a group of at least 15 small employer health benefit plan issuers operating in this state.
(b)  If, after a hearing under Subsection (a), the commissioner finds that the operation of the system is in the public interest, the commissioner by order shall:
(1)  authorize the operation of the system;
(2)  appoint a board of directors under Section 1501.303; and
(3)  direct the board to develop a plan of operation under Section 1501.306 to ensure the system is fully implemented on a date specified in the order that is not later than the 60th day after the effective date of the order.
(c)  Sections 1501.307-1501.326 apply to the operation of the system after the date the system is implemented as described by Subsection (b)(3).
Added by Acts 2017, 85th Leg., R.S., Ch. 105 (S.B. 1171), Sec. 2, eff. May 23, 2017.
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 G. Reinsurance for Small Employer Health Benefit Plans › Section 1501.303. System Board of Directors

Sec. 1501.303.  SYSTEM BOARD OF DIRECTORS.  (a)  The board of directors of the system is composed of:
(1)  nine members appointed by the commissioner;  and
(2)  the commissioner or the commissioner's representative, who serves as an ex officio member.
(b)  Five of the appointed members must be representatives of reinsured health benefit plan issuers selected from individuals nominated by small employer health benefit plan issuers in this state according to procedures developed by the commissioner.
(c)  Four of the appointed members must represent the public.  A member representing the public may not:
(1)  be an officer, director, or employee of an insurance company, agency, agent, broker, solicitor, or adjuster or any other business entity regulated by the department;
(2)  be a person required to register under Chapter 305, Government Code;  or
(3)  be related to a person described by Subdivision (1) or (2) within the second degree by affinity or consanguinity.
(d)  Appointed members serve two-year terms expiring December 31 of each odd-numbered year.  A member's term continues until a successor is appointed.
(e)  A member of the board may not be compensated for serving on the board but is entitled to reimbursement for actual expenses incurred in performing functions as a member of the board as provided by the General Appropriations Act.
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 G. Reinsurance for Small Employer Health Benefit Plans › Section 1501.304. Open Meetings; Public Information

Sec. 1501.304.  OPEN MEETINGS;  PUBLIC INFORMATION.  The board is subject to:
(1)  the open meetings law, Chapter 551, Government Code;  and
(2)  the public information law, Chapter 552, Government Code.
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 G. Reinsurance for Small Employer Health Benefit Plans › Section 1501.305. Board Member Immunity

Sec. 1501.305.  BOARD MEMBER IMMUNITY.  (a)  A member of the board is not liable for an act performed, or omission made, in good faith in the performance of powers and duties under this subchapter.
(b)  A cause of action does not arise against a member of the board for an act or omission described by Subsection (a).
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 G. Reinsurance for Small Employer Health Benefit Plans › Section 1501.306. System Plan of Operation

Sec. 1501.306.  SYSTEM PLAN OF OPERATION.  (a)  The board shall submit to the commissioner a plan of operation and any amendments to that plan necessary or suitable to ensure the fair, reasonable, and equitable administration of the system.
(b)  The commissioner, after notice and hearing, may approve the plan of operation if the commissioner determines the plan:
(1)  is suitable to ensure the fair, reasonable, and equitable administration of the system;  and
(2)  provides for the sharing of system gains or losses on an equitable and proportionate basis in accordance with this subchapter.
(c)  The plan of operation is effective on the written approval of the commissioner.
(d)  The plan of operation must:
(1)  establish procedures for:
(A)  handling and accounting for system assets and money;
(B)  making an annual fiscal report to the commissioner;
(C)  selecting an administering health benefit plan issuer or third-party administrator and establishing the powers and duties of the administering issuer or third-party administrator;
(D)  reinsuring risks in accordance with this subchapter;  and
(E)  collecting assessments from reinsured health benefit plan issuers to fund claims and administrative expenses incurred or estimated to be incurred by the system, including the imposition of penalties for late payment of an assessment;  and
(2)  provide for any additional matter necessary to implement and administer the system.
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 G. Reinsurance for Small Employer Health Benefit Plans › Section 1501.307. System Powers

