1. INTRODUCTION. The Commissioner of Insurance adopts amendments to Subchapter D, §§26.401 - 26.405 and 26.407 - 26.411, concerning the establishment of, and provision of health benefit plan coverage to, health group cooperatives pursuant to Insurance Code, Title 8, Chapter 1501. Section 26.409 is adopted with a change to the proposed text published in the November 18, 2005 issue of the Texas Register (30 TexReg 7686). Sections 26.401 - 26.405, 26.407, 26.408, 26.410 and 26.411 are adopted without changes.
2. REASONED JUSTIFICATION. The adopted amendments are necessary to implement SB 805, 79th Legislature, Regular Session, which revised the standards by which insurance companies and health maintenance organizations (HMOs) provide group health benefit plan coverage to health group cooperatives comprised of small or large employers. SB 805 enacted §1501.0575, making participation by health benefit plan issuers in health group cooperatives generally voluntary. The bill also amended §1501.0581 to provide that a health group cooperative may be composed of small employers or large employers, but not both; and that a health group cooperative consisting only of small employers is not required to allow a small employer to join the cooperative under certain statutorily specified conditions and so long as the Commissioner has been timely notified of the cooperative's election. The bill also amended Insurance Code §1501.063 to provide that a health group cooperative is considered a single employer under the Insurance Code, and that a cooperative composed only of small employers that has made the election specified in Insurance Code §1501.0581(o) to restrict membership to no more than 50 employees is to be treated as a small employer for purposes of Chapter 1501, including for purposes of any provision relating to premium rates and the issuance and renewal of coverage. The adopted amendments also are necessary to address changes to requirements governing the formation and operation of health group cooperatives and the obligations of insurance companies and HMOs (hereinafter referred to collectively as "health carriers") that issue health benefit plan coverage for these entities.
The department made one change to the published proposed amendment to §26.409(a) by removing the deletion indicated for §26.409(a)(20), and by changing the Insurance Code reference in paragraph (20) from Article 21.53F to Chapter 1367, Subchapter E. Under §26.409(a)(20), a health benefit plan issued by a health carrier through a cooperative is not subject to the state mandate relating to the offer of coverage for therapies for children with developmental delays as required by Insurance Code 21.53F. The proposed amendment to §26.409(a)(20) as published was intended to make only necessary conforming changes to Insurance Code references based on the enactment of the nonsubstantive code revision by the 78th Legislature, Regular Session. The proposed deletion of subsection (a)(20) was inadvertent, and no substantive change was intended by any of the amendments to §26.409. The repeal of Article 21.53F by HB 2922, 78th Legislature, Regular Session, did not include §9 of that article. Section 9 was enacted in HB 2292, 78th Legislature, Regular Session, subsequent to the repeal of Article 21.53F, and for that reason was not part of the nonsubstantive code revision of the Insurance Code by the 78th Legislature, Regular Session. However, as part of the conforming codification of the Insurance Code enacted by the 79th Legislature, Regular Session, in HB 2018, §9 of Article 21.53F was repealed and enacted as Insurance Code, Chapter 1367, Subchapter E.
3. HOW THE SECTIONS WILL FUNCTION. The adopted amendments to §26.401 add subsection (e), which requires that organizational documents otherwise required to be filed under the section include notification about whether the health group cooperative elects to restrict membership to 50 eligible employees. The adopted amendments also make conforming changes to Insurance Code references based on the enactment of the nonsubstantive code revision by the 78th Legislature, Regular Session.
The adopted amendments to §26.402 change provisions addressing authorized membership of a health group cooperative and add a new subsection (d) to conform the section to Insurance Code §1501.0581(a) - (c) and (o) - (p), as amended by SB 805.
The adopted amendment to §26.403 provides that a health group cooperative may offer other ancillary products and services, in accord with provisions of Insurance Code §1501.058, relating to powers and duties of cooperatives.
The adopted amendments to §26.404 provide that a health group cooperative is considered a large employer for all purposes of Insurance Code, Chapter 1501 and associated rules, unless it has elected to limit participation in the cooperative to 50 eligible employees, in which case it is considered a small employer for all purposes of Insurance Code, Chapter 1501 and associated rules, including guaranteed issuance of coverage.
The adopted amendments to §26.405 make necessary conforming changes to Insurance Code references based on nonsubstantive additions to and corrections in enacted codes pursuant to HB 2018, 79th Legislature, Regular Session.
