82R10135 TJS-F
By: Ellis S.B. No. 1782
A BILL TO BE ENTITLED
AN ACT
relating to regulation of health benefit plan issuers in this
state.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
ARTICLE 1. CREATION OF THE TEXAS HEALTH INSURANCE EXCHANGE
SECTION 1.01. Subtitle G, Title 8, Insurance Code, is
amended by adding Chapter 1509 to read as follows:
CHAPTER 1509. TEXAS HEALTH INSURANCE EXCHANGE
SUBCHAPTER A. GENERAL PROVISIONS
Sec. 1509.001. DEFINITIONS. In this chapter:
(1) "Board" means the board of directors of the
exchange.
(2) "Catastrophic plan" has the meaning assigned by
Section 1302(e), Patient Protection and Affordable Care Act (Pub.
L. No. 111-148).
(3) "Educated health care consumer" means an
individual who is knowledgeable about the health care system and
has background or experience in making informed decisions regarding
health, medical, and scientific matters.
(4) "Enrollee" means an individual who is enrolled in
a qualified health plan.
(5) "Exchange" means the Texas Health Insurance
Exchange.
(6) "Executive commissioner" means the executive
commissioner of the Health and Human Services Commission.
(7) "Qualified employer" means an employer that elects
to make all of its full-time employees eligible for one or more
qualified health plans offered through the exchange and, at the
option of the employer, some or all of its part-time employees and:
(A) has its principal place of business in this
state and elects to provide coverage through the exchange to all of
its eligible employees, wherever employed; or
(B) elects to provide coverage through the
exchange to all of its eligible employees who are principally
employed in this state and who are eligible to participate in a
qualified health plan.
(8) "Qualified health plan" means a health benefit
plan that has been certified by the board as meeting the criteria
specified by Section 1311(c), Patient Protection and Affordable
Care Act (Pub. L. No. 111-148).
(9) "Qualified individual" means an individual,
including a minor, who:
(A) seeks to enroll in a qualified health plan
offered to individuals through the exchange;
(B) resides in this state;
(C) at the time of enrollment, is not
incarcerated, other than incarceration pending the disposition of
charges; and
(D) is, and is reasonably expected to be, for the
entire period for which enrollment is sought, a citizen or national
of the United States or an alien lawfully present in the United
States.
(10) "Secretary" means the secretary of the United
States Department of Health and Human Services.
(11) "SHOP Exchange" means a Small Business Health
Options Program as defined by Section 1311(b)(1)(B), Patient
Protection and Affordable Care Act (Pub. L. No. 111-148).
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. DEFINITION OF SMALL EMPLOYER. (a) For
purposes of this chapter, "small employer" means a person who
employed at least two, and an average of not more than 50 employees
during the preceding calendar year. This subsection expires
December 31, 2013.
(b) All persons treated as a single employer under Section
414(b), (c), (m), or (o), Internal Revenue Code of 1986, are single
employers for purposes of this chapter.
(c) An employer and any predecessor employer are a single
employer for purposes of this chapter.
(d) In determining the number of employees of an employer
under this section, the number of employees:
(1) includes part-time employees and employees who are
not eligible for coverage through the employer; and
(2) for an employer that did not have employees during
the entire preceding calendar year, is the average number of
employees that the employer is reasonably expected to employ on
business days in the current calendar year.
(e) A small employer that makes enrollment in qualified
health benefit plans available to its employees through the
exchange and ceases to be a small employer by reason of an increase
in the number of its employees continues to be a small employer for
purposes of this chapter as long as it continuously makes
enrollment through the exchange available to its employees.
Sec. 1509.004. RULEMAKING AUTHORITY. The board may adopt
rules necessary and proper to implement this chapter. Rules adopted
under this section may not conflict with or prevent the application
of regulations promulgated by the secretary under the Patient
Protection and Affordable Care Act (Pub. L. No. 111-148).
Sec. 1509.005. AGENCY COOPERATION. (a) The exchange, 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
exchange.
(b) The exchange and the Health and Human Services
Commission shall cooperate fully to:
(1) ensure that the development of eligibility and
enrollment systems for the exchange and its tax credits are fully
integrated with the planning and development of the Health and
Human Services Commission's eligibility systems modernization
efforts;
(2) ensure full and seamless interoperability and
minimize duplication of cost and effort;
(3) develop and administer transition procedures
that:
(A) address the needs of individuals and families
who experience a change in income that results in a change in the
source of coverage, with a particular emphasis on children and
adults with special health care needs and chronic illnesses,
conditions, and disabilities, as well as all individuals who are
also enrolled in Medicare; and
(B) to the extent practicable under the Patient
Protection and Affordable Care Act (Pub. L. No. 111-148), provide
for the coordination of payments to Medicaid managed care
organizations and qualified health plans that experience changes in
enrollment resulting from changes in eligibility for Medicaid
during an enrollment period;
(4) ensure consistent methods and standards,
including formulas and verification methods, for prompt
calculation of income based on individuals' modified adjusted gross
incomes in order to guard against lapses in coverage and
inconsistent eligibility determinations and procedures;
(5) ensure maximum access to federal data sources for
the purpose of verifying income eligibility for Medicaid, the state
child health plan program, premium tax credits, and cost-sharing
reductions;
(6) ensure the prompt processing of applications and
enrollment in the correct state subsidy program, regardless of
whether the program is Medicaid, the state child health plan
program, premium tax credits, or cost-sharing reductions;
(7) ensure procedures for transitioning individuals
between Medicaid and tax-credit-based subsidies that protect
individuals against delays in eligibility and plan enrollment;
(8) ensure rapid resolution of inconsistent
information affecting eligibility and dissemination of clear and
understandable information to applicants regarding the resolution
process and any interim assistance that may be available while
resolution is pending and procedures to assure that individuals are
meaningfully informed of:
(A) the potential existence of overpayments of
advance tax credits;
(B) procedures for reconciling enrollee
liability for repayment in the event that an advance tax credit is
subsequently proved to be an overpayment;
(C) procedures by which individuals can report a
change in income that may affect the subsequent level of advance tax
payment or the availability of a safe harbor; and
(D) information regarding safe harbors against
overpayment liability or recoupment that may exist under federal or
state law; and
(9) develop cross-market participation by:
(A) encouraging the development of common
provider networks, network performance standards for health
benefit plans that participate in the exchange, Medicaid, and the
state child health plan program, and developing coverage terms and
quality standards in order to ensure maximum continuity and quality
of care;
(B) promoting participation by health benefit
plans that satisfy both qualified health plan and Medicaid managed
care plan criteria, in order to minimize disruption in care as a
result of enrollment shifts between subsidy sources;
(C) developing incentives, including quality
ratings, default enrollment preferences, and other approaches, in
order to encourage health benefit plans to participate in both
Medicaid and the exchange; and
(D) coordinating health benefit plan payments
and timely adjustments in all markets that may result from
enrollment changes.
Sec. 1509.006. EXEMPTION FROM STATE TAXES AND FEES. The
exchange is not subject to any state tax, regulatory fee, or
surcharge, including a premium or maintenance tax or fee.
Sec. 1509.007. COMPLIANCE WITH FEDERAL LAW. The exchange
shall comply with all applicable federal law and regulations.
Sec. 1509.008. TEMPORARY EXEMPTION FROM STATE PURCHASING
PROCEDURES. (a) The exchange is not subject to state purchasing or
procurement requirements under Subtitle D, Title 10, Government
Code, or any other law.
(b) This section expires January 1, 2016.
[Sections 1509.009-1509.050 reserved for expansion]
SUBCHAPTER B. ESTABLISHMENT AND GOVERNANCE
Sec. 1509.051. ESTABLISHMENT. The Texas Health Insurance
Exchange is established as the American Health Benefit Exchange and
the Small Business Health Options Program (SHOP) Exchange
authorized and required by Section 1311, Patient Protection and
Affordable Care Act (Pub. L. No. 111-148).
Sec. 1509.052. GOVERNANCE OF EXCHANGE; BOARD MEMBERSHIP.
(a) The exchange is governed by a board of directors.
(b) The board consists of seven members as follows:
(1) five appointed members:
(A) one of whom is appointed by the governor;
(B) two of whom are appointed by the lieutenant
governor; and
(C) two of whom are appointed by the speaker of
the house of representatives;
(2) the commissioner as an ex officio voting member;
and
(3) the executive commissioner as an ex officio voting
member.
(c) Each of the five board members appointed under
Subsection (b)(1) must have demonstrated experience in at least two
of the following areas:
(1) individual health care coverage;
(2) small employer health care coverage;
(3) health benefit plan administration;
(4) health care finance or economics;
(5) actuarial science;
(6) administration of a public or private health care
delivery system; and
(7) purchasing health plan coverage.
(d) The board must include members who are health care
consumers or small business owners.
(e) In making appointments under this section, the
governor, lieutenant governor, and speaker of the house of
representatives shall attempt to make appointments that increase
the board's diversity of expertise.
Sec. 1509.053. PRESIDING OFFICER. The board shall annually
designate one member of the board to serve as presiding officer.
Sec. 1509.054. TERMS; VACANCY. (a) Appointed members of
the board serve two-year terms.
(b) The appropriate appointing authority 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) Any board member
or a member of a committee formed by the board with a direct
interest in a matter, personally or through an employer, before the
board shall abstain from deliberations and actions on the matter in
which the conflict of interest arises and shall further abstain
from any vote on the matter, and may not otherwise 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.