Sec. 1501.307.  SYSTEM POWERS.  (a)  The system has the general powers and authority granted under state law to an insurer or a health maintenance organization authorized to engage in business, except that the system may not directly issue a health benefit plan.
(b)  The system may:
(1)  enter into contracts necessary or proper to implement this subchapter, including, with the commissioner's approval, contracts with similar programs of other states for the joint performance of common functions or with persons or other organizations for the performance of administrative functions;
(2)  sue or be sued, including taking legal action necessary or proper to recover assessments and penalties for, on behalf of, or against the system or a reinsured health benefit plan issuer;
(3)  take legal action necessary to avoid the payment of improper claims against the system;
(4)  issue reinsurance contracts in accordance with this subchapter;
(5)  establish guidelines, conditions, and procedures for reinsuring risks under the plan of operation;
(6)  establish actuarial functions as appropriate for the operation of the system;
(7)  assess reinsured health benefit plan issuers in accordance with Sections 1501.319-1501.323;
(8)  appoint appropriate legal, actuarial, and other committees necessary to provide technical assistance in:
(A)  the operation of the system;
(B)  policy and other contract design;  and
(C)  any other function within the authority of the system;  and
(9)  borrow money for a period not to exceed one year to accomplish the purposes of the system.
(c)  The system is exempt from all taxes.
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 G. Reinsurance for Small Employer Health Benefit Plans › Section 1501.308. System Notes as Legal Investment for Small Employer Health Benefit Plan Issuer

Sec. 1501.308.  SYSTEM NOTES AS LEGAL INVESTMENT FOR SMALL EMPLOYER HEALTH BENEFIT PLAN ISSUER.  A note or other evidence of indebtedness of the system that is not in default is a legal investment for a small employer health benefit plan issuer and may be carried as an admitted asset.
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 G. Reinsurance for Small Employer Health Benefit Plans › Section 1501.309. System Audit

Sec. 1501.309.  SYSTEM AUDIT.  (a)  The transactions of the system are subject to audit by the state auditor in accordance with Chapter 321, Government Code.
(b)  The state auditor shall report the cost of each audit conducted under this section to the board and the comptroller, and the board shall remit that amount to the comptroller.
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 G. Reinsurance for Small Employer Health Benefit Plans › Section 1501.310. Election of Status

Sec. 1501.310.  ELECTION OF STATUS.  (a)  Each small employer health benefit plan issuer shall notify the commissioner of the issuer's election to operate as a risk-assuming health benefit plan issuer or as a reinsured health benefit plan issuer.  An issuer that elects to operate as a risk-assuming health benefit plan issuer shall file an application in accordance with Section 1501.312.
(b)  A small employer health benefit plan issuer's election under this section is effective until the fifth anniversary of the date of the election.
(c)  The commissioner may permit a small employer health benefit plan issuer to modify its election at any time for good cause shown.
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 G. Reinsurance for Small Employer Health Benefit Plans › Section 1501.311. Change in Status

Sec. 1501.311.  CHANGE IN STATUS.  (a)  The commissioner shall establish an application process for a small employer health benefit plan issuer that elects to change its status under this subchapter.
(b)  A reinsured health benefit plan issuer that elects to change its status to operate as a risk-assuming health benefit plan issuer may not continue to reinsure a small employer health benefit plan with the system.  The issuer shall pay a prorated assessment based on business issued as a reinsured health benefit plan issuer for the portion of the year the business was reinsured.
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 G. Reinsurance for Small Employer Health Benefit Plans › Section 1501.312. Application to Operate as Risk-Assuming Health Benefit Plan Issuer

Sec. 1501.312.  APPLICATION TO OPERATE AS RISK-ASSUMING HEALTH BENEFIT PLAN ISSUER.  (a)  A small employer health benefit plan issuer may apply to operate as a risk-assuming health benefit plan issuer by filing an application with the commissioner in a form and manner prescribed by the commissioner.
(b)  In evaluating an application, the commissioner shall consider the small employer health benefit plan issuer's:
(1)  financial condition;
(2)  history of rating and underwriting small employer groups;
(3)  commitment to market fairly to all small employers in the state or in the issuer's established geographic service area;  and
(4)  experience managing the risk of small employer groups.
(c)  The commissioner shall provide public notice of an application and shall provide at least a 60-day period for public comment before making a decision on the application.  If the commissioner does not act on the application before the 90th day after the date the commissioner receives the application, the issuer may request and the commissioner shall grant a hearing.
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 G. Reinsurance for Small Employer Health Benefit Plans › Section 1501.313. Rescission of Approval to Operate as Risk-Assuming Health Benefit Plan Issuer

