reglab/statecodes huggingface dataset:
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 26 - EMPLOYER-RELATED HEALTH BENEFIT PLAN REGULATIONS › Subchapter D - COOPERATIVES › Division 1 - NONPROFIT HEALTH GROUP COOPERATIVES › Section 26.400 - Definitions and Filing

Current through Reg. 49, No. 28; July 12, 2024
(a) The terms
					 defined in §
											26.4 of
					 this title (relating to Definitions) are incorporated into this
					 subchapter.
(b) The following terms
					 have the meanings assigned in Insurance Code §
											1501.051:
(1) board of directors;
(2) board of trustees;
(3) cooperative;
(4) eligible single-employee business;
					 and
(5) expanded service
					 area.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 26 - EMPLOYER-RELATED HEALTH BENEFIT PLAN REGULATIONS › Subchapter D - COOPERATIVES › Division 1 - NONPROFIT HEALTH GROUP COOPERATIVES › Section 26.401 - Establishment of Health Group Cooperatives

Current through Reg. 49, No. 28; July 12, 2024
(a) Under the Insurance Code and this
					 subchapter, a person may form a health group cooperative for the purchase of
					 employer health benefit plans.
(b)
					 A health carrier may not form, or be a member of, a health group cooperative. A
					 health carrier may associate with a sponsoring entity of a health group
					 cooperative, such as a business association, chamber of commerce, or other
					 organization representing employers or serving an analogous function, to assist
					 the sponsoring entity in forming a health group cooperative.
(c) A health group cooperative must be
					 incorporated as a nonprofit organization and be authorized to transact business
					 in Texas, as required by the Business Organizations Code .
(d) A health group cooperative must file with
					 TDI its organizational documents and, if applicable, authorization to transact
					 business in Texas . The organizational documents must demonstrate the health
					 group cooperative's compliance with Insurance Code §§
											1501.058
					 (concerning Powers and Duties of Cooperatives), 1501.059 (concerning
					 Self-Insured or Self-funded Plan Prohibited), and 1501.061 (concerning
					 Requirements Applicable to Heath Benefit Plan Issuers with Which Cooperative
					 May Contract).
(e) A health group
					 cooperative consisting only of small employers that elects to restrict its
					 membership to 50 eligible employees in accordance with Insurance Code §
											1501.0581(o)
					 (concerning Special Provisions Relating to Health Group Cooperatives) must
					 include that election in the organizational documents filed under subsection
					 (d) of this section. A health group cooperative making this election may not
					 admit an eligible single-employee business, as defined in Insurance Code §
											1501.051 (concerning
					 Definitions).
(f) A health group
					 cooperative may elect to admit eligible single-employee businesses as members
					 of the cooperative and allow single-employee business members to enroll in
					 health-benefit-plan coverage as specified in Chapter 26, Subchapter D, Division
					 2 of this title (relating to Single-employee Business Participation in Health
					 Group Cooperatives).
(g) The
					 provisions of this subchapter do not limit or restrict an employer's access to
					 health benefit plans under this chapter or Insurance Code Chapter 1501
					 (concerning Health Insurance Portability and Availability Act).
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 26 - EMPLOYER-RELATED HEALTH BENEFIT PLAN REGULATIONS › Subchapter D - COOPERATIVES › Division 1 - NONPROFIT HEALTH GROUP COOPERATIVES › Section 26.402 - Membership of Health Group Cooperatives

Current through Reg. 49, No. 28; July 12, 2024
(a) The membership of a health group
					 cooperative may consist of:
(1) only small
					 employers;
(2) only large
					 employers;
(3) small and large
					 employers;
(4) small employers and
					 eligible single-employee businesses;
(5) large employers and eligible
					 single-employee businesses; or
(6)
					 small employers, large employers, and eligible single-employee
					 businesses.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 26 - EMPLOYER-RELATED HEALTH BENEFIT PLAN REGULATIONS › Subchapter D - COOPERATIVES › Division 1 - NONPROFIT HEALTH GROUP COOPERATIVES › Section 26.403 - Marketing Activities of Health Group Cooperatives

Current through Reg. 49, No. 28; July 12, 2024
(a) A health group cooperative may engage in
					 marketing activities related and restricted to membership in the cooperative,
					 including general availability of health coverage, and is not required to
					 maintain an agent's license for soliciting membership in the cooperative. All
					 health coverage issued through the cooperative must be issued through a
					 licensed agent that is employed by or contracted with the
					 cooperative.
(b) A sponsoring
					 entity of a health group cooperative may inform its members regarding the
					 health group cooperative and the general availability of coverage through the
					 health group cooperative. All coverage issued through the cooperative must be
					 issued through a licensed agent.
(c) A licensed agent that is used and
					 compensated by a health group cooperative is not required to be appointed by a
					 health carrier offering coverage through the health group cooperative. This
					 exemption does not allow an agent to market other products and services not
					 offered through the health group cooperative without an appointment from the
					 health carrier.
(d) A health group
					 cooperative or a member of the board of directors, the executive director, an
					 employee, or an agent of a health group cooperative is not liable for failure
					 to arrange for coverage of any particular illness, disease, or health condition
					 in arranging for coverage through the cooperative.
(e) A health group cooperative may offer
					 other ancillary products and services to its members that are customarily
					 offered in conjunction with health benefit plans.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 26 - EMPLOYER-RELATED HEALTH BENEFIT PLAN REGULATIONS › Subchapter D - COOPERATIVES › Division 1 - NONPROFIT HEALTH GROUP COOPERATIVES › Section 26.405 - Premium Tax Exemption for Previously Uninsured

