CHAPTER 1271. BENEFITS PROVIDED BY HEALTH MAINTENANCE ORGANIZATIONS; EVIDENCE OF COVERAGE; CHARGES
INSURANCE CODE
TITLE 8. HEALTH INSURANCE AND OTHER HEALTH COVERAGES
SUBTITLE C. MANAGED CARE
CHAPTER 1271. BENEFITS PROVIDED BY HEALTH MAINTENANCE
ORGANIZATIONS; EVIDENCE OF COVERAGE; CHARGES
SUBCHAPTER A. GENERAL PROVISIONS
Sec. 1271.001. APPLICABILITY OF DEFINITIONS. In this chapter,
terms defined by Section 843.002 have the meanings assigned by
that section.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1271.002. RIGHT TO EVIDENCE OF COVERAGE; ISSUANCE. (a)
Each enrollee residing in this state is entitled to evidence of
coverage under a health care plan.
(b) The health maintenance organization shall issue the evidence
of coverage, except as provided by Subsection (c).
(c) If the enrollee obtains coverage under a health care plan
through an insurance policy or a contract issued by a group
hospital service corporation, whether by option or otherwise, the
insurer or the group hospital service corporation shall issue the
evidence of coverage.
(d) By agreement between the health maintenance organization,
insurer, or group hospital service corporation and the subscriber
or person entitled to receive the evidence of coverage, policy,
or contract, the evidence of coverage required by this section
may be delivered electronically.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Amended by:
Acts 2005, 79th Leg., Ch.
728, Sec. 11.032(a), eff. September 1, 2005.
Sec. 1271.003. EVIDENCE OF COVERAGE NOT HEALTH INSURANCE POLICY.
An evidence of coverage is not a health insurance policy as that
term is defined by this code.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1271.004. INDIVIDUAL HEALTH CARE PLAN. (a) In this
section, "individual health care plan" means a health care plan:
(1) that provides health care services for individuals and their
dependents;
(2) under which an enrollee:
(A) pays the premium; and
(B) is not covered under the contract in accordance with a
continuation of services or continuation of benefits requirement
applicable under federal or state law; and
(3) in which the evidence of coverage meets the requirements of
the definition of "basic health care services" provided by
Section 843.002.
(b) A health maintenance organization may provide an individual
health care plan in accordance with this section and Section
1271.307.
(c) A health maintenance organization may limit enrollment in an
individual health care plan to individuals who reside or work
within the service area for the plan's network.
(d) The commissioner may adopt rules necessary to implement this
section and to meet the minimum requirements of federal law,
including regulations.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1271.005. APPLICABILITY OF OTHER LAW. (a) Chapters 1368
and 1652 apply to a health maintenance organization other than a
health maintenance organization that offers only a single health
care service plan.
(b) Subchapter B, Chapter 1355, applies to a health maintenance
organization providing benefits for mental health treatment in a
residential treatment center for children and adolescents or
crisis stabilization unit to the extent that:
(1) Subchapter B, Chapter 1355, does not conflict with this
chapter, Chapter 843, Subchapter A, Chapter 1452, or Subchapter
B, Chapter 1507; and
(2) the residential treatment center for children and
adolescents or crisis stabilization unit is located within the
service area of the health maintenance organization and is
subject to inspection and review as required by this chapter,
Chapter 843, Subchapter A, Chapter 1452, or Subchapter B, Chapter
1507, or rules adopted under this chapter, Chapter 843,
Subchapter A, Chapter 1452, or Subchapter B, Chapter 1507.
(c) A health maintenance organization shall comply with
Subchapter B, Chapter 542, with respect to prompt payment to an
enrollee.
(d) Notwithstanding any other law, Subchapter C, Chapter 1355,
applies to a group contract issued by a health maintenance
organization.
(e) Notwithstanding any other law, Section 1201.062 applies to
an evidence of coverage issued by a health maintenance
organization.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Amended by:
Acts 2005, 79th Leg., Ch.
728, Sec. 11.074(b), eff. September 1, 2005.
Sec. 1271.006. BENEFITS TO DEPENDENT CHILD AND GRANDCHILD. (a)
If children are eligible for coverage under the terms of an
evidence of coverage, any limiting age applicable to an unmarried
child of an enrollee, including an unmarried grandchild of an
enrollee, is 25 years of age. The limiting age applicable to a
child must be stated in the evidence of coverage.
