82R1064 TJS-D
By: Zerwas H.B. No. 636
A BILL TO BE ENTITLED
AN ACT
relating to creation of the Texas Health Insurance Connector.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. The legislature finds that:
(1) the small employer and individual health benefit
plan markets in this state are a fundamental and integral component
of the economy of this state that create significant employment and
business opportunity, including enabling more than 1.5 million
individuals, and 110,000 small businesses with more than 650,000
employees, to obtain health benefit plan coverage in 2009;
(2) the United States Congress exceeded its
constitutional authority by passing the Patient Protection and
Affordable Care Act, which contained a number of provisions that
have the potential to significantly undermine the operations of the
small employer and individual health benefit plan markets in this
state;
(3) the Patient Protection and Affordable Care Act
includes an option for a state to create a health insurance exchange
to facilitate the purchase of individual and small group health
coverage and to provide assistance with enrollment of eligible
individuals in qualified health plans in lieu of the federal
government operating a health insurance exchange in the state for
that purpose;
(4) the federal government operating a health
insurance exchange in this state would significantly hinder the
operation of the small employer and individual health benefit plan
markets in this state so as to cause significant economic harm
throughout the state, to a greater extent than would be the case
under a health insurance exchange administered in or by this state;
(5) a federal health insurance exchange operating in
this state would infringe on powers reserved to this state under the
Tenth Amendment to the United States Constitution; and
(6) it is in the best interest of the citizens of this
state that the State of Texas create a health insurance exchange,
the Texas Health Insurance Connector, to facilitate, and make
transparent the purchase of, small employer and individual health
benefit plan coverage in this state, to provide assistance with
enrollment of eligible individuals in qualified health plans, and
to protect the economy of and the insurance markets in this state.
SECTION 2. Subtitle G, Title 8, Insurance Code, is amended
by adding Chapter 1509 to read as follows:
CHAPTER 1509. TEXAS HEALTH INSURANCE CONNECTOR
SUBCHAPTER A. GENERAL PROVISIONS
Sec. 1509.001. DEFINITIONS. In this chapter:
(1) "Board" means the board of directors of the
connector.
(2) "Connector" means the Texas Health Insurance
Connector.
(3) "Enrollee" means an individual who is enrolled in
a qualified health plan.
(4) "Executive commissioner" means the executive
commissioner of the Health and Human Services Commission.
(5) "Qualified health plan" means a health benefit
plan that the board has certified under Section 1509.108.
(6) "Qualified individual" means an individual who is
eligible to become an enrollee in accordance with the criteria
adopted by the board under Section 1509.109.
(7) "Secretary" means the secretary of the United
States Department of Health and Human Services.
(8) "Small employer" has the meaning assigned by
Section 1501.002, except that the term does not include
governmental entities described by that section.
Sec. 1509.002. DEFINITION OF HEALTH BENEFIT PLAN. (a) In
this chapter, "health benefit plan" means an insurance policy,
insurance agreement, evidence of coverage, or other similar
coverage document that provides coverage for medical or surgical
expenses incurred as a result of a health condition, accident, or
sickness that is issued by:
(1) an insurance company;
(2) a group hospital service corporation operating
under Chapter 842;
(3) a fraternal benefit society operating under
Chapter 885;
(4) a stipulated premium company operating under
Chapter 884;
(5) an exchange operating under Chapter 942;
(6) a health maintenance organization operating under
Chapter 843;
(7) a multiple employer welfare arrangement that holds
a certificate of authority under Chapter 846; or
(8) an approved nonprofit health corporation that
holds a certificate of authority under Chapter 844.
(b) In this chapter, "health benefit plan" does not include:
(1) a plan that provides coverage:
(A) for wages or payments in lieu of wages for a
period during which an employee is absent from work because of
sickness or injury;
(B) as a supplement to a liability insurance
policy;
(C) for credit insurance;
(D) only for vision care;
(E) only for hospital expenses; or
(F) only for indemnity for hospital confinement;
(2) a Medicare supplemental policy as defined by
Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss);
(3) a workers' compensation insurance policy; or
(4) medical payment insurance coverage provided under
a motor vehicle insurance policy.