The adopted amendment to §26.407(a) requires a health carrier to make an informational filing with the Commissioner concerning intended offers of coverage to a cooperative not later than 30 days before the initial open enrollment period for the cooperative. The adopted amendment to §26.407(b) revises the specific updated information concerning the health carrier's offer of coverage to the cooperative that the health carrier must provide as part of its §26.407(a) filing with the department.
The adopted amendments to §26.408 provide that, subject to the limitations of §26.411, which regulates health carrier service areas, a health carrier may elect not to offer or issue coverage to health group cooperatives or may elect to offer or issue coverage to one or more health group cooperatives of its choosing. The adopted amendments also clarify that a health carrier must comply with the specified guaranteed issuance requirements in offering and issuing coverage to health group cooperatives that have made the election to limit participation to 50 eligible employees.
The adopted amendments to §26.409 make necessary conforming changes to Insurance Code references, including elimination of references to repealed provisions, based on the enactment of the nonsubstantive code revision by the 78th Legislature, Regular Session.
The adopted amendments to §26.410 make necessary changes to reflect the adopted revision to the section title for §26.407 and also make conforming changes to Insurance Code references based on the enactment of the nonsubstantive code revision by the 78th Legislature, Regular Session.
The adopted amendments to §26.411 make necessary conforming changes to Insurance Code references based on the enactment of the nonsubstantive code revision by the 78th Legislature, Regular Session.
The enactment of SB 805 eliminates the need for §26.412, which addressed the refusal to renew employer health benefit plans delivered or issued to a health group cooperative. SB 805 directs a health carrier to treat a health group cooperative either as a large employer or as a small employer under the refusal-to-renew provisions of Insurance Code §1501.063. For this reason, the department has adopted the repeal of §26.412, which is also published in this issue of the Texas Register.
4. SUMMARY OF COMMENTS AND AGENCY RESPONSE TO COMMENTS.
Comment: Two commenters objected to the proposed amendments in §26.404(b) and §26.408(b) that specify certain instances in which a small employer group plan issuer participating in the health group cooperative market would be required to issue coverage to certain cooperatives qualifying as small employers, even if the issuer did not want to select such cooperative for coverage. According to the commenters, the proposed amendments are contrary to the clearly stated intent in Insurance Code §1501.0575 as added by SB 805 that issuer participation in a cooperative or cooperatives is voluntary. The commenters emphasized that the language of the statute as amended clearly provides that a small employer group plan issuer may elect to participate in one or more cooperatives and may select the cooperatives in which it will participate. The commenters suggested revisions to §26.404(b) and §26.408(b) regarding voluntary participation in cooperatives by issuers.
Agency Response: The department agrees that the general provision set out in Insurance Code §1501.0575 as added by SB 805 indicates that issuer participation in a cooperative or cooperatives is voluntary, and that the issuer may elect to participate in one or more cooperatives and may select the cooperatives in which it will participate. However, the specific amendments to Insurance Code §1501.063 that were also enacted in SB 805 clearly provide (i) that a health group cooperative is considered a single employer under the Insurance Code, and (ii) that a cooperative composed only of small employers and that has made the election specified in Insurance Code §1501.0581(o) to restrict membership to no more than 50 employees is to be treated as a small employer for purposes of Chapter 1501, including for purposes of any provision relating to premium rates and the issuance and renewal of coverage. For these reasons, the department makes no changes to subsections §26.404(b) and §26.408(b) as proposed.
5. NAMES OF THOSE COMMENTING FOR AND AGAINST THE SECTIONS.
Neither for nor against, with recommended changes: Blue Cross Blue Shield of Texas; Texas Association of Life and Health Insurers.
6. STATUTORY AUTHORITY. The amendments are adopted under the Insurance Code §§1501.010, 1501.058, 1501.0581, and 36.001, and SECTION 7 of SB 805 as enacted by the 79th Legislature, Regular Session. Section 1501.010 authorizes the Commissioner of Insurance to adopt rules as necessary to implement Chapter 1501. Section 1501.058 requires compliance with federal laws applicable to cooperatives and health benefit plans issued through cooperatives, to the extent required by state law or rules adopted by the Commissioner. Section 1501.0581 requires a health carrier to make an informational filing with the Commissioner concerning intended offers of coverage to a cooperative and requires that the Commissioner by rule prescribe the form and the time of the filing. SECTION 7 of SB 805 directs the Commissioner, not later than January 1, 2006 , to adopt rules under §1501.010 as necessary to implement the change in law made by SB 805. Section 36.001 provides that the Commissioner of Insurance may adopt any rules necessary and appropriate to implement the powers and duties of the Texas Department of Insurance under the Insurance Code and other laws of this state.