(b) A health maintenance organization may provide benefits under
a health care plan to an enrollee's dependent grandchild who is
living with and in the household of the enrollee.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1271.007. RELIGIOUS CONVICTIONS. (a) This chapter,
Chapters 843, 1272, and 1367, Subchapter A, Chapter 1452, and
Subchapter B, Chapter 1507, do not require a health maintenance
organization, physician, or provider to recommend, offer advice
concerning, pay for, provide, assist in, perform, arrange, or
participate in providing or performing any health care service
that violates the religious convictions of the health maintenance
organization, physician, or provider.
(b) A health maintenance organization that limits or denies
health care services under this section shall state the
limitations in the evidence of coverage as required by Section
1271.052.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Amended by:
Acts 2005, 79th Leg., Ch.
728, Sec. 11.074(c), eff. September 1, 2005.
SUBCHAPTER B. CONTENTS OF EVIDENCE OF COVERAGE
Sec. 1271.051. EVIDENCE OF COVERAGE: CONTRACT AND CERTIFICATE
REQUIREMENTS. (a) An evidence of coverage that is a contract
must contain a clear and complete statement of the information
required by Sections 1271.052, 1271.053, and 1271.054.
(b) An evidence of coverage that is a certificate must contain a
reasonably complete facsimile of the information required by
Sections 1271.052, 1271.053, and 1271.054.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1271.052. INFORMATION ABOUT BENEFITS AND LIMITATIONS. An
evidence of coverage must state:
(1) the health care services, limited health care services, or
single health care service to which the enrollee is entitled
under the health care plan, limited health care service plan, or
single health care service plan;
(2) the issuance of other benefits, if any, to which the
enrollee is entitled under the health care plan, limited health
care service plan, or single health care service plan; and
(3) any limitation on the services, kinds of services, benefits,
or kinds of benefits to be provided, including any deductible or
copayment feature.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1271.053. INFORMATION ABOUT OBTAINING SERVICES. An
evidence of coverage must indicate where and in what manner
information is available about how to obtain services.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1271.054. INFORMATION ABOUT COMPLAINTS AND APPEALS. (a)
An evidence of coverage must contain a clear and understandable
description of the health maintenance organization's methods for
resolving enrollee complaints, including:
(1) the enrollee's right to appeal denial of an adverse
determination to an independent review organization; and
(2) the procedures for appealing to an independent review
organization.
(b) A health maintenance organization may indicate a subsequent
change to the methods for resolving enrollee complaints in a
separate document issued to the enrollee.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1271.055. OUT-OF-NETWORK SERVICES. (a) An evidence of
coverage must contain a provision regarding non-network
physicians and providers in accordance with the requirements of
this section.
(b) If medically necessary covered services are not available
through network physicians or providers, the health maintenance
organization, on the request of a network physician or provider
and within a reasonable period, shall:
(1) allow referral to a non-network physician or provider; and
(2) fully reimburse the non-network physician or provider at the
usual and customary rate or at an agreed rate.
(c) Before denying a request for a referral to a non-network
physician or provider, a health maintenance organization must
provide for a review conducted by a specialist of the same or
similar type of specialty as the physician or provider to whom
the referral is requested.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1271.056. UNFAIR OR DECEPTIVE PROVISIONS AND STATEMENTS
PROHIBITED. An evidence of coverage may not contain a provision
or statement that:
(1) is unjust, unfair, inequitable, misleading, or deceptive;
(2) encourages misrepresentation; or
(3) is untrue, misleading, or deceptive within the meaning of
Section 843.204.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
SUBCHAPTER C. COMMISSIONER APPROVAL
Sec. 1271.101. APPROVAL OF FORM OF EVIDENCE OF COVERAGE OR GROUP
CONTRACT. (a) An evidence of coverage or an amendment of an
evidence of coverage may not be issued or delivered to a person
in this state until the form of the evidence of coverage or
amendment has been filed with and approved by the commissioner.
(b) Except as provided by Subsection (c), the form of an
evidence of coverage or group contract to be used in this state
or an amendment to one of those forms is subject to the filing
and approval requirements of Section 1271.102.
(c) If the form of an evidence of coverage or group contract or
of an amendment to one of those forms is subject to the
jurisdiction of the commissioner under laws governing health
insurance or group hospital service corporations, the filing and
approval provisions of those laws apply to that form. However,
Subchapters B and E apply to that form to the extent that laws
governing health insurance or group hospital service corporations
do not apply to the requirements of Subchapters B and E.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1271.102. PROCEDURES FOR APPROVAL OF FORM OF EVIDENCE OF
COVERAGE OR GROUP CONTRACT; WITHDRAWAL OF APPROVAL. (a) The
commissioner shall, within a reasonable period, approve the form
of an evidence of coverage or group contract or an amendment to
one of those forms if the form meets the requirements of this
chapter.
