| (a) Each large 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 large employer market.
To expedite the review and approval process, all group and individual
health-benefit-plan form filings (excluding HMO filings covered in
subsection (b) 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 (relating to Submission Requirements for Filings and Departmental
Actions Related to Such Filings), 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 large 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 Subchapter
G of this title (relating to Plain Language Requirements for Health
Benefit Policies);
(11) the information required under this section; and
(12) the rate schedule applicable to any individual
health benefit plan, as required by Chapter 3, Subchapter A of this
title.
(b) 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 large 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 comply 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 (relating to Regulatory Requirements for
an HMO Subsequent to Issuance of 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 (concerning Benefits Provided by
Health Maintenance Organizations; Evidence of Coverage; Charges),
and this title; and
(B) cancellation, in accordance with §26.308 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 large 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, Subchapter D of this
title.
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