28 Tex. Admin. Code § 26.7 - Requirement to Insure Entire Groups
(a) A
small employer carrier that offers coverage to a small employer and its
employees must offer coverage to each eligible employee and to each dependent
of an eligible employee. Except as provided in subsection (b) of this section,
the small employer carrier must provide the same health benefit plan to each
employee or dependent eligible for coverage.
(b) If elected by the small employer, a small
employer carrier may offer one or more health benefit plans, provided that each
eligible employee may choose any of the plans offered. Except as provided in
Insurance Code Chapter 1501 (concerning Health Insurance Portability and
Availability Act) with respect to an affiliation period or exclusions for
preexisting conditions, the choice among benefit plans may not be limited,
restricted, or conditioned based on the risk characteristics of each employee
or dependent eligible for coverage.
(c) A small employer carrier may require each
small employer that applies for coverage, as part of the application process,
to provide a complete list of employees, eligible employees, and dependents of
eligible employees . The small employer carrier may also require the small
employer to provide reasonable and appropriate supporting documentation to
verify the information required under this subsection, and to confirm the
applicant's status as a small employer. The small employer carrier must make a
determination of eligibility within five business days of receipt of any
requested documentation. A small employer carrier may not condition the
issuance of coverage on an employer's production of a particular document,
where the employer can otherwise provide the information required by this
section. Similarly, if a particular document an employer produces does not
reasonably evidence the employer's compliance with this subsection, the
employer must produce other documentation to satisfy the requirements. Examples
of the types of reasonable and appropriate supporting documentation that a
small employer carrier may request from an employer as needed to fulfill the
purposes of this subsection are:
(1) a W-2
Summary Wage and Tax Form or other federal or state tax records;
(2) a loan agreement;
(3) an invoice;
(4) a business check;
(5) a sales tax license;
(6) articles of incorporation or other
business entity filings with the secretary of state ;
(7) assumed name filings;
(8) professional licenses; and
(9) reports required by the Texas Workforce
Commission.
(d) A small
employer carrier may not deny two individuals who are married the status of
eligible employee solely on the basis that the two individuals are married. The
small employer carrier must provide a reasonable opportunity for the
individuals to submit evidence as provided in subsection (c) of this section to
establish each individual's status as an eligible employee.
(1) A small employer carrier must provide
married eligible employees of the same employer the option to have one spouse
be treated under a small employer health benefit plan as an employee, and the
other spouse treated as an employee or alternatively as the dependent of the
other employee.
(2) A child of
either of the two individuals may only be covered under the same small employer
health benefit plan as a dependent by one of the two individuals.
(3) An election by a spouse to be treated as
a dependent under this subsection does not impact the individual's status as an
eligible employee for any other purpose under Insurance Code Chapter 1501,
except that the individual may be treated as a dependent for purposes of
employer premium contributions.
(e) A small employer carrier must secure a
waiver with respect to each eligible employee and each dependent of the
eligible employee who declines an offer of coverage under a health benefit plan
provided to a small employer. If a small employer elects to offer coverage
through more than one small employer carrier, waivers are only required to be
signed if the individual is declining all offered plans. The small employer
carriers may enter into an agreement designating which small employer carrier
will receive and retain the waiver. Waivers must be maintained by the small
employer carrier for a period of six years. The waiver must be signed by the
employee (on behalf of the employee or dependent) and must certify that the
individual who declined coverage was informed of the availability of coverage
under the health benefit plan. Receipt by the small employer carrier of a
facsimile transmission of the waiver is permissible, provided that the
transmission includes a representation from the small 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 employee and dependents were not induced or pressured by the small
employer, agent, or health carrier into declining coverage, but elected of
their own accord to decline the coverage.
(f) An agent must notify a small employer
carrier, before submitting an application for coverage with the health carrier
on behalf of a small employer or employee of a small employer, of any
circumstances that would indicate that the small employer has induced or
pressured the employee or dependent to decline coverage due to the individual's
risk characteristics.
(g) New
entrants in a health benefit plan issued to a small employer group must be
offered an opportunity to enroll in the health benefit plan currently held by
the employer group or be offered an opportunity to enroll in the health benefit
plan if the plan is provided through an individual franchise insurance policy,
or if more than one plan is available. If a small employer carrier has offered
more than one health benefit plan to eligible employees of a small employer
group under subsection (b) of this section, the new entrant must be offered the
same choice of health benefit plans as the other employees (members) in the
group. A new entrant who does not exercise the opportunity to enroll in the
health benefit plan within the period provided by the small employer carrier
may be treated as a late enrollee by the health carrier, provided that the
period provided to enroll in the health benefit plan complies with subsection
(h) of this section.
(h) Periods
provided for enrollment in and application for any health benefit plan provided
to a small employer group must comply with the following:
(1) the initial enrollment period must extend
at least 31 consecutive days after the date the new entrant begins employment
or, if the waiting period exceeds 31 days, at least 31 consecutive days after
the date the new entrant completes the waiting period for coverage;
(2) the new entrant must be notified of his
or her opportunity to enroll at least 31 days in advance of the last date
enrollment is permitted;
(3) the
new entrant's application for coverage will be considered timely if the
application is submitted within the initial enrollment period:
(A) in person;
(B) by mail, postmarked by the end of the
specified period; or
(C) in an
alternative method normally accepted by the small employer carrier, including,
facsimile transmission (fax), email, or web-based application ; and
(4) the small employer carrier
must provide an open enrollment period of at least 31 consecutive days on an
annual basis.
(i) A
small employer may establish a waiting period in accordance with Insurance Code
§
1501.156 (concerning
Employee Enrollment: Waiting Period) that must not exceed 90 days. A small
employer carrier may not apply a waiting period, elimination period, or other
similar limitation of coverage (other than an exclusion for preexisting medical
conditions or affiliation period consistent with Insurance Code §
1501.102 (concerning
Preexisting Condition Provision) and §1501.104 (concerning Affiliation
Period)), with respect to a new entrant, that is longer than the waiting period
established by the small employer.
(j) New entrants in a health plan issued to a
small employer group must be accepted for coverage by the small employer
carrier without any restrictions or limitations on coverage related to the risk
characteristics of the employees or their dependents, except that a health
carrier may exclude coverage for preexisting medical conditions or impose an
affiliation period, to the extent allowed under Insurance Code Chapter
1501.
(k) A small employer carrier
may assess a risk load to the premium rate associated with a new entrant,
consistent with the requirements of Insurance Code Chapter 1501, Subchapter E
(concerning Underwriting and Rating of Small Employer Health Benefit Plans) and
this chapter. The risk load must be the same risk load charged to the small
employer group immediately before acceptance of the new entrant into the
group.
Notes
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