7. TEXT.
§26.401. Establishment of Health Group Cooperatives.
(a) Subject to the requirements of the Insurance Code and this subchapter, a person may form a health group cooperative for the purchase of employer health benefit plans.
(b) A health carrier may not form, or be a member of, a health group cooperative. A health carrier may associate with a sponsoring entity of a health group cooperative, such as a business association, chamber of commerce, or other organization representing employers or serving an analogous function, to assist the sponsoring entity in forming a health group cooperative.
(c) A health group cooperative must be organized as a nonprofit corporation and has the rights and duties provided by the Texas Non-profit Corporation Act, Texas Civil Statutes, Articles 1396-1.01, et seq.
(d) On receipt of a certificate of incorporation or certificate of authority from the secretary of state, the health group cooperative shall comply with Insurance Code § 1501.056 by filing notification of the receipt of the certificate and a copy of the health group cooperative's organizational documents with the Filings Intake Division, Mail Code 106-1E, Texas Department of Insurance, P.O. Box 149104, Austin, Texas 78714-9104. The organizational documents shall demonstrate the health group cooperative's compliance with Insurance Code §§ 1501.058, 1501.059 and 1501.061.
(e) A health group cooperative electing to restrict its membership to 50 eligible employees pursuant to Insurance Code §1501.0581(o) must include that election in the organizational documents filed pursuant to subsection (d) of this section.
(f) The board of directors shall, by March 1 of each year, file with the department a statement of all amounts collected and expenses incurred for each of the preceding three calendar years. The board shall make the annual filing on Form Number HGC-1, which can be obtained from the Texas Department of Insurance, Filings Intake Division, MC 106-1E, P.O. Box 149104 , Austin , Texas 78714-9104 , as well as from the department's internet web site at www.tdi.state.tx.us. The board shall file Form Number HGC-1 with the Filings Intake Division, Mail Code 106-1E, Texas Department of Insurance, P.O. Box 149104 , Austin , Texas 78714-9104 .
(g) The provisions of this subchapter shall not be construed to limit or restrict an employer's access to health benefit plans under this chapter or Insurance Code Chapter 1501.
§26.402. Membership of Health Group Cooperatives.
(a) The membership of a health group cooperative may consist only of small employers or only of large employers, but may not consist of both small and large employers.
(b) To be eligible to arrange for coverage pursuant to Insurance Code § 1501.058(a)(1) a health group cooperative must, at the end of its initial open enrollment period, have at least ten participating employers. Thereafter, if the health group cooperative does not, at any time, have at least ten participating employers, to maintain eligibility for coverage the health group cooperative must add additional members by the end of the next open enrollment period to maintain at least ten participating employers. If, by the end of the next open enrollment period the health group cooperative does not have at least ten participating employers, the health carrier may elect to immediately cease providing coverage to the health group cooperative.
(c) Subject to the requirements of Insurance Code § 1501.101, and the limitation identified pursuant to subsection (d) of this section , a health group cooperative:
(1) shall allow any small employer to join a health group cooperative that consists of only small employers and, during the initial and annual open enrollment periods, enroll in health benefit plan coverage; and
(2) may allow a large employer to join a health group cooperative that consists of only large employers and, during the initial enrollment and annual open enrollment periods, enroll in health benefit plan coverage.
(d) A health group cooperative that has elected to limit membership to 50 employees and has filed notification with the department as required by §26.401(e) of this subchapter (relating to Establishment of Health Group Cooperatives) may decline to allow a small employer to join the cooperative if, after the small employer has joined the cooperative, the total number of eligible employees employed on business days during the preceding calendar year by all small employers participating in the cooperative would exceed 50.
(e) A health group cooperative may not use risk characteristics of an employer or employee to restrict or qualify membership in the health group cooperative.
(f) An employer's participation in a health group cooperative is voluntary, but an employer electing to participate in a health group cooperative must, through a contract with the health group cooperative, commit to purchasing coverage through the health group cooperative for two years, except as provided for in subsection (g) of this section.
