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 A - DEFINITIONS, SEVERABILITY, AND SMALL EMPLOYER HEALTH REGULATIONS › Section 26.6 - Status of Health Carriers as Small Employer Carriers

Current through Reg. 49, No. 28; July 12, 2024
(a) With the original filing to enter the
				  small employer market or when notifying TDI of a change in status, each health
				  carrier providing health benefit plans in this state must file with the
				  commissioner a statement indicating whether the health carrier will or will not
				  offer, renew, issue, or issue for delivery health benefit plans to small
				  employers in this state. The filing must include a certification, signed by an
				  officer of the company, that the carrier intends to operate in accordance with
				  the status certification unless or until it is changed in accordance with this
				  section, and provide a statement to the effect of one of the following
				  statements:
(1) the health carrier intends to
				  offer, renew, issue, and issue for delivery health benefit plans to small
				  employers in Texas and will operate in accordance with Insurance Code Chapter
				  1501 (concerning Health Insurance Portability and Availability Act) and this
				  subchapter;
(2) the health carrier
				  does not intend to offer, issue, or issue for delivery health benefit plans to
				  small employers in Texas, but the health carrier intends to renew existing
				  health benefit plans;
(3) the
				  health carrier does not intend to offer, issue, or issue for delivery health
				  benefit plans to small employers in Texas; intends to nonrenew all health
				  benefit plans issued to small employers in Texas; and will provide notice to
				  the commissioner and employers in accordance with §
											26.16
				  of this title (relating to Refusal to Renew and Application to Reenter Small
				  Employer Market) and Insurance Code §
											1501.110
				  (concerning Notice to Covered Persons); or
(4) the health carrier has no health benefit
				  plans issued to small employers or to employees of a small employer and does
				  not intend to offer, issue, or issue for delivery health benefit plans to small
				  employers.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 26 - EMPLOYER-RELATED HEALTH BENEFIT PLAN REGULATIONS › Subchapter A - DEFINITIONS, SEVERABILITY, AND SMALL EMPLOYER HEALTH REGULATIONS › Section 26.7 - Requirement to Insure Entire Groups

Current through Reg. 49, No. 28; July 12, 2024
(a) A
				  small employer carrier that offers coverage to a small employer and its
				  employees must offer coverage to each eligible employee and to each dependent
				  of an eligible employee. Except as provided in subsection (b) of this section,
				  the small employer carrier must provide the same health benefit plan to each
				  employee or dependent eligible for coverage.
(b) If elected by the small employer, a small
				  employer carrier may offer one or more health benefit plans, provided that each
				  eligible employee may choose any of the plans offered. Except as provided in
				  Insurance Code Chapter 1501 (concerning Health Insurance Portability and
				  Availability Act) with respect to an affiliation period or exclusions for
				  preexisting conditions , the choice among benefit plans may not be limited,
				  restricted, or conditioned based on the risk characteristics of each employee
				  or dependent eligible for coverage .
(c) A small employer carrier may require each
				  small employer that applies for coverage, as part of the application process,
				  to provide a complete list of employees, eligible employees, and dependents of
				  eligible employees . The small employer carrier may also require the small
				  employer to provide reasonable and appropriate supporting documentation to
				  verify the information required under this subsection, and to confirm the
				  applicant's status as a small employer. The small employer carrier must make a
				  determination of eligibility within five business days of receipt of any
				  requested documentation. A small employer carrier may not condition the
				  issuance of coverage on an employer's production of a particular document,
				  where the employer can otherwise provide the information required by this
				  section. Similarly, if a particular document an employer produces does not
				  reasonably evidence the employer's compliance with this subsection, the
				  employer must produce other documentation to satisfy the requirements. Examples
				  of the types of reasonable and appropriate supporting documentation that a
				  small employer carrier may request from an employer as needed to fulfill the
				  purposes of this subsection are:
(1) a W-2
				  Summary Wage and Tax Form or other federal or state tax records;
(2) a loan agreement;
(3) an invoice;
(4) a business check;
(5) a sales tax license;
(6) articles of incorporation or other
				  business entity filings with the secretary of state ;
(7) assumed name filings;
(8) professional licenses; and
(9) reports required by the Texas Workforce
				  Commission.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 26 - EMPLOYER-RELATED HEALTH BENEFIT PLAN REGULATIONS › Subchapter A - DEFINITIONS, SEVERABILITY, AND SMALL EMPLOYER HEALTH REGULATIONS › Section 26.10 - Establishment of Classes of Business

