28 Tex. Admin. Code § 26.8 - Guaranteed Issue, Contribution, and Participation Requirements
(a) A small employer carrier must issue a
health benefit plan to any small employer that elects to be covered under the
plan and agrees to satisfy other requirements of the plan without regard to
health-status-related factors.
(b)
Health carriers may require small employers to answer questions designed to
determine the level of contribution by the small employer, the number of
employees and eligible employees of the small employer, and the percentage of
participation of eligible employees of the small employer. In this section, an
"eligible employee" does not include employees within their waiting or
affiliation period for percentage of participation requirement
purposes.
(c) Availability of
coverage under a small employer health benefit plan is subject to the minimum
participation requirements of Insurance Code §
1501.154 (concerning
Minimum Participation Requirement) and §1501.155 (concerning Exception to
Minimum Participation Requirement) . A small employer that has only two
eligible employees will be subject to a 100 percent participation
requirement.
(d) A health carrier
must treat all similarly situated small 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 or group size.
(e) If a small employer fails to meet the
qualifying minimum participation requirement for a small employer health
benefit plan for six consecutive months, the health carrier may terminate
coverage under the plan on the first renewal date following that period. The
termination must conform to the terms and conditions of the plan concerning
termination for failure to meet the qualifying minimum participation
requirement 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) and §
26.15 of this title (relating to
Renewability of Coverage and Cancellation).
(f) In determining whether an employer has
the required percentage of participation of eligible employees, 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: 75 percent of five employees is 3.75, so
3.75 would be rounded down to three, and 75 percent participation by a five
employee group will be achieved if three of the eligible employees
participate.
(g) If a small
employer fails to meet, for six consecutive months, the qualifying minimum
group size requirement set forth in Insurance Code Chapter 1501 (concerning
Health Insurance Portability and Availability Act) for a small employer health
benefit plan, the health carrier may terminate coverage under the plan no
earlier than the first day of the next month following the end of that period.
The termination must conform to the terms and conditions of the plan concerning
termination for failure to meet the qualifying minimum group size requirement
and in accordance with Insurance Code §§
1501.108 -
1501.111 and §
26.15 of this
title.
Notes
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