(c) A member of the board or of the staff of the exchange may
not be employed by, affiliated with, a consultant to, a member of
the board of directors of, or otherwise a representative of an
issuer or other insurer, an agent or broker, a health care provider,
or a health care facility or health clinic while serving on the
board or on the staff of the exchange.
(d) A member of the board or of the staff of the exchange may
not be a member, a board member, or an employee of a trade
association of issuers, health facilities, health clinics, or
health care providers while serving on the board or on the staff of
the exchange.
(e) A member of the board or of the staff of the exchange may
not be a health care provider unless the member receives no
compensation for rendering services as a health care provider and
does not have an ownership interest in a professional health care
practice.
Sec. 1509.056. GENERAL DUTIES OF BOARD MEMBERS. (a) Each
board member has the responsibility and duty to meet the
requirements of this title and applicable state and federal laws
and regulations, to serve the public interest of the individuals
and small businesses seeking health care coverage through the
exchange, and to ensure the operational well-being and fiscal
solvency of the exchange.
(b) A member of the board may not make, participate in
making, or in any way attempt to use the board member's official
position to influence the making of any decision that the board
member knows or has reason to know will have a material financial
effect, distinguishable from its effect on the public generally, on
the board member or the board member's immediate family, or on:
(1) any source of income, other than gifts and loans by
a commercial lending institution in the regular course of business
on terms available to the public generally, aggregating $250 or
more in value, provided or promised to the member within the 12
months immediately preceding the date the decision is made; or
(2) any business entity in which the member is a
director, officer, partner, trustee, or employee, or holds any
position of management.
Sec. 1509.057. 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. 1509.058. 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. 1509.059. OPEN RECORDS AND OPEN MEETINGS. The board is
subject to Chapters 551 and 552, Government Code.
Sec. 1509.060. RECORDS. The board shall keep records of the
board's proceedings for at least seven years.
[Sections 1509.061-1509.100 reserved for expansion]
SUBCHAPTER C. POWERS AND DUTIES OF EXCHANGE
Sec. 1509.101. EMPLOYEES; COMMITTEES. (a) The board may
employ an executive director, a chief fiscal officer, a chief
operations officer, a director of health plan contracting, a chief
technology and information officer, a general counsel, and any
other agents and employees that the board considers necessary to
assist the exchange in carrying out its responsibilities and
functions.
(b) The executive director shall organize, administer, and
manage the operations of the exchange. The executive director may
hire other employees as necessary to carry out the responsibilities
of the exchange.
(c) The exchange may appoint appropriate legal, actuarial,
and other committees necessary to provide technical assistance in
operating the exchange and performing any of the functions of the
exchange.
(d) The board shall set the salary for an agent or employee
position under this section in an amount reasonably necessary to
attract and retain individuals of superior qualifications. In
determining the compensation for these positions, the board shall
conduct, through the use of independent outside advisors, salary
surveys of both other state and federal health insurance exchanges
that are most comparable to the exchange and other relevant labor
pools.
(e) The salaries established by the board under this section
may not exceed the highest comparable salary for a position of that
type, as determined by the salary surveys in Subsection (d).
(f) The board shall publish the salaries under this section
in the board's annual budget and post the budget on an Internet
website maintained by the exchange.
Sec. 1509.102. ADVISORY COMMITTEE. The board shall appoint
an advisory committee to allow for the involvement of the health
care and health insurance industries and other stakeholders in the
operation of the exchange. The advisory committee may provide
expertise and recommendations to the board but may not adopt rules
or enter into contracts on behalf of the exchange.
Sec. 1509.103. CONTRACTS. (a) Except as provided by
Subsection (b), the exchange may enter into any contract that the
exchange considers necessary to implement or administer this
chapter, including a contract with the Health and Human Services
Commission or an entity that has experience in individual and small
group health insurance, benefit administration, or other
experience relevant to the responsibilities assumed by the entity,
to perform functions or provide services in connection with the
operation of the exchange.
(b) This exchange may not enter into a contract with a
health benefit plan issuer under this section.
Sec. 1509.104. INFORMATION SHARING AND CONFIDENTIALITY.
The exchange may enter into information-sharing agreements with
federal and state agencies to carry out the exchange'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. 1509.105. MEMORANDUM OF UNDERSTANDING. The exchange
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
exchange, the department, and the commission.
Sec. 1509.106. LEGAL ACTION. (a) The exchange may sue or
be sued.
(b) The exchange may take any legal action necessary to
recover or collect amounts due the exchange, including:
(1) assessments due the exchange;
(2) amounts erroneously or improperly paid by the
exchange; and
(3) amounts paid by the exchange as a mistake of fact
or law.
Sec. 1509.107. FUNCTIONS. (a) The exchange shall make
qualified health plans available to qualified individuals and
qualified employers.
(b) The exchange may not make available any health benefit
plan that is not a qualified health plan.
(c) The exchange may allow a health benefit plan issuer to
offer a plan that provides limited scope dental benefits meeting
the requirements of Section 9832(c)(2)(A), Internal Revenue Code of
1986, through the exchange, either separately or in conjunction
with a qualified health plan, if the plan provides pediatric dental
benefits meeting the requirements of Section 1302(b)(1)(J),
Patient Protection and Affordable Care Act (Pub. L. No. 111-148).
(d) The exchange, or an issuer offering a health benefit
plan through the exchange, may not charge an individual a fee or
penalty for termination of coverage if the individual enrolls in
another type of minimum essential coverage because the individual
has become eligible for that coverage or because the individual's
employer-sponsored coverage has become affordable under the
standards of Section 36B(c)(2)(C), Internal Revenue Code of 1986.
(e) In implementing the requirements of this section, the
exchange 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, utilizing staff that
is trained to provide assistance in a culturally and linguistically
appropriate manner;
(3) provide oral interpretation services in any
language for individuals seeking coverage through the exchange and
make available a toll-free telephone number for the hearing and
speech impaired;
(4) maintain an Internet website through which an
enrollee or prospective enrollee may obtain standardized
comparative information on a qualified health plan's premiums,
coverage, cost-sharing, ratings, enrollee satisfaction, quality
measures, and other relevant information;
(5) use a standardized format for presenting health
benefit options in the exchange, including the use of the uniform
outline of coverage established under Section 2715, Public Health
Service Act (42 U.S.C. Section 300gg-51);
(6) assign a rating to each qualified health plan
certified by the exchange based on criteria developed by the
secretary;
(7) ensure that written information made available by
the exchange is presented in a plainly worded, easily
understandable format and made available in prevalent languages;
(8) determine each qualified health plan's level of
coverage in accordance with regulations issued by the secretary
under Section 1302(d)(2)(A), Patient Protection and Affordable
Care Act (Pub. L. No. 111-148); and
(9) in accordance with federal law and regulations,
inform individuals of eligibility requirements for Medicaid, the
state child health plan program, or any applicable state or local
public program and if through screening of the application by the
exchange, the exchange determines that an individual is eligible
for such program, enroll the individual in the program.
(f) In addition to performing the duties described by
Subsection (e), and consistent with Section 1413, Patient
Protection and Affordable Care Act (Pub. L. No. 111-148), the
exchange shall:
(1) enter into data-sharing agreements with relevant
state and federal agencies to facilitate eligibility
determinations and enrollment;
(2) provide enrollment information and other relevant
data, consistent with federal and state privacy rules, to the
qualified health plan in which a qualified individual or qualified
small employer is enrolled;
(3) conduct redeterminations of eligibility for
subsidies and assist in reenrollment as necessary, if an individual
experiences changes in income or circumstances;
(4) inform individuals of the potential for
overpayments of advance premium tax credits and of procedures by
which individuals can report a change of income that may affect the
subsequent level of premium tax credits, including the availability
of any safe harbor from recoupment of any overpayment, to the extent
permitted by that Act or any federal regulations promulgated under
that Act;
(5) establish, and make available electronically, a
calculator designed to:
(A) enable consumers to determine the actual cost
of coverage after the application of any premium tax credit or
cost-sharing subsidy available under federal law; and
(B) provide consumers with information on
out-of-pocket costs for in-network and, if feasible,
out-of-network services, taking into account any cost-sharing
reductions;
(6) establish capability through which qualified
employers may access coverage for their employees, and which shall
enable any qualified employer to specify a level of coverage so that
any of its employees may enroll in any qualified health plan offered
through the exchange at the specified level of coverage;
(7) subject to Section 1411, Patient Protection and
Affordable Care Act (Pub. L. No. 111-148), grant a certification
attesting that, for purposes of the individual responsibility
penalty under Section 5000A, Internal Revenue Code of 1986, an
individual is exempt from the individual responsibility
requirement or from the penalty imposed by that section because:
(A) there is no affordable qualified health plan
available through the exchange, or the individual's employer,
covering the individual; or
(B) the individual meets the requirements for any
other such exemption from the individual responsibility
requirement or penalty;
(8) transfer to the United States secretary of the
treasury the following:
(A) a list of the individuals who are issued a
certification under Subdivision (7), including the name and
taxpayer identification number of each individual;
(B) the name and taxpayer identification number
of each individual who was an employee of an employer but who was
determined to be eligible for the premium tax credit under Section
36B, Internal Revenue Code of 1986, because the employer did not
provide minimum essential coverage, or the employer provided the
minimum essential coverage, but it was determined under Section
36B(c)(2)(C) of that code to be either unaffordable to the employee
or not provide the required minimum actuarial value; and
(C) the name and taxpayer identification number
of each individual who notifies the exchange under Section
1411(b)(4), Patient Protection and Affordable Care Act (Pub. L. No.