Current through Reg. 49, No. 28; July 12, 2024
(a) A
				  small employer carrier that establishes more than one class of business in
				  accordance with the provisions of Insurance Code §
										1501.202
				  (concerning Establishment of Classes of Business) and §1501.203
				  (concerning Establishment of Classes of Business on Certain Bases Prohibited)
				  must maintain on file for inspection by the commissioner the following
				  information with respect to each class of business so established:
(1) a description of each criterion employed
				  by the health carrier (or any of its agents) for determining membership in the
				  class of business;
(2) a statement
				  describing the justification for establishing the class as a separate class of
				  business and documentation that the establishment of the class of business is
				  intended to reflect substantial differences in expected claims experience or
				  administrative costs related to the reasons set forth in Insurance Code Chapter
				  1501 (concerning Health Insurance Portability and Availability Act) ;
				  and
(3) a statement disclosing
				  which, if any, health benefit plans are currently available for purchase in the
				  class and any significant limitations related to the purchase of the
				  plans.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 26 - EMPLOYER-RELATED HEALTH BENEFIT PLAN REGULATIONS › Subchapter A - DEFINITIONS, SEVERABILITY, AND SMALL EMPLOYER HEALTH REGULATIONS › Section 26.11 - Restrictions Relating to Premium Rates

Current through Reg. 49, No. 28; July 12, 2024
(a) A small employer carrier must develop a
				  separate rate manual for each class of business. Base premium rates and new
				  business premium rates charged to small employers by the small employer carrier
				  must be computed solely from the applicable rate manual developed under this
				  subsection. To the extent that a portion of the premium rates charged by a
				  small employer carrier are based on objective criteria established by the small
				  employer carrier consistent with the criteria set out in Insurance Code Chapter
				  1501 (concerning Health Insurance Portability and Availability Act), the manual
				  must specify the criteria and factors considered by the health carrier in
				  exercising this discretion.
(b) A
				  small employer carrier must file with TDI, at least 60 days before the proposed
				  date of the change, any proposed change to the rating method used in the rate
				  manual for a class of business. The small employer carrier must ensure that the
				  rating method used is actuarially sound and appropriate to ensure compliance
				  with Insurance Code Chapter 1501 and this chapter, and that differences in
				  rates charged for each small employer health benefit plan are reasonable and
				  reflect objective differences in plan design. The commissioner may disapprove a
				  change to the rating method that does not meet the requirements of this
				  chapter. At the expiration of 60 days from the filing of the form with TDI, the
				  proposed change will be deemed compliant unless the commissioner has
				  disapproved it by written order.
(1) The
				  filing must contain at least the following information:
(A) the reasons the change in rating method
				  is being requested;
(B) a complete
				  description of each of the proposed modifications to the rating
				  method;
(C) a description of how
				  the change in rating method would affect the premium rates currently charged to
				  small employers in the class of business, including an estimate from a
				  qualified actuary of the number of groups or individuals and a description of
				  the types of groups or individuals whose premium rates may change by more than
				  10 percent due to the proposed change in rating method (not including general
				  increases in premium rates applicable to all small employers in a health
				  benefit plan);
(D) a certification
				  from a qualified actuary that the new rating method would be based on objective
				  and credible data and would be actuarially sound and appropriate; and
(E) a certification from a qualified actuary
				  that the proposed change in rating method would not produce premium rates for
				  small employers that would be in violation of Insurance Code Chapter
				  1501.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 26 - EMPLOYER-RELATED HEALTH BENEFIT PLAN REGULATIONS › Subchapter A - DEFINITIONS, SEVERABILITY, AND SMALL EMPLOYER HEALTH REGULATIONS › Section 26.12 - Disclosure

Current through Reg. 49, No. 28; July 12, 2024
In connection with the offering for sale of any small
					 employer health benefit plan, each small employer carrier and each agent must
					 make a reasonable disclosure, as part of its solicitation and sales material,
					 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 claim costs or the actual or expected variation
				  in health status of the employees of the small employer and their
				  dependents;
(2) provisions
				  concerning the small employer carrier's right to change premium rates and the
				  factors other than claim experience that affect changes in premium
				  rates;
(3) provisions relating to
				  renewability of policies and contracts; and
(4) any preexisting condition provision or
				  affiliation period.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 26 - EMPLOYER-RELATED HEALTH BENEFIT PLAN REGULATIONS › Subchapter A - DEFINITIONS, SEVERABILITY, AND SMALL EMPLOYER HEALTH REGULATIONS › Section 26.13 - Fair Marketing

Current through Reg. 49, No. 28; July 12, 2024
(a) A small
				  employer carrier must market each of its small employer health benefit plans to
				  small employers in this state. A small employer carrier may not suspend the
				  marketing or issuance of the small employer benefit plans unless the health
				  carrier has good cause and has received prior approval from the commissioner or
				  the commissioner's designee. In marketing consumer choice health benefit plans
				  to small employers, a small employer carrier must use at least the same sources
				  and methods of distribution that it uses to market other small employer health
				  benefit plans. Any agent authorized by a small employer carrier to market
				  consumer choice health benefit plans to small employers in this state must also
				  be authorized to market small employer health benefit plans that contain
				  state-mandated health benefits.
(b)
				  Before issuing coverage to a small employer, a small employer carrier must
				  offer the employer a choice of all health benefit plans that the small employer
				  carrier offers and for which the small employer qualifies. The small employer
				  carrier may provide the offer directly to the small employer or deliver it
				  through an agent, but in either case must offer each required plan
				  contemporaneously with the offer of any other small employer health benefit
				  plan. The offer must be in writing and include at least the following:
(1) information describing how the small
				  employer may enroll in the plan or plans;
(2) information set out in Insurance Code
				  §
											1501.354
				  (concerning Required Disclosures) and §
											26.12 of
				  this title (relating to Disclosure); and
(3) a written disclosure, as required by
				  Chapter 21, Subchapter AA of this title (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 A - DEFINITIONS, SEVERABILITY, AND SMALL EMPLOYER HEALTH REGULATIONS › Section 26.14 - Coverage

