28 Tex. Admin. Code § 7.1917 - Comprehensive Health Benefit Plans
(a) This
section applies only to a multiple employer welfare arrangement (MEWA) that
offers or seeks to offer a comprehensive health benefit plan and that:
(1) was issued an initial certificate of
authority under §846.054, concerning Issuance of Initial Certificate of
Authority, on or after January 1, 2024; or
(2) elects to be bound by Insurance Code §
846.0035, concerning
Applicability of Certain Laws to Association Providing Health Benefits, under §
7.1916 of this title (relating to
Election for the Application of Certain Laws).
(b) The MEWA must submit a form signed and
dated by an authorized officer or trustee to the department that includes the
following:
(1) a statement that is
substantially similar to the following: "This document is being submitted in
accordance with 28 Texas Administrative Code §
7.1917. {MEWA Name} will provide a
comprehensive health benefit plan as defined by 28 Texas Administrative Code §
7.1902"; and
(2) if the comprehensive health benefit plan
is not structured as a preferred provider benefit plan or an exclusive provider
benefit plan as defined in Insurance Code §
1301.001, concerning
Definitions, a description of the health care provider and benefit structure of
the plan and an explanation of how it does not qualify as a preferred provider
benefit plan or an exclusive provider benefit plan.
(c) In addition to the form required in
subsection (b) of this section, the MEWA must submit the following:
(1) a detailed compliance plan addressing the
following requirements:
(A) Insurance Code
Chapter 421, concerning Reserves in General;
(B) Insurance Code Chapter 422, concerning
Asset Protection Act;
(C) Insurance
Code Chapter 1451, Subchapter C, concerning Selection of Practitioners;
Subchapter F, concerning Access to Obstetrical or Gynecological Care; and
Subchapter K, concerning Health Care Provider Directories; and
(D) Insurance Code Chapter 4201, concerning
Utilization Review Agents;
(2) if the MEWA provides a comprehensive
health benefit plan that is structured in the manner of a preferred provider
benefit plan or an exclusive provider benefit plan as defined in Insurance Code
§
1301.001, concerning
Definitions, a detailed compliance plan addressing the following requirements:
(A) Insurance Code Chapter 1301, concerning
Preferred Provider Plans; and
(B)
Insurance Code Chapter 1467, concerning Out-of-Network Claim Dispute
Resolution; and
(3) for
each comprehensive health benefit plan that will be sponsored by the MEWA, an
opinion from an attorney attesting to the fact that the plan is in compliance
with all applicable federal and state laws. The opinion must adequately explain
how each plan complies with the Employee Retirement Income Security Act of 1974
(29 United States Code §
1001 et seq.) and the Patient Protection and
Affordable Care Act (42
United States Code §
18001 et seq.),
including how each plan complies with federal requirements applicable to large
group, small group, or individual markets, as applicable.
(d) A MEWA may use the MEWA forms accessible
on the department's website at www.tdi.texas.gov/forms as a resource to
comply with the requirements in subsections (b) and (c) of this
section.
Notes
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