(b) If the commissioner does not disapprove a form before the
31st day after the date the form is filed, the form is considered
approved. The commissioner may, by written notice, extend the
period for approval or disapproval as necessary for proper
consideration of the filing for not more than an additional 30
days.
(c) If the commissioner disapproves a form, the commissioner
shall notify the person who filed the form of the reason for the
disapproval.
(d) A hearing on the disapproval of a form shall be granted not
later than the 30th day after the date the person filing the form
makes a written request for a hearing.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1271.103. WITHDRAWAL OF APPROVAL OF FORM. (a) After
notice and opportunity for hearing, the commissioner may withdraw
approval of the form of an evidence of coverage or group contract
or an amendment to one of those forms if the commissioner
determines that the form violates this chapter, Chapter 843,
1272, or 1367, Subchapter A, Chapter 1452, or Subchapter B,
Chapter 1507, or a rule adopted by the commissioner.
(b) If the commissioner withdraws approval of a form under this
section, the form may not be issued until it is approved.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Amended by:
Acts 2005, 79th Leg., Ch.
728, Sec. 11.074(d), eff. September 1, 2005.
Sec. 1271.104. INFORMATION REQUIRED BY COMMISSIONER. The
commissioner may require the submission of any relevant
information the commissioner considers necessary in determining
whether to approve or disapprove a filing under this subchapter.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
SUBCHAPTER D. CERTAIN BENEFITS REQUIRED
Sec. 1271.151. PROVISION OF BASIC HEALTH CARE SERVICES. A
health maintenance organization that offers a basic health care
plan shall provide or arrange for basic health care services to
its enrollees as needed and without limitation as to time and
cost other than any limitation prescribed by rule of the
commissioner.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1271.152. STANDARDS FOR BASIC HEALTH CARE SERVICES. The
commissioner may adopt minimum standards relating to basic health
care services.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1271.153. PERIODIC HEALTH EVALUATIONS. (a) The basic
health care services provided under an evidence of coverage must
include periodic health evaluations for each adult enrollee.
(b) The services provided under this section must include a
health risk assessment at least once every three years and, for a
female enrollee, an annual well-woman examination provided in
accordance with Subchapter F, Chapter 1451.
(c) This section does not apply to an evidence of coverage for a
limited health care service plan or a single health care service
plan.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1271.154. WELL-CHILD CARE FROM BIRTH. (a) In this
section, "well-child care from birth" has the meaning used under
Section 1302, Public Health Service Act (42 U.S.C. Section
300e-1), and its subsequent amendments. The term includes newborn
screening required by the Texas Department of Health.
(b) A health maintenance organization shall ensure that each
health care plan provided by the health maintenance organization
includes well-child care from birth that complies with:
(1) federal requirements adopted under Chapter XI, Public Health
Service Act (42 U.S.C. Section 300e et seq.), and its subsequent
amendments; and
(2) the rules adopted by the Texas Department of Health to
implement those requirements.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1271.155. EMERGENCY CARE. (a) A health maintenance
organization shall pay for emergency care performed by
non-network physicians or providers at the usual and customary
rate or at an agreed rate.
(b) A health care plan of a health maintenance organization must
provide the following coverage of emergency care:
(1) a medical screening examination or other evaluation required
by state or federal law necessary to determine whether an
emergency medical condition exists shall be provided to covered
enrollees in a hospital emergency facility or comparable
facility;
(2) necessary emergency care shall be provided to covered
enrollees, including the treatment and stabilization of an
emergency medical condition; and
(3) services originated in a hospital emergency facility,
freestanding emergency medical care facility, or comparable
emergency facility following treatment or stabilization of an
emergency medical condition shall be provided to covered
enrollees as approved by the health maintenance organization,
subject to Subsections (c) and (d).
(c) A health maintenance organization shall approve or deny
coverage of poststabilization care as requested by a treating
physician or provider within the time appropriate to the
circumstances relating to the delivery of the services and the
condition of the patient, but not to exceed one hour from the
time of the request.
(d) A health maintenance organization shall respond to inquiries
from a treating physician or provider in compliance with this
provision in the health care plan of the health maintenance
organization.