111-148), that he or she has changed employers and each individual
who ceases coverage under a qualified health plan during a plan
year, and the effective date of that cessation;
(9) provide to each employer the name of each employee
of the employer described above who ceases coverage under a
qualified health plan during a plan year and the effective date of
the cessation;
(10) perform duties required of the exchange by the
secretary or the United States secretary of the treasury related to
determining eligibility for premium tax credits, reduced
cost-sharing, or individual responsibility requirement exemptions;
(11) select entities qualified to serve as Navigators
in accordance with Section 1311(i), Patient Protection and
Affordable Care Act (Pub. L. No. 111-148), and standards developed
by the secretary; and
(12) award grants to enable Navigators to:
(A) conduct public education activities to raise
awareness of the availability of qualified health plans;
(B) distribute fair and impartial information
concerning enrollment in qualified health plans, and the
availability of premium tax credits under Section 36B, Internal
Revenue Code of 1986, and cost-sharing reductions under Section
1402, Patient Protection and Affordable Care Act (Pub. L. No.
111-148);
(C) facilitate enrollment in qualified health
plans;
(D) provide referrals to any applicable office of
health insurance consumer assistance or health insurance ombudsman
established under Section 2793, Public Health Service Act (42
U.S.C. Section 300gg-93), or any other appropriate state agency or
agencies, for any enrollee with a grievance, complaint, or question
regarding the enrollee's health benefit plan or coverage or a
determination under that plan or coverage;
(E) provide information in a manner that is
culturally and linguistically appropriate to the needs of the
population being served by the exchange; and
(F) counsel exchange participants about the
exchange, Medicaid, and the state child health plan program
markets, including selection of plans and transition procedures for
transitioning among Medicaid, the state child health plan program,
exchange plans, and other coverage;
(13) ensure that there is a sufficient number of
Navigators that possess the experience and capacity to serve
disadvantaged, hard-to-reach, and culturally or linguistically
isolated populations;
(14) certify Navigators as able to carry out the
duties required by Section 1311(i)(3), Patient Protection and
Affordable Care Act (Pub. L. No. 111-148);
(15) review the rate of premium growth within the
exchange and outside the exchange and consider the information in
developing recommendations on whether to continue limiting
qualified employer status to small employers;
(16) credit the amount of any free choice voucher to
the monthly premium of the plan in which a qualified employee is
enrolled, in accordance with Section 10108, Patient Protection and
Affordable Care Act (Pub. L. No. 111-148), and collect the amount
credited from the offering employer;
(17) consult with stakeholders relevant to carrying
out the activities required under this chapter, including:
(A) educated health care consumers who are
enrollees in qualified health plans;
(B) individuals and entities with experience in
facilitating enrollment in qualified health plans;
(C) representatives of small businesses and
self-employed individuals;
(D) the Health and Human Services Commission; and
(E) advocates for enrolling hard-to-reach
populations;
(18) meet the following financial integrity
requirements:
(A) keep an accurate accounting of all
activities, receipts, and expenditures and annually submit to the
secretary, the governor, the commissioner, and the legislature a
report concerning such accountings; and
(B) fully cooperate with any investigation
conducted by the secretary pursuant to the secretary's authority
under the Patient Protection and Affordable Care Act (Pub. L. No.
111-148) and allow the secretary, in coordination with the
inspector general of the United States Department of Health and
Human Services, to investigate the affairs of the exchange, examine
the books and records of the exchange, and require periodic reports
in relation to the activities undertaken by the exchange;
(19) use a single application for enrollment in
Medicaid, the state child health plan program, and health benefit
plans offered in the exchange, including establishing eligibility
for premium tax credits and cost-sharing reductions, that may be:
(A) the single application form developed by the
secretary under Section 1413(b), Patient Protection and Affordable
Care Act (Pub. L. No. 111-148); or
(B) an application form developed in cooperation
with the Health and Human Services Commission for that purpose;
(20) undertake activities necessary to market and
publicize the availability of health care coverage and federal
subsidies through the exchange;
(21) undertake outreach and enrollment activities
that seek to assist enrollees and potential enrollees with
enrolling and reenrolling in the exchange in the least burdensome
manner, including populations that may experience barriers to
enrollment, such as the disabled and those with limited English
language proficiency;
(22) provide for:
(A) the processing of applications for coverage
under a qualified health plan;
(B) the enrollment of persons in qualified health
plans;
(C) the disenrollment of enrollees from
qualified health plans; and
(D) for individual coverage, the collection of
premiums and assistance in the administration of subsidies, as the
board considers appropriate; and
(23) for small employers, collect and aggregate
premiums and administer all other necessary and related tasks,
including enrollment and plan payment, in order to make the
offering of employee plan choice as simple as possible for
qualified small employers.
Sec. 1509.108. CERTIFICATION OF PLAN. The exchange shall
certify a health benefit plan as a qualified health plan if:
(1) the plan provides the essential health benefits
package described by Section 1302(a), Patient Protection and
Affordable Care Act (Pub. L. No. 111-148), except that the plan is
not required to provide essential benefits that duplicate the
minimum benefits of qualified dental plans, if:
(A) the exchange has determined that at least one
qualified dental plan is available to supplement the plan's
coverage; and
(B) the issuer makes prominent disclosure at the
time it offers the plan, in a form approved by the exchange, that
the plan does not provide the full range of essential pediatric
benefits and that qualified dental plans providing those benefits
and other dental benefits not covered by the plan are offered
through the exchange;
(2) the premium rates and contract language have been
approved by the commissioner;
(3) the plan provides at least a bronze level of
coverage, as described by Section 1302(d), Patient Protection and
Affordable Care Act (Pub. L. No. 111-148), unless the plan is a
catastrophic plan and is offered only to individuals eligible for
catastrophic coverage;
(4) the plan's cost-sharing requirements do not exceed
the limits established under Section 1302(c)(1), Patient
Protection and Affordable Care Act (Pub. L. No. 111-148), and if the
plan is offered to small employers, the plan's deductible does not
exceed the limits established under Section 1302(c)(2) of that Act;
(5) the health benefit plan issuer offering the plan:
(A) is licensed and in good standing to offer
health insurance coverage in this state;
(B) offers at least one qualified health plan in
the silver level and at least one plan in the gold level as
described by Section 1302(d), Patient Protection and Affordable
Care Act (Pub L. No. 111-148);
(C) charges the same premium rate for each
qualified health plan without regard to whether the plan is offered
through the exchange and without regard to whether the plan is
offered directly from the issuer or through an insurance producer;
and
(D) complies with the regulations developed by
the secretary under Section 1311(d), Patient Protection and
Affordable Care Act (Pub. L. No. 111-148), and other requirements
the exchange establishes;
(6) the plan meets the requirements of certification
under this chapter and any rules promulgated by the secretary under
Section 1311(c), Patient Protection and Affordable Care Act (Pub.
L. No. 111-148), including minimum standards in the areas of
marketing practices, network adequacy, essential community
providers in underserved areas, accreditation, quality
improvement, uniform enrollment forms and descriptions of
coverage, and information on quality measures for health benefit
plan performance; and
(7) the exchange determines that making the plan
available through the exchange is in the interest of qualified
individuals and qualified employers in this state.
Sec. 1509.109. PROHIBITED BASES FOR DENIAL OF
CERTIFICATION. The exchange may not deny certification to a health
benefit plan on the ground that the plan:
(1) is a fee-for-service plan; or
(2) provides treatments necessary to prevent patients'
deaths in circumstances the exchange determines are inappropriate
or too costly.
Sec. 1509.110. PREREQUISITES TO CERTIFICATION. (a) The
exchange shall require each health benefit plan issuer seeking
certification of a plan as a qualified health plan to:
(1) submit a justification for any premium increase
before implementation of that increase;
(2) prominently display the justification for any
premium increase on the health benefit plan issuer's Internet
website;
(3) make available to the public, in plain language as
that term is defined in Section 1311(e)(3)(B), Patient Protection
and Affordable Care Act (Pub. L. No. 111-148), and submit to the
exchange, the secretary, and the commissioner, accurate and timely
disclosure of:
(A) claims payment policies and practices;
(B) periodic financial disclosures;
(C) data on enrollment;
(D) data on disenrollment;
(E) data on the number of claims that are denied;
(F) data on rating practices;
(G) information on cost-sharing and payments
with respect to any out-of-network coverage;
(H) information on enrollee and participant
rights under Title I, Patient Protection and Affordable Care Act
(Pub. L. No. 111-148); and
(I) other information as determined appropriate
by the secretary;
(4) on request, inform an individual of the amount of
cost-sharing, including deductibles, copayments, and coinsurance,
under the individual's plan or coverage that the individual would
be responsible for paying with respect to the furnishing of a
specific item or service by a participating provider;
(5) make the information required to be disclosed
under Subdivision (4) made available to the individual on an
Internet website and by other means for individuals without access
to the Internet;
(6) promptly notify affected individuals of price and
benefit changes or other changes in circumstance that could
materially impact enrollment or coverage;
(7) make available to the exchange and regularly
update an electronic directory of contracting health care providers
so that individuals seeking coverage through the exchange can
search by health care provider name to determine which health plans
in the exchange include that health care provider in their network;
and
(8) as the board considers necessary, provide
regularly updated information to the exchange as to whether a
health care provider is accepting new patients for a particular
health plan.