Current through Reg. 49, No. 28; July 12, 2024
(a) In accordance with Insurance Code §
											1501.0581(g)(4)
					 (concerning Special Provisions Relating to Health Group Cooperatives), a health
					 carrier providing coverage through a health group cooperative is exempt from
					 premium tax and retaliatory tax for two years for premiums received for a
					 previously uninsured employee or dependent. The two-year period for the
					 exemption begins on the first date of coverage for the previously uninsured
					 employee or dependent.
(b) For the
					 purposes of this section and Insurance Code §
											1501.0581(g)(4),
					 a previously uninsured employee or dependent is an employee or the dependent of
					 an employee of an employer member of a health group cooperative who did not
					 have creditable coverage for the 63 days preceding the effective date of
					 coverage purchased through the health group cooperative.
(c) A health carrier must maintain
					 documentation for four years for each insured that demonstrates that coverage
					 of the insured or enrollee qualifies the health carrier for a tax exemption
					 under subsection (b) of this section. The documentation must comply with any
					 applicable rules or procedures adopted by the Comptroller of Public Accounts
					 related to the tax exemption.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 26 - EMPLOYER-RELATED HEALTH BENEFIT PLAN REGULATIONS › Subchapter D - COOPERATIVES › Division 1 - NONPROFIT HEALTH GROUP COOPERATIVES › Section 26.406 - Standard Presentation Form

Current through Reg. 49, No. 28; July 12, 2024
(a) A
					 health carrier offering coverage through a health group cooperative must use a
					 standard presentation form for employer members of the health group cooperative
					 that includes the information listed in subsection (b) of this section. A
					 standard presentation form may include additional information.
(b) A standard presentation form must
					 include, at a minimum:
(1) an explanation
					 that the coverage is being offered through a health group
					 cooperative;
(2) the name of the
					 health group cooperative;
(3) an
					 explanation of small employers' eligibility to join the health group
					 cooperative and purchase coverage without regard for membership in any other
					 organization or the health status or claims experience of the employer and
					 employees;
(4) an explanation of
					 any fees or charges associated with membership in the health group
					 cooperative;
(5) a statement that
					 coverage is available to a small employer on a guaranteed-issue basis from any
					 health carrier offering coverage in the small employer market with no
					 requirement of joining a health group cooperative;
(6) for multiple plans that are offered
					 through the health group cooperative, an explanation that the employer may
					 select any of the plans without limitation due to health status or claims
					 experience;
(7) a description of
					 the plans offered through the health group cooperative by the health carrier;
					 and
(8) if coverage is offered
					 under Insurance Code Chapter 1507 (concerning Consumer Choice of Benefits
					 Plans), a written disclosure in compliance with Chapter 21, Subchapter AA
					 (relating to Consumer Choice Health Benefit Plans).
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 26 - EMPLOYER-RELATED HEALTH BENEFIT PLAN REGULATIONS › Subchapter D - COOPERATIVES › Division 1 - NONPROFIT HEALTH GROUP COOPERATIVES › Section 26.407 - Health Carrier Filing Before Issuance of Coverage to a Health Group Cooperative

Current through Reg. 49, No. 28; July 12, 2024
(a) A health
					 carrier that intends to issue coverage to a health group cooperative must file
					 with TDI information concerning the health carrier's offer of coverage no later
					 than 30 days before the cooperative's initial enrollment period.
(b) A filing required by subsection (a) of
					 this section must include:
(1) the name of
					 the health carrier;
(2) the name,
					 address, and telephone number or other contact information of the health group
					 cooperative to which the health carrier intends to offer coverage;
(3) the county or expanded service area in
					 which the health carrier intends to offer coverage to the health group
					 cooperative;
(4) any limitations
					 concerning the number of participating employers or employees in a health group
					 cooperative that the health carrier is capable of administering; and
(5) the health benefit plan filed for use by
					 the health carrier as a product available to health group cooperatives, or when
					 appropriate under subsection (c) of this section, reference to a previously
					 approved form, including the form number and date of approval.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 26 - EMPLOYER-RELATED HEALTH BENEFIT PLAN REGULATIONS › Subchapter D - COOPERATIVES › Division 1 - NONPROFIT HEALTH GROUP COOPERATIVES › Section 26.408 - Issuance of Coverage to Health Group Cooperatives