Sec. 1509.003. RULES. (a) The board may adopt rules
necessary and proper to implement this chapter.
(b) The board may adopt rules necessary to implement state
responsibility in compliance with a federal law or regulation or
action of a federal court relating to a person or activity under
the purview of the connector if:
(1) the federal law, regulation, or action of the
federal court requires:
(A) a state to adopt the rules; or
(B) action by a state to ensure protection of the
citizens of the state;
(2) the rules will avoid federal preemption of state
insurance regulation; or
(3) the rules will prevent the loss of federal funds to
this state.
(c) The board may adopt a rule under Subsection (b) only if
the federal action requiring the adoption of a rule occurs or takes
effect between sessions of the legislature or at such a time during
a session of a legislature that sufficient time does not remain to
permit the preparation of a recommendation for legislative action
or permit the legislature to act. A rule adopted under this section
remains in effect until the 30th day after the end of the first
regular session of the legislature that follows the adoption of the
rule unless a law is enacted that authorizes the subject matter of
the rule. If a law is enacted that authorizes the subject matter of
the rule, the rule continues in effect.
Sec. 1509.004. AGENCY COOPERATION. (a) The connector, the
department, and the Health and Human Services Commission shall
cooperate fully in performing their respective duties under this
code or another law of this state relating to the operation of the
connector.
(b) The connector and the department shall cooperate to
promote a stable health benefit plan market in this state.
Sec. 1509.005. SUNSET PROVISION. The connector is subject
to review under Chapter 325, Government Code (Texas Sunset Act).
Unless continued in existence as provided by that chapter, the
connector is abolished and this chapter expires September 1, 2019.
Sec. 1509.006. CONNECTOR NOT INSURER. The connector is not
an insurer or health maintenance organization and is not subject to
regulation by the department.
Sec. 1509.007. EXEMPTION FROM STATE TAXES AND FEES. The
connector is not subject to any state tax, regulatory fee, or
surcharge, including a premium or maintenance tax or fee.
Sec. 1509.008. COMPLIANCE WITH FEDERAL LAW. The connector
shall comply with all applicable federal law and regulations.
[Sections 1509.009-1509.050 reserved for expansion]
SUBCHAPTER B. ESTABLISHMENT AND GOVERNANCE
Sec. 1509.051. ESTABLISHMENT. The Texas Health Insurance
Connector is established as the American Health Benefit Exchange
and the Small Business Health Options Program (SHOP) Exchange
required by Section 1311, Patient Protection and Affordable Care
Act (Pub. L. No. 111-148).
Sec. 1509.052. GOVERNANCE OF CONNECTOR; BOARD MEMBERSHIP.
(a) The connector is governed by a board of directors.
(b) The board consists of seven members composed as follows:
(1) five members appointed by the governor:
(A) two of whom must be chosen from a list
submitted to the governor by the lieutenant governor; and
(B) two of whom must be chosen from a list
submitted to the governor by the speaker of the house of
representatives;
(2) the commissioner, as a nonvoting ex officio
member; and
(3) the executive commissioner, as a nonvoting ex
officio member.
(c) At least three of the five board members appointed by
the governor must have experience in health care administration,
health care economics, or health insurance or be knowledgeable
concerning general business or actuarial principles. One of the
board members appointed by the governor must represent the
interests of health benefit plan consumers in this state, one must
represent the interests of small employers in this state, and one
must be an enrollee or be reasonably expected to qualify for
coverage under a qualified health plan in this state.
(d) A person may not serve as a member of the board if the
person is required to register as a lobbyist under Chapter 305,
Government Code, because of the person's activities for
compensation related to the operation of the connector or the
business of insurance in this state.
Sec. 1509.053. PRESIDING OFFICER. The governor shall
designate one member of the board to serve as presiding officer at
the pleasure of the governor.
