SUBCHAPTER A GENERAL PROVISIONS
- Texas Section 1501.001 - Short Title
This chapter may be cited as the Health Insurance Portability and Availability Act. Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April...
- Texas Section 1501.002 - Definitions
In this chapter: (1) "Agent" means a person who may act as an agent for the sale of a health benefit plan under a license...
- Texas Section 1501.003 - Applicability: Small Employer Health Benefit Plans
An individual or group health benefit plan is a small employer health benefit plan subject to Subchapters C-H if it provides health care benefits covering...
- Texas Section 1501.004 - Applicability: Large Employer Health Benefit Plans
An individual or group health benefit plan is a large employer health benefit plan subject to Subchapters C and M if the plan provides health...
- Texas Section 1501.005 - Exception: Certain Individually Underwritten Policies
Except as provided by Section 1501.003 or 1501.004, this chapter does not apply to an individual health insurance policy that is subject to individual underwriting,...
- Texas Section 1501.006 - Certification
(a) In accordance with rules adopted by the commissioner, each health benefit plan issuer shall certify that the issuer is offering, delivering, issuing for delivery,...
- Texas Section 1501.007 - Affiliates
(a) In this section, "affiliate" has the meaning described by Section 823.003. (b) For purposes of this chapter, health benefit plan issuers that are affiliates...
- Texas Section 1501.008 - Late Enrollees
(a) For purposes of this chapter, an employee or dependent eligible for enrollment in a small or large employer's health benefit plan is a late...
- Texas Section 1501.009 - School District Election
(a) An independent school district may elect to participate as a small employer without regard to the number of employees in the district. An independent...
- Texas Section 1501.0095 - School District Employee Election
(a) Notwithstanding any other provision of this chapter, a school district employee who is eligible for coverage under a large or small employer health benefit...
- Texas Section 1501.010 - General Rules
The commissioner shall adopt rules necessary to: (1) implement this chapter; and (2) meet the minimum requirements of federal law, including regulations. Added by Acts...
SUBCHAPTER B COALITIONS AND COOPERATIVES
- Texas Section 1501.011 - Determination Of Employer Status For Certain Employers
(a) For an employer that did not exist throughout the calendar year preceding the year in which the determination of whether the employer is a...
- Texas Section 1501.051 - Definitions
In this subchapter: (1) "Board of directors" means the board of directors elected by a private purchasing cooperative or a health group cooperative. (2) "Board...
- Texas Section 1501.052 - Texas Health Benefits Purchasing Cooperative; Board Of Trustees
(a) The Texas Health Benefits Purchasing Cooperative is a nonprofit corporation established to make health care coverage available to small and large employers and their...
- Texas Section 1501.053 - Texas Health Benefits Purchasing Cooperative: Executive Director And Other Employees
(a) The board of trustees shall employ an executive director. The executive director may hire other employees of the Texas cooperative as necessary. (b) Salaries...
- Texas Section 1501.054 - Regional Subdivisions Of Texas Health Benefits Purchasing Cooperative
The board of trustees may: (1) develop regional subdivisions of the Texas cooperative; and (2) authorize each subdivision to separately exercise the powers and duties...
- Texas Section 1501.055 - Applicability Of Public Information Law To Texas Health Benefits Purchasing Cooperative
The Texas cooperative is subject to the public information law, Chapter 552, Government Code. Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff....
- Texas Section 1501.056 - Private Purchasing Cooperatives And Health Group Cooperatives
(a) Two or more small or large employers may form a private purchasing cooperative to purchase small or large employer health benefit plans. Subject to...
- Texas Section 1501.057 - Immunity
(a) The Texas cooperative or a member of the board of trustees, the executive director, or an employee or agent of the Texas cooperative is...
- Texas Section 1501.0575 - Voluntary Participation By Issuer In Cooperative
A health benefit plan issuer may elect not to participate in a health group cooperative. The health benefit plan issuer may elect to participate in...
- Texas Section 1501.058 - Powers And Duties Of Cooperatives
(a) A cooperative shall: (1) arrange for small or large employer health benefit plan coverage for small employer groups, large employer groups, and, subject to...