Current through Reg. 49, No. 28; July 12, 2024
(a) Subject to the limitations identified in
					 §
											26.411
					 of this title (relating to Service Areas for Health Carriers Offering Coverage
					 Through a Health Group Cooperative), a health carrier may elect to not offer or
					 issue coverage to health group cooperatives or may elect to offer or issue
					 coverage to one or more health group cooperatives of its choosing.
(b) Notwithstanding subsection (a) of this
					 section, a health carrier must comply with the guaranteed issuance requirements
					 of Insurance Code Chapter 1501 (concerning Health Insurance Portability and
					 Availability Act) and this chapter with respect to offering and issuing
					 coverage to a health group cooperative that:
(1) consists of only small
					 employers;
(2) has elected to
					 restrict membership in the cooperative to 50 employees; and
(3) has notified TDI consistent with §
												26.401(e)
					 of this title (relating to Establishment of Health Group
					 Cooperatives).
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 26 - EMPLOYER-RELATED HEALTH BENEFIT PLAN REGULATIONS › Subchapter D - COOPERATIVES › Division 1 - NONPROFIT HEALTH GROUP COOPERATIVES › Section 26.410 - Expedited Approval for Plans Offered Through a Health Group Cooperative

Current through Reg. 49, No. 28; July 12, 2024
(a) Unless a health carrier has identified a
					 previously approved health benefit plan in the filing required by §
											26.407
					 of this title (relating to Health Carrier Filing Before Issuance of Coverage to
					 a Health Group Cooperative), the health carrier must file each health benefit
					 plan that will be offered to a health group cooperative for approval and must
					 clearly indicate in the filing that the health benefit plan is to be offered to
					 a health group cooperative and is subject to review under this
					 section.
(b) A health benefit plan
					 subject to review under this section may be filed as a file-and-use form
					 consistent with Insurance Code Chapter 1701, Subchapter B (concerning Filing
					 Requirement) and Subchapter C (concerning Sanctions; Applicability of Other
					 Laws) , and §
											3.5(a)(2)
					 of this title (relating to Filing Authorities and Categories).
(c) An insurer that does not elect to file
					 for approval under subsection (b) of this section must file for approval
					 consistent with Insurance Code §
											1701.051
					 (concerning Filing Required), and §1701.054 (concerning Approval of Form),
					 and §
											3.5(a)(1)
					 of this title. TDI will approve or disapprove the filing within 40 calendar
					 days of receipt of the complete filing.
(d) An HMO must file for approval an HMO
					 evidence of coverage that is to be offered solely to a health group cooperative
					 and must indicate that review of the evidence of coverage is subject to the
					 expedited process available under this section. The HMO must file the evidence
					 of coverage as required by Chapter 11 of this title (relating to Health
					 Maintenance Organizations), and TDI will approve or disapprove the evidence of
					 coverage within 20 calendar days of receipt of a complete filing.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 26 - EMPLOYER-RELATED HEALTH BENEFIT PLAN REGULATIONS › Subchapter D - COOPERATIVES › Division 1 - NONPROFIT HEALTH GROUP COOPERATIVES › Section 26.411 - Service Areas for Health Carriers Offering Coverage Through a Health Group Cooperative

Current through Reg. 49, No. 28; July 12, 2024
(a) A health
					 carrier may provide coverage to only one health group cooperative in any
					 county, except that a health carrier may provide coverage to additional health
					 group cooperatives if it is providing coverage in an expanded service
					 area.
(b) A health carrier may
					 provide health group cooperative coverage to an expanded service area that
					 includes the entire state on providing certification to TDI, signed by an
					 officer of the health carrier, that the health carrier intends to provide
					 health group cooperative coverage to an expanded service area that includes the
					 entire state.
(c) A health carrier
					 may apply for an expanded service area that includes less than the entire state
					 by submitting an application for approval to TDI. The health carrier may begin
					 using the expanded service area on approval or 60 days after the day the
					 application is received by TDI, unless the application is disapproved by TDI
					 within that time. The application must include, in a nondiscriminatory manner
					 and in compliance with Insurance Code Chapter 544 (concerning Prohibited
					 Discrimination):
(1) the geographic service
					 areas, defined in terms of counties or ZIP codes, to the extent possible;
					 and
(2) if the service area cannot
					 be defined by counties or ZIP codes, a map that clearly shows the geographic
					 service areas.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 26 - EMPLOYER-RELATED HEALTH BENEFIT PLAN REGULATIONS › Subchapter D - COOPERATIVES › Division 2 - SINGLE-EMPLOYEE BUSINESS PARTICIPATION IN HEALTH GROUP COOPERATIVES › Section 26.421 - Election to Permit Single-Employee Businesses to Participate in a Health Group Cooperative

Current through Reg. 49, No. 28; July 12, 2024
A health group cooperative that elects to admit eligible
						single-employee businesses must file an election with TDI at least 90 days
						before the date coverage becomes effective for single-employee business
						members. The election filing must contain:
(1) the election date;
(2) the results of the election;
(3) that the cooperative has a written
					 agreement with a small or large employer health benefit plan issuer;
					 and
(4) a signature by an
					 authorized officer of the cooperative.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 26 - EMPLOYER-RELATED HEALTH BENEFIT PLAN REGULATIONS › Subchapter D - COOPERATIVES › Division 2 - SINGLE-EMPLOYEE BUSINESS PARTICIPATION IN HEALTH GROUP COOPERATIVES › Section 26.422 - Condition Precedent to Filing Election to Admit Single-Employee Businesses as Members

