1. (a) Each health 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 the Insurance Code, Article 3.42, and Chapter 3, Subchapter A of this title (relating to Requirements for Filing of Policy Forms, Riders, Amendments, and Endorsements for Life, Accident and Health Insurance and Annuities), or the Insurance Code, Article 20A.09, and §11.301(4) of this title (relating to Filing Requirements) or §11.302(6) of this title (relating to Service Area Expansion Requests), as applicable, except as provided in subsection (b) of this section. A health 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. The form provided at Figure 43 of §26.27(b)(43) of this title (relating to Forms) (Form Number 1212 CERT ANN LIST-OTHER/SEHBP) may be used for this purpose. The previously approved forms should be listed in Provision E of that form. The certification shall be forwarded to the department as soon as reasonably possible after January 1, 1994.

2. (b) The following certification forms providing information relating to prototype policy forms, marketing in the small employer market and/or other markets, and geographic service areas shall accompany each health benefit plan form filing submitted for use in the small employer market.

   1. (1) A geographic service area certification provided at Figure 44 of §26.27(b)(44) of this title (relating to Forms) (Form Number 1212 CERT GEOG) shall be submitted by each health carrier providing health benefit plans to small employers and shall define the geographic service areas within which the small employer carrier will operate as a small employer carrier.

      1. (A) This certification form must accompany a small employer carrier's initial filing submitted for use in the small employer market.
      2. (B) After the initial filings of health benefit plans intended for use in the small employer market have been approved, this certification form will only be due annually, no later than March 1 of each calendar year; however, if the geographic service areas change at any time, a new certification form defining the new service areas will be due no later than 30 days prior to the change.

   2. (2) A prototype certification form provided at Figure 45 of §26.27(b)(45) of this title (relating to Forms) (Form Number 1212 CERT PROTOTYPES/MRKT) shall accompany each policy form filing and/or certification filing. A small employer carrier other than an HMO shall complete the certification form indicating:

      1. (A) which of the prototype policy forms will be used;
      2. (B) alternate forms which will be used, where permitted, and their Flesch score. If a small employer health carrier, other than an HMO, utilizes the prototype forms and only uses variations permitted in the prescribed and/or adopted forms, the certification with the description of the variations will suffice and policy forms will not be required to be submitted for review and approval. Approval of the use of the prototype forms based on the certification and the description of the variations will be communicated via an approval letter;
      3. (C) define the market in which the form will be used, such as, for use only in the small employer market or in all employer markets or other markets;
      4. (D) the type of group filing, if applicable;
      5. (E) the small employer carrier's required participation amount; election to issue or not issue medically underwritten plans, the required employer contribution amount; election or non-election of a grace period and the number of days; termination for failure of employer to maintain participation requirements; election of Policy Year definition, Prescription Drug Benefit Rider or Prescription Drug Card Program, preexisting condition limitation provision including the time period for the preexisting limitation; late enrollee election; election or non-election of reduction in benefits for failure to pre-certify and the reduction amount; form numbers, approval dates and description of any riders that will be offered with the standard benefit plans; and description of additional percentages payable, deductibles and coinsurance amounts the small employer carrier will offer and description of PPO service area, if applicable, utilizing Figure 30 of §26.27(b)(30) of this title (relating to Forms) (Form Number 1212 PPO).
   3. (3) A prototype certification form provided at Figure 46 of §26.27(b)(46) of this title (relating to Forms) (Form Number 1212 HMO-CERT) with elections for HMO small employer plans shall accompany the contract form filing for HMOs. The HMO small employer carrier shall complete the certification form for variable provisions of the prototype form.

3. (c) Each health 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 cofered in subsection (d) of this section) shall be submitted as follows:

   1. (1) a group policy face page or individual policy face page, as applicable;
   2. (2) the group certificate page or individual data page, as applicable;
   3. (3) the toll-free number and complaint notice page, as required by Chapter 1, Subchapter E of this title (relating to Notice of Policyholder Complaint Procedure);
   4. (4) the table of contents;
   5. (5) insert pages for the general provisions;
   6. (6) insert pages for the required provisions and any optional provisions, if elected and as applicable;
   7. (7) for the standard benefit forms, which include the Basic Coverage Benefit Plan and the Catastrophic Care Benefit Plan, an insert of the required benefits section that includes the schedule of benefits, definitions, benefits provided, alternate cost containment and preferred provider provisions, if any, exclusions and limitations, continuation/conversion provisions, coordination of benefits, and riders;
   8. (8) for small employer health benefit plans that are not one of the standard benefit forms, an insert page for the benefits section of the health benefit plan, including, but not limited to, schedule of benefits, definitions, benefits provided, alternate cost containment and preferred provider provisions, if any, exclusions and limitations, continuation/conversion provisions, coordination of benefits, and riders;
   9. (9) insert pages for any amendments, applications, enrollment forms, or other form filings which comprise part of the contract;
   10. (10) insert pages for any additional forms required under Chapter 3, Subchapter F of this title (relating to Group Health Insurance Mandatory Conversion Privilege);
   11. (11) insert pages for any required outline of coverage for individual products;
   12. (12) any additional form filings and documentation as outlined in Chapter 3, Subchapter A of this title (relating to Requirements for Filing of Policy Forms, Riders, Amendments, and Endorsements for Life, Accident, and Health Insurance and Annuities) and Chapter 3, Subchapter G of this title (relating to Plain Language Requirements for Health Benefit Policies);
   13. (13) the certifications required under this section and any other rating information required under §26.10 of this title (relating to Establishment of Classes of Business) and §26.11 of this title (relating to Restrictions Relating to Premium Rates); and
   14. (14) the rate schedule applicable to any individual health benefit plan, as required by Chapter 3, Subchapter A of this title (relating to Requirements for Filing of Policy Forms Riders, Amendments, and Endorsements for Life, Accident, and Health Insurance and Annuities).

4. (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. (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. (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. (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. (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. (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.