- Texas Section 1501.0581 - Special Provisions Relating To Health Group Cooperatives
(a) The membership of a health group cooperative may consist of only small employers; only large employers; both small and large employers; small employers and...
- Texas Section 1501.0582 - Health Group Cooperative: Expedited Approval Process
The department shall develop an expedited approval process for health benefit plan coverage arranged by a health group cooperative. Added by Acts 2005, 79th Leg.,...
- Texas Section 1501.059 - Self-insured Or Self-funded Plan Prohibited
A cooperative may not self-insure or self-fund any health benefit plan or portion of a plan. Added by Acts 2003, 78th Leg., ch. 1274, Sec....
- Texas Section 1501.060 - Scope Of Group Coverage
Subchapter B, Chapter 1251, does not limit the type of group that may be covered by a group health benefit plan issued through a cooperative....
- Texas Section 1501.061 - Requirements Applicable To Health Benefit Plan Issuers With Which Cooperative May Contract
A cooperative may contract only with a small or large employer health benefit plan issuer that demonstrates that the issuer: (1) is in good standing...
- Texas Section 1501.062 - Cooperative Not Insurer; Agents And Administrators
(a) A cooperative is not an insurer and the employees of the cooperative are not required to be licensed under Title 13. This exemption from...
- Texas Section 1501.063 - Status As Employer
(a) A small employer health coalition that otherwise meets the description of a small employer is considered a single small employer for all purposes under...
- Texas Section 1501.064 - Certain Use Of Appropriated Money Prohibited
The Texas cooperative may not use money appropriated by the state to pay or otherwise subsidize any portion of the premium for a small employer...
- Texas Section 1501.065 - Certain Actions Based On Risk Characteristics Or Health Status Prohibited
A cooperative may not limit, restrict, or condition an employer's or employee's membership in a cooperative or an employee's choice among benefit plans based on:...
- Texas Section 1501.066 - Election To Treat Participating Employers Separately For Rating Purposes
(a) Notwithstanding Section 1501.063, a health group cooperative may file with the commissioner, on a form and in the manner prescribed by the commissioner, an...
SUBCHAPTER C PROVISION OF COVERAGE
- Texas Section 1501.067 - Eligible Single-employee Business
The commissioner shall adopt rules governing the eligibility of a single-employee business to participate in a health group cooperative under this subchapter. The rules must...
- Texas Section 1501.101 - Geographic Service Areas
(a) Repealed by Acts 2015, 84th Leg., R.S., Ch. 42 , Sec. 3.01(6), eff. September 1, 2015. (b) A small employer health benefit plan issuer...
- Texas Section 1501.102 - Preexisting Condition Provision
(a) In this section, "creditable coverage" has the meaning assigned by Section 1205.004 and includes coverage provided under: (1) a political subdivision health benefits risk...
- Texas Section 1501.103 - Treatment Of Certain Conditions As Preexisting Prohibited
(a) A small or large employer health benefit plan issuer may not treat genetic information as a preexisting condition described by Section 1501.102(b) in the...
- Texas Section 1501.104 - Affiliation Period
(a) In this section, "affiliation period" means a period that, under a small or large employer health benefit plan offered by a health maintenance organization,...
- Texas Section 1501.105 - Waiting Period Permitted
Sections 1501.102-1501.104 do not preclude application of a waiting period that applies to all new enrollees under a small or large employer health benefit plan....
- Texas Section 1501.106 - Certain Limitations Or Exclusions Of Coverage Prohibited
(a) A small or large employer health benefit plan may not limit or exclude, by use of a rider or amendment applicable to a specific...
- Texas Section 1501.107 - Discounts, Rebates, And Reductions
(a) A small or large employer health benefit plan issuer may establish premium discounts, rebates, or a reduction in otherwise applicable copayments, coinsurance, or deductibles,...
- Texas Section 1501.108 - Renewability Of Coverage; Cancellation
(a) Except as provided by this section and Section 1501.109, a small or large employer health benefit plan issuer shall renew the small or large...
- Texas Section 1501.109 - Refusal To Renew; Discontinuation Of Coverage
(a) A small or large employer health benefit plan issuer may elect to refuse to renew all small or large employer health benefit plans delivered...
