Texas 2009 - 81st Regular

Texas House Bill HB3264 Compare Versions

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1	1	81R28496 KCR-D
2	2	By: Rose H.B. No. 3264
3	3	Substitute the following for H.B. No. 3264:
4	4	By: Isett C.S.H.B. No. 3264
5	5
6	6
7	7	A BILL TO BE ENTITLED
8	8	AN ACT
9	9	relating to notifying certain persons of the medical loss ratios of
10	10	health benefit plan issuers.
11	11	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
12	12	SECTION 1. Subtitle A, Title 8, Insurance Code, is amended
13	13	by adding Chapter 1223 to read as follows:
14	14	CHAPTER 1223. MEDICAL LOSS RATIO AND HEALTH BENEFIT PLAN PREMIUMS
15	15	Sec. 1223.001. DEFINITIONS. In this chapter:
16	16	(1) "Administrative cost and tax ratio" means the
17	17	ratio of the dollar amount of health care related administrative
18	18	costs incurred and premium and maintenance taxes paid by a health
19	19	benefit plan issuer with regard to a market segment of health
20	20	benefit plans issued by the issuer to the revenue received in
21	21	premiums for that same market segment of health benefit plans.
22	22	(2) "Enrollee" has the meaning assigned by Section
23	23	1457.001.
24	24	(3) "Evidence of coverage" has the meaning assigned by
25	25	Section 843.002.
26	26	(4) "Market segment of health benefit plans" means, as
27	27	applicable, one of the following categories of health benefit plans
28	28	issued by a health benefit plan issuer:
29	29	(A) individual evidences of coverage issued by a
30	30	health maintenance organization;
31	31	(B) individual preferred provider benefit plans;
32	32	(C) evidences of coverage issued by a health
33	33	maintenance organization, each of which covers two or more
34	34	enrollees but fewer than 51 enrollees;
35	35	(D) preferred provider benefit plans, each of
36	36	which covers two or more enrollees but fewer than 51 enrollees;
37	37	(E) evidences of coverage issued by a health
38	38	maintenance organization, each of which covers 51 or more
39	39	enrollees; and
40	40	(F) preferred provider benefit plans, each of
41	41	which covers 51 or more enrollees.
42	42	(5) "Medical loss ratio" means the ratio of the dollar
43	43	amount of benefits paid by a health benefit plan issuer with regard
44	44	to a market segment of health benefit plans issued by the issuer to
45	45	the revenue received in premiums for that same market segment of
46	46	health benefit plans. The ratio may not include in the calculation
47	47	of the dollar amount of benefits paid under a health benefit plan
48	48	amounts included in the issuer's administrative cost and tax ratio
49	49	or other home office and overhead costs, advertising costs,
50	50	commissions and other acquisition costs, taxes, capital costs,
51	51	administrative costs, utilization review costs, or claims
52	52	processing costs.
53	53	(6) "Preferred provider benefit plan" has the meaning
54	54	assigned by Section 1301.001.
55	55	Sec. 1223.002. APPLICABILITY OF CHAPTER. (a) This chapter
56	56	applies to a health benefit plan issuer that provides benefits for
57	57	medical or surgical expenses incurred as a result of a health
58	58	condition, accident, or sickness through an individual group,
59	59	blanket, or franchise preferred provider benefit plan or an
60	60	individual or group evidence of coverage or similar coverage
61	61	document that is offered by:
62	62	(1) an insurance company;
63	63	(2) a group hospital service corporation operating
64	64	under Chapter 842;
65	65	(3) a fraternal benefit society operating under
66	66	Chapter 885;
67	67	(4) a stipulated premium company operating under
68	68	Chapter 884;
69	69	(5) an exchange operating under Chapter 942;
70	70	(6) a health maintenance organization operating under
71	71	Chapter 843; or
72	72	(7) an approved nonprofit health corporation that
73	73	holds a certificate of authority under Chapter 844.
74	74	(b) Notwithstanding any provision in Chapter 1551, 1575,
75	75	1579, or 1601 or any other law, this chapter applies to a health
76	76	benefit plan issuer with respect to:
77	77	(1) a basic coverage plan under Chapter 1551;
78	78	(2) a basic plan under Chapter 1575;
79	79	(3) a primary care coverage plan under Chapter 1579;
80	80	and
81	81	(4) basic coverage under Chapter 1601.