Current through Reg. 49, No. 28; July 12, 2024
A health group cooperative may elect to admit eligible
						single-employee businesses only if a small or large employer
						health-benefit-plan issuer has agreed in writing to offer to issue coverage to
						the cooperative based on its membership once the election becomes
						effective.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 26 - EMPLOYER-RELATED HEALTH BENEFIT PLAN REGULATIONS › Subchapter D - COOPERATIVES › Division 2 - SINGLE-EMPLOYEE BUSINESS PARTICIPATION IN HEALTH GROUP COOPERATIVES › Section 26.423 - Initial and Annual Enrollment Periods

Current through Reg. 49, No. 28; July 12, 2024
(a) A health group cooperative that elects to
					 admit eligible single-employee businesses must permit participation and
					 enrollment in the cooperative's health benefit plan coverage during the initial
					 and annual open enrollment periods.
(b) For purposes of this section, the
					 provisions of Insurance Code §
											1501.0581(a-1)
					 (concerning Special Provisions Relating to Health Group Cooperatives) apply to
					 eligible single-employee businesses.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 26 - EMPLOYER-RELATED HEALTH BENEFIT PLAN REGULATIONS › Subchapter D - COOPERATIVES › Division 2 - SINGLE-EMPLOYEE BUSINESS PARTICIPATION IN HEALTH GROUP COOPERATIVES › Section 26.424 - Membership Eligibility Requirements for Single-Employee Businesses

Current through Reg. 49, No. 28; July 12, 2024
A single-employee business is eligible to join a health
						care cooperative if it:
(1) is owned
					 and operated by a sole proprietor;
(2) is engaged in commercial activity for the
					 purpose of the sole proprietor's livelihood or profit;
(3) is not operated solely to obtain health
					 benefit plan coverage under Insurance Code Chapter 1501 (concerning Health
					 Insurance Portability and Availability Act); and
(4) employed fewer than two employees on
					 business days during the preceding calendar year.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 26 - EMPLOYER-RELATED HEALTH BENEFIT PLAN REGULATIONS › Subchapter D - COOPERATIVES › Division 2 - SINGLE-EMPLOYEE BUSINESS PARTICIPATION IN HEALTH GROUP COOPERATIVES › Section 26.425 - Plan Issuance, Rating Requirements, and Mandated Benefits

Current through Reg. 49, No. 28; July 12, 2024
On the date an election under this division becomes
						effective and until the election is rescinded, the provisions of Insurance Code
						Chapter 1501 (concerning Health Insurance Portability and Availability Act)
						relating to guaranteed issuance of plans, rating requirements, and mandated
						benefits that are applicable to small employers apply to eligible
						single-employee businesses that are members of the health group
						cooperative.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 26 - EMPLOYER-RELATED HEALTH BENEFIT PLAN REGULATIONS › Subchapter D - COOPERATIVES › Division 2 - SINGLE-EMPLOYEE BUSINESS PARTICIPATION IN HEALTH GROUP COOPERATIVES › Section 26.426 - Rescission of Election

Current through Reg. 49, No. 28; July 12, 2024
(a) A health group
					 cooperative may rescind its election to admit eligible single-employee business
					 members only if the:
(1) election has been
					 effective for at least two years, except as provided by subsection (b) of this
					 section;
(2) health group
					 cooperative files notice of the rescission with the commissioner not later than
					 the 180th day before the effective date of the rescission; and
(3) health group cooperative provides written
					 notice of termination of coverage to all eligible single-employee business
					 members of the cooperative not later than the 180th day before the effective
					 date of the termination.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 26 - EMPLOYER-RELATED HEALTH BENEFIT PLAN REGULATIONS › Subchapter D - COOPERATIVES › Division 3 - HEALTH GROUP COOPERATIVE ELECTION TO TREAT MEMBERS AS SEPARATE EMPLOYERS FOR RATING PURPOSES › Section 26.431 - Election to Treat Members as Separate Employers for Rating Purposes

Current through Reg. 49, No. 28; July 12, 2024
(a) A health group cooperative may elect to
					 treat each member as a separate employer for purposes of rating small and large
					 employer health benefit plans subject to the rating requirements Insurance Code
					 Chapter 843 (concerning Health Maintenance Organizations), as
					 applicable.
(b) An existing health
					 group cooperative must file its election with TDI not later than the 90th day
					 before the date on which the election is to become effective. The election
					 filing must include:
(1) the election
					 date;
(2) the effective date of the
					 election; and
(3) a signature by an
					 authorized officer of the cooperative.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 26 - EMPLOYER-RELATED HEALTH BENEFIT PLAN REGULATIONS › Subchapter D - COOPERATIVES › Division 4 - PRIVATE PURCHASING COOPERATIVES › Section 26.441 - Private Purchasing Cooperatives

