Texas 2009 - 81st Regular

Texas Senate Bill SB78 Compare Versions

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1	1	S.B. No. 78
2	2
3	3
4	4	AN ACT
5	5	relating to promoting awareness and education about the purchase
6	6	and availability of health coverage.
7	7	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
8	8	ARTICLE 1. TEXLINK
9	9	SECTION 1.01. Chapter 524, Insurance Code, is amended to
10	10	read as follows:
11	11	CHAPTER 524. TEXLINK TO HEALTH COVERAGE [AWARENESS AND
12	12	EDUCATION] PROGRAM
13	13	SUBCHAPTER A. GENERAL PROVISIONS
14	14	Sec. 524.001. DEFINITIONS. In this chapter:
15	15	(1) "Division" means the division of the department
16	16	that administers the TexLink to Health Coverage Program.
17	17	(2) "Program" means the TexLink to Health Coverage
18	18	Program established in accordance with this chapter.
19	19	Sec. 524.002. DIVISION RESPONSIBILITIES. Under the
20	20	direction of the commissioner, the division implements this
21	21	chapter.
22	22	Sec. 524.003. TEXLINK TO HEALTH COVERAGE PROGRAM
23	23	ESTABLISHED. (a) The department shall develop and implement a
24	24	health coverage [public awareness and education] program that
25	25	complies with this chapter. The program must:
26	26	(1) educate the public about the importance and value
27	27	of health coverage;
28	28	(2) promote personal responsibility for health care
29	29	through the purchase of health coverage;
30	30	(3) assist small employers, individuals, and others
31	31	seeking to purchase health coverage with technical information
32	32	necessary to understand available health insurance coverage;
33	33	(4) promote and facilitate the development and
34	34	availability of new health coverage options;
35	35	(5) increase public awareness of health coverage
36	36	options available in this state; and
37	37	(6) [(2) educate the public on the value of health
38	38	coverage; and
39	39	[(3)] provide information on health coverage options,
40	40	including health savings accounts and compatible high deductible
41	41	health benefit plans.
42	42	(b) The program must include a public awareness and
43	43	education component.
44	44	SUBCHAPTER B. PUBLIC AWARENESS AND EDUCATION
45	45	Sec. 524.051. INFORMATION ABOUT SPECIFIC HEALTH BENEFIT
46	46	PLAN ISSUERS. In materials produced for the program, the division
47	47	[department] may include information about specific health benefit
48	48	plan [coverage] issuers but may not favor or endorse one particular
49	49	issuer over another.
50	50	Sec. 524.052 [524.002]. PUBLIC SERVICE ANNOUNCEMENTS. The
51	51	division [department] shall develop and make public service
52	52	announcements to educate consumers and employers about the
53	53	availability of health coverage in this state.
54	54	Sec. 524.053 [524.003]. INTERNET WEBSITE; PRINTED
55	55	MATERIALS; NEWSLETTER [PUBLIC EDUCATION]. (a) The division
56	56	[department] shall develop an Internet website and printed
57	57	materials designed to educate small employers, individuals, and
58	58	others seeking to purchase health coverage [the public] about [the
59	59	availability of] health coverage in accordance with Section
60	60	524.003(a) [this state], including information about health
61	61	savings accounts and compatible high deductible health benefit
62	62	plans.
63	63	(b) The division shall make the printed materials produced
64	64	under the program available to small employers, individuals, and
65	65	others seeking to purchase health coverage. The division may:
66	66	(1) distribute the printed materials through
67	67	facilities such as libraries, health care facilities, and schools
68	68	as well as other venues the division selects; and
69	69	(2) use other distribution methods the division
70	70	selects.
71	71	(c) The division may produce a newsletter to provide updated
72	72	information about health coverage to subscribers who elect to
73	73	receive the newsletter. The division may:
74	74	(1) produce a newsletter under this subsection for
75	75	small employers, for individuals, or for other purchasers of health
76	76	coverage;
77	77	(2) distribute the newsletter on a monthly, quarterly,
78	78	or other basis; and
79	79	(3) distribute the newsletter as a printed document or
80	80	electronically.
81	81	Sec. 524.054. TOLL-FREE TELEPHONE HOTLINE; ACCESS TO
82	82	INFORMATION. (a) The division may operate a toll-free telephone
83	83	hotline to respond to inquiries and provide information and
84	84	technical assistance concerning health insurance coverage.
85	85	(b) The Health and Human Services Commission, through its
86	86	2-1-1 telephone number for access to human services, may
87	87	disseminate information regarding health insurance coverage
88	88	provided to the commission by the department and may refer
89	89	inquiries regarding health insurance coverage to the toll-free
90	90	telephone hotline. The department may provide information to the
91	91	Health and Human Services Commission as necessary to implement this
92	92	subsection.
