28 Tex. Admin. Code § 26.303 - Coverage Requirements
(a) The large
employer carrier must accept or reject the entire group of individuals who meet
the participation criteria established by the employer and who choose coverage,
and may exclude only those eligible employees or dependents who have declined
coverage. The carrier may charge premiums in accordance with Insurance Code §
1501.107 (concerning
Discounts, Rebates, and Reductions) and §1501.610 (concerning Premium Rates:
Adjustments) to the group of employees or dependents who meet the participation
criteria established by the employer and who do not decline coverage.
(b) A large employer carrier must secure a
written waiver for each eligible employee who meets the participation criteria
and each dependent, if dependent coverage is offered to enrollees under a large
employer health benefit plan, who declines an offer of coverage under a health
benefit plan provided to a large employer. If a large employer elects to offer
coverage through more than one large employer carrier, waivers are only
required to be signed if the individual is declining all offered plans. The
large employer carriers may enter into an agreement designating which large
employer carrier will receive and retain the waiver. Waivers must be maintained
by the large employer carrier for a period of six years. The waiver must ensure
that the employee was not induced or pressured into declining coverage because
of the employee's health-status-related factors. The waiver must be signed by
the employee (on behalf of the employee or the dependent, if applicable) and
must certify that the individual who declined coverage was informed of the
availability of coverage under the health benefit plan. Receipt by the large
employer carrier of a facsimile transmission of the waiver is permissible,
provided the transmission includes a representation from the large employer
that the employer will maintain the original waiver on file for a period of six
years from the date of the facsimile transmission. The waiver form must:
(1) require that the reason for declining
coverage be stated on the form;
(2)
include a written warning of the penalties imposed on late enrollees;
and
(3) include a statement that
the following individuals were not induced or pressured by the large employer,
agent, or health carrier into declining coverage, but elected to decline
coverage:
(A) an eligible employee who meets
the large employer's participation criteria; and
(B) the employee's dependents, if dependent
coverage is offered to enrollees under a large employer health benefit
plan.
(c) An
agent must notify a large employer carrier, before submitting an application
for coverage with the health carrier on behalf of a large employer or its
employees, of any circumstances that would indicate that the large employer has
induced or pressured an eligible employee who meets the large employer's
participation criteria or a dependent to decline coverage due to the
individual's health-status-related factors.
(d) Health carriers may require large
employers to answer questions designed to determine the level of premium
contribution by the large employer and the percentage of participation of
eligible employees.
(e) In this
section, an "eligible employee" does not include employees who are within their
waiting or affiliation period for percentage of participation requirement
purposes. In determining whether an employer has the required percentage of
participation of eligible employees who meet the large employer's participation
criteria, 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: if a large employer
health carrier uses a minimum participation requirement of 75 percent of the
eligible employees meeting the large employer's participation criteria, 75
percent of 55 employees is 41.25. Round 41.25 down to 41; so, 75 percent
participation by a 55-employee group would be achieved if 41 of the eligible
employees who meet the large employer's participation criteria
participate.
(f) If a large
employer fails to meet the qualifying minimum participation requirement for six
consecutive months, the large employer health carrier may terminate coverage
under the plan on the first renewal date following that period. The termination
must comply with the terms and conditions of the plan concerning termination
for failure to meet the qualifying minimum participation percentage 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, respectively) and §
26.308 of this title (relating to
Renewability of Coverage and Cancellation). A large employer health carrier
must treat all similarly situated large 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.
(g) A large employer must continue to meet
the qualifying minimum group size requirement of §
26.301(c) of
this title (relating to Applicability, Definitions, and Scope) to be entitled
to elect to renew coverage under §
26.301(e) of
this title. If a large employer fails to meet, for six consecutive months, the
minimum group size requirement of §
26.301(c) of
this title, the health carrier may terminate coverage under the plan on the
first renewal date following that period. The termination must comply with the
terms and conditions of the plan concerning termination for failure to meet the
minimum group size requirements in §
26.301(c) of
this title, and in accordance with Insurance Code §§
1501.108 -
1501.111 and §
26.308 of this title.
Notes
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