Sec. 1509.054. TERMS; VACANCY. (a) Appointed members of
the board serve staggered six-year terms.
(b) The governor shall fill a vacancy on the board by
appointing, for the unexpired term, an individual who has the
appropriate qualifications to fill that position.
Sec. 1509.055. CONFLICT OF INTEREST. (a) A board member,
or a member of a committee formed by the board, with a direct
interest in a matter before the board, personally or through an
employer, shall abstain from deliberations and actions on the
matter in which the conflict of interest arises, shall abstain from
any vote on the matter, and may not in any manner participate in a
decision on the matter.
(b) Each board member shall file a conflict of interest
statement and a statement of ownership interests with the board to
ensure disclosure of all existing and potential personal interests
related to board business.
Sec. 1509.056. REIMBURSEMENT. A member of the board is not
entitled to compensation but is entitled to reimbursement for
travel or other expenses incurred while performing duties as a
board member in the amount provided by the General Appropriations
Act for state officials.
Sec. 1509.057. MEMBER'S IMMUNITY. (a) A member of the
board is not liable for an act or omission made in good faith in the
performance of powers and duties under this chapter.
(b) A cause of action does not arise against a member of the
board for an act or omission described by Subsection (a).
Sec. 1509.058. OPEN RECORDS AND OPEN MEETINGS. (a) The
board is subject to Chapter 551, Government Code. The board may
meet in executive session in accordance with Chapter 551,
Government Code, to discuss confidential or proprietary
information, including contract decisions and qualified health
plan rates.
(b) The board is subject to Chapter 552, Government Code,
except that, notwithstanding any other law, documents that contain
proprietary information, relate to deliberative processes or
communications, relate to contracting decisions, or reveal work
product, plans, or strategy that would influence decisions in the
health benefit plan marketplace are not public information.
Sec. 1509.059. RECORDS. The board shall keep records of the
board's proceedings for at least seven years.
Sec. 1509.060. BIENNIAL REPORT. Not later than January 1 of
each odd-numbered year, the board shall provide a report to the
governor, the legislature, the commissioner, and the executive
commissioner. The report must include information regarding the
development and implementation of the connector, specifically
detailing progress made by the connector in implementing the
requirements of this chapter.
Sec. 1509.061. ADDITIONAL REPORT. (a) The board shall
issue a report that meets the requirements of Section 1509.060 to
the entities described by that section not later than January 1,
2014.
(b) This section expires January 31, 2014.
[Sections 1509.062-1509.100 reserved for expansion]
SUBCHAPTER C. POWERS AND DUTIES OF CONNECTOR
Sec. 1509.101. EMPLOYEES; COMMITTEES. (a) The board may
employ, and determine the compensation of, an executive director, a
chief fiscal officer, a general counsel, a technology officer, and
any other agent or employee the board considers necessary to assist
the connector in carrying out the connector's responsibilities and
functions.
(b) The connector may appoint appropriate legal, actuarial,
and other committees necessary to provide technical assistance in
operating the connector and performing any of the functions of the
connector.
Sec. 1509.102. CONTRACTS. The connector may enter into any
contract that the connector considers necessary to implement or
administer this chapter, including a contract with the department
or the Health and Human Services Commission for the department or
commission, in exchange for payment, to perform functions or
provide services in connection with the operation of the connector.
Sec. 1509.103. INFORMATION SHARING AND CONFIDENTIALITY.
The connector may enter into information-sharing agreements with
federal and state agencies to carry out the connector's
responsibilities under this chapter. An agreement entered into
under this section must include adequate protection with respect to
the confidentiality of any information shared and comply with all
applicable state and federal law.
Sec. 1509.104. MEMORANDUM OF UNDERSTANDING. The connector
shall enter into a memorandum of understanding with the department
and the Health and Human Services Commission regarding the exchange
of information and the division of regulatory functions among the
connector, the department, and the commission.
Sec. 1509.105. LEGAL ACTION. (a) The connector may sue or
be sued.