(e) A health care plan of a health maintenance organization
shall comply with this section regardless of whether the
physician or provider furnishing the emergency care has a
contractual or other arrangement with the health maintenance
organization to provide items or services to covered enrollees.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Amended by:
Acts 2009, 81st Leg., R.S., Ch.
1273, Sec. 3, eff. March 1, 2010.
Sec. 1271.156. BENEFITS FOR REHABILITATION SERVICES AND
THERAPIES. (a) If benefits are provided for rehabilitation
services and therapies under an evidence of coverage, the
provision of a rehabilitation service or therapy that, in the
opinion of a physician, is medically necessary may not be denied,
limited, or terminated if the service or therapy meets or exceeds
treatment goals for the enrollee.
(b) For an enrollee with a physical disability, treatment goals
may include maintenance of functioning or prevention of or
slowing of further deterioration.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
SUBCHAPTER E. CHOICE OF PRIMARY CARE PHYSICIAN FOR CERTAIN
ENROLLEES
Sec. 1271.201. DESIGNATION OF SPECIALIST AS PRIMARY CARE
PHYSICIAN. (a) An evidence of coverage must provide that an
enrollee with a chronic, disabling, or life-threatening illness
may apply to the health maintenance organization's medical
director to use a nonprimary care physician specialist as the
enrollee's primary care physician.
(b) The application must:
(1) include information specified by the health maintenance
organization, including certification of the medical need; and
(2) be signed by the enrollee and the nonprimary care physician
specialist interested in serving as the enrollee's primary care
physician.
(c) To be eligible to serve as the enrollee's primary care
physician, a physician specialist must:
(1) meet the health maintenance organization's requirements for
primary care physician participation; and
(2) agree to accept the responsibility to coordinate all of the
enrollee's health care needs.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1271.202. APPEAL. If a health maintenance organization
denies a request under Section 1271.201, the enrollee may appeal
the decision through the health maintenance organization's
established complaint and appeals process.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1271.203. EFFECTIVE DATE OF DESIGNATION. (a) The
effective date of the designation of a nonprimary care physician
specialist as an enrollee's primary care physician under Section
1271.201 may not be applied retroactively.
(b) A health maintenance organization may not reduce the amount
of compensation owed to the original primary care physician for
services provided before the date of the new designation.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
SUBCHAPTER F. SCHEDULE OF CHARGES
Sec. 1271.251. APPROVAL OF FORMULA OR METHOD FOR COMPUTING
SCHEDULE OF CHARGES. (a) The formula or method for computing
the schedule of charges for enrollee coverage for health care
services must be filed with the commissioner before the formula
or method is used in conjunction with a health care plan.
(b) The formula or method must be established in accordance with
actuarial principles for the various categories of enrollees. The
filing of the method or formula must contain:
(1) a statement by a qualified actuary that certifies that the
formula or method is appropriate; and
(2) supporting information that the commissioner considers
adequate.
(c) The formula or method must produce charges that are not
excessive, inadequate, or unfairly discriminatory. Benefits must
be reasonable with respect to the rates produced by the formula
or method.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1271.252. CONSIDERATION OF INDIVIDUAL HEALTH STATUS
PROHIBITED. The charges resulting from the application of a
formula or method described by Section 1271.251 may not be
altered for an individual enrollee based on the status of that
enrollee's health.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1271.253. INFORMATION REQUIRED BY COMMISSIONER. The
commissioner may require the submission of any relevant
information the commissioner considers necessary in determining
whether to approve or disapprove a filing under this subchapter.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
SUBCHAPTER G. CONTINUATION OF COVERAGE, CONVERSION CONTRACTS, AND
RENEWAL
Sec. 1271.301. ENTITLEMENT TO CONTINUATION OF GROUP COVERAGE.
(a) In this section, "involuntary termination for cause" does
not include termination for any health-related reason.
(b) A health maintenance organization shall provide a group
coverage continuation privilege as required by and subject to the
eligibility provisions of this subchapter.
(c) An enrollee is entitled to continue group coverage as
provided by this subchapter if:
(1) the enrollee's coverage under a group contract is terminated
for any reason except involuntary termination for cause; and
(2) the enrollee for at least three consecutive months
immediately before the termination of coverage has been
continuously covered under the group contract and under any
previous group contract providing similar services and benefits
that the current group contract replaced.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1271.302. REQUEST FOR CONTINUED COVERAGE; DEADLINE. An
enrollee must provide to the employer or group contract holder a
written notice of election to continue group coverage under this
subchapter not later than the 60th day after the later of:
(1) the date the group coverage would otherwise terminate; or
(2) the date the enrollee is given notice of the right of
continuation by the employer or group contract holder.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Amended by:
Acts 2009, 81st Leg., R.S., Ch.