93	93	Sec. 524.055. EDUCATION FOR HIGH SCHOOL STUDENTS. (a) The
94	94	division may develop educational materials and a curriculum to be
95	95	used in high school classes that educate students about:
96	96	(1) the importance and value of health coverage;
97	97	(2) comparing health benefit plans; and
98	98	(3) understanding basic provisions contained in
99	99	health benefit plans.
100	100	(b) The division may consult with the Texas Education Agency
101	101	in developing educational materials and a curriculum under this
102	102	section.
103	103	Sec. 524.056. HEALTH COVERAGE FAIRS. (a) The division may
104	104	conduct health coverage fairs to provide small employers,
105	105	individuals, and others seeking to purchase health coverage the
106	106	opportunity to obtain information about health coverage from
107	107	division employees and from health benefit plan issuers and agents
108	108	that elect to participate.
109	109	(b) The division shall seek to obtain funding for health
110	110	coverage fairs conducted under this section through gifts and
111	111	grants obtained in accordance with Subchapter C.
112	112	Sec. 524.057. COMMUNITY EVENTS. The division may
113	113	participate in events held in this state to promote awareness of the
114	114	importance and value of health coverage and to educate small
115	115	employers, individuals, and others seeking to purchase health
116	116	coverage about health coverage in accordance with Section
117	117	524.003(a).
118	118	Sec. 524.058. HEALTH COVERAGE PROVIDED THROUGH COLLEGES AND
119	119	UNIVERSITIES. The division may cooperate with a public or private
120	120	college or university to promote enrollment in health coverage
121	121	programs sponsored by or through the college or university.
122	122	Sec. 524.059. SUPPORT FOR COMMUNITY-BASED PROJECTS. The
123	123	division may provide support and assistance to individuals and
124	124	organizations seeking to develop community-based health coverage
125	125	plans for uninsured individuals.
126	126	Sec. 524.060. OTHER EDUCATION. The division may [department
127	127	shall] provide other appropriate education to the public regarding
128	128	health coverage and the importance and value of health coverage in
129	129	accordance with Section 524.003(a).
130	130	Sec. 524.061 [524.004]. TASK FORCE. (a) The commissioner
131	131	may [shall] appoint a task force to make recommendations regarding
132	132	the division's duties under this subchapter [health coverage public
133	133	awareness and education program]. If appointed, the [The] task
134	134	force must be [is] composed of:
135	135	(1) one representative from each of the following
136	136	groups or entities:
137	137	(A) health [benefit] coverage consumers;
138	138	(B) small employers;
139	139	(C) employers generally;
140	140	(D) insurance agents;
141	141	(E) the office of public insurance counsel;
142	142	(F) the Texas Health Insurance Risk Pool;
143	143	(G) physicians;
144	144	(H) advanced practice nurses;
145	145	(I) hospital trade associations; and
146	146	(J) medical units of institutions of higher
147	147	education;
148	148	(2) a representative of the Health and Human Services
149	149	Commission responsible for programs under Medicaid and the
150	150	children's health insurance program; [and]
151	151	(3) one or more representatives of health benefit plan
152	152	issuers; and
153	153	(4) one or more representatives of a regional or local
154	154	health care program for employees of small employers under Chapter
155	155	75, Health and Safety Code.
156	156	(b) In addition to the individuals listed in Subsection (a),
157	157	the commissioner may select to serve on any task force one or more
158	158	individuals with experience in public relations, marketing, or
159	159	another related field of professional services.
160	160	(c) The division may [department shall] consult the task
161	161	force regarding the content for the public service announcements,
162	162	Internet website, printed materials, and other educational
163	163	materials required or authorized by this subchapter [chapter]. The
164	164	commissioner has authority to make final decisions as to what the
165	165	program's materials will contain.
166	166	Sec. 524.062. FEDERAL TAX "TOOL KIT" FOR CERTAIN
167	167	BUSINESSES. The department may:
168	168	(1) produce materials that:
169	169	(A) provide step-by-step instructions for a
170	170	small employer or single-employee business that is obtaining health
171	171	coverage for the benefit of the employer or business and the
172	172	employees of the business; and
173	173	(B) are designed to allow the employer or
174	174	business to obtain the coverage in a manner that qualifies for
175	175	favorable treatment under federal tax laws; and
176	176	(2) make department staff available to assist small
177	177	employers and single-employee businesses that are obtaining health
178	178	coverage as described by Subdivision (1).
179	179	Sec. 524.063. ASSISTANCE FOR SMALL EMPLOYERS AND
180	180	SINGLE-EMPLOYEE BUSINESSES. The department may train staff
181	181	concerning available health coverage options for small employers
182	182	and single-employee businesses to:
183	183	(1) respond to telephone inquiries from small
184	184	employers and single-employee businesses; and
185	185	(2) speak at events to provide information about
186	186	health coverage options for small employers and single-employee
187	187	businesses and about the importance and value of health coverage.