(b) In determining whether to certify an issuer, the
exchange shall consider premium increase justification information
obtained under Subsection (a), together with information and
recommendations provided by the commissioner under Section
2794(b), Public Health Service Act (42 U.S.C. Section 300gg-94(b)).
Sec. 1509.111. ADDITIONAL REQUIREMENTS RELATING TO
RULEMAKING BY BOARD. In adopting rules under this chapter, the
board shall:
(1) standardize benefits and cost-sharing within
tiers for products to be offered through the exchange;
(2) establish and use a competitive process, which is
not required to comply with Chapter 2151, Government Code, to
select participating health benefit plan issuers;
(3) determine the minimum requirements an issuer must
meet to be considered for participation in the exchange and the
standards and criteria for selecting qualified health plans to be
offered through the exchange that are in the best interests of
qualified individuals and qualified small employers;
(4) consistently and uniformly apply any
requirements, standards, and criteria under this chapter to all
issuers;
(5) in the course of selectively contracting for
health care coverage offered to qualified individuals and qualified
small employers through the exchange, seek to contract with issuers
to provide health care coverage choices that offer the optimal
combination of choice, value, quality, and service;
(6) ensure, in each region of the state, a choice of
qualified health plans at each of the five tiers of coverage
contained in Sections 1302(d) and (e), Patient Protection and
Affordable Care Act (Pub. L. No. 111-148);
(7) require issuers, as a condition of participation
in the exchange, to fairly and affirmatively offer, market, and
sell in the exchange at least one product within each of the five
levels of coverage described by Sections 1302(d) and (e), Patient
Protection and Affordable Care Act (Pub. L. No. 111-148), and, as
the board considers necessary, to offer additional products within
each of the five levels of coverage described by Section 1302(d) of
that Act; and
(8) require, as a condition of participation in the
exchange, issuers that sell any products outside the exchange to
fairly and affirmatively offer, market, and sell:
(A) all products made available to individuals in
the exchange to individuals purchasing coverage outside the
exchange; or
(B) all products made available to small
employers in the exchange to small employers purchasing coverage
outside the exchange.
Sec. 1509.112. EXEMPTION FROM STANDARDS PROHIBITED. (a)
The exchange may not exempt any health benefit plan issuer seeking
certification of a qualified health plan, regardless of the type or
size of the issuer, from state licensing or solvency requirements.
(b) The exchange shall apply the criteria of this section in
a manner that assures a fair competitive market between or among
health benefit plan issuers participating in the exchange.
Sec. 1509.113. DENTAL PLANS. (a) This chapter applies to
dental plans as provided in this section.
(b) A health benefit plan issuer may be certified to offer
dental coverage, without being certified to offer other health
coverages.
(c) A plan may be limited to dental and oral health benefits
without substantially duplicating the benefits typically offered
by health benefit plans that do not offer dental coverage.
(d) To be certified under this chapter, a dental plan must
include, at a minimum, the essential pediatric dental benefits
prescribed by the secretary pursuant to Section 1302(b)(1)(J),
Patient Protection and Affordable Care Act (Pub. L. No. 111-148),
and any other dental benefits the exchange or the secretary
specifies by regulation.
(e) An issuer may offer jointly with another issuer a
comprehensive plan through the exchange in which dental benefits
are provided by an issuer through a qualified dental plan and the
other benefits are provided by an issuer through a qualified health
plan. Plans offered under this subsection must be priced
separately and made available for purchase separately at the same
price at which they are offered together.
Sec. 1509.114. (a) The exchange may provide an integrated
and uniform consumer directory of health care providers indicating
which health benefit plan issuers the providers contract with and
whether the providers are currently accepting new patients.
(b) The exchange may establish methods by which health care
providers may transmit relevant information directly to the
exchange, rather than through an issuer.
[Sections 1509.115-1509.150 reserved for expansion]
SUBCHAPTER D. ASSESSMENTS FOR OPERATION OF EXCHANGE
Sec. 1509.151. ASSESSMENTS; PENALTY FOR NONPAYMENT. (a)
The exchange may charge the issuers of health benefit plans in this
state, including qualified health plans, an assessment as
reasonable and necessary for the exchange's organizational and
operating expenses. Assessments must be determined annually. The
exchange may charge interest for late assessments.
(b) The exchange 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.
(c) The commissioner shall adopt rules to implement and
enforce the assessment of health benefit plan issuers under this
section.
Sec. 1509.152. GRANTS AND FEDERAL FUNDS. (a) The exchange
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 exchange may accept federal funds and shall use
those funds in compliance with applicable federal law, regulations,
and guidelines.
Sec. 1509.153. USE OF EXCHANGE ASSETS; ANNUAL REPORT. (a)
The assets of the exchange may be used only to pay the costs of the
administration and operation of the exchange.
(b) The exchange shall prepare annually a complete and
detailed written report accounting for all funds received and
disbursed by the exchange during the preceding fiscal year. The
report must meet any reporting requirements provided in the General
Appropriations Act, regardless of whether the exchange receives any
funds under that Act. The exchange shall submit the report to the
governor, the legislature, the commissioner, and the executive
commissioner not later than January 31 of each year.
(c) General revenue may not be appropriated for the
exchange.
Sec. 1509.154. PUBLICATION OF FINANCIAL INFORMATION. The
exchange shall publish the average costs of licensing, regulatory
fees, and any other payments required by the exchange, and the
administrative costs of the exchange, on an Internet website to
educate consumers on those costs. This information must include
information on losses due to waste, fraud, and abuse.
[Sections 1509.155-1509.200 reserved for expansion]
SUBCHAPTER E. TRUST FUND
Sec. 1509.201. TRUST FUND. (a) The exchange 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 exchange may deposit assessments, gifts or
donations, and any federal funding obtained by the exchange in the
exchange 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.
[Sections 1509.202-1509.250 reserved for expansion]
SUBCHAPTER F. LEVEL PLAYING FIELD
Sec. 1509.251. LEVEL PLAYING FIELD. (a) The commissioner
shall adopt rules to ensure a level playing field and a fair
competitive market environment among issuers that offer qualified
health plans through the exchange and issuers that offer health
benefit plans or other health insurance coverage outside of the
exchange. Notwithstanding any other law, the rules shall, to the
extent practicable, ensure against adverse selection either in
favor of or against exchange-participating issuers.
(b) To discourage adverse selection or steering of
enrollees to or from the exchange, if the board opts to pay agents
helping people enroll in exchange-participating, qualified plans a
fee, instead of using existing compensation structures directly
from issuers, the exchange shall survey the market outside of the
exchange to determine prevailing agent commission rates and set
exchange fees in a manner that is consistent with prevailing rates
in the market outside of the exchange. This section does not
prohibit the exchange from paying a per member per month fee or
using another fee structure if:
(1) prevailing rates in the market outside of the
exchange are paid a percentage of premiums; and
(2) the total fee amounts earned are reasonably
expected to be similar.
(c) The department shall coordinate with the exchange as
necessary to survey the market on commission rates and identify
prevailing practices. Agent fees paid inside or outside of the
exchange must be fully transparent and clearly disclosed to the
purchaser.
SECTION 1.02. Effective January 1, 2014, Section 1509.004,
Insurance Code, as added by this Act, is amended by adding
Subsection (a-1) to read as follows:
(a-1) For purposes of this chapter, "small employer" means a
person who employed an average of not more than 100 employees during
the preceding calendar year.
SECTION 1.03. (a) As soon as practicable after the
effective date of this Act, but not later than October 31, 2011, the
governor, lieutenant governor, and speaker of the house of
representatives shall appoint the initial members of the board of
directors of the Texas Health Insurance Exchange.
(b) As soon as practicable 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 Exchange 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 practicable after the effective date of this
Act, but not later than January 31, 2012, the board of directors of
the Texas Health Insurance Exchange shall adopt rules and
procedures necessary to implement Chapter 1509, Insurance Code, as
added by this Act.
(d) Not later than January 1, 2017, the board shall issue a
report to the 85th Legislature recommending whether to adopt the
option in Section 1312(c), Patient Protection and Affordable Care
Act (Pub. L. No. 111-148), to merge the individual and small
employer markets. In the report, the board shall provide
information, based on at least two years of data from the exchange,
on the potential impact on rates paid by individuals and by small
employers in a merged individual and small employer market, as
compared to the rates paid by individuals and small employers if a
separate individual and small employer market is maintained.
(e) If, after the effective date of this Act but before the
initial members of the board of directors of the Texas Health
Insurance Exchange have been appointed as required by Subsection
(a), the Texas Department of Insurance becomes aware of any
planning and establishment grants as described by Section 1311,
Patient Protection and Affordable Care Act (Pub. L. No. 111-148),
or any other public or private funding source, the department may
apply for funding from that source.
(f) The exchange may not begin operations without adequate
funding.
(g) The board of directors of the Texas Health Insurance
Exchange may adopt rules on an emergency basis in accordance with
Section 2001.034, Government Code. Notwithstanding Section
2001.034(c), Government Code, a rule adopted under this subsection
may remain in effect until January 1, 2015. Rules adopted under
this subsection shall be deemed necessary for the immediate
preservation of the public peace, health, safety, and general
welfare and an additional finding under Sections 2001.034(a)(1) and
(2), Government Code, is not required. The authority to adopt rules
under this subsection expires January 1, 2015.
