2005 Texas Insurance Code CHAPTER 1271. BENEFITS PROVIDED BY HEALTH MAINTENANCE ORGANIZATIONS; EVIDENCE OF COVERAGE; CHARGES

INSURANCE CODE

SUBTITLE C. MANAGED CARE

CHAPTER 1271. BENEFITS PROVIDED BY HEALTH MAINTENANCE 
ORGANIZATIONS;  EVIDENCE OF COVERAGE;  CHARGES

SUBCHAPTER A. GENERAL PROVISIONS


	§ 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, § 3, eff. April 1, 2005.          


	§ 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, § 3, eff. April 1, 2005.  
Amended by Acts 2005, 79th Leg., ch. 728, § 11.032(a), eff. Sept. 
1, 2005.


	§ 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, § 3, eff. April 1, 2005.          


	§ 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, § 3, eff. April 1, 2005.          


	§ 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, § 3, eff. April 1, 2005.  
Amended by Acts 2005, 79th Leg., ch. 728, § 11.074(b), eff. Sept. 
1, 2005.


	§ 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, § 3, eff. April 1, 2005.          


	§ 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, § 3, eff. April 1, 2005.  
Amended by Acts 2005, 79th Leg., ch. 728, § 11.074(c), eff. Sept. 
1, 2005.

SUBCHAPTER B. CONTENTS OF EVIDENCE OF COVERAGE


	§ 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, § 3, eff. April 1, 2005.          


	§ 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, § 3, eff. April 1, 2005.          


	§ 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, § 3, eff. April 1, 2005.          


	§ 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, § 3, eff. April 1, 2005.          


	§ 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, § 3, eff. April 1, 2005.          


	§ 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, § 3, eff. April 1, 2005.          

SUBCHAPTER C. COMMISSIONER APPROVAL


	§ 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, § 3, eff. April 1, 2005.          


	§ 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, § 3, eff. April 1, 2005.          


	§ 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, § 3, eff. April 1, 2005.  
Amended by Acts 2005, 79th Leg., ch. 728, § 11.074(d), eff. Sept. 
1, 2005.


	§ 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, § 3, eff. April 1, 2005.          

SUBCHAPTER D. CERTAIN BENEFITS REQUIRED


	§ 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, § 3, eff. April 1, 2005.          


	§ 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, § 3, eff. April 1, 2005.          


	§ 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, § 3, eff. April 1, 2005.          


	§ 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, § 3, eff. April 1, 2005.          


	§ 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 or comparable 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, § 3, eff. April 1, 2005.          


	§ 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, § 3, eff. April 1, 2005.          

SUBCHAPTER E. CHOICE OF PRIMARY CARE PHYSICIAN FOR CERTAIN 
ENROLLEES


	§ 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, § 3, eff. April 1, 2005.          


	§ 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, § 3, eff. April 1, 2005.          


	§ 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, § 3, eff. April 1, 2005.          

SUBCHAPTER F. SCHEDULE OF CHARGES


	§ 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, § 3, eff. April 1, 2005.          


	§ 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, § 3, eff. April 1, 2005.          


	§ 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, § 3, eff. April 1, 2005.          

SUBCHAPTER G. CONTINUATION OF COVERAGE, CONVERSION CONTRACTS, AND 
RENEWAL


	§ 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, § 3, eff. April 1, 2005.          


	§ 1271.302. REQUEST FOR CONTINUED COVERAGE;  
DEADLINE.  An enrollee must make a written election to continue 
group coverage under this subchapter and pay the first contribution 
required to establish contributions on an advance monthly basis to 
the employer or group contract holder not later than the 31st 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, § 3, eff. April 1, 2005.          


	§ 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 in advance on a 
monthly basis on the due date of each payment.

Added by Acts 2003, 78th Leg., ch. 1274, § 3, eff. April 1, 2005.          


	§ 1271.304. TERMINATION OF CONTINUED COVERAGE.  Group 
continued coverage under this subchapter may not terminate until 
the earliest of:
		(1)  the end of the six-month period after the date the 
election to continue coverage is made;
		(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, § 3, eff. April 1, 2005.          


	§ 1271.305. NOTIFICATION OF RISK POOL ELIGIBILITY.  (a) 
At least 30 days before the end of the six-month period after the 
date an enrollee elects to continue group coverage, 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, § 3, eff. April 1, 2005.          


	§ 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, § 3, eff. April 1, 2005.          


	§ 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, § 3, eff. April 1, 2005.