188	188	Sec. 524.064. ACCOUNTANT. The department may employ an
189	189	accountant with experience in federal tax law and the purchase of
190	190	group health coverage as necessary to implement this chapter.
191	191	SUBCHAPTER C. FUNDING
192	192	Sec. 524.101 [524.005]. FUNDING. The department may accept
193	193	gifts and grants from any party, including a health benefit plan
194	194	issuer or a foundation associated with a health benefit plan
195	195	issuer, to assist with funding the program. The department shall
196	196	adopt rules governing acceptance of donations that are consistent
197	197	with Chapter 575, Government Code. Before adopting rules under
198	198	this section [subsection], the department shall:
199	199	(1) submit the proposed rules to the Texas Ethics
200	200	Commission for review; and
201	201	(2) consider the commission's recommendations
202	202	regarding the regulations.
203	203	ARTICLE 2. HEALTHY TEXAS PROGRAM
204	204	SECTION 2.01. Subtitle G, Title 8, Insurance Code, is
205	205	amended by adding Chapter 1508 to read as follows:
206	206	CHAPTER 1508. HEALTHY TEXAS PROGRAM
207	207	SUBCHAPTER A. GENERAL PROVISIONS
208	208	Sec. 1508.001. PURPOSE. (a) The purposes of the Healthy
209	209	Texas Program are to:
210	210	(1) provide access to quality small employer health
211	211	benefit plans at an affordable price;
212	212	(2) encourage small employers to offer health benefit
213	213	plan coverage to employees and the dependents of employees; and
214	214	(3) maximize reliance on proven managed care
215	215	strategies and procedures.
216	216	(b) The Healthy Texas Program is not intended to diminish
217	217	the availability of traditional small employer health benefit plan
218	218	coverage under Chapter 1501.
219	219	Sec. 1508.002. DEFINITIONS. In this chapter:
220	220	(1) "Dependent" has the meaning assigned by Section
221	221	1501.002(2).
222	222	(2) "Eligible employee" has the meaning assigned by
223	223	Section 1501.002(3).
224	224	(3) "Fund" means the healthy Texas small employer
225	225	premium stabilization fund established under Subchapter F.
226	226	(4) "Health benefit plan" and "health benefit plan
227	227	issuer" have the meanings assigned by Sections 1501.002(5) and
228	228	1501.002(6), respectively.
229	229	(5) "Program" means the Healthy Texas Program
230	230	established under this chapter.
231	231	(6) "Qualifying health benefit plan" means a health
232	232	benefit plan that provides benefits for health care services in the
233	233	manner described by this chapter.
234	234	(7) "Small employer" has the meaning assigned by
235	235	Section 1501.002(14).
236	236	Sec. 1508.003. RULES. The commissioner may adopt rules as
237	237	necessary to implement this chapter.
238	238	[Sections 1508.004-1508.050 reserved for expansion]
239	239	SUBCHAPTER B. EMPLOYER ELIGIBILITY; CONTRIBUTIONS
240	240	Sec. 1508.051. EMPLOYER ELIGIBILITY TO PARTICIPATE. (a) A
241	241	small employer may participate in the program if:
242	242	(1) during the 12-month period immediately preceding
243	243	the date of application for a qualifying health benefit plan, the
244	244	small employer does not offer employees group health benefits on an
245	245	expense-reimbursed or prepaid basis; and
246	246	(2) at least 30 percent of the small employer's
247	247	eligible employees receive annual wages from the employer in an
248	248	amount that is equal to or less than 300 percent of the poverty
249	249	guidelines for an individual, as defined and updated annually by
250	250	the United States Department of Health and Human Services.
251	251	(b) A small employer ceases to be eligible to participate in
252	252	the program if any health benefit plan that provides employee
253	253	benefits on an expense-reimbursed or prepaid basis, other than
254	254	another qualifying health benefit plan, is purchased or otherwise
255	255	takes effect after the purchase of a qualifying health benefit
256	256	plan.
257	257	Sec. 1508.052. COMMISSIONER ADJUSTMENTS AUTHORIZED.
258	258	(a) The commissioner by rule may adjust the 12-month period
259	259	described by Section 1508.051(a)(1) to an 18-month period if the
260	260	commissioner determines that the 12-month period is insufficient to
261	261	prevent inappropriate substitution of other health benefit plans
262	262	for qualifying health benefit plan coverage under this chapter.
263	263	(b) The commissioner by rule may adjust the percentage of
264	264	the poverty guidelines described by Section 1508.051(a)(2) to a
265	265	higher or lower percentage if the commissioner determines that the
266	266	adjustment is necessary to fulfill the purposes of this chapter. An
267	267	adjustment made by the commissioner under this subsection takes
268	268	effect on the first July 1 following the adjustment.