Current through Reg. 49, No. 28; July 12, 2024
(a) Continuation and conversion. All small
				  employer health benefit plans must provide for continuation and may provide an
				  option for conversion that complies with Insurance Code Chapters 1251
				  (concerning Group and Blanket Health Insurance) and 1271 (concerning Benefits
				  Provided by Health Maintenance Organizations; Evidence of Coverage; Charges)
				  and rules adopted under those statutes. A state-approved health benefit plan
				  that complies with the requirements of Title XIII, Public Health Service Act
				  (42 U.S.C.
				  §§
											300e, et seq., concerning Health
				  Maintenance Organizations) must provide coverage for continuation that complies
				  with the requirements of Insurance Code Chapter 1271) and must offer conversion
				  in compliance with 42 C.F.R. § 417.124(e) (concerning Administration and
				  Management) and applicable federal law.
(b) Plain language. Each health benefit plan,
				  certificate, policy, rider, or application used by health carriers to provide
				  coverage to small employers and their employees must comply with Insurance Code
				  §
										1501.258 (concerning Forms)
				  and §1501.260 (concerning Plain Language Required), be written in plain
				  language, and meet the requirements of Chapter 3, Subchapter G of this title
				  (relating to Plain Language Requirements for Health Benefit Policies).
				  Requirements for use of plain language are not applicable to a health benefit
				  plan group master policy or a policy application or enrollment form for a
				  health benefit plan group master policy.
(c) Dependent coverage. Every small employer
				  carrier providing health benefit plans to small employers is required to offer
				  dependent coverage to each eligible employee. Dependent coverage may be paid
				  for by the employer, the employee, or both.
(d) Point-of-service coverage. An HMO issuing
				  small employer HMO coverage may also offer point-of-service coverage that
				  complies, as applicable, with the requirements set forth in Insurance Code
				  Chapter 843 (concerning Health Maintenance Organizations); Chapter 11,
				  Subchapter Z of this title (relating to Point-of-Service Riders); and Chapter
				  21, Subchapter U of this title (relating to Arrangements Between Indemnity
				  Carriers and HMOs for Point-of-Service Coverage) that allow the enrollee to
				  access out-of-plan coverage at the option of the enrollee.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 26 - EMPLOYER-RELATED HEALTH BENEFIT PLAN REGULATIONS › Subchapter A - DEFINITIONS, SEVERABILITY, AND SMALL EMPLOYER HEALTH REGULATIONS › Section 26.15 - Renewability of Coverage and Cancellation

Current through Reg. 49, No. 28; July 12, 2024
(a) Except as provided by Insurance Code
				  §
										1501.109
				  (concerning Refusal to Renew; Discontinuation of Coverage), a small employer
				  carrier must renew any small employer health benefit plan at the option of the
				  small employer, unless:
(1) the premium has
				  not been paid as required by the terms of the plan;
(2) the small employer has committed fraud or
				  intentional misrepresentation of a material fact. An intentional
				  misrepresentation of a material fact does not include any misrepresentation
				  related to health status;
(3) the
				  small employer has not complied with a material provision of the health benefit
				  plan relating to premium contribution, group size, or minimum participation
				  requirements;
(4) the small
				  employer has no enrollee, in connection with the plan, who resides or works in
				  the service area of the small employer carrier or in the area where the small
				  employer carrier is authorized to do business; or
(5) membership of an employer in an
				  association terminates, but only if coverage is terminated uniformly without
				  regard to a health-status-related factor of a covered individual.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 26 - EMPLOYER-RELATED HEALTH BENEFIT PLAN REGULATIONS › Subchapter A - DEFINITIONS, SEVERABILITY, AND SMALL EMPLOYER HEALTH REGULATIONS › Section 26.16 - Refusal to Renew and Application to Reenter Small Employer Market

