1. (a) Periods provided for enrollment in and application for any health benefit plan provided to a large employer group shall comply with the following:

   1. (1) the initial enrollment period for the employees meeting the large employer's participation criteria must be at least 31 days, or if the waiting period exceeds 31 days, at least 31 days after the date the new entrant completes the waiting period for coverage;
   2. (2) the new entrant who meets the large employer's participation criteria shall be notified of his or her opportunity to enroll at least 31 days in advance of the last date enrollment is permitted;
   3. (3) a period of at least 31 days following the date of employment, or following the date the new entrant is eligible for coverage, shall be provided during which the new entrant's application for coverage may be submitted. For purposes of this paragraph, submitted means that the item(s) must be postmarked by the specified time period. At the discretion of the large employer carrier, alternative methods of submission such as fax, may be acceptable; and
   4. (4) an open enrollment period of at least 31 days shall be provided on an annual basis. Such enrollment period shall consist of an entire calendar month, beginning on the first day of the month and ending on the last day of the month. If the month is a 30-day month, the enrollment period shall begin on the first day of the month and end on the first day of the following month. If the month is February, the period shall last through March 2nd.
2. (b) If dependent coverage is offered to enrollees under a large employer health benefit plan, the initial enrollment period for the dependents must be at least 31 days, with a 31 day annual open enrollment period.

3. (c) A new employee who meets the participation criteria of a covered large employer may not be denied coverage if the application for coverage is received by the large employer carrier not later than the 31st day after the later of:

   1. (1) the date on which the employment begins; or
   2. (2) the date on which the waiting period established under Insurance Code, Article 26.83(h) expires.

4. (d) If dependent coverage is offered to the enrollees under a large employer health benefit plan, a dependent of a new employee who meets the participation criteria established by the large employer may not be denied coverage if the application for coverage is received by the large employer carrier not later than the 31st day after the later of:

   1. (1) the date on which the employment begins;
   2. (2) the date on which the waiting period established under Insurance Code, Article 26.83(h) expires; or
   3. (3) the date on which the dependent becomes eligible for enrollment.
5. (e) A large employer carrier may not exclude any employee who meets the participation criteria or an eligible dependent, including a late enrollee, who would otherwise be covered under a large employer group.

6. (f) A large employer health benefit plan may not limit or exclude initial coverage of a newborn child of a covered employee. Any coverage of a newborn child of a covered employee under this subsection terminates on the 32nd day after the date of the birth of the child unless:

   1. (1) dependent children are eligible for coverage under the large employer health benefit plan; and
   2. (2) notification of the birth and any required additional premium are received by the large employer not later than the 31st day after the date of birth. A large employer carrier shall not terminate coverage of a newborn child if such carrier's billing cycle does not coincide with this 31-day premium payment requirement, until the next billing cycle has occurred and there has been nonpayment of the additional required premium, within 30 days of the due date of such premium.
7. (g) If dependent children are eligible for coverage under the large employer health benefit plan, a large employer health benefit plan may not limit or exclude initial coverage of an adopted child of an insured. A child is considered to be the child of an insured if the insured is a party in a suit in which the adoption of the child by the insured is sought.

8. (h) If dependent children are eligible for coverage under the large employer health benefit plan, an adopted child of an insured may be enrolled, at the option of the insured, within either:

   1. (1) 31 days after the insured is a party in a suit for adoption; or
   2. (2) 31 days of the date the adoption is final.

9. (i) Coverage of an adopted child of an employee terminates unless notification of the adoption and any required additional premiums are received by the large employer not later than either:

   1. (1) the 31st day after the insured becomes a party in a suit in which the adoption of the child by the insured is sought; or
   2. (2) the 31st day after the date of the adoption. A large employer carrier shall not terminate coverage of an adopted child if such carrier's billing cycle does not coincide with his 31-day premium payment requirement, until the next billing cycle has occurred and there has been nonpayment of the additional required premium within 30 days of the date of such premium.
10. (j) For purposes of subsections (c), (d), (g), and (j) of this section, received by the large employer by a specified time period means that the item(s) must be postmarked by the specified time period.
11. (k) If a newborn or adopted child is enrolled in a health benefit plan or other creditable coverage within the time periods specified in subsections (g) or (j) of this section, respectively, and subsequently enrolls in another health benefit plan without a significant break in coverage, the other plan may not impose any preexisting condition exclusion with regard to the child. If a newborn or adopted child is not enrolled within the time periods specified in subsections (g) or (j) of this section, respectively, then in accordance with §26.306(h) of this title (relating to Exclusions, Limitations, Waiting Periods, Affiliation Periods and Preexisting Conditions and Restrictive Riders), the newborn or adopted child may be considered a late enrollee or excluded from coverage until the next open enrollment period.
12. (l) If dependent coverage is offered to enrollees under a large employer health benefit plan, and the plan conditions dependent coverage for a child 21 years of age or older on the child's being a full-time student at an educational institution, the plan shall provide coverage for the child in accordance with Insurance Code Article 21.24-2.
13. (m) If benefits for diagnostic medical procedures are included under a large employer health benefit plan, then the plan shall provide coverage for each male enrolled in the plan for expenses incurred in conducting an annual medically recognized diagnostic examination for the detection of prostate cancer in accordance with Insurance Code Article 21.53F.
14. (n) An HMO issuing coverage to a large employer whose health benefit plan requires an enrollee to obtain certain specialty health care services through a referral made by a primary care physician or other gatekeeper, shall permit female enrollees access to obstetrical or gynecological care in accordance with Insurance Code Article 21.53D and Chapter 11 of this title (relating to Health Maintenance Organizations).

Source Note:The provisions of this §26.305 adopted to be effective March 5, 1998, 23 TexReg 2297; amended to be effective February 2, 1999, 24 TexReg 575.