ARTICLE 2. EMERGENCY COVERAGE UNDER CERTAIN MANAGED CARE PLANS
SECTION 2.01. Section 843.107, Insurance Code, is amended
to read as follows:
Sec. 843.107. INDEMNITY BENEFITS; POINT-OF-SERVICE
PROVISIONS. (a) A health maintenance organization may offer:
(1) indemnity benefits covering out-of-area emergency
care;
(2) indemnity benefits, in addition to those relating
to out-of-area and emergency care, provided through an insurer or
group hospital service corporation;
(3) a point-of-service plan under Subchapter A,
Chapter 1273; or
(4) a point-of-service rider under Section 843.108.
(b) A health maintenance organization that offers indemnity
benefits covering out-of-area emergency care under this section
shall apply the same cost-sharing requirement to the emergency care
as it applies to emergency care provided in-area.
SECTION 2.02. Section 843.348, Insurance Code, is amended
by adding Subsection (k) to read as follows:
(k) A health maintenance organization may not require
preauthorization for emergency care.
SECTION 2.03. Sections 1271.155(a) and (b), Insurance Code,
are amended to read as follows:
(a) A health maintenance organization shall pay for
emergency care performed by non-network physicians or providers at
the same rate the health maintenance organization pays for
emergency care performed by network physicians or providers [at the
usual and customary rate or at an agreed rate].
(b) A health care plan of a health maintenance organization
must provide the following coverage of emergency care:
(1) a medical screening examination or other
evaluation required by state or federal law necessary to determine
whether an emergency medical condition exists shall be provided to
covered enrollees in a hospital emergency facility or comparable
facility;
(2) necessary emergency care shall be provided to
covered enrollees, including the treatment and stabilization of an
emergency medical condition; [and]
(3) services originated in a hospital emergency
facility, freestanding emergency medical care facility, or
comparable emergency facility following treatment or stabilization
of an emergency medical condition shall be provided to covered
enrollees as approved by the health maintenance organization,
subject to Subsections (c) and (d); and
(4) as required by Section 1867, Social Security Act
(42 U.S.C. Section 1395dd), medical screening examinations that are
within the capability of the emergency department of a hospital,
including ancillary services routinely available to the emergency
department to evaluate the patient's condition and any further
medical examination and treatment necessary to stabilize the
patient within the capabilities of the staff and facilities
available at the hospital shall be provided to covered enrollees.
SECTION 2.04. Section 1273.004, Insurance Code, is amended
to read as follows:
Sec. 1273.004. LIMITED BENEFITS AND SERVICES; COST-SHARING
PROVISIONS. (a) Indemnity benefits and services provided under a
point-of-service plan may be limited to those services described by
the blended contract and may be subject to different cost-sharing
provisions. The cost-sharing provisions for indemnity benefits may
be higher than the cost-sharing provisions for in-network health
maintenance organization coverage. For an enrollee in a limited
provider network, higher cost-sharing may be imposed only when the
enrollee obtains benefits or services outside the health
maintenance organization delivery network.
(b) Notwithstanding Subsection (a), indemnity benefits and
services provided under a point-of-service plan that covers
emergency care may not be subject to different cost-sharing
provisions. The cost-sharing provisions for indemnity benefits
related to emergency care may not be higher than the cost-sharing
provisions for in-network health maintenance organization
coverage. For an enrollee in a limited provider network, higher
cost-sharing provisions may not be imposed when the enrollee
obtains emergency care outside the health maintenance organization
delivery network.
SECTION 2.05. Section 1301.135, Insurance Code, is amended
by adding Subsection (i) to read as follows:
(i) An insurer that uses a preauthorization process for
medical care and health care services may not require
preauthorization for emergency care.
SECTION 2.06. Section 1301.155(b), Insurance Code, is
amended to read as follows:
(b) If an insured cannot reasonably reach a preferred
provider, an insurer shall provide reimbursement for the following
emergency care services at the preferred level of benefits until
the insured can reasonably be expected to transfer to a preferred
provider:
(1) a medical screening examination or other
evaluation required by state or federal law to be provided in the
emergency facility of a hospital that is necessary to determine
whether a medical emergency condition exists;
(2) necessary emergency care services, including the
treatment and stabilization of an emergency medical condition;
[and]
(3) services originating in a hospital emergency
facility or freestanding emergency medical care facility following
treatment or stabilization of an emergency medical condition; and
(4) as required by Section 1867, Social Security Act
(42 U.S.C. Section 1395dd), medical screening examinations that are
within the capability of the emergency department of a hospital,
including ancillary services routinely available to the emergency
department to evaluate the patient's condition and any further
medical examination and treatment necessary to stabilize the
patient within the capabilities of the staff and facilities
available at the hospital.
SECTION 2.07. The changes in law made by this article apply
only to a health insurance policy or contract or health maintenance
organization contract or agreement that is delivered, issued for
delivery, or renewed on or after January 1, 2012. A health
insurance policy or contract or health maintenance organization
contract or agreement that is delivered, issued for delivery, or
renewed before January 1, 2012, is covered by the law in effect
immediately before the effective date of this Act, and that law is
continued in effect for that purpose.
ARTICLE 3. SELECTION OF PRIMARY CARE PHYSICIANS AND PROVIDERS
UNDER PREFERRED PROVIDER BENEFIT PLANS AND HEALTH MAINTENANCE
ORGANIZATIONS
SECTION 3.01. Section 843.203, Insurance Code, is amended
by amending Subsection (b) and adding Subsections (d) and (e) to
read as follows:
(b) An enrollee shall at all times have the right to select
or change a primary care physician or primary care provider within
the health maintenance organization network of available primary
care physicians and primary care providers[, except that a health
maintenance organization may limit an enrollee's request to change
physicians or providers to not more than four changes in a 12-month
period]. An enrollee may designate any participating primary care
physician or primary care provider who is available to accept the
individual.
(d) For an enrollee who is a child, the health maintenance
organization must allow the child's parent or guardian to designate
as the child's primary care physician or primary care provider a
participating physician who specializes in pediatrics.
(e) A health maintenance organization shall notify each
enrollee of the enrollee's rights under Subsections (b) and (d).
SECTION 3.02. Subchapter D, Chapter 1301, Insurance Code,
is amended by adding Section 1301.164 to read as follows:
Sec. 1301.164. SELECTION OF PRIMARY CARE PHYSICIAN OR
PROVIDER. (a) If a preferred provider benefit plan requires or
provides for designation by an insured of a participating primary
care physician or primary care provider, the insurer shall allow an
insured to designate any participating primary care physician or
primary care provider who is available to accept the individual.
(b) For an enrollee who is a child, the insurer must allow
the child's parent or guardian to designate as the child's primary
care physician or primary care provider a participating physician
who specializes in pediatrics.
(c) An insurer shall notify each insured of the insured's
rights under this section.
SECTION 3.03. The change in law made by this article applies
only to a health insurance policy or contract or health maintenance
organization contract or agreement that is delivered or issued for
delivery on or after January 1, 2012. An insurance policy or
contract or health maintenance organization contract or agreement
that is delivered or issued for delivery before January 1, 2012, is
governed by the law as it existed immediately before the effective
date of this Act, and that law is continued in effect for that
purpose.
ARTICLE 4. HEALTH BENEFIT PLAN COVERAGE OF CERTAIN DEPENDENTS
SECTION 4.01. Section 846.260, Insurance Code, is amended
to read as follows:
Sec. 846.260. LIMITING AGE APPLICABLE TO UNMARRIED CHILD.
If children are eligible for coverage under the terms of a multiple
employer welfare arrangement's plan document, any limiting age
applicable to an unmarried child of an enrollee is 26 [25] years of
age.
SECTION 4.02. Section 1201.053(b), Insurance Code, is
amended to read as follows:
(b) On the application of an adult member of a family, an
individual accident and health insurance policy may, at the time of
original issuance or by subsequent amendment, insure two or more
eligible members of the adult's family, including a spouse,
unmarried children younger than 26 [25] years of age, including a
grandchild of the adult as described by Section 1201.062(a)(1), a
child the adult is required to insure under a medical support order
issued under Chapter 154, Family Code, or enforceable by a court in
this state, a foster child, a stepchild, a child of a domestic
partner if the domestic partner is eligible to be insured and is
insured under the policy, and any other individual dependent on the
adult.
SECTION 4.03. Section 1201.062(a), Insurance Code, is
amended to read as follows:
(a) An individual or group accident and health insurance
policy that is delivered, issued for delivery, or renewed in this
state, including a policy issued by a corporation operating under
Chapter 842, or a self-funded or self-insured welfare or benefit
plan or program, to the extent that regulation of the plan or
program is not preempted by federal law, that provides coverage for
a child of an insured or group member, on payment of a premium, must
provide coverage for:
(1) each grandchild of the insured or group member if
the grandchild is:
(A) unmarried;
(B) younger than 26 [25] years of age; and
(C) a dependent of the insured or group member
for federal income tax purposes at the time application for
coverage of the grandchild is made; and
(2) each child for whom the insured or group member
must provide medical support under an order issued under Chapter
154, Family Code, or enforceable by a court in this state.
SECTION 4.04. Section 1201.065(a), Insurance Code, is
amended to read as follows:
(a) An individual or group accident and health insurance
policy may contain criteria relating to a maximum age or enrollment
in school to establish continued eligibility for coverage of a
child 26 [25] years of age or older.