- Texas Section 1501.110 - Notice To Covered Persons
(a) A small or large employer health benefit plan issuer that cancels or refuses to renew coverage under a small or large employer health benefit...
SUBCHAPTER D GUARANTEED ISSUE OF SMALL EMPLOYER HEALTH BENEFIT PLANS; CONTINUATION OF COVERAGE
- Texas Section 1501.111 - Written Statement Of Denial, Cancellation, Or Refusal To Renew Required
Denial by a small or large employer health benefit plan issuer of an application from a small or large employer for coverage from the issuer...
- Texas Section 1501.151 - Guaranteed Issue
(a) A small employer health benefit plan issuer shall issue the small employer health benefit plan chosen by the small employer to each small employer...
- Texas Section 1501.152 - Exclusion Of Eligible Employee Or Dependent Prohibited
A small employer health benefit plan issuer may not exclude an eligible employee or dependent, including a late enrollee, who would otherwise be covered under...
- Texas Section 1501.153 - Employer Contribution
(a) This chapter does not require a small employer to make an employer contribution to the premium paid to a small employer health benefit plan...
- Texas Section 1501.154 - Minimum Participation Requirement
(a) Except as provided by Section 1501.155, coverage is available under a small employer health benefit plan if at least 75 percent of a small...
- Texas Section 1501.155 - Exception To Minimum Participation Requirement
(a) A small employer health benefit plan issuer may offer a small employer health benefit plan to a small employer with a participation level of...
- Texas Section 1501.156 - Employee Enrollment; Waiting Period
(a) The initial enrollment period under a small employer health benefit plan for employees and dependents must be at least 31 days, with a 31-day...
- Texas Section 1501.157 - Coverage For Newborn Children
(a) A small employer health benefit plan may not limit or exclude initial coverage of a newborn child of a covered employee. (b) Coverage of...
- Texas Section 1501.158 - Coverage For Adopted Children
(a) A small employer health benefit plan may not limit or exclude initial coverage of an adopted child of an insured. A child is considered...
SUBCHAPTER E UNDERWRITING AND RATING OF SMALL EMPLOYER HEALTH BENEFIT PLANS
- Texas Section 1501.159 - Continuation Of Coverage For Certain Dependents
An employee's dependent may choose to continue coverage under a small employer health benefit plan if: (1) the dependent: (A) is under one year of...
- Texas Section 1501.201 - Definitions
In this subchapter: (1) "Base premium rate" means, for each class of business and for a specific rating period, the lowest premium rate that is...
- Texas Section 1501.202 - Establishment Of Classes Of Business
(a) Except as otherwise provided by this subchapter, a small employer health benefit plan issuer may not establish a separate class or classes of business...
- Texas Section 1501.203 - Establishment Of Classes Of Business On Certain Bases Prohibited
(a) A small employer health benefit plan issuer may not establish a separate class of business based on: (1) participation requirements; or (2) whether the...
- Texas Section 1501.204 - Index Rates
Under a small employer health benefit plan: (1) the index rate for a class of business may not exceed the index rate for any other...
- Texas Section 1501.205 - Premium Rates: Establishment
(a) In this section: (1) "Risk characteristic" means: (A) a health status related factor; (B) the duration of coverage; or (C) any characteristic similar to...
- Texas Section 1501.206 - Premium Rates: Adjustments
(a) The percentage increase in the premium rate charged to a small employer for a new rating period may not exceed the sum of: (1)...
- Texas Section 1501.207 - Premium Rate Adjustment In Closed Plan
For a closed health benefit plan under which a small employer health benefit plan issuer is no longer enrolling new small employers, the issuer shall...
- Texas Section 1501.208 - Premium Rates: Industry Classification
A small employer health benefit plan issuer may use the industry classification to which a small employer belongs as a case characteristic in establishing the...
- Texas Section 1501.209 - Premium Rates: Number Of Employees
A small employer health benefit plan issuer may use the number of employees and dependents of a small employer as a case characteristic in establishing...
- Texas Section 1501.210 - Premium Rates: Nondiscrimination
(a) A small employer health benefit plan issuer shall apply rating factors, including case characteristics, consistently with respect to all small employers in a class...