Sec. 1501.313.  RESCISSION OF APPROVAL TO OPERATE AS RISK-ASSUMING HEALTH BENEFIT PLAN ISSUER.  The commissioner, after notice and hearing, may rescind approval to operate as a risk-assuming health benefit plan issuer if the commissioner finds that the issuer:
(1)  is not financially able to support the assumption of risk from issuing coverage to small employers without the protection provided by the system;
(2)  has failed to market fairly to all small employers in the state or in the issuer's established geographic service area;  or
(3)  has failed to provide coverage to eligible 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 G. Reinsurance for Small Employer Health Benefit Plans › Section 1501.314. Reinsurance

Sec. 1501.314.  REINSURANCE.  (a)  A small employer health benefit plan issuer may reinsure risks covered under a small employer health benefit plan with the system as provided by this subchapter.
(b)  The system shall reinsure the level of coverage provided under the small employer health benefit plan.
(c)  A small employer health benefit plan issuer may reinsure:
(1)  an entire small employer group not later than the 60th day after the date the group's coverage under the small employer health benefit plan takes effect;
(2)  an eligible employee of a small employer or the employee's dependent not later than the 60th day after the date the person's coverage takes effect;  or
(3)  a newly eligible employee of a reinsured small employer group, the employee's dependent, or an individual covered under the small employer health benefit plan not later than the 60th day after the date the individual's coverage takes 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 G. Reinsurance for Small Employer Health Benefit Plans › Section 1501.315. Limits on Reinsurance

Sec. 1501.315.  LIMITS ON REINSURANCE.  (a)  The system may not reimburse a reinsured health benefit plan issuer for the claims of a reinsured individual until the issuer has incurred an initial level of claims of $5,000 in a calendar year for that individual for benefits covered by the system.  In addition, the reinsured health benefit plan issuer is responsible for 10 percent of the next $50,000 of benefit payments during a calendar year, and the system shall reinsure the remainder.  A reinsured health benefit plan issuer's liability to a reinsured individual may not exceed a maximum of $10,000 in a calendar year.
(b)  The board annually shall adjust the initial level of claims and the maximum liability to be retained by a reinsured health benefit plan issuer under Subsection (a) to reflect increases in:
(1)  costs;  and
(2)  the use of small employer health benefit plans in this state.
(c)  An adjustment under Subsection (b) may not be less than the annual change in the medical component of the Consumer Price Index for All Urban Consumers published by the Bureau of Labor Statistics of the United States Department of Labor unless the board proposes and the commissioner approves a lower adjustment factor.
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 G. Reinsurance for Small Employer Health Benefit Plans › Section 1501.316. Termination of Reinsurance

Sec. 1501.316.  TERMINATION OF REINSURANCE.  A small employer health benefit plan issuer may terminate reinsurance with the system for one or more reinsured employees or dependents of employees of a small employer on a contract anniversary of the small employer 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 G. Reinsurance for Small Employer Health Benefit Plans › Section 1501.317. Application of Managed Care Procedures

Sec. 1501.317.  APPLICATION OF MANAGED CARE PROCEDURES.  Except as provided by the plan of operation, a reinsured health benefit plan issuer shall apply consistently with respect to reinsured and nonreinsured business all managed care procedures, including utilization review, individual case management, preferred provider provisions, and other managed care provisions or methods of operation.
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 G. Reinsurance for Small Employer Health Benefit Plans › Section 1501.318. Premium Rates for Reinsurance

Sec. 1501.318.  PREMIUM RATES FOR REINSURANCE.  (a)  As part of the plan of operation, the board shall adopt a method to determine premium rates to be charged by the system for reinsuring small employer groups and individuals under this subchapter.
(b)  The method adopted must:
(1)  include a classification system for small employer groups that reflects the variations in premium rates allowed by this chapter;  and
(2)  provide for the development of base reinsurance premium rates that reflect the allowable variations.
(c)  Subject to approval by the commissioner, the board shall establish the base reinsurance premium rates at levels that reasonably approximate the gross premiums charged to small employers by small employer health benefit plan issuers for small employer health benefit plans, adjusted to reflect retention levels required under this subchapter.
(d)  The board shall periodically review the method adopted under this section, including the classification system and any rating factors, to ensure that the method reasonably reflects the claims experience of the system.  The board may propose changes to the method.  Any changes are subject to approval by the commissioner.
(e)  An entire small employer group may be reinsured at a rate that is 1-1/2 times the base reinsurance premium rate for that group.  An eligible employee of a small employer or the employee's dependent covered under a small employer health benefit plan may be reinsured at a rate that is five times the base reinsurance premium rate for that individual.
(f)  The board may consider adjustments to the premium rates charged by the system to reflect the use of effective cost containment and managed care arrangements.
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 G. Reinsurance for Small Employer Health Benefit Plans › Section 1501.319. Determination of Net Loss

