| (vi) the individual has a change in family composition
due to marriage, birth of a child, adoption of a child, or because
an insured becomes a party in a suit for the adoption of a child;
(vii) an individual becomes a dependent due to marriage,
birth of a child, adoption of a child, or because an insured becomes
a party in a suit for the adoption of a child; and
(viii) the individual described in clauses (v) - (vii)
of this subparagraph requests enrollment no later than the 31st day
after the date of the marriage, birth, adoption of the child, loss
of the child's coverage, or within 31 days of the date an insured
becomes a party in a suit for the adoption of a child.
(29) Limited scope dental or vision benefits--Dental
or vision benefits that are sold under a separate policy or rider
and that are limited in scope to a narrow range or type of benefits
that are generally excluded from hospital, medical, or surgical benefits
contracts.
(30) Medical care--Amounts paid for:
(A) the diagnosis, cure, mitigation, treatment, or
prevention of disease, or amounts paid for the purpose of affecting
any structure or function of the body;
(B) transportation primarily for and essential to the
medical care described in subparagraph (A) of this paragraph; or
(C) insurance covering medical care described in either
subparagraph (A) or (B) of this paragraph.
(31) Medical condition--Any physical or mental condition
including, but not limited to, any condition resulting from illness,
injury (whether or not the injury is accidental), pregnancy, or congenital
malformation. Genetic information does not constitute a medical condition
in the absence of a diagnosis of a condition related to the information.
(32) New business premium rate--As defined in Insurance
Code §1501.201.
(33) New entrant--An eligible employee, or the dependent
of an eligible employee, who becomes eligible for coverage in an employer
group after the initial period for enrollment in a health benefit
plan. After the initial enrollment period, this includes any employee
or dependent who becomes eligible for coverage and who is not a late
enrollee.
(34) Participation criteria--As defined in Insurance
Code §1501.601 (concerning Participation Criteria).
(35) Person--As defined in Insurance Code §1501.002.
(36) Plan year--For purposes of Insurance Code Chapter
1501 and this chapter, a 365-day period that begins on the plan or
policy's effective date or a period of one full calendar year, under
a health benefit plan providing coverage to small or large employers
and their employees, as defined in the plan or policy. Health carriers
must use the same definition of plan year in all small or large employer
health benefit plans.
(37) Point-of-service coverage--Coverage provided under
a point-of-service plan as described in §21.2901 of this title
(relating to Definitions) and as permitted by Insurance Code §1501.255
(concerning Health Maintenance Organization Plans).
(38) Point-of-service option--Coverage that complies
with the out-of-plan coverage set forth in either Chapter 11, Subchapter
Z of this title (relating to Point-of-Service Riders), or Chapter
21, Subchapter U of this title (relating to Arrangements Between Indemnity
Carriers and HMOs for Point-of-Service Coverage), and that allows
the enrollee to access out-of-plan coverage at the option of the enrollee.
(39) Point-of-service plan--As defined in Insurance
Code §1273.051 (concerning Definitions).
(40) Postmark--A date stamp by the U.S. Postal Service
or other delivery entity, including any electronic delivery available.
(41) Preexisting condition provision--As defined in
Insurance Code §1501.002.
(42) Premium--As defined in Insurance Code §1501.002.
(43) Premium rate quote--A statement of the premium
a health carrier offers and will accept to make coverage effective
for a small or large employer.
(44) Public health plan--Any plan established or maintained
by a state, county, or other political subdivision of a state that
provides health insurance coverage to individuals.
(45) Qualified actuary--An actuary who is a member:
(A) of the Society of Actuaries; and
(B) in good standing of the American Academy of Actuaries.
(46) Rating period--As defined in Insurance Code §1501.201.
(47) Reinsured carrier--A small employer carrier participating
in the Texas Health Reinsurance System.
(48) Renewal date--For each small or large employer's
health benefit plan, the earlier of the date, if any, specified in
the plan for renewal; the policy anniversary date; or the date the
small or large employer's plan is changed. To determine the renewal
date for employer association or multiple employer trust group health
benefit plans, health carriers may use the date specified for renewal,
or the policy anniversary date, of either the master contract or the
contract or certificate of coverage of each small or large employer
in the association or trust. Health carriers must use the same method
of determining renewal dates for all small or large employer health
benefit plans. A change in the premium rate is not considered a renewal
if the change is due solely:
(A) to the addition or deletion of an employee or dependent
if the deletion is due to a request by the employee, death or retirement
of the employee or dependent, termination of employment of the employee,
or because a dependent is no longer eligible; or
(B) to fraud or intentional misrepresentation of a
material fact by a small or large employer or an eligible employee
or dependent.
(49) Risk-assuming carrier--A risk-assuming health
benefit plan issuer as defined in Insurance Code §1501.301 (concerning
Definitions).
(50) Risk characteristic--The health-status-related
factors, duration of coverage, or any similar characteristic, except
genetic information, related to the health status or experience of
a small employer group or of any member of that group.
(51) Risk load--The percentage above the applicable
base premium rate that is charged by a small employer carrier to a
small employer to reflect the risk characteristics of that group.
A small employer carrier may not use genetic information to alter
or otherwise affect risk load.
(52) Short-term limited duration insurance--Health
insurance coverage provided under a contract with an issuer that:
(A) has an expiration date specified in the contract,
taking into account any extensions that may be elected by the policyholder
without the issuer's consent; and
(B) is within 12 months of the date the contract becomes
effective.
(53) Significant break in coverage--A period of 63
consecutive days during which the individual does not have creditable
coverage. Neither a waiting period nor an affiliation period is counted
in determining a significant break in coverage.
(54) Small employer--As defined in Insurance Code §1501.002.
A small employer includes an independent school district that elects
to participate in the small employer market under Insurance Code §1501.009
(concerning School District Election).
(55) Small employer carrier--A health carrier, to the
extent that health carrier is offering, delivering, issuing for delivery,
or renewing, under Insurance Code §1501.003 (concerning Applicability:
Small Employer Health Benefit Plans), health benefit plans subject
to Insurance Code Chapter 1501.
(56) Small employer health benefit plan--As defined
in Insurance Code §1501.002.
(57) State-mandated health benefits--As defined in
§21.3502 of this title (relating to Definitions).
(58) TDI--The Texas Department of Insurance.
(59) Waiting period--As defined in Insurance Code §1501.002.
If an employee or dependent enrolls as a late enrollee, under special
circumstances that except the employee or dependent from the definition
of late enrollee, or during an open enrollment period, any period
of eligibility before the effective date of enrollment is not a waiting
period.
|
| Source Note: The provisions of this §26.4 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 July 10, 2001, 26 TexReg 5016; amended to be effective April 6, 2005, 30 TexReg 1931; amended to be effective May 17, 2017, 42 TexReg 2539 |
