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State Codes and Statutes

Statutes > Texas > Insurance-code > Title-8-health-insurance-and-other-health-coverages > 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.