Current through Reg. 49, No. 28; July 12, 2024
(a) A small employer carrier may elect to
				  refuse to renew all small employer health benefit plans delivered or issued for
				  delivery by the small employer carrier in this state or in a geographic service
				  area. The small employer carrier must notify the commissioner and each affected
				  covered small employer of the election as provided in Insurance Code §
										1501.109
				  (concerning Refusal to Renew; Discontinuation of Coverage).
(b) The small employer carrier may not write
				  a new small employer health benefit plan in this state or in the geographic
				  service area, as applicable, for five years after notice to the commissioner of
				  the election to refuse to renew. A small employer carrier that elects not to
				  renew may not resume offering health benefit plans to small employers in this
				  state or in the geographic area for which the election was made until it has
				  filed a petition with the commissioner to be reinstated as a small employer
				  carrier and the petition has been approved. In reviewing the petition, the
				  commissioner may ask for information and assurances as the commissioner finds
				  reasonable and appropriate.
(c) A
				  small employer carrier may elect to discontinue a particular type of small
				  employer coverage only if the small employer carrier:
(1) before the 90th day preceding the date of
				  the discontinuation of the coverage:
(A)
				  provides notice of the discontinuation to each employer and TDI; and
(B) offers to each employer the option to
				  purchase other small employer coverage offered by the small employer carrier 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 A - DEFINITIONS, SEVERABILITY, AND SMALL EMPLOYER HEALTH REGULATIONS › Section 26.18 - Election and Application to Be Risk-Assuming or Reinsured Carrier

Current through Reg. 49, No. 28; July 12, 2024
(a) Each small employer carrier must file
				  with the commissioner, no later than with the first filing of a small employer
				  health benefit plan, notification of whether the carrier elects to operate as a
				  risk-assuming or reinsured carrier.
(1) A
				  small employer carrier's operation as a risk-assuming carrier is subject to
				  approval by the commissioner, and each small employer carrier electing to
				  operate as a risk-assuming carrier must file an application with the
				  commissioner contemporaneously with its election to operate as a risk-assuming
				  carrier. A risk-assuming carrier's application, in addition to the financial
				  information already on file with TDI, must include a:
(A) history of rating and underwriting small
				  employer groups, including a description of underwriting experience to identify
				  high risks and the percentage of aggregate rate increases for the past three
				  years for small employer groups for Texas and nationwide;
(B) description of the carrier's commitment
				  to fairly market to all small employers in Texas or in the small employer
				  carrier's established geographic service areas, including sample material used,
				  or planned to be used, to market to small employers;
(C) description of experience in managing the
				  risk of small groups, including;
(i) the
				  number of years, volume of business, results, etc.;
(ii) a list of other states with guaranteed
				  issue requirements where the carrier provides small employer group
				  coverage;
(iii) the total number of
				  lives currently covered under those guaranteed issue plans; and
(iv) a list of other states where the carrier
				  voluntarily participates in reinsurance programs;
(D) description of plans to manage the risk
				  of guaranteed issue as a risk-assuming carrier;
(E) list of affiliated small employer
				  carriers and whether they have been approved as either a risk-assuming or
				  reinsured carrier;
(F) list of any
				  other affiliated small employer carrier applicants, indicating their requested
				  designation as either a risk-assuming or reinsured carrier; and
(G) the name, title, and signature of the
				  chief executive officer, attorney, or actuary for the named health
				  carrier.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 26 - EMPLOYER-RELATED HEALTH BENEFIT PLAN REGULATIONS › Subchapter A - DEFINITIONS, SEVERABILITY, AND SMALL EMPLOYER HEALTH REGULATIONS › Section 26.20 - Reporting Requirements

Current through Reg. 49, No. 28; July 12, 2024
(a) Small
				  employer health carriers offering a small employer health benefit plan must
				  file annually, not later than March 1 of each year, an actuarial certification
				  Form Number 1212 CERT ACTUARIAL, Annual Small Employer Health Benefit Plan
				  Actuarial Certification, Rev. 09/16, signed by a qualified actuary stating that
				  the underwriting and rating methods of the small employer carrier:
(1) comply with accepted actuarial
				  practices;
(2) are uniformly
				  applied to each small employer health benefit plan covering a small employer;
				  and
(3) comply with the provisions
				  of Insurance Code Chapter 1501 (concerning Health Insurance Portability and
				  Availability Act) and this chapter.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 26 - EMPLOYER-RELATED HEALTH BENEFIT PLAN REGULATIONS › Subchapter A - DEFINITIONS, SEVERABILITY, AND SMALL EMPLOYER HEALTH REGULATIONS › Section 26.25 - Unfair Competition and Unfair Practices

Current through Reg. 49, No. 28; July 12, 2024
A misrepresentation about the effects of Insurance Code
					 Chapter 1501 (concerning Health Insurance Portability and Availability Act) or
					 this subchapter in marketing small employer health plans or in the marketing,
					 renewing, or canceling of other health insurance products will be considered a
					 violation of Insurance Code Chapter 541 (concerning Unfair Methods of
					 Competition and Unfair or Deceptive Acts or Practices) and §543.001
					 (concerning Misrepresentation Prohibited).
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 26 - EMPLOYER-RELATED HEALTH BENEFIT PLAN REGULATIONS › Subchapter A - DEFINITIONS, SEVERABILITY, AND SMALL EMPLOYER HEALTH REGULATIONS › Section 26.28 - Territorial Exclusions