(b) The connector may take any legal action necessary to
recover or collect amounts due the connector, including:
(1) assessments due the connector;
(2) amounts erroneously or improperly paid by the
connector; and
(3) amounts paid by the connector as a mistake of fact
or law.
Sec. 1509.106. FUNCTIONS. The connector shall:
(1) by rule establish procedures consistent with
federal law and regulations for the certification,
recertification, and decertification of health benefit plans as
qualified health plans;
(2) provide for the operation of a toll-free telephone
hotline to respond to requests for assistance;
(3) maintain an Internet website through which an
enrollee or prospective enrollee may:
(A) obtain standardized, comparative information
concerning qualified health plans issued in this state; and
(B) locate comparative coverage information
concerning qualified health plans through a searchable database of
diseases, disabilities, or other medical conditions;
(4) assign a rating to each qualified health plan
certified by the connector based on criteria developed by the
secretary;
(5) use a standard format for presenting information
concerning qualified health plan options;
(6) inform individuals of the eligibility
requirements for Medicaid, the state child health plan program, or
any other similar federal, state, or local public health benefit
program;
(7) if the connector determines that an individual is
eligible for Medicaid, the state child health plan program, or any
other similar federal, state, or local public health benefit
program, coordinate with the Health and Human Services Commission
to enroll the individual in the program for which the individual is
eligible;
(8) establish, and make available electronically, a
calculator to determine the actual cost of coverage after the
application of any premium tax credit or cost-sharing subsidy
available under federal law;
(9) as applicable, certify that an individual is
exempt from the individual responsibility penalty under Section
5000A, Internal Revenue Code of 1986, and notify the secretary of
the exemption;
(10) establish a navigator program as described by
Section 1311(i), Patient Protection and Affordable Care Act (Pub.
L. No. 111-148);
(11) provide for the processing of applications for
coverage under a qualified health plan, the enrollment of persons
in qualified health plans, and the disenrollment of enrollees from
qualified health plans;
(12) establish billing and payment policies for
issuers of qualified health plans;
(13) engage in marketing and outreach activities; and
(14) collect and maintain information concerning
qualified health plans, including data concerning enrollment,
disenrollment, claims, and claims denials.
Sec. 1509.107. TYPES OF PLANS. The connector shall, in a
manner consistent with federal law, establish certification
requirements for at least six different types of qualified health
plans, at least two of which must include a health savings account
described by Section 223, Internal Revenue Code of 1986, at least
one of which must offer benchmark coverage or benchmark equivalent
coverage described by Section 1937(b), Social Security Act (42
U.S.C. Section 1396u-7), and at least one of which must offer
limited scope dental benefits either separately or in conjunction
with another type of plan.
Sec. 1509.108. CERTIFICATION OF PLAN. The board shall
certify a health benefit plan as a qualified health plan if the
health benefit plan meets the requirements for certification set
forth by the secretary. The connector may not, as a condition of
certification, require a health benefit plan issuer to:
(1) participate in both the individual and small
employer markets; or
(2) offer benefit levels that exceed benefit levels
required under federal law.
Sec. 1509.109. QUALIFICATION OF INDIVIDUALS. The board by
rule shall establish criteria for eligibility for a potential
enrollee to be considered a qualified individual. At a minimum, the
criteria must require that the individual:
(1) seek to enroll in a qualified health plan in the
individual health benefit plan market offered through the
connector;
(2) reside in and be a citizen or lawful resident of
this state, except as provided by Section 1312, Patient Protection
and Affordable Care Act (Pub. L. No. 111-148); and
(3) at the time of enrollment, not be incarcerated,
other than being incarcerated pending the disposition of any
criminal charges.
Sec. 1509.110. PREMIUM COLLECTION AND AGGREGATION. The
board by rule shall establish a mechanism for the collection and
aggregation of premium payments directly or indirectly from
enrollees and the payment of premiums to issuers of qualified
health plans. Rules adopted under this section must include rules
regarding an employer's authority to withhold premium payments from
an enrollee's paycheck and to submit those premium payments to
issuers of qualified health plans.