Sec. 1501.319.  DETERMINATION OF NET LOSS.  (a)  Not later than March 1 of each year, the board shall determine the system's net loss for the preceding calendar year, including administrative expenses and incurred losses for the year, and report the net loss to the commissioner.
(b)  In determining the net loss, the board shall take into account investment income and other appropriate gains and losses.
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 G. Reinsurance for Small Employer Health Benefit Plans › Section 1501.320. Assessments to Recover Net Losses

Sec. 1501.320.  ASSESSMENTS TO RECOVER NET LOSSES.  (a)  The board shall recover any net loss of the system by assessing each reinsured health benefit plan issuer an amount determined annually by the board based on information in annual statements and other reports required by and filed with the board.
(b)  The board shall establish, as part of the plan of operation, a formula by which to make assessments against reinsured health benefit plan issuers.  With the approval of the commissioner, the board may periodically change the assessment formula as appropriate.  The board shall base the assessment formula on each reinsured issuer's share of:
(1)  the total premiums earned in the preceding calendar year from small employer health benefit plans delivered or issued for delivery by reinsured health benefit plan issuers to small employer groups in this state;  and
(2)  the premiums earned in the preceding calendar year from newly issued small employer health benefit plans delivered or issued for delivery during the calendar year by reinsured health benefit plan issuers to small employer groups in this state.
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 G. Reinsurance for Small Employer Health Benefit Plans › Section 1501.321. Limits on Assessments

Sec. 1501.321.  LIMITS ON ASSESSMENTS.  (a)  The formula established under Section 1501.320(b) may not result in an assessment for a reinsured health benefit plan issuer that is less than 50 percent or more than 150 percent of an amount based on the proportion of the total premiums earned in the preceding calendar year from small employer health benefit plans delivered or issued for delivery to small employer groups in this state by that issuer to the total premiums earned in the preceding calendar year from small employer health benefit plans delivered or issued for delivery to small employer groups in this state by all reinsured health benefit plan issuers.
(b)  In determining assessments, the board may not consider premiums earned by a reinsured health benefit plan issuer that are less than an amount determined by the board to justify the cost of collecting an assessment based on those premiums.
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 G. Reinsurance for Small Employer Health Benefit Plans › Section 1501.322. Adjustment to Assessments on Federally Qualified Health Maintenance Organizations

Sec. 1501.322.  ADJUSTMENT TO ASSESSMENTS ON FEDERALLY QUALIFIED HEALTH MAINTENANCE ORGANIZATIONS.  With the commissioner's approval, the board may adjust the formula established under Section 1501.320(b) for a reinsured health benefit plan issuer that is an approved health maintenance organization that is federally qualified under Title XIII, Public Health Service Act (42 U.S.C. Section 300e et seq.), to the extent that any restriction is imposed on that issuer that is not imposed on other issuers.
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 G. Reinsurance for Small Employer Health Benefit Plans › Section 1501.323. Advance Interim Assessments

Sec. 1501.323.  ADVANCE INTERIM ASSESSMENTS.  (a)  The system may make advance interim assessments as reasonable and necessary for organizational and interim operating expenses.
(b)  After the end of the fiscal year, the system shall credit an interim assessment made under this section as an offset against regular assessments due.
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 G. Reinsurance for Small Employer Health Benefit Plans › Section 1501.324. Limit on Total Assessments

Sec. 1501.324.  LIMIT ON TOTAL ASSESSMENTS.  The maximum assessment amount payable for a calendar year may not exceed five percent of the total premiums earned in the preceding calendar year from small employer health benefit plans delivered or issued for delivery by reinsured health benefit plan issuers in this state.
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 G. Reinsurance for Small Employer Health Benefit Plans › Section 1501.325. Estimate of Assessments; Evaluation and Protection of System

