28 Tex. Admin. Code § 3.3038 - Mandatory Guaranteed Renewability Provisions for Individual Hospital, Medical, or Surgical Coverage; Exceptions
(a) Except as provided by this section, all
individual hospital, medical, or surgical coverage (as defined in §
3.3002(b)(12) of
this title (relating to Definitions)) must be renewed or continued in force at
the option of the insured.
(b)
Medicare eligibility or entitlement is not a basis for nonrenewal or
termination of individual hospital, medical, or surgical coverage; however,
such coverage sold to an insured before the insured attains Medicare
eligibility may contain a clause that excludes payments for benefits under the
policy to the extent that Medicare pays for such benefits.
(c) Individual hospital, medical, or surgical
coverage may only be discontinued or nonrenewed based on one or more of the
following circumstances:
(1) the policyholder
has failed to pay premiums or contributions in accordance with the terms of the
policy, including any timeliness requirements;
(2) the policyholder has performed an act or
practice that constitutes fraud, or has made an intentional misrepresentation
of material fact, relating in any way to the policy, including claims for
benefits under the policy;
(3) the
insurer is ceasing to offer individual hospital, medical, or surgical coverage
under the particular type of policy, or is ceasing to offer any form of
individual hospital, medical, or surgical coverage in this state or in the
insurer's service area, in accordance with subsections (d) and (e) of this
section;
(4) in regard only to
coverage offered by an issuer under Insurance Code Chapter 842, concerning
Group Hospital Service Corporations, or Chapter 1301, concerning Preferred
Provider Benefit Plans, the insured no longer resides, lives, or works in the
service area of the issuer, or area for which the issuer is authorized to do
business, but only if coverage is terminated uniformly without regard to any
health-status-related factor of covered individuals.
(d) An insurer may elect to discontinue
offering a particular type of individual hospital, medical, or surgical
coverage plan in the individual market only if the insurer:
(1) provides written notice to the
commissioner and each covered individual of the discontinuation before the 90th
day preceding the date of the discontinuation of the coverage;
(2) offers to each covered individual on a
guaranteed issue basis the option to purchase any other individual hospital,
medical, or surgical insurance coverage offered by the insurer at the time of
the discontinuation; and
(3) acts
uniformly without regard to any health-status related factors of a covered
individual or dependents of a covered individual who may become eligible for
the coverage.
(e) An
insurer may elect to refuse to renew all individual hospital, medical, or
surgical coverage plans delivered or issued for delivery by the insurer in this
state or in the insurer's service area, only if the insurer:
(1) notifies the commissioner of the election
not later than the 180th day before the date coverage under the first
individual hospital, medical, or surgical health benefit plan
terminates;
(2) notifies each
affected covered individual not later than the 180th day before the date on
which coverage terminates for that individual; and
(3) acts uniformly without regard to any
health-status related factor of covered individuals or dependents of covered
individuals who may become eligible for coverage.
(f) An insurer that elects not to renew all
individual hospital, medical, or surgical coverage in Texas or in the insurer's
service area in accordance with subsection (e) of this section may not issue
any such coverage in Texas or in the insurer's service area during the
five-year period beginning on the date of discontinuation of the last such
coverage not renewed.
(g) Nothing
in this section prohibits or restricts an insurer's ability to make changes in
premium rates by classes in accordance with applicable laws and
regulations.
(h) Nothing in this
section may be interpreted as prohibiting an insurer from making policy
modifications mandated by state law, or, acting consistently with §
3.3040(b) of
this title (relating to Prohibited Policy Provisions), from honoring requests
from a policyholder for modifications to an individual policy or offering
policy modifications uniformly to all insureds under a particular policy form,
if:
(1) the modification meets the definition
of a uniform modification under subsection (i) of this section; and
(2) the notice describes the uniform
modifications and includes any rate change notice required under Insurance Code
§
1201.109, concerning
Notice of Rate Increase for Major Medical Expense Insurance Policy.
(i) For the purposes of this
section, a "uniform modification" is a change to coverage that is made at the
time of coverage renewal, applies uniformly for all insureds covered under the
policy form, and complies with the requirements of
45 CFR §
147.106(e) and (f),
concerning Guaranteed Renewability of Coverage.
(j) A notice that is required to be provided
to the commissioner under this section must be submitted as an informational
filing consistent with the procedures specified in Chapter 3, Subchapter A, of
this title (relating to Submission Requirements for Filings and Departmental
Actions Related to Such Filings).
(k) If a nonrenewal addressed under this
section occurs in connection with a change to the insurer's service area, the
insurer must make network configuration filings consistent with requirements in
Chapter 3, Subchapter X, of this title (relating to Preferred and Exclusive
Provider Plans).
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.