Sec. 1509.111. PREMIUM INCREASE JUSTIFICATION. (a) The
connector shall require an issuer of a qualified health plan to file
with the connector an explanation of any premium increase before
implementation of the increase.
(b) A health benefit plan issuer shall prominently display
the explanation of any premium increase on the health benefit plan
issuer's Internet website.
[Sections 1509.112-1509.150 reserved for expansion]
SUBCHAPTER D. COVERAGE REQUIREMENTS OR LIMITATIONS
Sec. 1509.151. PROHIBITED COVERAGE THROUGH CONNECTOR. A
qualified health plan offered through the connector may not provide
coverage for an abortion, as defined by Section 171.002, Health and
Safety Code.
[Sections 1509.152-1509.200 reserved for expansion]
SUBCHAPTER E. ASSESSMENTS FOR OPERATION OF CONNECTOR
Sec. 1509.201. ASSESSMENTS; PENALTY FOR NONPAYMENT. (a)
The connector may charge the issuers of qualified health plans and
health benefit plans applying for certification as qualified health
plans an assessment as reasonable and necessary for the connector's
organizational and operating expenses.
(b) The connector may refuse to recertify or may decertify a
health benefit plan as a qualified health plan if the issuer of the
plan fails or refuses to pay an assessment under this section.
Sec. 1509.202. GRANTS AND FEDERAL FUNDS. (a) The connector
may accept a grant from a public or private organization and may
spend those funds to pay the costs of program administration and
operations.
(b) The connector may accept federal funds and shall use
those funds in compliance with applicable federal law, regulations,
and guidelines.
Sec. 1509.203. USE OF CONNECTOR ASSETS; ANNUAL REPORT. (a)
The assets of the connector may be used only to pay the costs of the
administration and operation of the connector.
(b) The connector shall prepare annually a complete and
detailed written report accounting for all funds received and
disbursed by the connector during the preceding fiscal year. The
report must meet any reporting requirements provided in the General
Appropriations Act, regardless of whether the connector receives
any funds under that Act. The connector shall submit the report to
the governor, the legislature, the commissioner, and the executive
commissioner not later than January 31 of each year.
[Sections 1509.204-1509.250 reserved for expansion]
SUBCHAPTER F. TRUST FUND
Sec. 1509.251. TRUST FUND. (a) The connector fund is
established as a special trust fund outside of the state treasury in
the custody of the comptroller separate and apart from all public
money or funds of this state.
(b) The connector may deposit assessments, gifts or
donations, and any federal funding obtained by the connector into
the connector fund in accordance with procedures established by the
comptroller.
(c) Interest or other income from the investment of the fund
shall be deposited to the credit of the fund.
SECTION 3. (a) As soon as possible after the effective date
of this Act, but not later than October 31, 2011, the governor shall
appoint the initial members of the board of directors of the Texas
Health Insurance Connector. In making the appointments, the
governor shall designate two persons to terms expiring February 1,
2013, two persons to terms expiring February 1, 2015, and one person
to a term expiring February 1, 2017.
(b) As soon as possible after the appointments required by
Subsection (a) of this section are made, but not later than November
30, 2011, the board of directors of the Texas Health Insurance
Connector shall hold a special meeting to discuss the adoption of
rules and procedures necessary to implement Chapter 1509, Insurance
Code, as added by this Act.
(c) As soon as possible after the effective date of this
Act, but not later than January 31, 2012, the board of directors of
the Texas Health Insurance Connector shall adopt rules and
procedures necessary to implement Chapter 1509, Insurance Code, as
added by this Act.
SECTION 4. This Act takes effect immediately if it receives
a vote of two-thirds of all the members elected to each house, as
provided by Section 39, Article III, Texas Constitution. If this
Act does not receive the vote necessary for immediate effect, this
Act takes effect September 1, 2011.