| (a) Except as provided by this section, all individual
hospital, medical, or surgical coverage (as defined in §3.3002(b)(12)
of this title (relating to Definitions)) must be renewed or continued
in force at the option of the insured.
(b) Medicare eligibility or entitlement is not a basis
for nonrenewal or termination of individual hospital, medical, or
surgical coverage; however, such coverage sold to an insured before
the insured attains Medicare eligibility may contain a clause that
excludes payments for benefits under the policy to the extent that
Medicare pays for such benefits.
(c) Individual hospital, medical, or surgical coverage
may only be discontinued or nonrenewed based on one or more of the
following circumstances:
(1) the policyholder has failed to pay premiums or
contributions in accordance with the terms of the policy, including
any timeliness requirements;
(2) the policyholder has performed an act or practice
that constitutes fraud, or has made an intentional misrepresentation
of material fact, relating in any way to the policy, including claims
for benefits under the policy;
(3) the insurer is ceasing to offer individual hospital,
medical, or surgical coverage under the particular type of policy,
or is ceasing to offer any form of individual hospital, medical, or
surgical coverage in this state or in the insurer's service area,
in accordance with subsections (d) and (e) of this section;
(4) in regard only to coverage offered by an issuer
under Insurance Code Chapter 842, concerning Group Hospital Service
Corporations, or Chapter 1301, concerning Preferred Provider Benefit
Plans, the insured no longer resides, lives, or works in the service
area of the issuer, or area for which the issuer is authorized to
do business, but only if coverage is terminated uniformly without
regard to any health-status-related factor of covered individuals.
(d) An insurer may elect to discontinue offering a
particular type of individual hospital, medical, or surgical coverage
plan in the individual market only if the insurer:
(1) provides written notice to the commissioner and
each covered individual of the discontinuation before the 90th day
preceding the date of the discontinuation of the coverage;
(2) offers to each covered individual on a guaranteed
issue basis the option to purchase any other individual hospital,
medical, or surgical insurance coverage offered by the insurer at
the time of the discontinuation; and
(3) acts uniformly without regard to any health-status
related factors of a covered individual or dependents of a covered
individual who may become eligible for the coverage.
(e) An insurer may elect to refuse to renew all individual
hospital, medical, or surgical coverage plans delivered or issued
for delivery by the insurer in this state or in the insurer's service
area, only if the insurer:
(1) notifies the commissioner of the election not later
than the 180th day before the date coverage under the first individual
hospital, medical, or surgical health benefit plan terminates;
(2) notifies each affected covered individual not later
than the 180th day before the date on which coverage terminates for
that individual; and
(3) acts uniformly without regard to any health-status
related factor of covered individuals or dependents of covered individuals
who may become eligible for coverage.
(f) An insurer that elects not to renew all individual
hospital, medical, or surgical coverage in Texas or in the insurer's
service area in accordance with subsection (e) of this section may
not issue any such coverage in Texas or in the insurer's service area
during the five-year period beginning on the date of discontinuation
of the last such coverage not renewed.
(g) Nothing in this section prohibits or restricts
an insurer's ability to make changes in premium rates by classes in
accordance with applicable laws and regulations.
(h) Nothing in this section may be interpreted as prohibiting
an insurer from making policy modifications mandated by state law,
or, acting consistently with §3.3040(b) of this title (relating
to Prohibited Policy Provisions), from honoring requests from a policyholder
for modifications to an individual policy or offering policy modifications
uniformly to all insureds under a particular policy form, if:
(1) the modification meets the definition of a uniform
modification under subsection (i) of this section; and
(2) the notice describes the uniform modifications
and includes any rate change notice required under Insurance Code §1201.109,
concerning Notice of Rate Increase for Major Medical Expense Insurance
Policy.
(i) For the purposes of this section, a "uniform modification"
is a change to coverage that is made at the time of coverage renewal,
applies uniformly for all insureds covered under the policy form,
and complies with the requirements of 45 CFR §147.106(e) and
(f), concerning Guaranteed Renewability of Coverage.
(j) A notice that is required to be provided to the
commissioner under this section must be submitted as an informational
filing consistent with the procedures specified in Chapter 3, Subchapter
A, of this title (relating to Submission Requirements for Filings
and Departmental Actions Related to Such Filings).
(k) If a nonrenewal addressed under this section occurs
in connection with a change to the insurer's service area, the insurer
must make network configuration filings consistent with requirements
in Chapter 3, Subchapter X, of this title (relating to Preferred and
Exclusive Provider Plans).
|