- Texas Section 1501.211 - Rules Concerning Premium Rates
Rules adopted under Section 1501.010 may ensure that: (1) rating practices used by small employer health benefit plan issuers are consistent with the purposes of...
- Texas Section 1501.212 - Restricted Provider Network
(a) A small employer health benefit plan may use a restricted provider network to provide benefits under the plan. (b) A small employer health benefit...
- Texas Section 1501.213 - Premium Rates: Health Maintenance Organization Health Benefit Plan
(a) The premium rates for a state-approved health benefit plan offered by a health maintenance organization under Section 1501.255 must be established in accordance with...
- Texas Section 1501.214 - Enforcement
If the commissioner determines that a small employer health benefit plan issuer subject to this chapter exceeds the applicable premium rate established under this subchapter,...
- Texas Section 1501.215 - Reporting Requirements
(a) Annually, each small employer health benefit plan issuer that offers a small employer health benefit plan shall file with the commissioner an actuarial certification...
SUBCHAPTER F COVERAGE UNDER SMALL EMPLOYER HEALTH BENEFIT PLANS
- Texas Section 1501.216 - Premium Rates: Notice Of Increase
(a) Not less than 60 days before the date on which a premium rate increase takes effect on a small employer health benefit plan delivered...
- Texas Section 1501.251 - Exception From Certain Mandated Benefit Requirements
Except as expressly provided by this chapter, a small employer health benefit plan is not subject to a law that requires coverage or the offer...
- Texas Section 1501.252 - Health Benefit Plans
(a) A small employer health benefit plan issuer shall offer a standard health benefit plan as authorized by Chapter 1507. (b) A small employer health...
- Texas Section 1501.254 - Alcohol And Substance Abuse Benefits
(a) This section applies only if the basic coverage health benefit plan developed by the commissioner under Section 1501.253 includes coverage for alcohol and substance...
- Texas Section 1501.255 - Health Maintenance Organization Plans
(a) In this section, "point-of-service contract" means a health benefit plan offered through a health maintenance organization that: (1) includes corresponding indemnity benefits in addition...
- Texas Section 1501.256 - Coordination With Federal Law
(a) To the extent required to comply with federal law applicable to a small employer health benefit plan described by this subchapter, the commissioner by...
- Texas Section 1501.257 - Cost Containment
(a) A small employer health benefit plan issuer may use cost containment and managed care features in a small employer health benefit plan, including: (1)...
- Texas Section 1501.258 - Forms
(a) A small employer health benefit plan issuer shall comply with: (1) Chapter 1701 as it relates to policy form approval; and (2) Chapter 1271...
- Texas Section 1501.259 - Riders; Filing With Commissioner
(a) A small employer health benefit plan issuer shall file with the commissioner, in a form and manner prescribed by the commissioner, each rider to...
SUBCHAPTER G REINSURANCE FOR SMALL EMPLOYER HEALTH BENEFIT PLANS
- Texas Section 1501.260 - Plain Language Required
(a) A health benefit plan issuer may not issue and the commissioner may not approve a health benefit plan certificate or policy or a rider...
- Texas Section 1501.301 - Definitions
In this subchapter: (1) "Board" means the board of directors of the Texas Health Reinsurance System. (2) "Plan of operation" means the plan of operation...
- Texas Section 1501.302 - Texas Health Reinsurance System
The Texas Health Reinsurance System is a nonprofit entity administered by a board of directors and subject to the supervision and control of the commissioner....
- Texas Section 1501.303 - System Board Of Directors
(a) The board of directors of the system is composed of: (1) nine members appointed by the commissioner; and (2) the commissioner or the commissioner's...
- Texas Section 1501.304 - Open Meetings; Public Information
The board is subject to: (1) the open meetings law, Chapter 551, Government Code; and (2) the public information law, Chapter 552, Government Code. Added...
- Texas Section 1501.305 - Board Member Immunity
(a) A member of the board is not liable for an act performed, or omission made, in good faith in the performance of powers and...
