(a) Each small employer carrier must file each form,
including, but not limited to, each policy, contract, certificate,
agreement, evidence of coverage, endorsement, amendment, enrollment
form, and application that will be used to provide a health benefit
plan in the small employer market, in accordance with Insurance Code
Chapter 1701 (concerning Policy Forms), and Chapter 3, Subchapter
A of this title (relating to Submission Requirements for Filings and
Departmental Actions Related to Such Filings), or Insurance Code Chapter
1271 (concerning Benefits Provided by Health Maintenance Organizations;
Evidence of Coverage; Charges), and §11.301 of this title (relating
to Filing Requirements) or §11.302 of this title (relating to
Service Area Expansion or Reduction Applications), as applicable.
(b) Each small 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 small
employer market. To expedite the review and approval process, all
group and individual health benefit plan form filings (excluding HMO
filings that are covered in subsection (c) 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, 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 small 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 Chapter 3,
Subchapter G of this title (relating to Plain Language Requirements
for Health Benefit Policies);
(11) the certifications required under this section
and any other rating information required under §26.10 of this
title (relating to Establishment of Classes of Business) and §26.11
of this title (relating to Restrictions Relating to Premium Rates);
and
(12) the rate schedule applicable to any individual
health benefit plan, as required by Chapter 3, Subchapter A of this
title.
(c) In addition to subsection (a) of this section,
the following provisions apply to each HMO. The HMO must submit health
benefit plan forms for use in the small employer market that include
the following.
(1) Any HMO group or individual agreement must address
and include all required provisions of Insurance Code Chapter 1501
(concerning Health Insurance Portability and Availability Act). The
agreement must be in compliance with any other applicable provisions
of the Insurance Code. In addition, the agreement must comply with
the provisions of Chapter 11, Subchapter F of this title (relating
to Evidence of Coverage) where those provisions are not in conflict
with Insurance Code Chapter 1501.
(2) The filing must include any alternative pages to
the agreement or the schedule of benefits and any alternative schedules
of benefit.
(3) The filing must include any additional riders,
amendments, applications, enrollment forms, or other forms and any
other required documentation outlined in Chapter 11, Subchapter F
of this title.
(4) The filing must include any applicable requirements
of Chapter 11, Subchapter D, of this title (relating to Regulatory
Requirements for an HMO Subsequent to Issuance of a Certificate of
Authority), and Chapter 11, Subchapter F of this title, except for:
(A) continuation and conversion of coverage, in accordance
with Insurance Code Chapter 1271 and this title; and
(B) cancellation, in accordance with §26.15 of
this title (relating to Renewability of Coverage and Cancellation).
(5) The filing must include any rider forms that will
be used with health benefit plans offered to small employers. The
rider forms, if developed subsequent to approval of the agreement,
must be submitted with an explanation of the market in which the forms
will be used. All rider forms must comply with Insurance Code Chapter
1271, and applicable provisions of Chapter 11, Subchapters D and F
of this title.
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Source Note: The provisions of this §26.19 adopted to be effective December 30, 1993, 18 TexReg 9375; amended to be effective April 9, 1996, 21 TexReg 2648; amended to be effective March 5, 1998, 23 TexReg 2297; amended to be effective April 6, 2005, 30 TexReg 1931; amended to be effective May 17, 2017, 42 TexReg 2539 |