(g) A contract between an employer and a health group cooperative must allow an employer to terminate without penalty its health benefit plan coverage with a health group cooperative before the end of the two year minimum contractual period required by subsection (f) of this section if it can demonstrate to the health group cooperative that continuing to purchase coverage through the cooperative would be a financial hardship in accordance with subsection (h) of this section.
(h) The contract between an employer and a health group cooperative may define what constitutes a financial hardship for the purposes of subsection (g) of this section. If the contract does not define the term, an employer may demonstrate financial hardship if it can show that at the end of the immediately preceding fiscal quarter, or upon receipt of notice of a rate increase, the premium cost to the employer, as a percentage of the employer's gross receipts, increased by a factor of at least .50.
§26.403. Marketing Activities of Health Group Cooperatives.
(a) A health group cooperative may engage in marketing activities related and restricted to membership in the cooperative, including general availability of health coverage, and is not required to maintain an agent's license for soliciting membership in the cooperative. All health coverage issued through the cooperative must be issued through a licensed agent that is employed by or contracted with the cooperative.
(b) A sponsoring entity of a health group cooperative may inform its members regarding the health group cooperative and the general availability of coverage through the health group cooperative. All coverage issued through the cooperative must be issued through a licensed agent.
(c) A licensed agent that is used and compensated by a health group cooperative is not required to be appointed by a health carrier offering coverage through the health group cooperative. This exemption does not allow an agent to market other products and services not offered through the health group cooperative without an appointment from the health carrier.
(d) A health group cooperative or a member of the board of directors, the executive director, or an employee or agent of a health group cooperative is not liable for failure to arrange for coverage of any particular illness, disease, or health condition in arranging for coverage through the cooperative.
(e) A health group cooperative may offer other ancillary products and services to its members that are customarily offered in conjunction with health benefit plans.
§26.404. Health Group Cooperative's Status as Employer.
(a) Except as provided by subsection (b) of this section, a health group cooperative is considered a large employer for all purposes of Insurance Code Chapter 1501 and this chapter.
(b) A health group cooperative that is composed of only small employers and that has elected to limit participation in the cooperative to 50 employees is considered a small employer for all purposes of Insurance Code Chapter 1501 and this chapter, including guaranteed issuance of coverage.
§26.405. Premium Tax Exemption for Previously Uninsured.
(a) In accordance with Insurance Code §1501.0581(g)(4), a health carrier providing coverage through a health group cooperative is exempt from premium tax and retaliatory tax for two years for premiums received for a previously uninsured employee or dependent. The two-year period for the exemption begins upon the first date of coverage for the previously uninsured employee or dependent.
(b) For the purposes of this section and Insurance Code §1501.0581(g)(4), a previously uninsured employee or dependent is an employee or the dependent of an employee of an employer member of a health group cooperative that did not have creditable coverage for the 63 days preceding the effective date of coverage purchased through the health group cooperative.
(c) A health carrier shall maintain for four years documentation for each insured that demonstrates that coverage of the insured or enrollee qualifies the health carrier for a tax exemption pursuant to subsection (b) of this section. The documentation shall comply with any applicable rules or procedures adopted by the Comptroller of Public Accounts related to the tax exemption.
§26.407. Health Carrier Filing Prior to Issuance of Coverage to a Health Group Cooperative.
(a) A health carrier that intends to issue coverage to a health group cooperative shall file with the commissioner, not later than 30 days prior to the initial open enrollment period for the cooperative, information concerning the health carrier's offer of coverage to the cooperative. The health carrier shall submit this filing to the Filings Intake Division, Mail Code 106-1E, Texas Department of Insurance, P. O. Box 149104 , Austin , Texas 78714-9104 or 333 Guadalupe, Austin, Texas 78701 .
(b) A filing required by subsection (a) of this section shall include:
(1) the name of the health carrier;
(2) the name, address, and telephone number or other contact information of the health group cooperative to which the health carrier intends to offer coverage;
(3) the county or expanded service area in which the health carrier intends to offer coverage to the health group cooperative;
(4) any limitations concerning the number of participating employers or employees in a health group cooperative that the health carrier is capable of administering;
(5) the health benefit plan filed for use by the health carrier as a product available to health group cooperatives, or when appropriate pursuant to subsection (c) of this section, reference to a previously approved form, including the form number and date of approval; and
(6) any other information requested by the department .