SECTION 4.05. Section 1251.151(a), Insurance Code, is
amended to read as follows:
(a) A group policy or contract of insurance for hospital,
surgical, or medical expenses incurred as a result of accident or
sickness, including a group contract issued by a group hospital
service corporation, that provides coverage under the policy or
contract for a child of an insured must, on payment of a premium,
provide coverage for any grandchild of the insured if the
grandchild is:
(1) unmarried;
(2) younger than 26 [25] years of age; and
(3) a dependent of the insured for federal income tax
purposes at the time the application for coverage of the grandchild
is made.
SECTION 4.06. Section 1251.152(a), Insurance Code, is
amended to read as follows:
(a) For purposes of this section:
(1) "Child," with respect to an individual, includes
the individual's stepchild or foster child or a child of the
individual's domestic partner if the domestic partner is eligible
for coverage and is covered under the group policy or contract.
(2) "Dependent" [, "dependent"] includes:
(A) [(1)] a child of an employee or member who
is:
(i) [(A)] unmarried; and
(ii) [(B)] younger than 26 [25] years of
age; and
(B) [(2)] a grandchild of an employee or member
who is:
(i) [(A)] unmarried;
(ii) [(B)] younger than 26 [25] years of
age; and
(iii) [(C)] a dependent of the insured for
federal income tax purposes at the time the application for
coverage of the grandchild is made.
SECTION 4.07. Section 1271.006(a), Insurance Code, is
amended to read as follows:
(a) If children are eligible for coverage under the terms of
an evidence of coverage, any limiting age applicable to an
unmarried child of an enrollee, including an unmarried grandchild
of an enrollee, a stepchild of an enrollee, a child of an enrollee's
domestic partner if the domestic partner is eligible to be enrolled
and is enrolled, an adopted child of an enrollee, and a foster child
of an enrollee, is 26 [25] years of age. The limiting age
applicable to a child must be stated in the evidence of coverage.
SECTION 4.08. Section 1501.002(2), Insurance Code, is
amended to read as follows:
(2) "Dependent" means:
(A) a spouse;
(B) a child younger than 26 [25] years of age,
including a newborn child;
(C) a child of any age who is:
(i) medically certified as disabled; and
(ii) dependent on the parent;
(D) an individual who must be covered under:
(i) Section 1251.154; or
(ii) Section 1201.062; and
(E) any other child eligible under an employer's
health benefit plan, including a child described by Section
1503.003, a stepchild, a child of an employee's domestic partner if
the domestic partner is eligible to receive and does receive
coverage under the plan, or a foster child.
SECTION 4.09. Section 1501.609(b), Insurance Code, is
amended to read as follows:
(b) Any limiting age applicable under a large employer
health benefit plan to an unmarried child of an enrollee is 26 [25]
years of age.
SECTION 4.10. Sections 1503.003(a) and (b), Insurance Code,
are amended to read as follows:
(a) A health benefit plan may not condition coverage for a
child younger than 26 [25] years of age on the child's being
enrolled at an educational institution.
(b) A health benefit plan that requires as a condition of
coverage for a child 26 [25] years of age or older that the child be
a full-time student at an educational institution must provide the
coverage:
(1) for the entire academic term during which the
child begins as a full-time student and remains enrolled,
regardless of whether the number of hours of instruction for which
the child is enrolled is reduced to a level that changes the child's
academic status to less than that of a full-time student; and
(2) continuously until the 10th day of instruction of
the subsequent academic term, on which date the health benefit plan
may terminate coverage for the child if the child does not return to
full-time student status before that date.
SECTION 4.11. Section 1506.003, Insurance Code, is amended
to read as follows:
Sec. 1506.003. DEFINITION OF DEPENDENT. In this chapter:
(1) "Child," with respect to an individual, includes
the individual's stepchild or foster child.
(2) "Dependent" [, "dependent"] means:
(A) [(1)] a resident spouse or unmarried child
younger than 26 [25] years of age; or
(B) [(2)] a child who is:
(i) [(A)] a full-time student younger than
26 [25] years of age who is financially dependent on the parent;
(ii) [(B)] 18 years of age or older and is
an individual for whom a person may be obligated to pay child
support; or
(iii) [(C)] disabled and dependent on the
parent regardless of the age of the child.
SECTION 4.12. Section 1506.158(a), Insurance Code, is
amended to read as follows:
(a) An individual's pool coverage ends:
(1) on the date the individual ceases to be a legally
domiciled resident of this state, unless the individual:
(A) is a student younger than 26 [25] years of age
and is financially dependent on a parent covered by the pool;
(B) is a child for whom an individual covered by
the pool may be obligated to pay child support; or
(C) is a child who is disabled and dependent on a
parent covered by the pool, regardless of the age of the child;
(2) on the first day of the month following the date
the individual requests coverage to end;
(3) on the date the individual covered by the pool
dies;
(4) on the date state law requires cancellation of the
coverage;
(5) at the option of the pool, on the 31st day after
the date the pool sends to the individual any inquiry concerning the
individual's eligibility, including an inquiry concerning the
individual's residence, to which the individual does not reply;
(6) on the 31st day after the date a premium payment
for pool coverage becomes due if the payment is not made before that
day;
(7) on the date the individual is 65 years of age and
eligible for coverage under Medicare, unless the coverage received
from the pool is Medicare supplement coverage issued by the pool; or
(8) at the time the individual ceases to meet the
eligibility requirements for coverage.
SECTION 4.13. Section 1551.004(a), Insurance Code, is
amended to read as follows:
(a) In this chapter, "dependent" with respect to an
individual eligible to participate in the group benefits program
under Section 1551.101 or 1551.102 means the individual's:
(1) spouse;
(2) unmarried child younger than 26 [25] years of age;
(3) child of any age who the board of trustees
determines lives with or has the child's care provided by the
individual on a regular basis if:
(A) the child is mentally retarded or physically
incapacitated to the extent that the child is dependent on the
individual for care or support, as determined by the board of
trustees;
(B) the child's coverage under this chapter has
not lapsed; and
(C) the child is at least 26 [25] years old and
was enrolled as a participant in the health benefits coverage under
the group benefits program on the date of the child's 26th [25th]
birthday;
(4) child of any age who is unmarried, for purposes of
health benefit coverage under this chapter, on expiration of the
child's continuation coverage under the Consolidated Omnibus
Budget Reconciliation Act of 1985 (Pub. L. No. 99-272) and its
subsequent amendments; and
(5) ward, as that term is defined by Section 601, Texas
Probate Code.
SECTION 4.14. Section 1551.158(a), Insurance Code, is
amended to read as follows:
(a) A dependent child who is unmarried and whose coverage
under this chapter ends when the child becomes 26 [25] years of age
may, on expiration of continuation coverage under the Consolidated
Omnibus Budget Reconciliation Act of 1985 (Pub. L. No. 99-272),
reinstate health benefit plan coverage under this chapter if the
child, or the child's participating parent or guardian, pays the
full cost of the health benefit plan coverage.
SECTION 4.15. Section 1575.003(1), Insurance Code, is
amended to read as follows:
(1) "Dependent" means:
(A) the spouse of a retiree;
(B) an unmarried child of a retiree or deceased
active member if the child is younger than 26 [25] years of age,
including:
(i) an adopted child;
(ii) a foster child, stepchild, or other
child who is in a regular parent-child relationship; or
(iii) a recognized natural child;
(C) a retiree's recognized natural child,
adopted child, foster child, stepchild, or other child who is in a
regular parent-child relationship and who lives with or has his or
her care provided by the retiree or surviving spouse on a regular
basis regardless of the child's age, if the child is mentally
retarded or physically incapacitated to an extent that the child is
dependent on the retiree or surviving spouse for care or support, as
determined by the trustee; or
(D) a deceased active member's recognized
natural child, adopted child, foster child, stepchild, or other
child who is in a regular parent-child relationship, without regard
to the age of the child, if, while the active member was alive, the
child:
(i) lived with or had the child's care
provided by the active member on a regular basis; and
(ii) was mentally retarded or physically
incapacitated to an extent that the child was dependent on the
active member or surviving spouse for care or support, as
determined by the trustee.
SECTION 4.16. Section 1579.004, Insurance Code, is amended
to read as follows:
Sec. 1579.004. DEFINITION OF DEPENDENT. In this chapter,
"dependent" means:
(1) a spouse of a full-time employee or part-time
employee;
(2) an unmarried child of a full-time or part-time
employee if the child is younger than 26 [25] years of age,
including:
(A) an adopted child;
(B) a foster child, stepchild, or other child who
is in a regular parent-child relationship; and
(C) a recognized natural child;
(3) a full-time or part-time employee's recognized
natural child, adopted child, foster child, stepchild, or other
child who is in a regular parent-child relationship and who lives
with or has his or her care provided by the employee or the
surviving spouse on a regular basis, regardless of the child's age,
if the child is mentally retarded or physically incapacitated to an
extent that the child is dependent on the employee or surviving
spouse for care or support, as determined by the board of trustees;
and
(4) notwithstanding any other provision of this code,
any other dependent of a full-time or part-time employee specified
by rules adopted by the board of trustees.
SECTION 4.17. Section 1601.004(a), Insurance Code, is
amended to read as follows:
(a) In this chapter, "dependent," with respect to an
individual eligible to participate in the uniform program under
Section 1601.101 or 1601.102, means the individual's:
(1) spouse;
(2) unmarried child younger than 26 [25] years of age;
and
(3) child of any age who lives with or has the child's
care provided by the individual on a regular basis if the child is
mentally retarded or physically incapacitated to the extent that
the child is dependent on the individual for care or support, as
determined by the system.