- Texas Section 1501.306 - System Plan Of Operation
(a) The board shall submit to the commissioner a plan of operation and any amendments to that plan necessary or suitable to ensure the fair,...
- Texas Section 1501.307 - System Powers
(a) The system has the general powers and authority granted under state law to an insurer or a health maintenance organization authorized to engage in...
- Texas Section 1501.308 - System Notes As Legal Investment For Small Employer Health Benefit Plan Issuer
A note or other evidence of indebtedness of the system that is not in default is a legal investment for a small employer health benefit...
- Texas Section 1501.309 - System Audit
(a) The transactions of the system are subject to audit by the state auditor in accordance with Chapter 321, Government Code. (b) The state auditor...
- Texas Section 1501.310 - Election Of Status
(a) Each small employer health benefit plan issuer shall notify the commissioner of the issuer's election to operate as a risk-assuming health benefit plan issuer...
- Texas Section 1501.311 - Change In Status
(a) The commissioner shall establish an application process for a small employer health benefit plan issuer that elects to change its status under this subchapter....
- Texas Section 1501.312 - Application To Operate As Risk-assuming Health Benefit Plan Issuer
(a) A small employer health benefit plan issuer may apply to operate as a risk-assuming health benefit plan issuer by filing an application with the...
- Texas Section 1501.313 - Rescission Of Approval To Operate As Risk-assuming Health Benefit Plan Issuer
The commissioner, after notice and hearing, may rescind approval to operate as a risk-assuming health benefit plan issuer if the commissioner finds that the issuer:...
- Texas Section 1501.314 - Reinsurance
(a) A small employer health benefit plan issuer may reinsure risks covered under a small employer health benefit plan with the system as provided by...
- Texas Section 1501.315 - Limits On Reinsurance
(a) The system may not reimburse a reinsured health benefit plan issuer for the claims of a reinsured individual until the issuer has incurred an...
- Texas Section 1501.316 - Termination Of Reinsurance
A small employer health benefit plan issuer may terminate reinsurance with the system for one or more reinsured employees or dependents of employees of a...
- Texas Section 1501.317 - Application Of Managed Care Procedures
Except as provided by the plan of operation, a reinsured health benefit plan issuer shall apply consistently with respect to reinsured and nonreinsured business all...
- Texas Section 1501.318 - Premium Rates For Reinsurance
(a) As part of the plan of operation, the board shall adopt a method to determine premium rates to be charged by the system for...
- Texas Section 1501.319 - Determination Of Net Loss
(a) Not later than March 1 of each year, the board shall determine the system's net loss for the preceding calendar year, including administrative expenses...
- Texas Section 1501.320 - Assessments To Recover Net Losses
(a) The board shall recover any net loss of the system by assessing each reinsured health benefit plan issuer an amount determined annually by the...
- Texas Section 1501.321 - Limits On Assessments
(a) The formula established under Section 1501.320(b) may not result in an assessment for a reinsured health benefit plan issuer that is less than 50...
- Texas Section 1501.322 - Adjustment To Assessments On Federally Qualified Health Maintenance Organizations
With the commissioner's approval, the board may adjust the formula established under Section 1501.320(b) for a reinsured health benefit plan issuer that is an approved...
- Texas Section 1501.323 - Advance Interim Assessments
(a) The system may make advance interim assessments as reasonable and necessary for organizational and interim operating expenses. (b) After the end of the fiscal...
- Texas Section 1501.324 - Limit On Total Assessments
The maximum assessment amount payable for a calendar year may not exceed five percent of the total premiums earned in the preceding calendar year from...
- Texas Section 1501.325 - Estimate Of Assessments; Evaluation And Protection Of System
(a) Not later than March 1 of each year, the board shall file with the commissioner an estimate of the assessments necessary to fund the...
SUBCHAPTER H MARKETING OF SMALL EMPLOYER HEALTH BENEFIT PLANS
- Texas Section 1501.326 - Deferment Of Assessment
(a) A reinsured health benefit plan issuer may petition the commissioner for a deferment in whole or in part of an assessment imposed by the...
- Texas Section 1501.351 - Marketing Requirements
(a) Each small employer health benefit plan issuer shall market a small employer health benefit plan to eligible small employers in this state through properly...
