Texas Administrative Code
Title 28 - INSURANCE
Part 1 - TEXAS DEPARTMENT OF INSURANCE
Chapter 26 - EMPLOYER-RELATED HEALTH BENEFIT PLAN REGULATIONS
Subchapter C - LARGE EMPLOYER HEALTH INSURANCE REGULATIONS
Section 26.313 - Filing Requirements

Universal Citation: 28 TX Admin Code § 26.313

Current through Reg. 50, No. 13; March 28, 2025

(a) Each large employer carrier, other than an HMO, must use a policy shell format for any group or individual health-benefit-plan form used to provide a health benefit plan in the large employer market. To expedite the review and approval process, all group and individual health-benefit-plan form filings (excluding HMO filings covered in subsection (b) of this section) must be submitted in the following order:

(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 (relating to Submission Requirements for Filings and Departmental Actions Related to Such Filings), 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 large 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, alternative 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 that 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 Subchapter G of this title (relating to Plain Language Requirements for Health Benefit Policies);

(11) the information required under this section; and

(12) the rate schedule applicable to any individual health benefit plan, as required by Chapter 3, Subchapter A of this title.

(b) In addition to subsection (a) of this section, the following provisions apply to each HMO. The HMO must submit health-benefit-plan forms for use in the large employer market that include the following:

(1) Any HMO group or individual agreement must address and include all required provisions of Insurance Code Chapter 1501 (concerning Health Insurance Portability and Availability Act). The agreement must comply with any other applicable provisions of the Insurance Code. In addition, the agreement must 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 Insurance Code Chapter 1501.

(2) The filing must include any alternative pages to the agreement or the schedule of benefits and any alternative schedules of benefit.

(3) The filing must 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.

(4) The filing must include any applicable requirements of Chapter 11, Subchapter D (relating to Regulatory Requirements for an HMO Subsequent to Issuance of a Certificate of Authority) and Chapter 11, Subchapter F of this title, except for:
(A) continuation and conversion of coverage, in accordance with Insurance Code Chapter 1271 (concerning Benefits Provided by Health Maintenance Organizations; Evidence of Coverage; Charges), and this title; and

(B) cancellation, in accordance with § 26.308 of this title (relating to Renewability of Coverage and Cancellation).

(5) The filing must include any rider forms that will be used with health benefit plans offered to large employers. The rider forms, if developed subsequent to approval of the agreement, must be submitted with an explanation of the market in which the forms will be used. All rider forms must comply with Insurance Code Chapter 1271, and applicable provisions of Chapter 11, Subchapter D of this title.

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