Section 26.304 - Requirement to Insure Entire Groups(a) A large employer carrier that offers coverage to a large employer and its employees must offer coverage to each eligible employee who meets the large employer's participation criteria. If dependent coverage is offered to enrollees under a large employer health benefit plan, a large employer carrier must offer coverage to each eligible dependent. Except as provided in subsection (b) of this section, the large employer carrier must provide the same health benefit plan to each employee and dependent.(b) If elected by the large employer, a large employer carrier may offer one or more health benefit plans, provided that each eligible employee who meets the participation criteria may choose any of the plans offered. Except as provided in Insurance Code § 1501.104 (concerning Affiliation Period) and §1501.106 (concerning Certain Limitations or Exclusions of Coverage Prohibited), with respect to an affiliation period or exclusions for preexisting conditions, the choice among benefit plans may not be limited, restricted, or conditioned based on the health-status-related factors of the employees or dependents, if applicable.(c) A large employer carrier may require each large employer that applies for coverage, as part of the application process, to provide a complete list of employees, eligible employees, and if dependent coverage is offered to enrollees under a large employer health benefit plan, a complete list of dependents of eligible employees. The large employer carrier may also require the large employer to provide reasonable and appropriate supporting documentation to verify the information required under this subsection, and to confirm the applicant's status as a large employer. The large employer carrier must make a determination of eligibility within five business days of receipt of any requested documentation. A large employer carrier may not condition the issuance of coverage on an employer's production of a particular document, where the employer can otherwise provide the information required by this section. Similarly, if a particular document an employer produces does not reasonably evidence the employer's compliance with this subsection, the employer must produce other documentation to satisfy the requirements. Examples of the types of reasonable and appropriate supporting documentation that a large employer carrier may request from an employer as needed to fulfill the purposes of this subsection are: (1) a W-2 Summary Wage and Tax Form or other federal or state tax records;(6) articles of incorporation or other business entity filings with the secretary of state ;(7) assumed name filings;(8) professional licenses; and(9) reports required by the Texas Workforce Commission.(d) A large employer carrier may not deny two individuals who are married the status of eligible employee solely on the basis that the two individuals are married. The large employer carrier must provide a reasonable opportunity for the individuals to submit evidence as provided in subsection (c) of this section to establish each individual's status as an eligible employee. (1) A large employer carrier must provide married eligible employees of the same employer the option to have one spouse be treated under a large employer health benefit plan as an employee, and the other spouse treated as an employee or alternatively as the dependent of the other employee.(2) A child of either of the two individuals may only be covered under the large employer health benefit plan as a dependent by one of the two individuals.(3) An election by a spouse to be treated as a dependent under this subsection does not impact the individual's status as an eligible employee for any other purpose under Insurance Code Chapter 1501 (concerning Health Insurance Portability and Availability Act), except that the individual may be treated as a dependent for purposes of employer premium contributions.(e) New entrants who meet the large employer's participation criteria in a health benefit plan issued to a large employer group must be offered an opportunity to enroll in the health benefit plan currently held by the employer group or be offered an opportunity to enroll in the health benefit plan if the plan is provided through an individual franchise insurance policy or more than one plan is available. If a large employer carrier has offered more than one health benefit plan to eligible employees of a large employer group under subsection (b) of this section, the new entrant must be offered the same choice of health benefit plans as the other employees (members) in the group. A new entrant who does not exercise the opportunity to enroll in the health benefit plan within the period provided by the large employer carrier may be treated as a late enrollee by the health carrier, provided that the period provided to enroll in the health benefit plan complies with § 26.305(a) of this title (relating to Enrollment).(f) New entrants meeting the participation criteria in a health benefit plan issued to a large employer group must be accepted for coverage by the large employer carrier without any restrictions or limitations on coverage related to the health-status-related factors of the employee or dependent, except that a health carrier may exclude coverage for preexisting medical conditions or impose an affiliation period, to the extent allowed under Insurance Code Chapter 1501.28 Tex. Admin. Code § 26.304
The provisions of this §26.304 adopted to be effective March 5, 1998, 23 TexReg 2297; amended to be effective April 6, 2005, 30 TexReg 1931; amended to be effective December 6, 2010, 35 TexReg 10768; Amended by Texas Register, Volume 42, Number 19, May 12, 2017, TexReg 2557, eff. 5/17/2017