(c) The form filing required by subsection (b)(5) of this section shall comply, as appropriate, with all applicable filing requirements under Chapter 3 of this title (relating to Life, Accident and Health Insurance and Annuities) or Chapter 11 of this title (relating to Health Maintenance Organizations).
§26.408. Issuance of Coverage to Health Group Cooperatives.
(a) Subject to the limitations identified in §26.411 of this subchapter (relating to Service Areas for Health Carriers Offering Coverage Through a Health Group Cooperative), a health carrier may elect to not offer or issue coverage to health group cooperatives or may elect to offer or issue coverage to one or more health group cooperatives of its choosing.
(b) Notwithstanding subsection (a) of this section, a health carrier must comply with the guaranteed issuance requirements of Insurance Code Chapter 1501 and this chapter with respect to offering and issuing coverage to a health group cooperative that:
(1) consists of only small employers;
(2) has elected to restrict membership in the cooperative to 50 employees; and
(3) has notified the department consistent with §26.401(e) of this subchapter (relating to Establishment of Health Group Cooperatives) .
§26.409. Health Benefit Plans Offered Through Health Group Cooperatives.
(a) A health benefit plan issued by a health carrier through a health group cooperative is not subject to the following state mandates:
(1) the offer of in vitro fertilization coverage as required by Insurance Code §§1366.001 and 1366.003;
(2) coverage of HIV, AIDS, or HIV-related illnesses as required by Insurance Code §§1364.001 and 1364.003;
(3) coverage of chemical dependency and stays in a chemical dependency treatment facility as required by Insurance Code Chapter 1368;
(4) coverage or offer of coverage of serious mental illness as required by Insurance Code §§1355.001 - 1355.007;
(5) the offer of mental or emotional illness coverage as required by Insurance Code §1355.106;
(6) coverage of inpatient mental health and stays in a psychiatric day treatment facility as required by Insurance Code §1355.104;
(7) the offer of speech and hearing coverage as required by Insurance Code Chapter 1365;
(8) coverage of mammography screening for the presence of occult breast cancer as required by Insurance Code §1356.005;
(9) standards for proof of Alzheimer's disease as required by Insurance Code §1354.002;
(10) coverage of stays in a crisis stabilization unit and/or residential treatment center for children and adolescents as required by Insurance Code §§1355.055 and 1355.056;
(11) continuation of coverage of certain drugs under a drug formulary as required by Insurance Code §1369.055;
(12) coverage of off-label drugs as required by Insurance Code §§1369.001 - 1369.005;
(13) coverage for formulas necessary for the treatment of phenylketonuria as required by Insurance Code Chapter 1359;
(14) coverage of contraceptive drugs and devices as required by Insurance Code §§1369.101 - 1369.109 and §21.404(3) of this title (relating to Underwriting);
(15) coverage of diagnosis and treatment affecting temporomandibular joint and treatment for a person unable to undergo dental treatment in an office setting or under local anesthesia as required by Insurance Code Chapter 1360;
(16) coverage of bone mass measurement for osteoporosis as required by Insurance Code §1361.003;
(17) coverage of diabetes care as required by Insurance Code Chapter 1358;
(18) coverage of childhood immunizations as required by Insurance Code §§1367.051 - 1367.055 and 1367.053;
(19) coverage for screening tests for hearing loss in children and related diagnostic follow-up care as required by Insurance Code §§1367.101 - 1367.105;
(20) offer of coverage for therapies for children with developmental delays as required by Insurance Code Chapter 1367, Subchapter E;
(21) coverage of certain tests for detection of prostate cancer as required by Insurance Code Chapter 1362;
(22) coverage of acquired brain injury treatment/services as required by Insurance Code Chapter 1352;
(23) coverage of certain tests for detection of colorectal cancer as required by Insurance Code Chapter 1363;
(24) coverage for reconstructive surgery for craniofacial abnormalities in a child as required by Insurance Code §§1367.151 - 1367.154;
(25) coverage of rehabilitation therapies as required by Insurance Code §1271.156;
(26) limitations on the treatment of complications in pregnancy established by §21.405 of this title (relating to Policy Terms and Conditions);
(27) coverage for services related to immunizations and vaccinations under managed care plans as required by Insurance Code Chapter 1353;
(28) limitations or restrictions on copayments and deductibles imposed by §11.506(2)(A) and (B) of this title (relating to Mandatory Contractual Provisions: Group, Individual and Conversion Agreement and Group Certificate);
(29) coverage of a minimum stay for maternity as required by Insurance Code §§1366.051 - 1366.059;
(30) coverage of reconstructive surgery incident to mastectomy as required by Insurance Code §§ 1357.001 - 1357.007; and
(31) coverage of a minimum stay for mastectomy treatment/services as required by Insurance Code §§ 1357.051 - 1357.057.