Sec. 1501.325.  ESTIMATE OF ASSESSMENTS;  EVALUATION AND PROTECTION OF SYSTEM.  (a)  Not later than March 1 of each year, the board shall file with the commissioner an estimate of the assessments necessary to fund the losses for small employer groups incurred by the system during the preceding calendar year.
(b)  If the board determines that the necessary assessments exceed five percent of the total premiums earned in the preceding calendar year from small employer health benefit plans delivered or issued for delivery by reinsured health benefit plan issuers to small employer groups in this state, the board shall evaluate the operation of the system and shall report its findings, including any recommendations for changes to the plan of operation, to the commissioner not later than April 1 of the year following the calendar year in which the losses were incurred.  The evaluation must:
(1)  include an estimate of future assessments;  and
(2)  consider:
(A)  the administrative costs of the system;
(B)  the appropriateness of the premiums charged;
(C)  the level of health benefit plan issuer retention under the system;  and
(D)  the costs of coverage for small employer groups.
(c)  If the board fails to timely file a report required by Subsection (b), the commissioner may:
(1)  evaluate the operations of the system;  and
(2)  implement amendments to the plan of operation that the commissioner considers necessary to reduce future losses and assessments.
(d)  A reinsured health benefit plan issuer may not cede additional eligible lives to the system during a calendar year if the assessment amount payable for the preceding calendar year is at least five percent of the total premiums earned in that calendar year from small employer health benefit plans delivered or issued for delivery by reinsured health benefit plan issuers in this state.
(d-1)  Expired.
(e)  A reinsured health benefit plan issuer may not cede additional eligible lives to the system after the board determines that the expected loss from the reinsurance system for a year will exceed the total amount of assessments payable at a rate of five percent of the total premiums earned for the preceding calendar year.  A reinsured health benefit plan issuer may not resume ceding additional eligible lives to the system until the board determines that the expected loss will be less than the maximum established by this subsection.
(e-1)  Expired.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
Amended by:
Acts 2005, 79th Leg., Ch. 823 (S.B. 805), Sec. 5, 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 G. Reinsurance for Small Employer Health Benefit Plans › Section 1501.326. Deferment of Assessment

Sec. 1501.326.  DEFERMENT OF ASSESSMENT.  (a)  A reinsured health benefit plan issuer may petition the commissioner for a deferment in whole or in part of an assessment imposed by the board.
(b)  The commissioner may defer all or part of the assessment if the commissioner determines that payment of the assessment would endanger the ability of the reinsured health benefit plan issuer to fulfill its contractual obligations.
(c)  The board shall assess the amount of a deferred assessment against other reinsured health benefit plan issuers in a manner consistent with the basis for assessment established by this subchapter.
(d)  A reinsured health benefit plan issuer that receives a deferment:
(1)  is liable to the system for the amount deferred;  and
(2)  until the issuer pays the outstanding assessment, may not:
(A)  market, deliver, or issue for delivery a small employer health benefit plan;  or
(B)  reinsure any individual or group with the system.
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 H. Marketing of Small Employer Health Benefit Plans › Section 1501.351. Marketing Requirements

Sec. 1501.351.  MARKETING REQUIREMENTS.  (a)  Each small employer health benefit plan issuer shall market a small employer health benefit plan to eligible small employers in this state through properly licensed agents.
(b)  Each small employer purchasing a small employer health benefit plan must be given a summary, in a format prescribed by the commissioner, of the health benefit plans established by the commissioner under Subchapter F.
(c)  An agent shall offer and explain to a small employer on inquiry and request by the employer each health benefit plan established by the commissioner under Subchapter F.
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 H. Marketing of Small Employer Health Benefit Plans › Section 1501.352. Health Status and Claims Experience; Prohibited Acts

Sec. 1501.352.  HEALTH STATUS AND CLAIMS EXPERIENCE;  PROHIBITED ACTS.  (a)  A small employer health benefit plan issuer or agent may not, because of the health status or claims experience of the eligible employees of a small employer and those employees' dependents, directly or indirectly encourage or direct the employer to:
(1)  refrain from applying for coverage with the issuer;
(2)  seek coverage from another issuer;
(3)  apply for a particular small employer health benefit plan; or
(4)  become or not become a member of a particular small employer health coalition.
(b)  A small employer health benefit plan issuer may not directly or indirectly enter into an agreement or arrangement with an agent that provides for or results in compensation paid to the agent for the sale of small employer health benefit plans that varies because of health status or claims experience.
(c)  Subsection (b) does not apply to an arrangement that provides compensation to an agent based on a percentage of premium, provided that:
(1)  the percentage may not vary because of health status or claims experience; and
(2)  the small employer health benefit plan issuer does not:
(A)  exclude any additional premium charged to the small employer because of health status or claims experience from the premium amount to which the percentage is applied; or
(B)  apply a smaller percentage to any additional premium charged to the small employer because of health status or claims experience than is applied to other premiums charged to the small employer.
(d)  A small employer health benefit plan issuer or agent may not encourage a small employer to exclude an eligible employee from health coverage provided in connection with the employee's employment.
(e)  A small employer health benefit plan issuer may not terminate, fail to renew, or limit its contract or agreement of representation with an agent for a reason related to the health status or claims experience of a small employer group placed by the agent with the issuer.
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. 11.059(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 H. Marketing of Small Employer Health Benefit Plans › Section 1501.353. Agent Compensation