269	269	Sec. 1508.053. MINIMUM EMPLOYER PARTICIPATION
270	270	REQUIREMENTS. A small employer that meets the eligibility
271	271	requirements described by Section 1508.051(a) may apply to purchase
272	272	a qualifying health benefit plan if 60 percent or more of the
273	273	employer's eligible employees elect to participate in the plan.
274	274	Sec. 1508.054. EMPLOYER CONTRIBUTION REQUIREMENTS. (a) A
275	275	small employer that purchases a qualifying health benefit plan
276	276	must:
277	277	(1) pay 50 percent or more of the premium for each
278	278	employee covered under the qualifying health benefit plan;
279	279	(2) offer coverage to all eligible employees receiving
280	280	annual wages from the employer in an amount described by Section
281	281	1508.051(a)(2) or 1508.052(b), as applicable; and
282	282	(3) contribute the same percentage of premium for each
283	283	covered employee.
284	284	(b) A small employer that purchases a qualifying health
285	285	benefit plan under the program may elect to pay, but is not required
286	286	to pay, all or any portion of the premium paid for dependent
287	287	coverage under the qualifying health benefit plan.
288	288	[Sections 1508.055-1508.100 reserved for expansion]
289	289	SUBCHAPTER C. PROGRAM PARTICIPATION; REQUIRED COVERAGE AND
290	290	BENEFITS
291	291	Sec. 1508.101. PARTICIPATING PLAN ISSUERS. (a) Subject to
292	292	Subsection (b), any health benefit plan issuer may participate in
293	293	the program.
294	294	(b) The commissioner by rule may limit which health benefit
295	295	plan issuers may participate in the program if the commissioner
296	296	determines that the limitation is necessary to achieve the purposes
297	297	of this chapter.
298	298	(c) If the commissioner limits participation in the program
299	299	under Subsection (b), the commissioner shall contract on a
300	300	competitive procurement basis with one or more health benefit plan
301	301	issuers to provide qualifying health benefit plan coverage under
302	302	the program.
303	303	(d) Nothing in this chapter prohibits a regional or local
304	304	health care program described by Chapter 75, Health and Safety
305	305	Code, from participating in the program. The commissioner by rule
306	306	shall establish participation requirements applicable to regional
307	307	and local health care programs that consider the unique plan
308	308	designs, benefit levels, and participation criteria of each
309	309	program.
310	310	Sec. 1508.102. PREEXISTING CONDITION PROVISION REQUIRED. A
311	311	health benefit plan offered under the program must include a
312	312	preexisting condition provision that meets the requirements
313	313	described by Section 1501.102.
314	314	Sec. 1508.103. EXCEPTION FROM MANDATED BENEFIT
315	315	REQUIREMENTS. Except as expressly provided by this chapter, a
316	316	small employer health benefit plan issued under the program is not
317	317	subject to a law of this state that requires coverage or the offer
318	318	of coverage of a health care service or benefit.
319	319	Sec. 1508.104. CERTAIN COVERAGE PROHIBITED OR REQUIRED.
320	320	(a) A qualifying health benefit plan may only provide coverage for
321	321	in-plan services and benefits, except for:
322	322	(1) emergency care; or
323	323	(2) other services not available through a plan
324	324	provider.
325	325	(b) In-plan services and benefits provided under a
326	326	qualifying health benefit plan must include the following:
327	327	(1) inpatient hospital services;
328	328	(2) outpatient hospital services;
329	329	(3) physician services; and
330	330	(4) prescription drug benefits.
331	331	(c) The commissioner may approve in-plan benefits other
332	332	than those required under Subsection (b) or emergency care or other
333	333	services not available through a plan provider if the commissioner
334	334	determines the inclusion to be essential to achieve the purposes of
335	335	this chapter.
336	336	(d) The commissioner may, with respect to the categories of
337	337	services and benefits described by Subsections (b) and (c):
338	338	(1) prepare specifications for a coverage provided
339	339	under this chapter;
340	340	(2) determine the methods and procedures of claims
341	341	administration;
342	342	(3) establish procedures to decide contested cases
343	343	arising from coverage provided under this chapter;
344	344	(4) study, on an ongoing basis, the operation of all
345	345	coverages provided under this chapter, including gross and net
346	346	costs, administration costs, benefits, utilization of benefits,
347	347	and claims administration;
348	348	(5) administer the healthy Texas small employer
349	349	premium stabilization fund established under Subchapter F;
350	350	(6) provide the beginning and ending dates of
351	351	coverages for enrollees in a qualifying health benefit plan;
352	352	(7) develop basic group coverage plans applicable to
353	353	all individuals eligible to participate in the program;
354	354	(8) provide for optional group coverage plans in
355	355	addition to the basic group coverage plans described by Subdivision
356	356	(7);
357	357	(9) provide, as determined to be appropriate by the
358	358	commissioner, additional statewide optional coverage plans;
359	359	(10) develop specific health benefit plans that permit
360	360	access to high-quality, cost-effective health care;
361	361	(11) design, implement, and monitor health benefit
362	362	plan features intended to discourage excessive utilization,
363	363	promote efficiency, and contain costs for qualifying health benefit
364	364	plans;
365	365	(12) develop and refine, on an ongoing basis, a health
366	366	benefit strategy for the program that is consistent with evolving
367	367	benefits delivery systems;
368	368	(13) develop a funding strategy that efficiently uses
369	369	employer contributions to achieve the purposes of this chapter; and
370	370	(14) modify the copayment and deductible amounts for
371	371	prescription drug benefits under a qualifying health benefit plan,
372	372	if the commissioner determines that the modification is necessary
373	373	to achieve the purposes of this chapter.
