28 Tex. Admin. Code § 26.13 - Fair Marketing

(a) A small employer carrier must market each of its small employer health benefit plans to small employers in this state. A small employer carrier may not suspend the marketing or issuance of the small employer benefit plans unless the health carrier has good cause and has received prior approval from the commissioner or the commissioner's designee. In marketing consumer choice health benefit plans to small employers, a small employer carrier must use at least the same sources and methods of distribution that it uses to market other small employer health benefit plans. Any agent authorized by a small employer carrier to market consumer choice health benefit plans to small employers in this state must also be authorized to market small employer health benefit plans that contain state-mandated health benefits.

(b) Before issuing coverage to a small employer, a small employer carrier must offer the employer a choice of all health benefit plans that the small employer carrier offers and for which the small employer qualifies. The small employer carrier may provide the offer directly to the small employer or deliver it through an agent, but in either case must offer each required plan contemporaneously with the offer of any other small employer health benefit plan. The offer must be in writing and include at least the following:

(1) information describing how the small employer may enroll in the plan or plans;

(2) information set out in Insurance Code § 1501.354 (concerning Required Disclosures) and § 26.12 of this title (relating to Disclosure); and

(3) a written disclosure, as required by Chapter 21, Subchapter AA of this title (relating to Consumer Choice Health Benefit Plans).

(c) On request, a small employer carrier must explain its health benefit plans to a small employer each of the small employer health benefit plans it offers.

(d) A small employer carrier must comply with this subsection when providing a premium rate quote to a small employer.

(1) A small employer carrier must provide a premium rate quote to a small employer, directly or through an authorized agent, within 15 business days of receiving the small employer's completed application for coverage and individual enrollment forms.

(2) A small employer carrier may request, directly or through an authorized agent, any additional information, using the applicable rate manual and associated underwriting guidelines developed under § 26.11 of this title (relating to Restrictions Relating to Premium Rates), necessary to provide the premium rate quote. If the carrier requests this additional information before the end of the 15-day period described in paragraph (1) of this subsection, the request for additional information tolls the running of the 15-day period until the small employer carrier receives the requested additional information.

(3) A small employer carrier may give a small employer an estimated cost of coverage before the end of the 15-day period described in paragraph (1) of this subsection, so long as the carrier makes clear that the estimate is not a premium rate quote.

(4) A small employer carrier may not impose any additional conditions to its provision of a premium rate quote.

(e) A small employer carrier may not apply more stringent or detailed requirements related to the application process for, or otherwise discriminate in the offer of, any small employer health benefit plan than are applied for other health benefit plans offered by the health carrier to small employers.

(f) If a small employer carrier denies coverage under a health benefit plan to a small employer on any basis, the denial must be in writing and specifically state the reasons for the denial (subject to any restrictions related to confidentiality of medical information).

(g) A small employer carrier must establish and maintain a means to provide information to small employers who request information on the availability of small employer health benefit plans in this state. The information provided to small employers must include information about how to apply for coverage from the health carrier and may include the names and phone numbers of agents located geographically proximate to the caller or other information that is reasonably designed to assist the caller in locating an authorized agent or applying for coverage.

(h) The small employer carrier may not require a small employer to join or contribute to any association or group as a condition of being accepted for coverage by the small employer carrier, except that, if membership in an association or other group is a requirement for accepting a small employer into a particular health benefit plan, a small employer carrier may apply that requirement, subject to the requirements of Insurance Code Chapter 1501 (concerning Health Insurance Portability and Availability Act).

(i) A small employer carrier may not require, as a condition to the offer or sale of a health benefit plan to a small employer, that the small employer purchase or qualify for any other insurance product or service.

(j) Health carriers offering individual and group health benefit plans in this state must determine whether the plans are subject to the requirements of Insurance Code Chapter 1501 and this subchapter. Health carriers must obtain the following information from applicants for those plans at the time of application:

(1) whether any portion of the premium will be paid by a small employer;

(2) whether the prospective policyholder, certificate holder, or any prospective covered individual intends to treat the health benefit plan as part of a plan or program under the United States Internal Revenue Code of 1986, 26 U.S.C. § 106 (concerning Contributions by Employer to Accident and Health Plans), or §162 (concerning Trade or Business Expenses);

(3) whether the health benefit plan is an employee welfare benefit plan under 29 C.F.R. § 2510.3-1 (concerning Employee Welfare Benefit Plan); or

(4) whether the applicant is a small employer.

(k) If a health carrier fails to comply with subsection (j) of this section, the health carrier will be deemed to be on notice of any information that could reasonably have been attained if the health carrier had complied with subsection (j) of this section.

(l) A small employer carrier may not discriminate between small employer groups when obtaining information relating to a small employer, including information related to the risk characteristics of the small employer group or other aspects of the application or application process.

(m) A small employer carrier may not terminate, fail to renew, limit its contract or agreement of representation with, or take any other negative action against an agent for the agent's request that the carrier issue or renew a health benefit plan to a small employer.

Notes

28 Tex. Admin. Code § 26.13

The provisions of this §26.13 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; Adopted by Texas Register, Volume 42, Number 19, May 12, 2017, TexReg 2546, eff. 5/17/2017