AI-assisted research summary: A health benefit plan issuer has limited authority to refuse or delay coverage in certain geographic service areas, with waiting periods and exceptions tied to commissioner determinations and capacity.
Sec. 1501.101. GEOGRAPHIC SERVICE AREAS. (a) Repealed by Acts 2015, 84th Leg., R.S., Ch. 42 , Sec. 3.01(6), eff. September 1, 2015. (b) A small employer health benefit plan issuer that refuses to issue a small employer health benefit plan in a geographic service area may not offer a health benefit plan to a small employer in the applicable service area before the fifth anniversary of the date of the refusal. (c) A small or large employer health benefit plan issuer is not required to offer or issue a small or large employer health benefit plan to: (1) a small or large employer that is not located within a geographic service area of the issuer; (2) an employee of a small or large employer who neither resides nor works in the geographic service area of the issuer; or (3) a small or large employer located within a geographic service area of the issuer with respect to which area the issuer demonstrates to the commissioner's satisfaction that the issuer: (A) reasonably anticipates that it will not have the capacity to deliver services adequately because of obligations to existing covered individuals; and (B) is acting uniformly without regard to the claims experience of the employer or any health status related factor of employees, employees' dependents, or new employees or dependents who may become eligible for the coverage. (d) A small or large employer health benefit plan issuer that is unable to offer coverage in a geographic service area in accordance with a determination made by the commissioner under Subsection (c)(3) may not offer a small or large employer benefit plan, as applicable, in that service area before the 180th day after the later of: (1) the date the issuer refuses to offer coverage; or (2) the date the issuer demonstrates to the satisfaction of the commissioner that it has regained the capacity to deliver services to small or large employers in the geographic service area. (e) If the commissioner determines that requiring the acceptance of small or large employers under this chapter would place a small or large employer health benefit plan issuer in a financially impaired condition and that the issuer is acting uniformly without regard to the claims experience of the small or large employer or any health status related factors of eligible employees, eligible employees' dependents, or new employees or dependents who may become eligible for the coverage, the issuer may not offer coverage to small or large employers until the later of: (1) the 180th day after the date the commissioner makes the determination; or (2) the date the commissioner determines that accepting small or large employers would not place the issuer in a financially impaired condition. Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005. Amended by: Acts 2015, 84th Leg., R.S., Ch. 42 (S.B. 784), Sec. 3.01(6), eff. September 1, 2015.