| (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.
(c) An agent must notify a large employer carrier,
before submitting an application for coverage with the health carrier
on behalf of a large employer or its employees, of any circumstances
that would indicate that the large employer has induced or pressured
an eligible employee who meets the large employer's participation
criteria or a dependent to decline coverage due to the individual's
health-status-related factors.
(d) Health carriers may require large employers to
answer questions designed to determine the level of premium contribution
by the large employer and the percentage of participation of eligible
employees.
(e) In this section, an "eligible employee" does not
include employees who are within their waiting or affiliation period
for percentage of participation requirement purposes. In determining
whether an employer has the required percentage of participation of
eligible employees who meet the large employer's participation criteria,
if the percentage of eligible employees is not a whole number, the
result of applying the percentage to the number of eligible employees
must be rounded down to the nearest whole number. For example, if
a large employer health carrier uses a minimum participation requirement
of 75 percent of the eligible employees meeting the large employer's
participation criteria, 75 percent of 55 employees is 41.25. Round
41.25 down to 41; so, 75 percent participation by a 55-employee group
would be achieved if 41 of the eligible employees who meet the large
employer's participation criteria participate.
(f) If a large employer fails to meet the qualifying
minimum participation requirement for six consecutive months, the
large employer health carrier may terminate coverage under the plan
on the first renewal date following that period. The termination must
comply with the terms and conditions of the plan concerning termination
for failure to meet the qualifying minimum participation percentage
and in accordance with Insurance Code §§1501.108 - 1501.111
(concerning Renewability of Coverage; Cancellation; Refusal to Renew;
Discontinuation of Coverage; Notice to Covered Persons; and Written
Statement of Denial, Cancellation, or Refusal to Renew Required, respectively)
and §26.308 of this title (relating to Renewability of Coverage
and Cancellation). A large employer health carrier must treat all
similarly situated large employer groups in a consistent and uniform
manner when terminating health benefit plans due to a participation
level of less than the qualifying participation level.
(g) A large employer must continue to meet the qualifying
minimum group size requirement of §26.301(c) of this title (relating
to Applicability, Definitions, and Scope) to be entitled to elect
to renew coverage under §26.301(e) of this title. If a large
employer fails to meet, for six consecutive months, the minimum group
size requirement of §26.301(c) of this title, the health carrier
may terminate coverage under the plan on the first renewal date following
that period. The termination must comply with the terms and conditions
of the plan concerning termination for failure to meet the minimum
group size requirements in §26.301(c) of this title, and in accordance
with Insurance Code §§1501.108 - 1501.111 and §26.308
of this title.
|
| Source Note: The provisions of this §26.303 adopted 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 |