Current through Reg. 49, No. 28; July 12, 2024
(a)
					 Two or more small or large employers may form a private purchasing cooperative
					 for the purchase of small or large employer health benefit plans. A private
					 purchasing cooperative must be organized as a nonprofit corporation and has the
					 rights and duties provided by the Texas Nonprofit Corporation Act, Business
					 Organizations Code Chapter 22.
(b)
					 On receipt of a certificate of incorporation or certificate of authority from
					 the secretary of state, the private purchasing cooperative must file
					 notification of the receipt of the certificate and a copy of the cooperative's
					 organizational documents with the commissioner.
(c) When a private purchasing cooperative or
					 the Texas Health Benefits Purchasing Cooperative arranges for coverage under a
					 health benefit plan for a small or large employer, the health benefit plan
					 issued to a:
(1) small employer must be a
					 small employer health benefit plan;
(2) large employer must be a large employer
					 health benefit plan; and
(3) school
					 district electing to be treated as a small employer under Insurance Code §
												1501.009
					 (concerning School District Election), must be a small employer health benefit
					 plan.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 26 - EMPLOYER-RELATED HEALTH BENEFIT PLAN REGULATIONS › Subchapter D - COOPERATIVES › Division 4 - PRIVATE PURCHASING COOPERATIVES › Section 26.442 - Powers and Duties of Texas Health Benefits Purchasing Cooperative and Private Purchasing Cooperatives

Current through Reg. 49, No. 28; July 12, 2024
(a) A
					 private purchasing cooperative described in this section and the Texas Health
					 Benefits Purchasing Cooperative described in Insurance Code Chapter 1501:
(1) must arrange for small or large employer
					 health benefit plan coverage for small or large employer groups that
					 participate in the cooperative by contracting with small or large employer
					 carriers that meet the criteria established in Insurance Code §
												1501.061
					 (concerning Requirements Applicable to Health Benefit Plan Issuers with Which
					 Cooperative May Contract) and subsection (b) of this section;
(2) must collect premiums to cover the cost
					 of:
(A) small or large employer health benefit
					 plan coverage purchased through the cooperative; and
(B) the cooperative's administrative
					 expenses;
(3) may
					 contract with agents to market coverage issued through the
					 cooperative;
(4) must establish
					 administrative and accounting procedures for the operation of the
					 cooperative;
(5) must establish
					 procedures under which an applicant for or participant in coverage issued
					 through the cooperative may have a grievance reviewed by an impartial
					 person;
(6) may contract with a
					 small or large employer carrier or third-party administrator to provide
					 administrative services to the cooperative;
(7) must contract with small or large
					 employer carriers for the provision of services to small or large employers
					 covered through the cooperative;
(8) must develop and implement a plan to
					 maintain public awareness of the cooperative and publicize the eligibility
					 requirements for, and the procedures for enrollment in coverage through the
					 cooperative;
(9) may negotiate the
					 premiums paid by its members; and
(10) may offer other ancillary products and
					 services to its members that are customarily offered in conjunction with health
					 benefit plans.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 26 - EMPLOYER-RELATED HEALTH BENEFIT PLAN REGULATIONS › Subchapter E - HEALTHY TEXAS PROGRAM › Division 1 - GENERAL PROVISIONS › Section 26.501 - Purpose

Current through Reg. 49, No. 28; July 12, 2024
The purpose of this subchapter is to implement the
						provisions of the Healthy Texas Program as set out in the Insurance Code
						Chapter 1508 and to facilitate the attainment of its objectives to:
(1) provide access to quality small employer
					 health benefit plans at an affordable price;
(2) encourage small employers to offer health
					 benefit plan coverage to employees and the dependents of employees;
					 and
(3) maximize reliance on proven
					 managed care strategies and procedures.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 26 - EMPLOYER-RELATED HEALTH BENEFIT PLAN REGULATIONS › Subchapter E - HEALTHY TEXAS PROGRAM › Division 1 - GENERAL PROVISIONS › Section 26.502 - Definitions

Current through Reg. 49, No. 28; July 12, 2024
The following words and terms, when used in this
						subchapter, shall have the following meanings, unless the context clearly
						indicates otherwise.
(1)
					 Dependent--Has the meaning assigned by the Insurance Code §
											1501.002(2).
(2) Eligible employee--Has the meaning
					 assigned by the Insurance Code §
											1501.002(3).
(3) Fund--The Healthy Texas small employer
					 premium stabilization fund established under the Insurance Code Chapter 1508,
					 Subchapter F.
(4) Health benefit
					 plan--Has the meaning assigned by the Insurance Code §
											1501.002(5).
(5) Health benefit plan issuer--Has the
					 meaning assigned by the Insurance Code §
											1501.002(6).
(6) Participating health benefit plan
					 issuer--A health benefit plan issuer which has elected to participate in the
					 Healthy Texas Program in accordance with the Insurance Code Chapter 1508 and
					 this subchapter.
(7) Qualifying
					 group health benefit plan--A health benefit plan that provides benefits for
					 health care services in the manner described by the Insurance Code Chapter
					 1508, and as approved by the commissioner.
(8) Small employer--Has the meaning assigned
					 by the Insurance Code §
											1501.002(14).
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 26 - EMPLOYER-RELATED HEALTH BENEFIT PLAN REGULATIONS › Subchapter E - HEALTHY TEXAS PROGRAM › Division 2 - PARTICIPATION BY HEALTH BENEFIT PLAN ISSUERS › Section 26.511 - Health Benefit Plan Issuer Participation

