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RULE §26.19 Filing Requirements


Published: 2015

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(a) Each small employer carrier shall file each form, including, but not limited to, each policy, contract, certificate, agreement, evidence of coverage, endorsement, amendment, enrollment form, and application that will be used to provide a health benefit plan in the small employer market, with the department in accordance with Insurance Code Article 3.42, and Chapter 3, Subchapter A of this title (relating to Submission Requirements for Filings and Departmental Actions Related to Such Filings), or Insurance Code Article 20A.09, and §11.301 of this title (relating to Filing Requirements) or §11.302 of this title (relating to Service Area Expansion or Reduction Application), as applicable, except as provided in subsection (b) of this section. A small employer carrier desiring to use existing forms to provide a health benefit plan in the small employer market shall file a certification stating which previously approved forms the health carrier intends to use in that market provided such forms have been amended to comply with applicable laws. Form Number 1212 CERT ANN LIST-OTHER/SEHBP shall be used for this purpose. The certification shall be forwarded to the department as soon as reasonably possible after January 1, 1994, and for newly elected small employer carriers no later than with the first filing of a small employer health benefit plan. (b) Each small employer carrier shall submit a geographic service area certification form, provided in Form Number 1212 CERT GEOG, prior to offering any small employer health benefit plan and subsequent to such filing only if the small employer carrier changes the elections it made in the certification. The certification form shall define the geographic service areas within which the small employer carrier will operate as a small employer carrier.   (1) Each small employer carrier shall submit this certification form no later than with the initial filing of a small employer health benefit plan.   (2) If a small employer carrier elects to alter its geographic service areas, the small employer carrier shall notify the department of its intent at least 30 days prior to the date the small employer carrier intends to effect the change. The small employer carrier shall utilize Form Number 1212 CERT GEOG to submit this information. This subsection does not exempt a health carrier from any other legal requirements, such as those for withdrawal from the market under §§7.1801, et seq. of this title (relating to Withdrawal Plan Requirements and Procedures). (c) Each small employer carrier, other than an HMO, shall use a policy shell format for any group or individual health benefit plan form used to provide a health benefit plan in the small employer market. To expedite the review and approval process, all group and individual health benefit plan form filings (excluding HMO filings which are covered in subsection (d) of this section) shall be submitted as follows:   (1) a group policy face page or individual policy face page, as applicable;   (2) the group certificate page or individual data page, as applicable;   (3) as applicable under Chapter 3, Subchapter A of this title, the toll-free number and complaint notice page, as required by Chapter 1, Subchapter E of this title (relating to Notice of Toll-Free Telephone Numbers and Procedures for Obtaining Information and Filing Complaints);   (4) the table of contents;   (5) insert pages for the general provisions;   (6) insert pages for the required provisions and any optional provisions, if elected and as applicable;   (7) for small employer health benefit plans, an insert page for the benefits section of the health benefit plan, including, but not limited to, schedule of benefits, definitions, benefits provided, exclusions and limitations, continuation provisions, and if applicable, alternate cost containment, preferred provider, conversion and coordination of benefits provisions, and riders;   (8) insert pages for any amendments, applications, enrollment forms, or other form filings which comprise part of the contract;   (9) insert pages for any required outline of coverage for individual products;   (10) any additional form filings and documentation as outlined in Chapter 3, Subchapter A of this title and Chapter 3, Subchapter G of this title (relating to Plain Language Requirements for Health Benefit Policies);   (11) the certifications required under this section and any other rating information required under §26.10 of this chapter (relating to Establishment of Classes of Business) and §26.11 of this chapter (relating to Restrictions Relating to Premium Rates); and   (12) the rate schedule applicable to any individual health benefit plan, as required by Chapter 3, Subchapter A of this title. (d) In addition to subsections (a) and (b) of this section, the following provisions apply to each health carrier that is an HMO. The HMO shall submit health benefit plan forms for use in the small employer market in accordance with the following.   (1) Any HMO group or individual agreement shall address and include all required provisions of the Insurance Code, Chapter 26. Such agreement shall be in compliance with any other applicable provisions of the Insurance Code. In addition, the agreement shall comply with the provisions of Chapter 11, Subchapter F of this title (relating to Evidence of Coverage) where those provisions are not in conflict with the Insurance Code, Chapter 26.   (2) The filing shall include any alternate page(s) to the agreement or the schedule of benefits and any alternate schedule(s) of benefit.   (3) The filing shall include any additional riders, amendments, applications, enrollment forms, or other forms and any other required documentation outlined in Chapter 11, Subchapter F of this title (relating to Evidence of Coverage).   (4) The filing shall include any applicable requirements of Chapter 11, Subchapter D of this title (relating to Regulatory Requirements for an HMO Subsequent to Issuance of a Certificate of Authority), and Chapter 11, Subchapter F of this title (relating to Evidence of Coverage), except for Continuation/Conversion of Coverage which shall be in accordance with Insurance Code, Article 20A.09(k) and this title, and Cancellation which shall be in accordance with §26.15 of this title (relating to Renewability of Coverage and Cancellation).   (5) The filing shall include any rider forms that will be used with health benefit plans offered to small employers. The rider forms, if developed subsequent to approval of the agreement, shall be submitted with an explanation of the market in which the forms will be used. All rider forms shall comply with the Insurance Code, Article 20A.09, and applicable provisions of Chapter 11, Subchapter D of this title (relating to Regulatory Requirements for an HMO Subsequent to Issuance of a Certificate of Authority) and Chapter 11, Subchapter F of this title (relating to Evidence of Coverage).

Source Note: The provisions of this §26.19 adopted to be effective December 30, 1993, 18 TexReg 9375; amended to be effective April 9, 1996, 21 TexReg 2648; amended to be effective March 5, 1998, 23 TexReg 2297; amended to be effective April 6, 2005, 30 TexReg 1931