Current through Reg. 49, No. 28; July 12, 2024
Subject to the provisions of Chapter 3 of this title
					 (relating to Life, Accident, and Health Insurance and Annuities) and Chapter 11
					 of this title (relating to Health Maintenance Organizations), a small employer
					 health benefit plan may not exclude health care services, supplies, or drugs
					 provided for medical emergencies outside the plan service area, including
					 outside the United States.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 26 - EMPLOYER-RELATED HEALTH BENEFIT PLAN REGULATIONS › Subchapter A - DEFINITIONS, SEVERABILITY, AND SMALL EMPLOYER HEALTH REGULATIONS › Section 26.30 - Composite Premiums

Current through Reg. 49, No. 28; July 12, 2024
(a) Definitions.
				  For purposes of this section:
(1) "Composite
				  premiums" are premiums offered to enrollees of a small group health plan that
				  are determined using the average premium per enrollee and corresponding average
				  premiums for different coverage tiers, as described in this section.
(2) "Per-member premiums" are premiums
				  offered to enrollees that are determined on an individual basis.
(3) "Tier" refers to each premium category in
				  subsection (d).
(4) "Tier factor"
				  is a multiplier used to determine premium for each tier.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 26 - EMPLOYER-RELATED HEALTH BENEFIT PLAN REGULATIONS › Subchapter B - TEXAS HEALTH REINSURANCE SYSTEM PLAN OF OPERATION › Section 26.201 - The Texas Health Reinsurance System Plan of Operation

Current through Reg. 49, No. 28; July 12, 2024
(a) Definitions. The following words and
				  terms, when used in this section, shall have the following meanings, unless the
				  context clearly indicates otherwise.
(1)
				  Commissioner--The Commissioner of Insurance.
(2) Department--The Texas Department of
				  Insurance.
(3) THR System--The
				  Texas Health Reinsurance System.
(4) Plan of Operation--The guidelines or
				  bylaws necessary or suitable to assure the fair, reasonable, and equitable
				  administration of the THR System, as established in Texas Insurance Code,
				  Articles 26.51 et seq.
(5)
				  Procedures Manual--The manuals, handbooks, or guidelines, if any, created
				  and/or adopted by the THR System in addition to its Plan of
				  Operation.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 26 - EMPLOYER-RELATED HEALTH BENEFIT PLAN REGULATIONS › Subchapter C - LARGE EMPLOYER HEALTH INSURANCE REGULATIONS › Section 26.301 - Applicability, Definitions, and Scope

Current through Reg. 49, No. 28; July 12, 2024
(a) The applicable
				  terms defined in §
										26.4 of
				  this title (relating to Definitions) are incorporated into this
				  subchapter.
(b) Insurance Code
				  Chapter 1501, concerning the Health Insurance Portability and Availability Act,
				  and this subchapter regulate all health benefit plans sold to large employers,
				  whether the plans are sold directly or through associations or other groupings
				  of large employers.
(c) Except as
				  otherwise provided, this subchapter applies to any health benefit plan
				  providing health care benefits covering 51 or more employees of a large
				  employer, whether provided on a group or individual franchise insurance policy
				  basis, regardless of whether the policy was issued in this state, if it
				  provides coverage to any citizen or inhabitant of this state and if the plan
				  meets one of the following conditions:
(1) A
				  portion of the premium or benefits is paid by a large employer.
(2) The health benefit plan is treated by the
				  employer or by a covered individual as part of a plan or program for the
				  purposes of the United States Internal Revenue Code of 1986 (26 U.S.C.
				  §
												106, concerning Contributions by
				  Employer to Accident and Health Plans, or §162, concerning Trade or
				  Business Expenses).
(3) The health
				  benefit plan is a group policy issued to a large employer.
(4) The health benefit plan is an employee
				  welfare benefit plan under
				  29 C.F.R. §
												2510.3-1 (concerning Employee Welfare Benefit
				  Plan).
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 26 - EMPLOYER-RELATED HEALTH BENEFIT PLAN REGULATIONS › Subchapter C - LARGE EMPLOYER HEALTH INSURANCE REGULATIONS › Section 26.302 - Status of Health Carriers as Large Employer Carriers

Current through Reg. 49, No. 28; July 12, 2024
(a) With the original filing to enter the
				  large employer market or when notifying TDI of a change in status, each health
				  carrier providing health benefit plans in this state must file with the
				  commissioner a statement indicating whether the health carrier will or will not
				  offer, renew, issue, or issue for delivery health benefit plans to large
				  employers in this state. The filing must include a certification, signed by an
				  officer of the company, that the carrier intends to operate in accordance with
				  the status certification unless or until changed in accordance with this
				  section, and provide a statement that:
(1)
				  the health carrier intends to offer, renew, issue, and issue for delivery
				  health benefit plans to large employers in Texas, and will operate in
				  accordance with Insurance Code Chapter 1501 (concerning Health Insurance
				  Portability and Availability Act) and this subchapter;
(2) the health carrier does not intend to
				  offer, issue, or issue for delivery health benefit plans to large employers in
				  Texas, but the health carrier intends to renew existing health benefit
				  plans;
(3) the health carrier does
				  not intend to offer, issue, or issue for delivery health benefit plans to large
				  employers in Texas; intends to nonrenew all health benefit plans issued to
				  large employers in Texas; and will provide notice to the commissioner and
				  employers in accordance with §
											26.309
				  of this title (relating to Refusal to Renew and Application to Reenter Large
				  Employer Market) and Insurance Code §
											1501.110
				  (concerning Notice to Covered Persons); or
(4) the health carrier has no health benefit
				  plans issued to large employers or to employees of a large employer and does
				  not intend to offer, issue, or issue for delivery health benefit plans to large
				  employers.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 26 - EMPLOYER-RELATED HEALTH BENEFIT PLAN REGULATIONS › Subchapter C - LARGE EMPLOYER HEALTH INSURANCE REGULATIONS › Section 26.303 - Coverage Requirements