550, Sec. 5, eff. June 19, 2009.
Sec. 1271.303. PAYMENT FOR CONTINUED COVERAGE. (a) An enrollee
electing continuation of group coverage must pay to the employer
or group contract holder the amount of contribution required by
the employer or group contract holder, plus an amount equal to
two percent of the group rate for the coverage being continued
under the group contract.
(b) The enrollee must make the payment not later than the 45th
day after the initial election for coverage and on the due date
of each payment thereafter. Following the first payment made
after the initial election for coverage, the payment of any other
premium shall be considered timely if made by the 30th day after
the date on which payment is due.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Amended by:
Acts 2009, 81st Leg., R.S., Ch.
550, Sec. 6, eff. June 19, 2009.
Sec. 1271.304. TERMINATION OF CONTINUED COVERAGE. Group
continued coverage under this subchapter may not terminate until
the earliest of:
(1) the date the maximum continuation period provided by law
would end, which is:
(A) for any enrollee not eligible for continuation coverage
under Title X, Consolidated Omnibus Budget Reconciliation Act of
1985 (29 U.S.C. Section 1161 et seq.) (COBRA), the end of the
nine-month period after the date the election to continue
coverage is made; or
(B) for any enrollee eligible for continuation coverage under
COBRA, six additional months following any period of continuation
provided under that statute;
(2) the date on which failure to make timely payments terminates
coverage;
(3) the date on which the enrollee is covered for similar
services and benefits by any other plan or program, including a
hospital, surgical, medical, or major medical expense insurance
policy, hospital or medical service subscriber contract, or
medical practice or other prepayment plan; or
(4) the date on which the group coverage terminates in its
entirety.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Amended by:
Acts 2009, 81st Leg., R.S., Ch.
550, Sec. 7, eff. June 19, 2009.
Sec. 1271.305. NOTIFICATION OF RISK POOL ELIGIBILITY. (a) At
least 30 days before the end of the continuation period described
by Section 1271.304(1) that is applicable to the enrollee, the
health maintenance organization shall notify the enrollee that
the enrollee may be eligible for coverage under the Texas Health
Insurance Risk Pool as provided by Chapter 1506.
(b) The health maintenance organization shall provide to the
enrollee the address for applying to the pool for coverage.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Amended by:
Acts 2009, 81st Leg., R.S., Ch.
550, Sec. 8, eff. June 19, 2009.
Sec. 1271.306. CONVERSION CONTRACTS. (a) A health maintenance
organization may offer to each enrollee a conversion contract.
(b) A health maintenance organization shall issue the conversion
contract without evidence of insurability if written application
for the contract and payment of the first premium are made not
later than the 31st day after the date of termination of
coverage.
(c) A conversion contract must meet the minimum standards for
services and benefits for conversion contracts. The commissioner
shall adopt rules to prescribe the minimum standards for services
and benefits applicable to conversion contracts.
(d) The premium for a conversion contract shall be determined in
accordance with the health maintenance organization's premium
rates for coverage provided under the group contract or plan. The
premium may be based on the geographic location of each person to
be covered and must be based on the type of conversion contract
and the coverage provided by the contract. The premium may not
exceed 200 percent of the premium rates for the same coverage
provided under a group contract or plan.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1271.307. RENEWABILITY OF COVERAGE: INDIVIDUAL HEALTH CARE
PLANS AND CONVERSION CONTRACTS. (a) In this section,
"individual health care plan" has the meaning assigned by Section
1271.004.
(b) An individual health care plan or a conversion contract that
provides health care services to an enrollee is renewable at the
option of the enrollee. A health maintenance organization may
decline to renew an individual health care plan or conversion
contract only:
(1) for failure to pay premiums or contributions in accordance
with the terms of the plan or because the issuer of the plan has
not received timely premium payments;
(2) for fraud or intentional misrepresentation;
(3) because the health maintenance organization ceases to offer
coverage in the individual market in accordance with rules
established by the commissioner;
(4) because the enrollee no longer resides or works in the area
in which the health maintenance organization is authorized to
provide coverage, if coverage under the plan is terminated
uniformly for this reason without regard to any factor related to
the health status of a covered enrollee; or
(5) in accordance with applicable federal law, including
regulations.
(c) The commissioner may adopt rules necessary to implement this
section and to meet the minimum requirements of federal law,
including regulations.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.