| (a) A small employer carrier must issue a health benefit
plan to any small employer that elects to be covered under the plan
and agrees to satisfy other requirements of the plan factors.
(b) Health carriers may require small employers to
answer questions designed to determine the level of contribution by
the small employer, the number of employees and eligible employees
of the small employer, and the percentage of participation of eligible
employees of the small employer. In this section, an "eligible employee"
does not include employees within their waiting or affiliation period
for percentage of participation requirement purposes.
(c) Availability of coverage under a small employer
health benefit plan is subject to the minimum participation requirements
of Insurance Code §1501.154 (concerning Minimum Participation
Requirement) and §1501.155 (concerning Exception to Minimum Participation
Requirement). A small employer that has only two eligible employees
will be subject to a 100 percent participation requirement.
(d) A health carrier must treat all similarly situated
small 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 or group size.
(e) If a small employer fails to meet the qualifying
minimum participation requirement for a small employer health benefit
plan for six consecutive months, the health carrier may terminate
coverage under the plan on the first renewal date following that period.
The termination must conform to the terms and conditions of the plan
concerning termination for failure to meet the qualifying minimum
participation requirement 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) and §26.15 of this title (relating to Renewability
of Coverage and Cancellation).
(f) In determining whether an employer has the required
percentage of participation of eligible employees, 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, 75 percent of five
employees is 3.75, so 3.75 would be rounded down to three, and 75
percent participation by a five employee group will be achieved if
three of the eligible employees participate.
(g) If a small employer fails to meet, for six consecutive
months, the qualifying minimum group size requirement set forth in
Insurance Code Chapter 1501 (concerning Health Insurance Portability
and Availability Act) for a small employer health benefit plan, the
health carrier may terminate coverage under the plan no earlier than
the first day of the next month following the end of that period.
The termination must conform to the terms and conditions of the plan
concerning termination for failure to meet the qualifying minimum
group size requirement and in accordance with Insurance Code §§1501.108
- 1501.111 and §26.15 of this title.
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| Source Note: The provisions of this §26.8 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 13, 2012, 37 TexReg 3415; amended to be effective May 17, 2017, 42 TexReg 2539 |