374	374	[Sections 1508.105-1508.150 reserved for expansion]
375	375	SUBCHAPTER D. PROGRAM ADMINISTRATION
376	376	Sec. 1508.151. EMPLOYER CERTIFICATION. (a) At the time of
377	377	initial application, a health benefit plan issuer shall obtain from
378	378	a small employer that seeks to purchase a qualifying health benefit
379	379	plan a written certification that the employer meets the
380	380	eligibility requirements described by Section 1508.051 and the
381	381	minimum employer participation requirements described by Section
382	382	1508.053.
383	383	(b) Not later than the 90th day before the renewal date of a
384	384	qualifying health benefit plan, a health benefit plan issuer shall
385	385	obtain from the small employer that purchased the qualifying health
386	386	benefit plan a written certification that the employer continues to
387	387	meet the eligibility requirements described by Section 1508.051 and
388	388	the minimum employer participation requirements described by
389	389	Section 1508.053.
390	390	(c) A participating health benefit plan issuer may require a
391	391	small employer to submit appropriate documentation in support of a
392	392	certification described by Subsection (a) or (b).
393	393	Sec. 1508.152. APPLICATION PROCESS. (a) Subject to
394	394	Subsection (b), a health benefit plan issuer shall accept
395	395	applications for qualifying health benefit plan coverage from small
396	396	employers at all times throughout the calendar year.
397	397	(b) The commissioner may limit the dates on which a health
398	398	benefit plan issuer must accept applications for qualifying health
399	399	benefit plan coverage if the commissioner determines the limitation
400	400	to be necessary to achieve the purposes of this chapter.
401	401	Sec. 1508.153. EMPLOYEE ENROLLMENT; WAITING PERIOD. (a) A
402	402	qualifying health benefit plan must provide employees with an
403	403	initial enrollment period that is 31 days or longer, and annually at
404	404	least one open enrollment period that is 31 days or longer. The
405	405	commissioner by rule may require an additional open enrollment
406	406	period if the commissioner determines that the additional open
407	407	enrollment period is necessary to achieve the purposes of this
408	408	chapter.
409	409	(b) A small employer may establish a waiting period for
410	410	employees during which an employee is not eligible for coverage
411	411	under a qualifying health benefit plan. The last day of a waiting
412	412	period established under this subsection may not be later than the
413	413	90th day after the date on which the employee begins employment with
414	414	the small employer.
415	415	(c) A health benefit plan issuer may not deny coverage under
416	416	a qualifying health benefit plan to a new employee of a small
417	417	employer that purchased the qualifying health benefit plan if the
418	418	health benefit plan issuer receives an application for coverage
419	419	from the employee not later than the 31st day after the latter of:
420	420	(1) the first day of the employee's employment; or
421	421	(2) the first day after the expiration of a waiting
422	422	period established under Subsection (b).
423	423	(d) Subject to Subsection (e), a health benefit plan issuer
424	424	may deny coverage under a qualifying health benefit plan to an
425	425	employee of a small employer who applies for coverage after the
426	426	period described by Subsection (c).
427	427	(e) A health benefit plan issuer that denies an employee
428	428	coverage under Subsection (d):
429	429	(1) may only deny the employee coverage until the next
430	430	open enrollment period; and
431	431	(2) may subject the enrollee to a one-year preexisting
432	432	condition provision, as described by Section 1508.102, if the
433	433	period during which the preexisting condition provision applies
434	434	does not exceed 18 months from the date of the initial application
435	435	for coverage under the qualifying health benefit plan.
436	436	Sec. 1508.154. REPORTS. A health benefit plan issuer that
437	437	participates in the program shall submit reports to the department
438	438	in the form and at the time the commissioner prescribes.
439	439	[Sections 1508.155-1508.200 reserved for expansion]
440	440	SUBCHAPTER E. RATING OF QUALIFIED HEALTH BENEFIT PLANS
441	441	Sec. 1508.201. RATING; PREMIUM PRACTICES IN GENERAL.
