Current through Reg. 50, No. 13; March 28, 2025
(a) A
health carrier offering or providing a consumer choice health benefit plan must
provide each prospective or current policyholder or contract holder with a
written or electronic disclosure statement in a manner that gives the
policyholder or contract holder the ability to keep a copy of the disclosure
statement. The disclosure statement must provide a sufficiently detailed
description of the state-mandated health benefits that are reduced or not
included in the plan to enable the prospective or current policyholder or
contract holder to make an informed decision.
(b) Form CCP 1 fulfills the requirements of
this section and is available on the department's website at
www.tdi.texas.gov.
(c) If a health carrier chooses to generate
its own disclosure statement, it must comply with readability standards
applicable to forms reviewed under Chapter 3 of this title (relating to Life,
Accident, and Health Insurance and Annuities) and Chapter 11 of this title
(relating to Health Maintenance Organizations) and the statement must use at
least 12-point type. The disclosure statement also must:
(1) acknowledge that the consumer choice
health benefit plan being offered or purchased does not provide some or all
state-mandated health benefits and explain, if applicable, that the plan does
include all health benefits required by the Affordable Care Act;
(2) in plain language, list each health
benefit or coverage not provided at the state-mandated level in the consumer
choice health benefit plan, define the listed health benefit or coverage,
describe the benefit or coverage in the consumer choice plan being offered, and
describe the benefit or coverage that would be provided in a state-mandated
plan;
(3) instruct consumers to
refer to the Summary of Benefits and Coverage to see the specific level of
benefits provided by the plan;
(4)
when applicable because the health carrier has materially modified a consumer
choice plan in a way that necessitates a change to the disclosure, or when the
disclosure must be updated to reflect changes in state law, contain the
following language, in bold type, directly above the list required by paragraph
(2) of this subsection, as applicable:
(A)
"The benefits or coverages you are agreeing to on this renewal are different
from your current plan."; or
(B)
"The benefits required by state law have changed since you first received this
disclosure.";
(5)
explain that the health carrier offers one or more state-mandated plans and
provide:
(A) a phone number where the
consumer can purchase the state-mandated plan;
(B) a URL that connects the consumer to the
health carrier's website where the state-mandated plan is available for
purchase; and
(C) for individual
market plans, indicate whether the state-mandated plan is available on the
federal health benefit exchange and if it is not, explain that the plan will
not qualify for reduced premiums or cost-sharing;
(6) contain acknowledgments of the following:
(A) that the consumer choice health benefit
plan does not provide the same level of coverage required in a state-mandated
plan;
(B) that more information
about consumer choice health benefit plans is available from the department
either online at
www.tdi.texas.gov/consumer/consumerchoice.html,
or by calling the TDI Consumer Help Line at 1-800-252-3439; and
(C) if the plan is being issued in the
individual market, that if the plan does not meet the consumer's needs, in most
cases the consumer will not be able to get a new plan until the next open
enrollment period;
(7)
inform the prospective or current policyholder or contract holder that the
health carrier must provide a copy of the written disclosure statement upon
request;
(8) for a disclosure being
delivered consistent with subsection (e)(2) of this section, include the
following language in bold type, directly above the acknowledgements in
paragraph (6) of this subsection: "By signing your application to enroll in
this plan, you acknowledge the following:"; and
(9) for initial coverage or enrollment, other
than for a disclosure being delivered consistent with subsection (e)(2) of this
section, provide space for the prospective policyholder or contract holder to
print and sign their name, and to sign to acknowledge receipt of the disclosure
statement, accompanied by the following language in bold type: "Don't sign this
document if you don't understand it. No firme este documento si no lo
comprende."
(d) A health
carrier must provide the written disclosure statement described in subsection
(a) of this section:
(1) to a prospective
policyholder or contract holder, not later than the time of the offer of a
consumer choice health benefit plan, except as provided by subsection (e) of
this section; and
(2) to a current
policyholder or contract holder, along with any offer to renew the contract or
policy.
(e) A health
carrier must provide the written disclosure statement described in subsection
(a) of this section to a prospective or current policyholder or contract holder
applying for coverage through the federal health benefit exchange as follows:
(1) at the time of application, if the
federal health benefit exchange provides a mechanism for a health carrier to
provide the written disclosure statement and obtain a signature at the time of
application; or
(2) if the health
carrier is unable to provide the written disclosure and obtain a signature at
the time of application, the health carrier must include the disclosure
statement as the first page in the plan brochure provided on the healthcare.gov
website.
(f) A health
carrier must request a signature on the written disclosure statement:
(1) at the time of initial coverage or
enrollment; and
(2) any time a
policyholder is enrolling in coverage under a different consumer choice plan
from the plan for which the initial disclosure statement was signed, including
instances where the health carrier discontinues a plan, consistent with
Insurance Code §
1202.051, concerning
Renewability and Continuation of Individual Health Insurance Policies;
Insurance Code §
1271.307, concerning
Renewability of Coverage: Individual Health Care Plans and Conversion
Contracts; and Insurance Code §
1501.109, concerning
Refusal to Renew; Discontinuation of Coverage.
(g) Except as provided by subsection (e) of
this section, when a health carrier provides the written disclosure statement
referenced in subsection (a) of this section to a prospective policyholder or
contract holder:
(1) through an agent, the
agent may not transmit the application to the health carrier for consideration
until the agent has secured the signed written disclosure statement from the
applicant; and
(2) directly to the
applicant, the health carrier may not process the application until the health
carrier has secured the signed written disclosure statement from the
applicant.
(h) The
health carrier must, on request, provide the prospective or current
policyholder or contract holder with a copy of the written disclosure statement
free of charge.
(i) When a health
carrier is offering or issuing a consumer choice health benefit plan to an
association, the health carrier must satisfy the requirements of subsection (e)
of this section by providing the written disclosure statement to prospective or
existing certificate holders.
(j) A
health carrier offering or issuing a consumer choice health benefit plan to a
prospective or current policyholder, contract holder, or an association must
update and file with the Commissioner, for approval, its written disclosure
statement that conforms with this section no later than six months from the
effective date of this section.