Sec. 1501.353.  AGENT COMPENSATION.  (a)  A small employer health benefit plan issuer shall pay the same commission, percentage of premium, or other amount to an agent for renewal of a small employer health benefit plan as the issuer paid for original placement of the plan, except that the issuer may increase compensation for renewal of a plan to reflect an increase in the cost of living or similar factors.
(b)  A small employer health benefit plan issuer may not implement, directly or indirectly, agent commission schedules that vary the level of agent commissions based on the size of the group or otherwise reduce access to small employer health benefit plans.
(c)  Notwithstanding Subsection (b), a small employer health benefit plan issuer may:
(1)  vary agent commission amounts or percentages based on group size if the variation in the commission amounts or percentages are inversely related to the size of the group;
(2)  vary agent commission amounts or percentages based on the cumulative premium paid by a single small employer over a specific period if the variation in the commission amounts or percentages are inversely related to the cumulative premium paid during the period;  or
(3)  pay agent commissions as a percentage of premiums charged to a small employer if the commission percentage is based on all premiums paid by the small employer.
(d)  A small employer health benefit plan issuer may not use an agent compensation schedule that provides compensation in a specific dollar amount for each individual covered during a specified period or for each group of individuals covered during a specified period.
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. 11.059(b), 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 H. Marketing of Small Employer Health Benefit Plans › Section 1501.354. Required Disclosures

Sec. 1501.354.  REQUIRED DISCLOSURES.  (a)  In connection with offering a small employer health benefit plan for sale, each small employer health benefit plan issuer and agent shall make a reasonable disclosure, as part of its solicitation and sales materials, of:
(1)  the extent to which premium rates for a specific small employer are established or adjusted based on the actual or expected variation in:
(A)  claim costs;  or
(B)  health status of the employer's employees and their dependents;
(2)  provisions concerning the issuer's right to change premium rates and factors other than claims experience that affect changes in premium rates;
(3)  provisions relating to renewability of policies and contracts;  and
(4)  any preexisting condition provisions.
(b)  On request by a small employer, each small employer health benefit plan issuer shall disclose the benefits and premiums available under all small employer coverage for which the employer is qualified.
(c)  A small employer health benefit plan issuer is not required to disclose information to a small employer that is proprietary or trade secret information under applicable law.
(d)  Information provided under this section to a small employer must be provided in a manner that is:
(1)  understandable by the average small employer;  and
(2)  sufficient to reasonably inform a small employer of its rights and obligations under a small employer 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 H. Marketing of Small Employer Health Benefit Plans › Section 1501.355. Rules Concerning Marketing and Availability

Sec. 1501.355.  RULES CONCERNING MARKETING AND AVAILABILITY.  Rules adopted under Section 1501.010 may establish additional standards to provide for the fair marketing and broad availability of small employer health benefit plans to small employers in this state.
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 H. Marketing of Small Employer Health Benefit Plans › Section 1501.356. Reporting Requirements

Sec. 1501.356.  REPORTING REQUIREMENTS.  (a)  In this section, "case characteristics" has the meaning assigned by Section 1501.201.
(b)  The department may require periodic reports by small employer health benefit plan issuers and agents regarding small employer health benefit plans issued by those issuers and agents.  The reporting requirements must include information regarding:
(1)  case characteristics;  and
(2)  the number of small employer health benefit plans in various categories that are marketed or issued to 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 H. Marketing of Small Employer Health Benefit Plans › Section 1501.357. Violations

Sec. 1501.357.  VIOLATIONS.  A violation of Section 1501.352 by a small employer health benefit plan issuer or agent is an unfair method of competition and an unfair or deceptive act or practice under Chapter 541.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.