(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.
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