442	442	(a) A health benefit plan issuer participating in the program
443	443	must:
444	444	(1) use rating practices for qualifying health benefit
445	445	plans that are consistent with the purposes of this chapter; and
446	446	(2) in setting premiums for qualifying health benefit
447	447	plans, consider the availability of reimbursement from the fund.
448	448	(b) A health benefit plan issuer participating in the
449	449	program shall apply rating factors consistently with respect to all
450	450	small employers in a class of business.
451	451	(c) Differences in premium rates charged for qualifying
452	452	health benefit plans must be reasonable and reflect objective
453	453	differences in plan design.
454	454	Sec. 1508.202. PREMIUM RATE DEVELOPMENT AND CALCULATION.
455	455	(a) Rating factors used to underwrite qualifying health benefit
456	456	plans must produce premium rates for identical groups that:
457	457	(1) differ only by the amounts attributable to health
458	458	benefit plan design; and
459	459	(2) do not reflect differences because of the nature
460	460	of the groups assumed to select a particular health benefit plan.
461	461	(b) A health benefit plan issuer shall treat each qualifying
462	462	health benefit plan that is issued or renewed in a calendar month as
463	463	having the same rating period.
464	464	(c) A health benefit plan issuer may use only age and gender
465	465	as case characteristics, as defined by Section 1501.201(2), in
466	466	setting premium rates for a qualifying health benefit plan.
467	467	(d) The commissioner by rule may establish additional
468	468	rating criteria and requirements for qualifying health benefit
469	469	plans if the commissioner determines that the criteria and
470	470	requirements are necessary to achieve the purposes of this chapter.
471	471	Sec. 1508.203. FILING; APPROVAL. (a) A health benefit
472	472	plan issuer shall file with the department, for review and approval
473	473	by the commissioner, premium rates to be charged for qualifying
474	474	health benefit plans.
475	475	(b) If the commissioner limits health benefit plan issuer
476	476	participation in the program under Section 1508.101(b), premium
477	477	rates proposed to be charged for each qualifying health benefit
478	478	plan will be considered as an element in the contract procurement
479	479	process required under that section.
480	480	[Sections 1508.204-1508.250 reserved for expansion]
481	481	SUBCHAPTER F. HEALTHY TEXAS SMALL EMPLOYER PREMIUM STABILIZATION
482	482	FUND
483	483	Sec. 1508.251. ESTABLISHMENT OF FUND. (a) To the extent
484	484	that funds appropriated to the department are available for this
485	485	purpose, the commissioner shall establish a fund from which health
486	486	benefit plan issuers may receive reimbursement for claims paid by
487	487	the health benefit plan issuers for individuals covered under
488	488	qualifying group health plans.
489	489	(b) The fund established under this section shall be known
490	490	as the healthy Texas small employer premium stabilization fund.
491	491	(c) The commissioner shall adopt rules necessary to
492	492	implement and administer the fund, including rules that set out the
493	493	procedures for operation of the fund and distribution of money from
494	494	the fund.
495	495	Sec. 1508.252. OPERATION OF FUND; CLAIM ELIGIBILITY.
496	496	(a) A health benefit plan issuer is eligible to receive
497	497	reimbursement in an amount that is equal to 80 percent of the dollar
498	498	amount of claims paid between $5,000 and $75,000 in a calendar year
499	499	for an enrollee in a qualifying health benefit plan.
500	500	(b) A health benefit plan issuer is eligible for
501	501	reimbursement from the fund only for the calendar year in which
502	502	claims are paid.
503	503	(c) Once the dollar amount of claims paid on behalf of a
504	504	covered individual reaches or exceeds $75,000 in a given calendar
505	505	year, a health benefit plan issuer may not receive reimbursement
506	506	for any other claims paid on behalf of the individual in that
507	507	calendar year.
508	508	Sec. 1508.253. REIMBURSEMENT REQUEST SUBMISSION. (a) A
509	509	health benefit plan issuer seeking reimbursement from the fund
510	510	shall submit a request for reimbursement in the form prescribed by
511	511	the commissioner by rule.
512	512	(b) A health benefit plan issuer must request reimbursement
513	513	from the fund annually, not later than the date determined by the
514	514	commissioner, following the end of the calendar year for which the
515	515	reimbursement requests are made.
516	516	(c) The commissioner may require a health benefit plan
517	517	issuer participating in the program to submit claims data in
518	518	connection with reimbursement requests as the commissioner
519	519	determines to be necessary to ensure appropriate distribution of
520	520	reimbursement funds and oversee the operation of the fund. The
521	521	commissioner may require that the data be submitted on a per covered
522	522	individual, aggregate, or categorical basis.
523	523	Sec. 1508.254. FUND AVAILABILITY. (a) The commissioner
524	524	shall compute the total claims reimbursement amount for all health
525	525	benefit plan issuers participating in the program for the calendar
526	526	year for which claims are reported and reimbursement requested.