82	82	(c) Notwithstanding any other law, this chapter applies to a
83	83	health benefit plan issuer with respect to a standard health
84	84	benefit plan provided under Chapter 1507.
85	85	(d) Notwithstanding Section 1501.251 or any other law, this
86	86	chapter applies to a health benefit plan issuer with respect to
87	87	coverage under a small employer health benefit plan subject to
88	88	Chapter 1501.
89	89	Sec. 1223.003. EXCEPTION. This chapter does not apply with
90	90	respect to:
91	91	(1) a plan that provides coverage:
92	92	(A) for wages or payments in lieu of wages for a
93	93	period during which an employee is absent from work because of
94	94	sickness or injury;
95	95	(B) as a supplement to a liability insurance
96	96	policy;
97	97	(C) for credit insurance;
98	98	(D) only for dental or vision care;
99	99	(E) only for hospital expenses;
100	100	(F) only for a specified disease or condition; or
101	101	(G) only for indemnity for hospital confinement;
102	102	(2) a Medicare supplemental policy as defined by
103	103	Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss);
104	104	(3) a workers' compensation insurance policy;
105	105	(4) medical payment insurance coverage provided under
106	106	a motor vehicle insurance policy; or
107	107	(5) a multiple employer welfare arrangement that holds
108	108	a certificate of authority under Chapter 842.
109	109	Sec. 1223.004. NOTIFICATION OF MEDICAL LOSS RATIO. (a) A
110	110	health benefit plan issuer shall annually report to the department
111	111	the issuer's medical loss ratio for each market segment of health
112	112	benefit plans written by the health benefit plan issuer in the
113	113	previous calendar year.
114	114	(b) The department shall post on the department's Internet
115	115	website or another website maintained by the department for the
116	116	benefit of consumers or enrollees:
117	117	(1) the information received under Subsection (a) and,
118	118	if applicable, the information received under Section 1223.005; and
119	119	(2) an explanation of the meaning of the terms
120	120	"medical loss ratio" and "administrative cost and tax ratio," how
121	121	those ratios are calculated, and how those ratios may affect
122	122	consumers or enrollees.
123	123	(c) A health benefit plan issuer shall provide each enrollee
124	124	or the plan sponsor, as applicable, with the Internet website
125	125	address at which the enrollee or sponsor may access the information
126	126	described by Subsection (b). A health benefit plan issuer must
127	127	provide the information required under this subsection:
128	128	(1) to an enrollee, at the time of the initial
129	129	enrollment of the enrollee in a health benefit plan issued by the
130	130	health benefit plan issuer; and
131	131	(2) at the time of renewal of a health benefit plan to:
132	132	(A) each enrollee, if the health benefit plan is
133	133	an individual health benefit plan; or
134	134	(B) the plan sponsor, if the health benefit plan
135	135	is a group health benefit plan.
136	136	(d) The commissioner shall adopt rules necessary to
137	137	implement this section.
138	138	Sec. 1223.005. NOTIFICATION OF ADMINISTRATIVE COST AND TAX
139	139	RATIO. (a) A health benefit plan issuer may report the issuer's
140	140	administrative cost and tax ratio for each market segment of health
141	141	benefit plans issued by the health benefit plan issuer to the
142	142	department at the same time the issuer reports the issuer's medical
143	143	loss ratio to the department under Section 1223.004(a).
144	144	(b) An administrative cost and tax ratio reported under this
145	145	section must cover the same period that is covered by the medical
146	146	loss ratio with which the administrative cost and tax ratio is
147	147	reported.
148	148	(c) The commissioner shall adopt rules to implement this
149	149	section.
150	150	SECTION 2. The change in law made by this Act applies only
151	151	to a health benefit plan that is delivered, issued for delivery, or
152	152	renewed on or after January 1, 2010. A health benefit plan that is
153	153	delivered, issued for delivery, or renewed before January 1, 2010,
154	154	is covered by the law in effect at the time the health benefit plan
155	155	was delivered, issued for delivery, or renewed, and that law is
156	156	continued in effect for that purpose.
157	157	SECTION 3. This Act takes effect September 1, 2009.