| (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. 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).
(c) On request, a small employer carrier must explain
to a small employer each of the small employer health benefit plans
it offers.
(d) A small employer carrier must comply with this
subsection when providing a premium rate quote to a small employer.
(1) A small employer carrier must provide a premium
rate quote to a small employer, directly or through an authorized
agent, within 15 business days of receiving the small employer's completed
application for coverage and individual enrollment forms.
(2) A small employer carrier may request, directly
or through an authorized agent, any additional information, using
the applicable rate manual and associated underwriting guidelines
developed under §26.11 of this title (relating to Restrictions
Relating to Premium Rates), necessary to provide the premium rate
quote. If the carrier requests this additional information before
the end of the 15-day period described in paragraph (1) of this subsection,
the request for additional information tolls the running of the 15-day
period until the small employer carrier receives the requested additional
information.
(3) A small employer carrier may give a small employer
an estimated cost of coverage before the end of the 15-day period
described in paragraph (1) of this subsection, so long as the carrier
makes clear that the estimate is not a premium rate quote.
(4) A small employer carrier may not impose any additional
conditions to its provision of a premium rate quote.
(e) A small employer carrier may not apply more stringent
or detailed requirements related to the application process for, or
otherwise discriminate in the offer of, any small employer health
benefit plan than are applied for other health benefit plans offered
by the health carrier to small employers.
(f) If a small employer carrier denies coverage under
a health benefit plan to a small employer on any basis, the denial
must be in writing and specifically state the reasons for the denial
(subject to any restrictions related to confidentiality of medical
information).
(g) A small employer carrier must establish and maintain
a means to provide information to small employers who request information
on the availability of small employer health benefit plans in this
state. The information provided to small employers must include information
about how to apply for coverage from the health carrier and may include
the names and phone numbers of agents located geographically proximate
to the caller or other information that is reasonably designed to
assist the caller in locating an authorized agent or applying for
coverage.
(h) The small employer carrier may not require a small
employer to join or contribute to any association or group as a condition
of being accepted for coverage by the small employer carrier, except
that, if membership in an association or other group is a requirement
for accepting a small employer into a particular health benefit plan,
a small employer carrier may apply that requirement, subject to the
requirements of Insurance Code Chapter 1501 (concerning Health Insurance
Portability and Availability Act).
(i) A small employer carrier may not require, as a
condition to the offer or sale of a health benefit plan to a small
employer, that the small employer purchase or qualify for any other
insurance product or service.
(j) Health carriers offering individual and group health
benefit plans in this state must determine whether the plans are subject
to the requirements of Insurance Code Chapter 1501 and this subchapter.
Health carriers must obtain the following information from applicants
for those plans at the time of application:
(1) whether any portion of the premium will be paid
by a small employer;
(2) whether the prospective policyholder, certificate
holder, or any prospective covered individual 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 benefit 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 small employer.
(k) If a health carrier fails to comply with subsection
(j) of this section, the health carrier will be deemed to be on notice
of any information that could reasonably have been attained if the
health carrier had complied with subsection (j) of this section.
(l) A small employer carrier may not discriminate between
small employer groups when obtaining information relating to a small
employer, including information related to the risk characteristics
of the small employer group or other aspects of the application or
application process.
(m) A small employer carrier may not terminate, fail
to renew, limit its contract or agreement of representation with,
or take any other negative action against an agent for the agent's
request that the carrier issue or renew a health benefit plan to a
small employer.
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| Source Note: The provisions of this §26.13 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 |