Current through Reg. 49, No. 28; July 12, 2024
(a) The large
				  employer carrier must accept or reject the entire group of individuals who meet
				  the participation criteria established by the employer and who choose coverage,
				  and may exclude only those eligible employees or dependents who have declined
				  coverage. The carrier may charge premiums in accordance with Insurance Code
				  §
										1501.107
				  (concerning Discounts, Rebates, and Reductions) and §1501.610 (concerning
				  Premium Rates: Adjustments) to the group of employees or dependents who meet
				  the participation criteria established by the employer and who do not decline
				  coverage.
(b) A large employer
				  carrier must secure a written waiver for each eligible employee who meets the
				  participation criteria and each dependent, if dependent coverage is offered to
				  enrollees under a large employer health benefit plan, who declines an offer of
				  coverage under a health benefit plan provided to a large employer. If a large
				  employer elects to offer coverage through more than one large employer carrier,
				  waivers are only required to be signed if the individual is declining all
				  offered plans. The large employer carriers may enter into an agreement
				  designating which large employer carrier will receive and retain the waiver.
				  Waivers must be maintained by the large employer carrier for a period of six
				  years. The waiver must ensure that the employee was not induced or pressured
				  into declining coverage because of the employee's health-status-related
				  factors. The waiver must be signed by the employee (on behalf of the employee
				  or the dependent, if applicable) and must certify that the individual who
				  declined coverage was informed of the availability of coverage under the health
				  benefit plan. Receipt by the large employer carrier of a facsimile transmission
				  of the waiver is permissible, provided the transmission includes a
				  representation from the large employer that the employer will maintain the
				  original waiver on file for a period of six years from the date of the
				  facsimile transmission. The waiver form must:
(1) require that the reason for declining
				  coverage be stated on the form;
(2)
				  include a written warning of the penalties imposed on late enrollees;
				  and
(3) include a statement that
				  the following individuals were not induced or pressured by the large employer,
				  agent, or health carrier into declining coverage, but elected to decline
				  coverage:
(A) an eligible employee who meets
				  the large employer's participation criteria; and
(B) the employee's dependents, if dependent
				  coverage is offered to enrollees under a large 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 C - LARGE EMPLOYER HEALTH INSURANCE REGULATIONS › Section 26.305 - Enrollment

Current through Reg. 49, No. 28; July 12, 2024
(a) Periods provided for enrollment in and
				  application for any health benefit plan provided to a large employer group must
				  comply with the following:
(1) the initial
				  enrollment period for the employees meeting the large employer's participation
				  criteria must extend at least 31 consecutive days after the employee's initial
				  date of employment, or if the waiting period exceeds 31 days, at least 31
				  consecutive days after the date the new entrant completes the waiting period
				  for coverage;
(2) the new entrant
				  who meets the large employer's participation criteria must be notified of his
				  or her opportunity to enroll at least 31 days in advance of the last date
				  enrollment is permitted;
(3) a new
				  entrant's application for coverage is timely if he or she submits the
				  application within 31 consecutive days following the initial date of
				  employment, or following the date the new entrant is eligible for coverage:
(A) in person;
(B) by mail, postmarked by the end of the
				  specified period; or
(C) in an
				  alternative method normally accepted by the large employer carrier, including
				  facsimile transmission (fax), email, or web-based application; and
(4) the large employer carrier
				  must provide an annual open enrollment period of at least 31 consecutive
				  days.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 26 - EMPLOYER-RELATED HEALTH BENEFIT PLAN REGULATIONS › Subchapter C - LARGE EMPLOYER HEALTH INSURANCE REGULATIONS › Section 26.307 - Fair Marketing