SECTION 4.18. The changes in law made by this article apply
only to a health benefit plan that is delivered, issued for
delivery, or renewed on or after January 1, 2012. A health benefit
plan that is delivered, issued for delivery, or renewed before
January 1, 2012, is covered by the law in effect immediately before
the effective date of this Act, and that law is continued in effect
for that purpose.
ARTICLE 5. RESCISSION OF HEALTH BENEFIT PLAN
SECTION 5.01. Chapter 1202, Insurance Code, is amended by
adding Subchapter C to read as follows:
SUBCHAPTER C. RESCISSION OF HEALTH BENEFIT PLAN
Sec. 1202.101. DEFINITION. In this subchapter,
"rescission" means the termination of an insurance agreement,
contract, evidence of coverage, insurance policy, or other similar
coverage document in which the health benefit plan issuer, as
applicable, refunds premium payments or demands the recoupment of
any benefit already paid under the plan.
Sec. 1202.102. APPLICABILITY. (a) This subchapter applies
only to a health benefit plan, including a small or large employer
health benefit plan written under Chapter 1501, that provides
benefits for medical or surgical expenses incurred as a result of a
health condition, accident, or sickness, including an individual,
group, blanket, or franchise insurance policy or insurance
agreement, a group hospital service contract, or an individual or
group evidence of coverage or similar coverage document that is
offered 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) a reciprocal exchange operating under Chapter 942;
(6) a Lloyd's plan operating under Chapter 941;
(7) a health maintenance organization operating under
Chapter 843;
(8) a multiple employer welfare arrangement that holds
a certificate of authority under Chapter 846; or
(9) an approved nonprofit health corporation that
holds a certificate of authority under Chapter 844.
(b) This subchapter does not apply to:
(1) a health benefit plan that provides coverage:
(A) only for a specified disease or for another
limited benefit other than an accident policy;
(B) only for accidental death or dismemberment;
(C) for wages or payments in lieu of wages for a
period during which an employee is absent from work because of
sickness or injury;
(D) as a supplement to a liability insurance
policy;
(E) for credit insurance;
(F) only for dental or vision care;
(G) only for hospital expenses; or
(H) 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),
as amended;
(3) a workers' compensation insurance policy;
(4) medical payment insurance coverage provided under
a motor vehicle insurance policy;
(5) a long-term care insurance policy, including a
nursing home fixed indemnity policy, unless the commissioner
determines that the policy provides benefit coverage so
comprehensive that the policy is a health benefit plan described by
Subsection (a);
(6) a Medicaid managed care plan offered under Chapter
533, Government Code;
(7) any policy or contract of insurance with a state
agency, department, or board providing health services to eligible
individuals under Chapter 32, Human Resources Code; or
(8) a child health plan offered under Chapter 62,
Health and Safety Code, or a health benefits plan offered under
Chapter 63, Health and Safety Code.
Sec. 1202.103. RESCISSION PROHIBITED; EXCEPTION. (a)
Notwithstanding any other law, except as provided by Subsection
(b), a health benefit plan issuer may not rescind coverage under a
health benefit plan with respect to an enrollee in the plan.
(b) A health benefit plan issuer may rescind coverage under
a health benefit plan with respect to an enrollee if the enrollee
engages in conduct that constitutes fraud or makes an intentional
misrepresentation of a material fact.
Sec. 1202.104. NOTICE OF INTENT TO RESCIND. (a) A health
benefit plan issuer may not rescind a health benefit plan on the
basis of a material misrepresentation without first notifying the
affected enrollee in writing of the issuer's intent to rescind the
health benefit plan.
(b) The notice required under Subsection (a) must include,
as applicable:
(1) the principal reasons for the decision to rescind
the health benefit plan;
(2) the date on which the rescission is effective and
the prior date to which the rescission retroactively reaches;
(3) an itemized list of any pending or paid claims the
health benefit plan issuer intends to recoup following the
rescission;
(4) an explanation of how the enrollee may obtain any
documentation used by the health benefit plan issuer to justify the
rescission;
(5) a statement that the enrollee is entitled to
appeal a rescission decision to an independent review organization
and that the health benefit plan issuer bears the burden of proof on
appeal;
(6) an explanation of any time limit with which the
enrollee must comply to appeal the rescission decision to an
independent review organization, and a description of the
consequences of failure to appeal within that time limit; and
(7) a statement that there is no cost to the individual
to appeal the rescission decision to an independent review
organization.
Sec. 1202.105. INDEPENDENT REVIEW PROCESS; PAYMENT OF
CLAIMS. (a) An enrollee may appeal a health benefit plan issuer's
rescission decision to an independent review organization in the
manner prescribed by the commissioner by rule.
(b) A health benefit plan issuer shall comply with all
requests for information made by the independent review
organization and with the independent review organization's
determination regarding the appropriateness of the issuer's
decision to rescind.
(c) A health benefit plan issuer shall pay all otherwise
valid medical claims under an individual's plan until the later of:
(1) the date on which an independent review
organization determines that the decision to rescind is
appropriate; or
(2) the time to appeal to an independent review
organization has expired without an affected individual initiating
an appeal.
(d) The commissioner shall adopt rules necessary to
implement and enforce this section, including rules establishing
certification standards for independent review organizations for
purposes of this chapter.
Sec. 1202.106. BURDEN OF PROOF. In an appeal to an
independent review organization under Section 1202.105 or an
enforcement action or cause of action based on a violation of this
subchapter by a health benefit plan issuer, the health benefit plan
issuer must prove that the issuer did not violate this subchapter.
SECTION 5.02. The change in law made by this article applies
only to a health benefit plan that is delivered, issued for
delivery, or renewed on or after January 1, 2012. A health benefit
plan that is delivered, issued for delivery, or renewed before
January 1, 2012, is governed by the law as it existed immediately
before the effective date of this Act, and that law is continued in
effect for that purpose.
ARTICLE 6. HEALTH BENEFIT PLAN COVERAGE FOR CERTAIN CHILDREN
SECTION 6.01. Subtitle G, Title 8, Insurance Code, is
amended by adding Chapter 1521 to read as follows:
CHAPTER 1521. COVERAGE FOR CHILDREN; PREEXISTING CONDITIONS;
ENROLLMENT IN PLANS
Sec. 1521.001. DEFINITION. In this chapter, "preexisting
condition" means a condition present before the effective date of
an individual's coverage under a health benefit plan.
Sec. 1521.002. APPLICABILITY OF CHAPTER. (a) This chapter
applies only to a health benefit plan that provides benefits for
medical or surgical expenses incurred as a result of a health
condition, accident, or sickness, including an individual, group,
blanket, or franchise insurance policy or insurance agreement, a
group hospital service contract, or an individual or group evidence
of coverage or similar coverage document that is offered 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) This chapter applies to group health coverage made
available by a school district in accordance with Section 22.004,
Education Code.
(c) Notwithstanding Section 172.014, Local Government Code,
or any other law, this chapter applies to health and accident
coverage provided by a risk pool created under Chapter 172, Local
Government Code.
(d) Notwithstanding any provision in Chapter 1551, 1575,
1579, or 1601 or any other law, this chapter applies to:
(1) a basic coverage plan under Chapter 1551;
(2) a basic plan under Chapter 1575;
(3) a primary care coverage plan under Chapter 1579;
and
(4) basic coverage under Chapter 1601.
(e) Notwithstanding Section 1501.251 or any other law, this
chapter applies to coverage under a small or large employer health
benefit plan subject to Chapter 1501.
(f) Notwithstanding Section 1507.003 or 1507.053, this
chapter applies to a standard health benefit plan provided under
Chapter 1507.
Sec. 1521.003. EXCEPTION. This chapter does not apply to:
(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 dental or 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;
(4) medical payment insurance coverage provided under
a motor vehicle insurance policy; or
(5) a long-term care policy, including a nursing home
fixed indemnity policy, unless the commissioner determines that the
policy provides benefit coverage so comprehensive that the policy
is a health benefit plan as described by Section 1521.002.
Sec. 1521.004. PREEXISTING CONDITION PROVISION PROHIBITED.
A health benefit plan issuer may not, with respect to an individual
younger than 19 years of age:
(1) deny the individual's application for coverage due
to a preexisting condition;
(2) limit or deny coverage under the health benefit
plan to the individual on the basis that the benefits requested are
required to treat a preexisting condition; or
(3) charge the individual a premium in an amount that
is more than two times the premium charged by the health benefit
plan issuer to an individual younger than 19 years of age who does
not have a preexisting condition, if the individual enrolls in a
health benefit plan described by Section 1521.006 during an
enrollment period described by Section 1521.006.
Sec. 1521.005. COVERAGE FOR CERTAIN DEPENDENTS REQUIRED.
If a health benefit plan includes dependent coverage, the health
benefit plan issuer shall approve the enrollment of an individual
who is the minor child of an enrollee in the health benefit plan.
Sec. 1521.006. CHILD-ONLY PLANS REQUIRED; PENALTY. (a) A
health benefit plan issuer shall offer, market, and sell health
benefit plans in this state that exclusively cover individuals
younger than 19 years of age.
(b) A health benefit plan issuer that does not comply with
Subsection (a) may not issue new individual health benefit plans of
any nature in this state.
(c) The department by rule shall require a health benefit
plan issuer to have, and shall adopt rules concerning, enrollment
periods for applicants described by Subsection (a). A health
benefit plan issuer must have at least two enrollment periods per
year of at least 60 days each.
