28 Tex. Admin. Code § 26.14 - Coverage

(a) Continuation and conversion. All small employer health benefit plans must provide for continuation and may provide an option for conversion that complies with Insurance Code Chapters 1251 (concerning Group and Blanket Health Insurance) and 1271 (concerning Benefits Provided by Health Maintenance Organizations; Evidence of Coverage; Charges) and rules adopted under those statutes. A state-approved health benefit plan that complies with the requirements of Title XIII, Public Health Service Act (42 U.S.C. §§ 300e, et seq., concerning Health Maintenance Organizations) must provide coverage for continuation that complies with the requirements of Insurance Code Chapter 1271) and must offer conversion in compliance with 42 C.F.R. § 417.124(e) (concerning Administration and Management) and applicable federal law.

(b) Plain language. Each health benefit plan, certificate, policy, rider, or application used by health carriers to provide coverage to small employers and their employees must comply with Insurance Code § 1501.258 (concerning Forms) and §1501.260 (concerning Plain Language Required), be written in plain language, and meet the requirements of Chapter 3, Subchapter G of this title (relating to Plain Language Requirements for Health Benefit Policies). Requirements for use of plain language are not applicable to a health benefit plan group master policy or a policy application or enrollment form for a health benefit plan group master policy.

(c) Dependent coverage. Every small employer carrier providing health benefit plans to small employers is required to offer dependent coverage to each eligible employee. Dependent coverage may be paid for by the employer, the employee, or both.

(d) Point-of-service coverage. An HMO issuing small employer HMO coverage may also offer point-of-service coverage that complies, as applicable, with the requirements set forth in Insurance Code Chapter 843 (concerning Health Maintenance Organizations); Chapter 11, Subchapter Z of this title (relating to Point-of-Service Riders); and Chapter 21, Subchapter U of this title (relating to Arrangements Between Indemnity Carriers and HMOs for Point-of-Service Coverage) that allow the enrollee to access out-of-plan coverage at the option of the enrollee.

Notes

28 Tex. Admin. Code § 26.14

The provisions of this §26.14 adopted 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