527	527	(b) If the total amount requested by health benefit plan
528	528	issuers participating in the program for reimbursement for a
529	529	calendar year exceeds the amount of funds available for
530	530	distribution for claims paid during that same calendar year, the
531	531	commissioner shall provide for the pro rata distribution of any
532	532	available funds. A health benefit plan issuer participating in the
533	533	program is eligible to receive a proportional amount of any
534	534	available funds that is equal to the proportion of total eligible
535	535	claims paid by all participating health benefit plan issuers that
536	536	the requesting health benefit plan issuer paid.
537	537	(c) If the amount of funds available for distribution for
538	538	claims paid by all health benefit plan issuers participating in the
539	539	program during a calendar year exceeds the total amount requested
540	540	for reimbursement by all participating health benefit plan issuers
541	541	during that calendar year, the commissioner shall carry forward any
542	542	excess funds and make those excess funds available for distribution
543	543	in the next calendar year. Excess funds carried over under this
544	544	section are added to the fund in addition to any other money
545	545	appropriated for the fund for the calendar year into which the funds
546	546	are carried forward.
547	547	Sec. 1508.255. PROGRAM REPORTING. (a) Each health benefit
548	548	plan issuer participating in the program shall provide the
549	549	department, in the form prescribed by the commissioner, monthly
550	550	reports of total enrollment under qualifying health benefit plans.
551	551	(b) On the request of the commissioner, each health benefit
552	552	plan issuer participating in the program shall furnish to the
553	553	department, in the form prescribed by the commissioner, data other
554	554	than data described by Subsection (a) that the commissioner
555	555	determines necessary to oversee the operation of the fund.
556	556	Sec. 1508.256. CLAIMS EXPERIENCE DATA. (a) Based on
557	557	available data and appropriate actuarial assumptions, the
558	558	commissioner shall separately estimate the per covered individual
559	559	annual cost of total claims reimbursement from the fund for
560	560	qualifying health benefit plans.
561	561	(b) On request, a health benefit plan issuer participating
562	562	in the program shall furnish to the department claims experience
563	563	data for use in the estimates described by Subsection (a).
564	564	Sec. 1508.257. TOTAL ELIGIBLE ENROLLMENT DETERMINATION.
565	565	(a) The commissioner shall determine total eligible enrollment
566	566	under qualifying health benefit plans by dividing the total funds
567	567	available for distribution from the fund by the estimated per
568	568	covered individual annual cost of total claims reimbursement from
569	569	the fund.
570	570	(b) At the end of the first year of enrollment and annually
571	571	thereafter, the commissioner shall submit a report to the governor
572	572	and the legislature regarding enrollment for the previous year and
573	573	limitations on future enrollment that ensure that the program does
574	574	not necessitate a substantial increase in funding to continue the
575	575	program, as consistent with Section 1508.001.
576	576	Sec. 1508.258. EVALUATION AND PROTECTION OF FUND; EMPLOYER
577	577	ENROLLMENT SUSPENSION. (a) The commissioner shall suspend the
578	578	enrollment of new employers in qualifying health benefit plans if
579	579	the commissioner determines that the total enrollment reported by
580	580	all health benefit plan issuers under qualifying health benefit
581	581	plans exceeds the total eligible enrollment determined under
582	582	Section 1508.257 and is likely to result in anticipated annual
583	583	expenditures from the fund in excess of the total funds available
584	584	for distribution from the fund.
585	585	(b) The commissioner shall provide a health benefit plan
586	586	issuer participating in the program with notification of any
587	587	enrollment suspension under Subsection (a) as soon as practicable
588	588	after:
589	589	(1) receipt of all enrollment data; and
590	590	(2) determination of the need to suspend enrollment.
591	591	(c) A suspension of issuance of qualifying health benefit
592	592	plans to employers under Subsection (a) does not preclude the
593	593	addition of new employees of an employer already covered under a
594	594	qualifying health benefit plan or new dependents of employees
595	595	already covered under a qualifying health benefit plan.
596	596	Sec. 1508.259. EMPLOYER ENROLLMENT REACTIVATION. If, at
597	597	any point during a suspension of enrollment under Section 1508.258,
598	598	the commissioner determines that funds are sufficient to provide
599	599	for the addition of new enrollments, the commissioner:
600	600	(1) may reactivate new enrollments; and
601	601	(2) shall notify all participating group health
602	602	benefit plan issuers that enrollment of new employers may be
603	603	resumed.
604	604	Sec. 1508.260. FUND ADMINISTRATOR. (a) The commissioner
605	605	may obtain the services of an independent organization to
606	606	administer the fund.
607	607	(b) The commissioner shall establish guidelines for the
608	608	submission of proposals by organizations for the purposes of
609	609	administering the fund and may approve, disapprove, or recommend
610	610	modification to the proposal of an applicant to administer the
611	611	fund.