- Texas Section 1501.352 - Health Status And Claims Experience; Prohibited Acts
(a) A small employer health benefit plan issuer or agent may not, because of the health status or claims experience of the eligible employees of...
- Texas Section 1501.353 - Agent Compensation
(a) A small employer health benefit plan issuer shall pay the same commission, percentage of premium, or other amount to an agent for renewal of...
- Texas Section 1501.354 - Required Disclosures
(a) In connection with offering a small employer health benefit plan for sale, each small employer health benefit plan issuer and agent shall make a...
- Texas Section 1501.355 - Rules Concerning Marketing And Availability
Rules adopted under Section 1501.010 may establish additional standards to provide for the fair marketing and broad availability of small employer health benefit plans to...
- Texas Section 1501.356 - Reporting Requirements
(a) In this section, "case characteristics" has the meaning assigned by Section 1501.201. (b) The department may require periodic reports by small employer health benefit...
- Texas Section 1501.357 - Violations
A violation of Section 1501.352 by a small employer health benefit plan issuer or agent is an unfair method of competition and an unfair or...
SUBCHAPTER M LARGE EMPLOYER HEALTH BENEFIT PLANS
- Texas Section 1501.358 - Applicability To Third-party Administrator
If a small employer health benefit plan issuer enters into an agreement with a third-party administrator to provide administrative, marketing, or other services related to...
- Texas Section 1501.601 - Participation Criteria
(a) In this subchapter, "participation criteria" means any criteria or rules established by a large employer to determine the employees who are eligible for enrollment...
- Texas Section 1501.602 - Coverage Requirements
(a) A large employer health benefit plan issuer: (1) may refuse to provide coverage to a large employer in accordance with the issuer's underwriting standards...
- Texas Section 1501.603 - Exclusion Of Eligible Employee Or Dependent Prohibited
A large employer health benefit plan issuer may not exclude an employee who meets the participation criteria or an eligible dependent, including a late enrollee,...
- Texas Section 1501.604 - Declining Coverage
(a) A large employer health benefit plan issuer shall obtain a written waiver from each employee who meets the participation criteria and declines coverage under...
- Texas Section 1501.605 - Minimum Contribution Or Participation Requirements
(a) A large employer health benefit plan issuer may require a large employer to meet a minimum contribution or participation requirement as a condition of...
- Texas Section 1501.606 - Employee Enrollment; Waiting Period
(a) The initial enrollment period for employees meeting the participation criteria under a large employer health benefit plan must be at least 31 days, with...
- Texas Section 1501.607 - Coverage For Newborn Children
(a) A large employer health benefit plan may not limit or exclude initial coverage of a newborn child of a covered employee. (b) Coverage of...
- Texas Section 1501.608 - Coverage For Adopted Children
(a) This section applies only if children are eligible for coverage under a large employer health benefit plan. (b) A large employer health benefit plan...
- Texas Section 1501.609 - Coverage For Unmarried Children
(a) This section applies only if children are eligible for coverage under a large employer health benefit plan. (b) Any limiting age applicable under a...
- Texas Section 1501.610 - Premium Rates; Adjustments
(a) A large employer health benefit plan issuer may charge premiums in accordance with this section to the group of employees or dependents who meet...
- Texas Section 1501.611 - Marketing Requirements
On request, each large employer purchasing a health benefit plan shall be given a summary of all plans for which the employer is eligible. Added...
- Texas Section 1501.612 - Encouraging Exclusion Of Employee Prohibited
A large employer health benefit plan issuer or agent may not encourage a large employer to exclude an employee who meets the participation criteria from...
- Texas Section 1501.613 - Agents
A large employer health benefit plan issuer may not terminate, fail to renew, or limit its contract or agreement of representation with an agent because...
- Texas Section 1501.615 - Additional Reporting Requirements
The department may require periodic reports by large employer health benefit plan issuers and agents regarding the large employer health benefit plans issued by those...
- Texas Section 1501.616 - Applicability To Third-party Administrator
If a large employer health benefit plan issuer enters into an agreement with a third-party administrator to provide administrative, marketing, or other services related to...