SECTION 21.3530. Health Carrier Disclosure

(a) A health carrier offering or providing a consumer choice health benefit plan must provide each prospective or current policyholder or contract holder with a written or electronic disclosure statement in a manner that gives the policyholder or contract holder the ability to keep a copy of the disclosure statement. The disclosure statement must provide a sufficiently detailed description of the state-mandated health benefits that are reduced or not included in the plan to enable the prospective or current policyholder or contract holder to make an informed decision.

(b) Form CCP 1 fulfills the requirements of this section and is available on the department's website at www.tdi.texas.gov.

(c) If a health carrier chooses to generate its own disclosure statement, it must comply with readability standards applicable to forms reviewed under Chapter 3 of this title (relating to Life, Accident, and Health Insurance and Annuities) and Chapter 11 of this title (relating to Health Maintenance Organizations) and the statement must use at least 12-point type. The disclosure statement also must:

(1) acknowledge that the consumer choice health benefit plan being offered or purchased does not provide some or all state-mandated health benefits and explain, if applicable, that the plan does include all health benefits required by the Affordable Care Act;

(2) in plain language, list each health benefit or coverage not provided at the state-mandated level in the consumer choice health benefit plan, define the listed health benefit or coverage, describe the benefit or coverage in the consumer choice plan being offered, and describe the benefit or coverage that would be provided in a state-mandated plan;

(3) instruct consumers to refer to the Summary of Benefits and Coverage to see the specific level of benefits provided by the plan;

(4) when applicable because the health carrier has materially modified a consumer choice plan in a way that necessitates a change to the disclosure, or when the disclosure must be updated to reflect changes in state law, contain the following language, in bold type, directly above the list required by paragraph (2) of this subsection, as applicable:

(A) "The benefits or coverages you are agreeing to on this renewal are different from your current plan."; or

(B) "The benefits required by state law have changed since you first received this disclosure.";

(5) explain that the health carrier offers one or more state-mandated plans and provide:

(A) a phone number where the consumer can purchase the state-mandated plan;

(B) a URL that connects the consumer to the health carrier's website where the state-mandated plan is available for purchase; and

(C) for individual market plans, indicate whether the state-mandated plan is available on the federal health benefit exchange and if it is not, explain that the plan will not qualify for reduced premiums or cost-sharing;

(6) contain acknowledgments of the following:

(A) that the consumer choice health benefit plan does not provide the same level of coverage required in a state-mandated plan;

(B) that more information about consumer choice health benefit plans is available from the department either online at www.tdi.texas.gov/consumer/consumerchoice.html, or by calling the TDI Consumer Help Line at 1-800-252-3439; and

(C) if the plan is being issued in the individual market, that if the plan does not meet the consumer's needs, in most cases the consumer will not be able to get a new plan until the next open enrollment period;

(7) inform the prospective or current policyholder or contract holder that the health carrier must provide a copy of the written disclosure statement upon request;

(8) for a disclosure being delivered consistent with subsection (e)(2) of this section, include the following language in bold type, directly above the acknowledgements in paragraph (6) of this subsection: "By signing your application to enroll in this plan, you acknowledge the following:"; and

(9) for initial coverage or enrollment, other than for a disclosure being delivered consistent with subsection (e)(2) of this section, provide space for the prospective policyholder or contract holder to print and sign their name, and to sign to acknowledge receipt of the disclosure statement, accompanied by the following language in bold type: "Don't sign this document if you don't understand it. No firme este documento si no lo comprende."

(d) A health carrier must provide the written disclosure statement described in subsection (a) of this section:

(1) to a prospective policyholder or contract holder, not later than the time of the offer of a consumer choice health benefit plan, except as provided by subsection (e) of this section; and

(2) to a current policyholder or contract holder, along with any offer to renew the contract or policy.

(e) A health carrier must provide the written disclosure statement described in subsection (a) of this section to a prospective or current policyholder or contract holder applying for coverage through the federal health benefit exchange as follows:

(1) at the time of application, if the federal health benefit exchange provides a mechanism for a health carrier to provide the written disclosure statement and obtain a signature at the time of application; or

(2) if the health carrier is unable to provide the written disclosure and obtain a signature at the time of application, the health carrier must include the disclosure statement as the first page in the plan brochure provided on the healthcare.gov website.

(f) A health carrier must request a signature on the written disclosure statement:

(1) at the time of initial coverage or enrollment; and

(2) any time a policyholder is enrolling in coverage under a different consumer choice plan from the plan for which the initial disclosure statement was signed, including instances where the health carrier discontinues a plan, consistent with Insurance Code §1202.051, concerning Renewability and Continuation of Individual Health Insurance Policies; Insurance Code §1271.307, concerning Renewability of Coverage: Individual Health Care Plans and Conversion Contracts; and Insurance Code §1501.109, concerning Refusal to Renew; Discontinuation of Coverage.

(g) Except as provided by subsection (e) of this section, when a health carrier provides the written disclosure statement referenced in subsection (a) of this section to a prospective policyholder or contract holder:

(1) through an agent, the agent may not transmit the application to the health carrier for consideration until the agent has secured the signed written disclosure statement from the applicant; and

(2) directly to the applicant, the health carrier may not process the application until the health carrier has secured the signed written disclosure statement from the applicant.

(h) The health carrier must, on request, provide the prospective or current policyholder or contract holder with a copy of the written disclosure statement free of charge.

(i) When a health carrier is offering or issuing a consumer choice health benefit plan to an association, the health carrier must satisfy the requirements of subsection (e) of this section by providing the written disclosure statement to prospective or existing certificate holders.

(j) A health carrier offering or issuing a consumer choice health benefit plan to a prospective or current policyholder, contract holder, or an association must update and file with the Commissioner, for approval, its written disclosure statement that conforms with this section no later than six months from the effective date of this section.

Source Note: The provisions of this §21.3530 adopted to be effective June 2, 2004, 29 TexReg 5101; amended to be effective May 28, 2017, 42 TexReg 2730; amended to be effective June 7, 2021, 46 TexReg 3538