Current through Reg. 49, No. 28; July 12, 2024
(a) A
					 health benefit plan issuer electing to participate in the Healthy Texas Program
					 by offering qualifying group health benefit plans shall file an application
					 with the department to be a participating health benefit plan issuer in a form
					 and manner prescribed by the commissioner.
(b) A health benefit plan issuer electing to
					 participate in the program must do so under the terms and conditions of the
					 Insurance Code Chapter 1508 and this subchapter.
(c) A participating health benefit plan
					 issuer must offer only qualifying group health benefit plans to small employers
					 participating in the Healthy Texas Program.
(d) The commissioner has determined that
					 limitation concerning which health benefit plan issuers may participate in the
					 Healthy Texas Program is necessary to achieve the purposes of the program, and
					 will, in accordance with the Insurance Code §
											1508.101(c),
					 contract on a competitive procurement basis with one or more health benefit
					 plan issuers to provide qualifying health benefit plan coverage.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 26 - EMPLOYER-RELATED HEALTH BENEFIT PLAN REGULATIONS › Subchapter E - HEALTHY TEXAS PROGRAM › Division 2 - PARTICIPATION BY HEALTH BENEFIT PLAN ISSUERS › Section 26.512 - Application, Initial Certification of Eligibility, and Enrollment

Current through Reg. 49, No. 28; July 12, 2024
(a) Applications from employers applying for
					 qualifying group health benefit plans must be made directly to a participating
					 health benefit plan issuer. For purposes of submission acknowledgment, a
					 participating health benefit plan issuer shall maintain a record of the date
					 and time it receives an employer application for coverage under a qualifying
					 group health benefit plan.
(b) A
					 participating health benefit plan issuer shall provide all necessary
					 information, including application and enrollment forms to applicants on
					 request.
(c) A participating health
					 benefit plan issuer:
(1) Shall collect the
					 initial employer eligibility certifications required by the Insurance Code
					 §
												1508.151;
(2) May collect appropriate documentation in
					 support of a certification as provided in the Insurance Code §
												1508.151(c);
(3) Shall be responsible for examination of
					 such employer eligibility certifications and any supporting documentation to
					 verify that applicants meet applicable eligibility requirements; and
(4) Shall base verification upon review of
					 the employer certification and any supporting documentation requested and
					 received.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 26 - EMPLOYER-RELATED HEALTH BENEFIT PLAN REGULATIONS › Subchapter E - HEALTHY TEXAS PROGRAM › Division 2 - PARTICIPATION BY HEALTH BENEFIT PLAN ISSUERS › Section 26.513 - Annual Recertification of Eligibility

Current through Reg. 49, No. 28; July 12, 2024
(a) A participating health benefit plan
					 issuer shall, at least 90 days prior to the annual renewal date of the group
					 health benefit plan, provide any forms necessary for small employers to submit
					 recertification of eligibility.
(b)
					 A participating health benefit plan issuer shall annually collect
					 certifications of continued eligibility for the Healthy Texas Program and shall
					 be responsible for examination of such certifications to verify that small
					 employers and enrollees participating in the program continue to meet
					 eligibility requirements and continue to comply with the terms of the program.
					 The commissioner may prescribe a standardized health benefit plan renewal
					 certification form to be utilized for employer renewal certification purposes.
					 A participating health benefit plan issuer shall determine whether the small
					 employer and enrollees continue to meet the requirements for participation in
					 the Healthy Texas Program and shall provide written notice of such eligibility
					 determination to the small employer within two weeks of receipt of the annual
					 recertification.
(c) The failure of
					 an employer to provide written certification demonstrating continued
					 eligibility and continued compliance with the terms of the Healthy Texas
					 Program shall be a basis for nonrenewal of a qualifying health benefit
					 plan.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 26 - EMPLOYER-RELATED HEALTH BENEFIT PLAN REGULATIONS › Subchapter E - HEALTHY TEXAS PROGRAM › Division 2 - PARTICIPATION BY HEALTH BENEFIT PLAN ISSUERS › Section 26.514 - Health Plan Renewal Provisions

Current through Reg. 49, No. 28; July 12, 2024
(a) A
					 qualifying group health benefit plan is renewable at the option of a
					 participating small employer so long as:
(1)
					 the Healthy Texas Program is active and operational;
(2) the small employer continues to meet
					 eligibility requirements that are set forth in the Insurance Code Chapter 1508
					 and §
												26.521
					 of this subchapter (relating to Small Employer Participation); and
(3) the small employer timely provides a
					 participating health benefit plan issuer the initial or renewal certification
					 information as addressed in §26.512(c) of this division (relating to
					 Application, Initial Certification of Eligibility, and Enrollment),
					 §26.513(b) and (c) of this division (relating to Annual Recertification of
					 Eligibility), and §
												26.521(j)
					 of this subchapter.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 26 - EMPLOYER-RELATED HEALTH BENEFIT PLAN REGULATIONS › Subchapter E - HEALTHY TEXAS PROGRAM › Division 2 - PARTICIPATION BY HEALTH BENEFIT PLAN ISSUERS › Section 26.515 - Notice of Discontinuance of Health Plan; Issuer Withdrawal from Participation