(b) A health benefit plan issued by an HMO through a health group cooperative must provide for the basic health care services as provided in §11.508 or §11.509 of this title (relating to Mandatory Benefit Standards: Group, Individual and Conversion Agreements and Additional Mandatory Benefit Standards, Group Agreement Only):
(c) A health benefit plan offered by an insurer through a health group cooperative is not subject to §3.3704(a)(6) of this title (relating to Freedom of Choice: Availability of Preferred Providers).
§26.4 10 . Expedited Approval for Plans Offered Through a Health Group Cooperative.
(a) Unless a health carrier has identified a previously approved health benefit plan in the filing required by §26.407(b)(7) of this title (relating to Health Carrier Filing Prior to Issuance of Coverage to a Health Group Cooperative , the health carrier must file for approval a health benefit plan that will be offered to a health group cooperative and shall clearly indicate in the filing that the health benefit plan is to be offered to a health group cooperative and is subject to review under this section.
(b) A health benefit plan subject to review under this section and filed with the department by an insurer may be filed as a file and use form consistent with Insurance Code §§1701.051 - 1701.059 and 1701.101 - 1701.103 and §3.5(a)(2) of this title (relating to Filing Authorities and Categories).
(c) An insurer that does not elect to file for approval under subsection (b) of this section shall file the form for approval consistent with Insurance Code §§1701.051 and 1701.054 and §3.5(a)(1) of this title. The department shall approve or disapprove the filing within 40 calendar days of receipt of the complete filing.
(d) An HMO must file for approval an HMO evidence of coverage that is to be offered solely to a health group cooperative and shall indicate that review of the evidence of coverage is subject to the expedited process available under this section. The HMO shall file the evidence of coverage consistent with the requirements of Subchapter F of Chapter 11 of this title (relating to Evidence of Coverage) and the department shall approve or disapprove the evidence of coverage within 20 calendar days of receipt of a complete filing.
§26.411. Service Areas for Health Carriers Offering Coverage Through a Health Group Cooperative.
(a) A health carrier may provide coverage to only one health group cooperative in any county, except that a health carrier may provide coverage to additional health group cooperatives if it is providing coverage in an expanded service area.
(b) A health carrier may provide health group cooperative coverage to an expanded service area that includes the entire state upon providing certification, signed by an officer of the health carrier, that the health carrier intends to provide health group cooperative coverage to an expanded service area that includes the entire state. The health carrier must send the certification to the Filings Intake Division, Mail Code 106-1E, Texas Department of Insurance, P. O. Box 149104 , Austin , Texas 78714-9104 or 333 Guadalupe, Austin , Texas , 78701 .
(c) A health carrier may apply for an expanded service area that includes less than the entire state by submitting an application for approval to the Filings Intake Division, Mail Code 106-1E, Texas Department of Insurance, P. O. Box 149104, Austin, Texas 78714-9104 or 333 Guadalupe, Austin, Texas 78701. The health carrier may begin using the expanded service area upon approval or 60 days after the day the application is received by the department unless the application is disapproved by the department within that time. The application must include:
(1) the geographic service areas, defined in terms of counties or ZIP Codes, to the extent possible;
(2) if the service area cannot be defined by counties or ZIP Code, a map which clearly shows the geographic service areas must be submitted in conjunction with the application;
(3) service areas by ZIP Code shall be defined in a non-discriminatory manner and in compliance with the Insurance Code §§544.001 - 544.004 and 544.051 - 544.054; and
(4) any other information requested by the department.
(d) A filing under this section does not affect any HMO service areas that have been established in accordance with Chapter 843 of the Insurance Code. An HMO may not issue coverage to a health group cooperative service area that is not also contained entirely within the HMO's service area that has been established pursuant to Chapter 843 of the Insurance Code.