Current through Reg. 49, No. 28; July 12, 2024
(a) On request, a
				  large employer carrier must provide to the large employer a summary of all
				  health benefit plans offered by the large employer carrier for which the large
				  employer qualifies.
(b) Denial by a
				  large employer carrier of an application for coverage or cancellation, or
				  refusal to renew, must be in writing and must state with specificity the
				  reasons for the denial, cancellation, or refusal to renew (subject to any
				  restrictions related to confidentiality of medical information). The large
				  employer carrier must notify the large employer in accordance with Insurance
				  Code §
										1501.109
				  (concerning Refusal to Renew; Discontinuation of Coverage) and §1501.110
				  (concerning Notice to Covered Persons).
(c) A large employer carrier may not require,
				  as a condition to the offer or sale of a health benefit plan to a large
				  employer, that the large employer purchase or qualify for any other insurance
				  product or service.
(d) The large
				  employer carrier may not require a large employer to join or contribute to any
				  association or group as a condition of being accepted for coverage by the large
				  employer carrier, except that, if membership in an association or other group
				  is a requirement for accepting a large employer into a particular health
				  benefit plan, a large employer carrier may apply that requirement, subject to
				  the requirements of Insurance Code Chapter 1501 (concerning Health Insurance
				  Portability and Availability Act).
(e) Health carriers offering individual and
				  group health benefit plans in this state are responsible for determining
				  whether the plans are subject to the requirements of Insurance Code Chapter
				  1501 and this subchapter. At the time of application, health carriers must
				  obtain the following information from applicants for those plans:
(1) whether any portion of the premium will
				  be paid by a large employer;
(2)
				  whether the prospective policyholder, certificate holder, or any prospective
				  insured intends to treat the health benefit plan as part of a plan or program
				  under the United States Internal Revenue Code of 1986 (26 U.S.C.
				  §
												106, concerning Contributions by
				  Employer to Accident and Health Plans, or §162, concerning Trade or
				  Business Expenses);
(3) whether the
				  health plan is an employee welfare benefit plan under 29 C.F.R. § 2510.3-1
				  (concerning Employee Welfare Benefit Plan); or
(4) whether the applicant is a large
				  employer.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 26 - EMPLOYER-RELATED HEALTH BENEFIT PLAN REGULATIONS › Subchapter C - LARGE EMPLOYER HEALTH INSURANCE REGULATIONS › Section 26.308 - Renewability of Coverage and Cancellation

Current through Reg. 49, No. 28; July 12, 2024
(a) Except as provided by Insurance Code
				  §
										1501.109
				  (concerning Refusal to Renew; Discontinuation of Coverage) , a large employer
				  carrier must renew any large employer health benefit plan at the option of the
				  large employer, unless:
(1) the premium has
				  not been paid as required by the terms of the plan;
(2) the large employer has committed fraud or
				  intentional misrepresentation of a material fact;
(3) the large employer has not complied with
				  a material provision of the health benefit plan relating to premium
				  contribution, group size, or minimum participation requirements;
(4) the large employer has no enrollee, in
				  connection with the plan, who resides or works in the service area of the large
				  employer carrier or in the area where the large employer carrier is authorized
				  to do business; or
(5) membership
				  of an employer in an association terminates, but only if coverage is terminated
				  uniformly without regard to a health-status-related factor of a covered
				  individual.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 26 - EMPLOYER-RELATED HEALTH BENEFIT PLAN REGULATIONS › Subchapter C - LARGE EMPLOYER HEALTH INSURANCE REGULATIONS › Section 26.309 - Refusal to Renew and Application to Reenter Large Employer Market

Current through Reg. 49, No. 28; July 12, 2024
(a) A large employer carrier may elect to
				  refuse to renew all large employer health benefit plans delivered or issued for
				  delivery by the large employer carrier in this state or in a geographic service
				  area. The large employer carrier must notify the commissioner and each affected
				  covered large employer of the election as provided in Insurance Code §
										1501.109
				  (concerning Refusal to Renew; Discontinuation of Coverage).
(b) The large employer carrier may not write
				  a new large employer health benefit plan in this state or in the geographic
				  service area, as applicable, for five years after notice to the commissioner of
				  the election to refuse to renew. A large employer carrier that elects not to
				  renew all large employer health benefit plans under Insurance Code §
										1501.109
				  and this section may not resume offering health benefit plans to large
				  employers in this state or in the geographic area for which the election was
				  made until it has filed a petition with the commissioner to be reinstated as a
				  large employer carrier and the petition has been approved . In reviewing the
				  petition, the commissioner may ask for information and assurances as the
				  commissioner finds reasonable and appropriate.
(c) A large employer carrier may elect to
				  discontinue a particular type of large employer coverage, only if the large
				  employer carrier:
(1) before the 90th day
				  preceding the date of the discontinuation of the coverage:
(A) provides notice of the discontinuation to
				  each employer and TDI ; and
(B)
				  offers to each employer the option to purchase other large employer coverage
				  offered by the large employer carrier 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 C - LARGE EMPLOYER HEALTH INSURANCE REGULATIONS › Section 26.310 - Unfair Competition and Unfair Practices