Current through Reg. 49, No. 28; July 12, 2024
(a) A
					 participating health benefit plan issuer may elect to discontinue Healthy Texas
					 coverage only if the participating health benefit plan issuer has filed written
					 notice of withdrawal from participation in the Healthy Texas Program with the
					 commissioner on a form and in the manner prescribed by the commissioner and the
					 participating health benefit plan issuer:
(1)
					 before the 90th day preceding the date of the discontinuation of the coverage:
(A) provides notice of the discontinuation to
					 each employer and the department; and
(B) offers to each employer the option to
					 purchase other small employer coverage offered by the participating health
					 benefit plan issuer at the time of the discontinuation; and
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 26 - EMPLOYER-RELATED HEALTH BENEFIT PLAN REGULATIONS › Subchapter E - HEALTHY TEXAS PROGRAM › Division 2 - PARTICIPATION BY HEALTH BENEFIT PLAN ISSUERS › Section 26.516 - Grace Period

Current through Reg. 49, No. 28; July 12, 2024
A qualifying group health benefit plan shall provide a
						30-day grace period for payment of premiums.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 26 - EMPLOYER-RELATED HEALTH BENEFIT PLAN REGULATIONS › Subchapter E - HEALTHY TEXAS PROGRAM › Division 2 - PARTICIPATION BY HEALTH BENEFIT PLAN ISSUERS › Section 26.517 - Health Plan Contact Information

Current through Reg. 49, No. 28; July 12, 2024
A participating health benefit plan issuer shall submit
						to the department:
(1) the name,
					 mailing address, email address, and telephone number of a health plan issuer
					 contact person assigned to the Healthy Texas Program;
(2) the mailing address, email address, and
					 toll-free telephone number to which consumer inquiries regarding the Healthy
					 Texas Program are to be directed;
(3) the service area in which the Healthy
					 Texas Program will be available; and
(4) any revisions or updates to the
					 information specified in paragraphs (1) - (3) of this section, or subsequently
					 required contact information, in the timeframe and manner prescribed by the
					 commissioner.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 26 - EMPLOYER-RELATED HEALTH BENEFIT PLAN REGULATIONS › Subchapter E - HEALTHY TEXAS PROGRAM › Division 3 - PARTICIPATION BY SMALL EMPLOYERS › Section 26.522 - Verification of Income

Current through Reg. 49, No. 28; July 12, 2024
(a) In order for a
					 small employer to qualify for coverage under the Healthy Texas Program,
					 eligible employees must, as a group, satisfy the income criteria set forth in
					 the Insurance Code §
											1508.051(a)(2).
(b) A participating health benefit plan
					 issuer shall collect from the employer such documentation in the form of
					 payroll data or other documentation as is necessary and sufficient to verify
					 that the income requirements of the Healthy Texas Program have been
					 satisfied.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 26 - EMPLOYER-RELATED HEALTH BENEFIT PLAN REGULATIONS › Subchapter E - HEALTHY TEXAS PROGRAM › Division 4 - PARTICIPATION BY REGIONAL AND LOCAL HEALTH CARE PROGRAMS › Section 26.531 - Purpose

Current through Reg. 49, No. 28; July 12, 2024
The purpose of this division is to establish
						participation requirements applicable to regional and local health care
						programs described by the Health and Safety Code Chapter 75 that elect to
						participate in the Healthy Texas Program. Regional and local health care
						programs are programs that provide health care services or benefits to
						employees of participating small employers who are located within the
						boundaries of a participating county or counties as applicable. Section 75.052
						provides that a regional or local health care program may be operated by a
						joint council, tax-exempt nonprofit entity, or other entity that operates the
						program under a contract with a county commissioners court or courts, as
						applicable, or is an entity in which the county or counties participate or that
						is established or designated by the commissioners court or courts, as
						applicable, to operate the program.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 26 - EMPLOYER-RELATED HEALTH BENEFIT PLAN REGULATIONS › Subchapter E - HEALTHY TEXAS PROGRAM › Division 4 - PARTICIPATION BY REGIONAL AND LOCAL HEALTH CARE PROGRAMS › Section 26.532 - Applicability and Scope

Current through Reg. 49, No. 28; July 12, 2024
This division applies to any existing or newly formed
						regional or local health care program described by the Health and Safety Code
						Chapter 75 that desires to participate in the Healthy Texas
						Program.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 26 - EMPLOYER-RELATED HEALTH BENEFIT PLAN REGULATIONS › Subchapter E - HEALTHY TEXAS PROGRAM › Division 4 - PARTICIPATION BY REGIONAL AND LOCAL HEALTH CARE PROGRAMS › Section 26.533 - Submission of Election to Participate in Healthy Texas