(d) During a required enrollment period, a health benefit
plan issuer must issue individual health benefit plan coverage on a
guaranteed issue basis to an applicant younger than 19 years of age
and may not issue a health benefit plan with a preexisting condition
exclusion rider or endorsement described by Section 1521.004.
(e) The department by rule shall adopt standard special
enrollment procedures in which an applicant described by Subsection
(a) may enroll in an individual health benefit plan under this
section on a guaranteed issue basis during a period other than an
enrollment period under Subsection (c) if the applicant or a
parent, managing conservator, or legal guardian of the applicant
experiences a qualifying event under the Health Insurance
Portability and Accountability Act of 1996 (42 U.S.C. Section 1320d
et seq.).
Sec. 1521.007. CONFLICT WITH OTHER LAW. If this chapter
conflicts with another law relating to coverage provided by a
health benefit plan to an individual who is younger than 19 years of
age, including a provision of Chapter 846, 1201, 1251, 1252, 1501,
1504, 1507, 1508, 1575, 1579, 1625, 1651, or 1652, this chapter
controls.
SECTION 6.02. Each health benefit plan issuer required to
issue individual health benefit plan coverage under Section
1521.005, Insurance Code, as added by this article, shall offer an
initial enrollment period satisfying the requirements of Section
1521.006(d), Insurance Code, as added by this article, beginning
not later than March 1, 2012. Notwithstanding Section 1521.005,
Insurance Code, as added by this article, the initial enrollment
period required by this section must be at least 90 days.
SECTION 6.03. This article applies only to a health benefit
plan that is delivered, issued for delivery, or renewed on or after
January 1, 2012. A health benefit plan that is delivered, issued
for delivery, or renewed before January 1, 2012, is governed by the
law as it existed immediately before the effective date of this Act,
and that law is continued in effect for that purpose.
ARTICLE 7. HEALTH BENEFIT PLAN COVERAGE FOR CERTAIN PREVENTIVE
CARE SERVICES
SECTION 7.01. Subtitle G, Title 8, Insurance Code, is
amended by adding Chapter 1522 to read as follows:
CHAPTER 1522. PREVENTIVE CARE SERVICES
Sec. 1522.001. APPLICABILITY OF CHAPTER. (a) This chapter
applies only to a health benefit plan that provides benefits for
medical or surgical expenses incurred as a result of a health
condition, accident, or sickness, including an individual, group,
blanket, or franchise insurance policy or insurance agreement, a
group hospital service contract, or an individual or group evidence
of coverage or similar coverage document that is offered 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) This chapter applies to group health coverage made
available by a school district in accordance with Section 22.004,
Education Code.
(c) Notwithstanding Section 172.014, Local Government Code,
or any other law, this chapter applies to health and accident
coverage provided by a risk pool created under Chapter 172, Local
Government Code.
(d) Notwithstanding any provision in Chapter 1551, 1575,
1579, or 1601 or any other law, this chapter applies to:
(1) a basic coverage plan under Chapter 1551;
(2) a basic plan under Chapter 1575;
(3) a primary care coverage plan under Chapter 1579;
and
(4) basic coverage under Chapter 1601.
(e) Notwithstanding Section 1501.251 or any other law, this
chapter applies to coverage under a small or large employer health
benefit plan subject to Chapter 1501.
(f) Notwithstanding Section 1507.003 or 1507.053, this
chapter applies to a standard health benefit plan provided under
Chapter 1507.
Sec. 1522.002. EXCEPTION. This chapter does not apply to:
(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 dental or 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;
(4) medical payment insurance coverage provided under
a motor vehicle insurance policy; or
(5) a long-term care policy, including a nursing home
fixed indemnity policy, unless the commissioner determines that the
policy provides benefit coverage so comprehensive that the policy
is a health benefit plan as described by Section 1522.001.
Sec. 1522.003. CERTAIN COST-SHARING PROVISIONS PROHIBITED.
A health benefit plan issuer may not impose a deductible,
copayment, coinsurance, or other cost-sharing provision applicable
to benefits for:
(1) a preventive item or service that has in effect a
rating of "A" or "B" in the most recent recommendations of the
United States Preventive Services Task Force;
(2) an immunization recommended for routine use in the
most recent immunization schedules published by the United States
Centers for Disease Control and Prevention of the United States
Public Health Service; or
(3) preventive care and screenings supported by the
most recent comprehensive guidelines adopted by the United States
Health Resources and Services Administration.
Sec. 1522.004. CONFLICT WITH OTHER LAW. If this chapter
conflicts with another law relating to the imposition of a
deductible, copayment, coinsurance, or other cost-sharing
provision, this chapter controls.
SECTION 7.02. This article applies only to a health benefit
plan that is delivered or issued for delivery on or after January 1,
2012. A health benefit plan that is delivered or issued for
delivery before January 1, 2012, is governed by the law as it
existed immediately before the effective date of this Act, and that
law is continued in effect for that purpose.
ARTICLE 8. CERTAIN LIFETIME AND ANNUAL LIMITATIONS ON HEALTH
BENEFIT PLAN COVERAGE
SECTION 8.01. Subtitle G, Title 8, Insurance Code, is
amended by adding Chapter 1523 to read as follows:
CHAPTER 1523. CERTAIN LIFETIME AND ANNUAL LIMITATIONS ON COVERAGE
PROHIBITED
Sec. 1523.001. APPLICABILITY OF CHAPTER. (a) This chapter
applies only to a health benefit plan that provides benefits for
medical or surgical expenses incurred as a result of a health
condition, accident, or sickness, including an individual, group,
blanket, or franchise insurance policy or insurance agreement, a
group hospital service contract, or an individual or group evidence
of coverage or similar coverage document that is offered 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) This chapter applies to group health coverage made
available by a school district in accordance with Section 22.004,
Education Code.
(c) Notwithstanding Section 172.014, Local Government Code,
or any other law, this chapter applies to health and accident
coverage provided by a risk pool created under Chapter 172, Local
Government Code.
(d) Notwithstanding any provision in Chapter 1551, 1575,
1579, or 1601 or any other law, this chapter applies to:
(1) a basic coverage plan under Chapter 1551;
(2) a basic plan under Chapter 1575;
(3) a primary care coverage plan under Chapter 1579;
and
(4) basic coverage under Chapter 1601.
(e) Notwithstanding Section 1501.251 or any other law, this
chapter applies to coverage under a small or large employer health
benefit plan subject to Chapter 1501.
(f) Notwithstanding Section 1507.003 or 1507.053, this
chapter applies to a standard health benefit plan provided under
Chapter 1507.
Sec. 1523.002. EXCEPTION. This chapter does not apply to:
(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 dental or 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;
(4) medical payment insurance coverage provided under
a motor vehicle insurance policy; or
(5) a long-term care policy, including a nursing home
fixed indemnity policy, unless the commissioner determines that the
policy provides benefit coverage so comprehensive that the policy
is a health benefit plan as described by Section 1523.001.
Sec. 1523.003. CERTAIN ANNUAL AND LIFETIME LIMITS
PROHIBITED; REENROLLMENT REQUIRED. A health benefit plan issuer
may not establish:
(1) a lifetime or annual benefit amount for an
enrollee in relation to essential health benefits listed in 42
U.S.C. Section 18022(b)(1) and other benefits identified by the
United States secretary of health and human services as essential
health benefits; or
(2) an annual limit on the services for which the
health benefit plan will provide coverage, including an annual
limit on an enrollee's number of:
(A) visits to a physician;
(B) days of inpatient or outpatient treatment; or
(C) prescription refills.
Sec. 1523.004. REINSTATEMENT OF COVERAGE. (a) A health
benefit plan issuer, with relation to a former enrollee whose
participation in or benefits under a health benefit plan terminated
by reason of the enrollee exceeding a lifetime maximum benefit,
shall:
(1) notify the former enrollee:
(A) that the lifetime maximum benefit no longer
applies to the former enrollee; and
(B) that the former enrollee is eligible to
reenroll in a health benefit plan issued by the health benefit plan
issuer; and
(2) on request of the former enrollee, enroll the
former enrollee in a health benefit plan that is identical or
substantially similar to the enrollee's former health benefit plan.
(b) The notice required by Subsection (a) must be mailed to
the former enrollee at the enrollee's last known address as shown in
the records of the health benefit plan issuer.
Sec. 1523.005. CONFLICT WITH OTHER LAW. If this chapter
conflicts with another law relating to lifetime or annual benefit
limits or annual limits for specified services under a health
benefit plan, this chapter controls.
SECTION 8.02. Each health benefit plan issuer required to
offer to former enrollees reenrollment in a health benefit plan
under Section 1523.004, Insurance Code, as added by this article,
shall send to each former enrollee entitled to a notice under that
section the notice required by that section not later than December
1, 2011.
SECTION 8.03. (a) Except as provided by Subsection (b) of
this section, this article applies only to a health benefit plan
that is delivered, issued for delivery, or renewed on or after
January 1, 2012. A health benefit plan that is delivered, issued
for delivery, or renewed before January 1, 2012, is governed by the
law as it existed immediately before the effective date of this Act,
and that law is continued in effect for that purpose.
(b) The change in law made by Section 1523.004, Insurance
Code, as added by this article, applies to a health benefit plan
that is delivered, issued for delivery, or renewed before, on, or
after January 1, 2012.
ARTICLE 9. EFFECTIVE DATE
SECTION 9.01. 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.