Current through Reg. 49, No. 28; July 12, 2024
A misrepresentation about the effects of Insurance Code
					 Chapter 1501 (concerning Health Insurance Portability and Availability Act) or
					 this subchapter in marketing large employer health plans or in the marketing,
					 renewing, or canceling of other health insurance products will be considered a
					 violation of Insurance Code Chapter 541 (concerning Unfair Methods of
					 Competition and Unfair or Deceptive Acts or Practices) and §543.001
					 (concerning Misrepresentation Prohibited).
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 26 - EMPLOYER-RELATED HEALTH BENEFIT PLAN REGULATIONS › Subchapter C - LARGE EMPLOYER HEALTH INSURANCE REGULATIONS › Section 26.312 - Point-of-Service Coverage

Current through Reg. 49, No. 28; July 12, 2024
(a) A large
				  employer carrier that offers point-of-service coverage must comply, as
				  applicable, with the requirements set forth in either Chapter 11, Subchapter Z
				  of this title (relating to Point-of-Service Riders) or Chapter 21, Subchapter U
				  of this title (relating to Arrangements Between Indemnity Carriers and HMOs for
				  Point-of-Service Coverage).
(b) If
				  an HMO issues coverage to a large employer and eligible employees have access
				  only to in-plan coverage through one or more HMOs, each of the HMOs issuing
				  coverage must offer the eligible employees the option of obtaining coverage
				  that complies with the out-of-plan coverage set forth in either Chapter 11,
				  Subchapter Z of this title or Chapter 21, Subchapter U of this title, and that
				  allows the enrollee to access out-of-plan coverage at the option of the
				  enrollee in compliance with Insurance Code §
										1273.052
				  (concerning Offer of Coverage Through Non-Network Plan Required).
(c) All HMOs offering coverage to eligible
				  employees of a large employer may enter into a written agreement designating
				  one or more of the HMOs to offer the point-of-service option required under
				  this section.
(1) A copy of the agreement
				  must be retained on file by each of the HMOs participating in the agreement and
				  be made available to TDI on request.
(2) If an HMO participating in the agreement
				  ceases to offer coverage to the large employer, a new agreement that complies
				  with all of the requirements of this section must be entered into by all
				  remaining HMOs offering coverage to employees of the large employer.
(3) If for any reason, an agreement is not in
				  existence that ensures that all eligible employees have the option of selecting
				  out-of-plan coverage under this section from at least one of the HMOs offering
				  coverage to the eligible employees, each HMO must offer the eligible employees
				  the option of selecting out-of-plan coverage as required by this
				  section.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 26 - EMPLOYER-RELATED HEALTH BENEFIT PLAN REGULATIONS › Subchapter C - LARGE EMPLOYER HEALTH INSURANCE REGULATIONS › Section 26.313 - Filing Requirements

Current through Reg. 49, No. 28; July 12, 2024
(a) Each large
				  employer carrier, other than an HMO, must use a policy shell format for any
				  group or individual health-benefit-plan form used to provide a health benefit
				  plan in the large employer market. To expedite the review and approval process,
				  all group and individual health-benefit-plan form filings (excluding HMO
				  filings covered in subsection (b) of this section) must be submitted in the
				  following order:
(1) a group policy face page
				  or individual policy face page, as applicable;
(2) the group certificate page or individual
				  data page, as applicable;
(3) as
				  applicable under Chapter 3, Subchapter A of this title (relating to Submission
				  Requirements for Filings and Departmental Actions Related to Such Filings), the
				  toll-free number and complaint notice page, as required by Chapter 1,
				  Subchapter E of this title (relating to Notice of Toll-Free Telephone Numbers
				  and Procedures for Obtaining Information and Filing Complaints);
(4) the table of contents;
(5) insert pages for the general
				  provisions;
(6) insert pages for
				  the required provisions and any optional provisions, if elected and as
				  applicable;
(7) for large employer
				  health benefit plans, an insert page for the benefits section of the health
				  benefit plan including, but not limited to, schedule of benefits, definitions,
				  benefits provided, exclusions and limitations, continuation provisions, and if
				  applicable, alternative cost containment, preferred provider, conversion and
				  coordination-of-benefits provisions, and riders;
(8) insert pages for any amendments,
				  applications, enrollment forms, or other form filings that comprise part of the
				  contract;
(9) insert pages for any
				  required outline of coverage for individual products;
(10) any additional form filings and
				  documentation as outlined in Chapter 3, Subchapter A of this title and
				  Subchapter G of this title (relating to Plain Language Requirements for Health
				  Benefit Policies);
(11) the
				  information required under this section; and
(12) the rate schedule applicable to any
				  individual health benefit plan, as required by Chapter 3, Subchapter A of this
				  title.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 26 - EMPLOYER-RELATED HEALTH BENEFIT PLAN REGULATIONS › Subchapter C - LARGE EMPLOYER HEALTH INSURANCE REGULATIONS › Section 26.314 - Territorial Exclusions

Current through Reg. 49, No. 28; July 12, 2024
Subject to the provisions of Chapter 3 of this title
					 (relating to Life, Accident and Health Insurance and Annuities) and Chapter 11
					 of this title (relating to Health Maintenance Organizations), a large employer
					 health benefit plan may not exclude health care services, supplies, or drugs
					 provided for medical emergencies outside the plan service area, including
					 outside the United States.