Current through Reg. 49, No. 28; July 12, 2024
(a) As provided in this division, a regional
					 or local health care program described by the Health and Safety Code Chapter 75
					 may file an election with the commissioner, on an application form and in the
					 manner prescribed by the commissioner, to participate in the Healthy Texas
					 Program and its small employer premium stabilization fund, utilizing the
					 options set forth in subsections (b) and (c) of this section.
(b) A regional or local health care program
					 may apply to participate through purchase of an available Healthy Texas health
					 benefit plan pursuant to the Health and Safety Code §
											75.102(a)(3)
					 in accordance with Divisions 3 and 6 of this subchapter (relating to
					 Participation by Small Employers and Healthy Texas Small Employer Premium
					 Stabilization Fund, respectively) applicable to the facilitation of purchase or
					 direct purchase of a Healthy Texas qualifying health benefit plan, and as
					 further provided in §26.534 of this division (relating to Participation
					 Through Direct Purchase of Health Benefit Plan).
(c) A regional or local health care program
					 also may apply to participate through the completion of a process that results
					 in a regional or local health care program with benefit, operational and
					 administrative provisions that meet or exceed the standards set forth in
					 §26.535 of this division (relating to Participation Through Eligible
					 Regional or Local Health Care Program Implementation).
(d) Any newly formed regional or local health
					 care program electing to participate must meet all requirements for
					 participation as provided in this division, and must file its election not
					 later than the 90th day before the date coverage for health care is to become
					 effective for such regional or local health care program.
(e) Any existing regional or local health
					 care program electing to participate must meet all requirements for
					 participation as provided in this division, and must file its election not
					 later than the 90th day before the anniversary date on which post-anniversary
					 date coverage for health care is to become effective for such regional or local
					 health care program.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 26 - EMPLOYER-RELATED HEALTH BENEFIT PLAN REGULATIONS › Subchapter E - HEALTHY TEXAS PROGRAM › Division 4 - PARTICIPATION BY REGIONAL AND LOCAL HEALTH CARE PROGRAMS › Section 26.534 - Participation Through Direct Purchase of Health Benefit Plan

Current through Reg. 49, No. 28; July 12, 2024
A regional or local health care program may apply to
						participate through purchase of an available Healthy Texas health benefit plan
						pursuant to the Health and Safety Code §
											75.102(a)(3),
						so long as the eligibility criteria in paragraphs (1) and (2) of this section
						are met.
(1) Employers of employees
					 for whom the regional or local health care program is purchasing or
					 facilitating the purchase of health benefit plan coverage through Healthy Texas
					 must:
(A) comply with the provisions of
					 §26.521(a) - (e) and (g) - (k) of this subchapter (relating to Small
					 Employer Participation); and
(B)
					 contribute an amount of premium costs for employees which, when combined with
					 any amount obtained from any other eligible source as provided in the Health
					 and Safety Code §
												75.055,
					 amounts to at least 50 percent of the premium for each employee covered under
					 the Healthy Texas benefit plan.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 26 - EMPLOYER-RELATED HEALTH BENEFIT PLAN REGULATIONS › Subchapter E - HEALTHY TEXAS PROGRAM › Division 4 - PARTICIPATION BY REGIONAL AND LOCAL HEALTH CARE PROGRAMS › Section 26.535 - Participation Through Eligible Regional or Local Health Care Program Implementation

Current through Reg. 49, No. 28; July 12, 2024
(a) A regional
					 or local health care program may apply to participate through the development
					 and implementation of a regional or local health care program with benefit,
					 operational and administrative provisions that meet or exceed the standards
					 specified in this section.
(b) A
					 regional or local health care program participating in the Healthy Texas
					 Program under this section must provide benefits and service levels for
					 participating enrollees that meet or exceed those that are established by the
					 commissioner for the benefit categories set forth in paragraphs (1) - (9) of
					 this subsection. Such compliance must be certified by an authorized
					 representative of the governing body of the regional or local health care
					 program on a form and in the manner prescribed by the commissioner for the
					 following categories of benefits and service levels:
(1) an annual maximum benefit requirement per
					 enrollee;
(2) an annual maximum
					 financial requirement prerequisite to payment of eligible claims of
					 participating enrollees;
(3)
					 cost-sharing maximum requirements for benefits or services covered by or
					 through a regional or local health care program;
(4) an annual out-of-pocket maximum
					 requirement;
(5) hospital inpatient
					 and outpatient benefits;
(6)
					 radiology and diagnostic tests;
(7)
					 emergency care;
(8) maternity
					 coverage with a limited copay for the initial prenatal visit; and
(9) immunization coverage at 100 percent of
					 cost.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 26 - EMPLOYER-RELATED HEALTH BENEFIT PLAN REGULATIONS › Subchapter E - HEALTHY TEXAS PROGRAM › Division 4 - PARTICIPATION BY REGIONAL AND LOCAL HEALTH CARE PROGRAMS › Section 26.536 - Withdrawal from Participation

Current through Reg. 49, No. 28; July 12, 2024
(a) Any
					 existing participating regional or local health care program may withdraw from
					 participation in the Healthy Texas Program at any time by written notice filed
					 with the commissioner on a form and in the manner prescribed by the
					 commissioner.
(b) Any existing
					 participating regional or local health care program also must provide enrollees
					 under the program written notice of its intention to withdraw from
					 participation in the Healthy Texas Program not later than the 90th day prior to
					 the anniversary date on which the withdrawal is to become effective.