| (a) A large employer carrier that offers coverage to
a large employer and its employees must offer coverage to each eligible
employee who meets the large employer's participation criteria. If
dependent coverage is offered to enrollees under a large employer
health benefit plan, a large employer carrier must offer coverage
to each eligible dependent. Except as provided in subsection (b) of
this section, the large employer carrier must provide the same health
benefit plan to each employee and dependent.
(b) If elected by the large employer, a large employer
carrier may offer one or more health benefit plans, provided that
each eligible employee who meets the participation criteria may choose
any of the plans offered. Except as provided in Insurance Code §1501.104
(concerning Affiliation Period) and §1501.106 (concerning Certain
Limitations or Exclusions of Coverage Prohibited), 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 health-status-related factors of the employees or dependents,
if applicable.
(c) A large employer carrier may require each large
employer that applies for coverage, as part of the application process,
to provide a complete list of employees, eligible employees, and if
dependent coverage is offered to enrollees under a large employer
health benefit plan, a complete list of dependents of eligible employees.
The large employer carrier may also require the large 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 large employer. The large employer carrier
must make a determination of eligibility within five business days
of receipt of any requested documentation. A large 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 large 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.
(d) A large employer carrier may not deny two individuals
who are married the status of eligible employee solely on the basis
that the two individuals are married. The large employer carrier must
provide a reasonable opportunity for the individuals to submit evidence
as provided in subsection (c) of this section to establish each individual's
status as an eligible employee.
(1) A large employer carrier must provide married eligible
employees of the same employer the option to have one spouse be treated
under a large employer health benefit plan as an employee, and the
other spouse treated as an employee or alternatively as the dependent
of the other employee.
(2) A child of either of the two individuals may only
be covered under the large employer health benefit plan as a dependent
by one of the two individuals.
(3) An election by a spouse to be treated as a dependent
under this subsection does not impact the individual's status as an
eligible employee for any other purpose under Insurance Code Chapter
1501 (concerning Health Insurance Portability and Availability Act),
except that the individual may be treated as a dependent for purposes
of employer premium contributions.
(e) New entrants who meet the large employer's participation
criteria in a health benefit plan issued to a large employer group
must be offered an opportunity to enroll in the health benefit plan
currently held by the employer group or be offered an opportunity
to enroll in the health benefit plan if the plan is provided through
an individual franchise insurance policy or more than one plan is
available. If a large employer carrier has offered more than one health
benefit plan to eligible employees of a large employer group under
subsection (b) of this section, the new entrant must be offered the
same choice of health benefit plans as the other employees (members)
in the group. A new entrant who does not exercise the opportunity
to enroll in the health benefit plan within the period provided by
the large employer carrier may be treated as a late enrollee by the
health carrier, provided that the period provided to enroll in the
health benefit plan complies with §26.305(a) of this title (relating
to Enrollment).
(f) New entrants meeting the participation criteria
in a health benefit plan issued to a large employer group must be
accepted for coverage by the large employer carrier without any restrictions
or limitations on coverage related to the health-status-related factors
of the employee or dependent, except that a health carrier may exclude
coverage for preexisting medical conditions or impose an affiliation
period, to the extent allowed under Insurance Code Chapter 1501.
|
| Source Note: The provisions of this §26.304 adopted to be effective March 5, 1998, 23 TexReg 2297; amended to be effective April 6, 2005, 30 TexReg 1931; amended to be effective December 6, 2010, 35 TexReg 10768 ; amended to be effective May 17, 2017, 42 TexReg 2539 |