612	612	(c) An organization approved to administer the fund shall
613	613	submit reports to the commissioner, in the form and at the times
614	614	required by the commissioner, as necessary to facilitate evaluation
615	615	and ensure orderly operation of the fund, including an annual
616	616	report of the affairs and operations of the fund. The annual report
617	617	must also be delivered to the governor, the lieutenant governor,
618	618	and the speaker of the house of representatives.
619	619	(d) An organization approved to administer the fund shall
620	620	maintain records in the form prescribed by the commissioner and
621	621	make those records available for inspection by or at the request of
622	622	the commissioner.
623	623	(e) The commissioner shall determine the amount of
624	624	compensation to be allocated to an approved organization as payment
625	625	for fund administration. Compensation is payable only from the
626	626	fund.
627	627	(f) The commissioner may remove an organization approved to
628	628	administer the fund from fund administration. An organization
629	629	removed from fund administration under this subsection must
630	630	cooperate in the orderly transition of services to another approved
631	631	organization or to the commissioner.
632	632	Sec. 1508.261. STOP-LOSS INSURANCE; REINSURANCE. (a) The
633	633	administrator of the fund, on behalf of and with the prior approval
634	634	of the commissioner, may purchase stop-loss insurance or
635	635	reinsurance from an insurance company licensed to write that
636	636	coverage in this state.
637	637	(b) Stop-loss insurance or reinsurance may be purchased to
638	638	the extent that the commissioner determines funds are available for
639	639	the purchase of that insurance.
640	640	Sec. 1508.262. PUBLIC EDUCATION AND OUTREACH. (a) The
641	641	commissioner may use an amount of the fund, not to exceed eight
642	642	percent of the annual amount of the fund, for purposes of developing
643	643	and implementing public education, outreach, and facilitated
644	644	enrollment strategies targeted to small employers who do not
645	645	provide health insurance.
646	646	(b) The commissioner shall solicit and accept
647	647	recommendations concerning the development and implementation of
648	648	education, outreach, and enrollment strategies under Subsection
649	649	(a) from agents licensed under Title 13 to write health benefit
650	650	plans in this state.
651	651	(c) The commissioner may contract with marketing
652	652	organizations to perform or provide assistance with education,
653	653	outreach, and enrollment strategies described by Subsection (a).
654	654	SECTION 2.02. The commissioner of insurance shall adopt any
655	655	rules necessary to implement the change in law made by Chapter 1508,
656	656	Insurance Code, as added by this article, not later than January 4,
657	657	2010.
658	658	SECTION 2.03. (a) The commissioner of insurance shall make
659	659	an initial determination concerning limitation of health benefit
660	660	plan issuer participation in the program established under Chapter
661	661	1508, Insurance Code, as added by this article, not later than
662	662	January 18, 2010. If the commissioner determines that limited
663	663	participation is necessary to achieve the purposes of Chapter 1508,
664	664	Insurance Code, as added by this article, the commissioner shall
665	665	issue a request for proposal from health benefit plan issuers to
666	666	participate in the program not later than May 1, 2010.
667	667	(b) The commissioner of insurance shall ensure that the
668	668	Healthy Texas Program is fully operational in a manner that allows
669	669	health benefit plan issuers participating in the program to make
670	670	the first annual request for reimbursement on January 1, 2011.
671	671	SECTION 2.04. This Act does not make an appropriation. This
672	672	Act takes effect only if a specific appropriation for the
673	673	implementation of the Act is provided in a general appropriations
674	674	act of the 81st Legislature.
675	675	ARTICLE 3. EFFECTIVE DATE
676	676	SECTION 3.01. This Act takes effect September 1, 2009.
677	677	______________________________ ______________________________
678	678	President of the Senate Speaker of the House
679	679	I hereby certify that S.B. No. 78 passed the Senate on
680	680	April 9, 2009, by the following vote: Yeas 31, Nays 0;
681	681	May 29, 2009, Senate refused to concur in House amendment and
682	682	requested appointment of Conference Committee; May 30, 2009, House
683	683	granted request of the Senate; June 1, 2009, Senate adopted
684	684	Conference Committee Report by the following vote: Yeas 30,
685	685	Nays 1.
686	686	______________________________
687	687	Secretary of the Senate
688	688	I hereby certify that S.B. No. 78 passed the House, with
689	689	amendment, on May 19, 2009, by the following vote: Yeas 144,
690	690	Nays 0, one present not voting; May 30, 2009, House granted request
691	691	of the Senate for appointment of Conference Committee;
692	692	May 31, 2009, House adopted Conference Committee Report by the
693	693	following vote: Yeas 135, Nays 8, one present not voting.
694	694	______________________________
695	695	Chief Clerk of the House
696	696	Approved:
697	697	______________________________
698	698	Date
699	699	______________________________
700	700	Governor