28 Tex. Admin. Code § 21.2004 - Enrollment of Child Who Is the Subject of a Medical Support Order
(a) If the insurer offers coverage of
dependent children under the policy, enrollment of a child who is the subject
of a medical support order in the health coverage shall be automatic for the
first 31 days after receipt of a medical support order or notice of a medical
support order by the employer, or the insurer if there is no employer and the
insurer provides health coverage to the parent ordered to provide medical
support. The insurer shall enroll the child without regard to any enrollment
period restriction that might otherwise be applicable to the parent or the
child. Receipt of a medical support order or notice of a medical support order
requiring that health coverage be provided for a child shall be considered a
change in the family circumstances of the employee or member, for health
coverage purposes, equivalent to the birth or adoption of a child. For purposes
of this section, the change of family circumstances shall not be construed to
require coverage of any person other than the child subject to the court order
and, if not already covered, the parent ordered to provide medical
support.
(b) Within 31 days after
receipt of a medical support order or notice of a medical support order by the
employer or the insurer as specified in subsection (a) of this section, the
insurer shall complete all necessary forms and procedures to enroll the child
in health coverage on a permanent basis:
(1)
on application of a parent of the child, a custodial parent of the child, a
child support agency having a duty to collect or enforce support for the child,
or the child over 18 years of age; and
(2) if the required premium is paid within 31
days of the receipt of the medical support order or notice of the medical
support order by the employer, or the insurer if there is no employer except
that the insurer shall not terminate coverage of a child that is the subject of
a medical support order if such insurer's billing cycle does not coincide with
this 31 day premium payment requirement, until the next billing cycle has
occurred and there has been nonpayment of the additional required premium,
within 30 days of the due date of such premium.
(c) As a prerequisite to the child's
permanent enrollment in group health coverage, an insurer offering coverage of
dependent children may require the parent, who is required by a medical support
order to provide coverage, and who is eligible for dependent health coverage,
if not already enrolled, to enroll in the health coverage plan within 31 days
after receipt of a medical support order or notice of a medical support order
by the employer, or the insurer if there is no employer.
(d) If the child is not enrolled on a
permanent basis, the insurer shall report in accordance with the Family Code,
Chapter 154, Subchapter D, the reasons coverage cannot be made
permanent.
(e) With respect to a
child residing outside the insurer's service area, the insurer shall not use
the child's status as the subject of a medical support order to charge a higher
premium for coverage of the child than it charges for coverage of other
dependent children under the policy.
(f) The application of subsection (e) of this
section is illustrated in the following paragraphs and assumes a monthly
premium for Employee Only coverage is $210; a monthly premium for Employee and
Child(ren) coverage is $430; and a monthly premium for Family coverage is $650.
(1) An employee who elected Employee Only
coverage must subsequently provide coverage to 2 children pursuant to a medical
support order. The total premium charged to this employee for adding the 2
children may not exceed $220 ($430 minus $210).
(2) An employee who elected Employee and
Child(ren) coverage must subsequently provide coverage to an additional child
pursuant to a medical support order. The employee may not be charged an
additional premium for adding the additional child.
(3) An employee who elected Family coverage
must subsequently provide coverage to an additional child pursuant to a medical
support order. The employee may not be charged an additional premium for adding
the additional child.
Notes
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