Texas 2015 - 84th Regular

Texas House Bill HB4016 Compare Versions

Only one version of the bill is available at this time.

Old	New	Differences
1	1	84R13564 PMO-D
2	2	By: Herrero H.B. No. 4016
3	3
4	4
5	5	A BILL TO BE ENTITLED
6	6	AN ACT
7	7	relating to coordination of health benefits under certain insurance
8	8	policies.
9	9	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
10	10	SECTION 1. Chapter 1203, Insurance Code, is amended by
11	11	adding Subchapter B to read as follows:
12	12	SUBCHAPTER B. MANDATED COORDINATION OF HEALTH BENEFITS
13	13	Sec. 1203.051. APPLICABILITY OF SUBCHAPTER. (a) This
14	14	subchapter applies only to a health benefit plan that provides
15	15	benefits for medical, surgical, or dental expenses incurred as a
16	16	result of a health condition, accident, or sickness, including an
17	17	individual, group, blanket, or franchise insurance policy or
18	18	insurance agreement, or a group hospital service contract, or an
19	19	individual or group evidence of coverage or similar coverage
20	20	document that is offered by:
21	21	(1) an insurance company;
22	22	(2) a group hospital service corporation operating
23	23	under Chapter 842;
24	24	(3) a fraternal benefit society operating under
25	25	Chapter 885;
26	26	(4) a stipulated premium company operating under
27	27	Chapter 884;
28	28	(5) a reciprocal exchange operating under Chapter 942;
29	29	(6) a Lloyd's plan operating under Chapter 941; or
30	30	(7) a health maintenance organization operating under
31	31	Chapter 843.
32	32	(b) This subchapter applies to group insurance contracts,
33	33	individual insurance contracts, and subscriber contracts that pay
34	34	or reimburse for the cost of dental care.
35	35	(c) This subchapter applies to the medical care components
36	36	of individual and group long-term care contracts.
37	37	(d) This subchapter does not apply to:
38	38	(1) workers' compensation insurance coverage;
39	39	(2) hospital indemnity coverage benefits or other
40	40	fixed indemnity coverage;
41	41	(3) accident-only coverage;
42	42	(4) specified disease or specified accident coverage;
43	43	(5) school accident-type coverages that cover
44	44	students for accidents only, including athletic injuries, either on
45	45	a "24-hour" or a "to and from school" basis;
46	46	(6) benefits provided in long-term care insurance
47	47	policies for nonmedical services, including personal care, adult
48	48	day care, homemaker services, assistance with activities of daily
49	49	living, respite care, custodial care, or payment of a fixed daily
50	50	benefit without regard to expenses incurred or the receipt of
51	51	services;
52	52	(7) Medicare supplement policies;
53	53	(8) a state plan under Medicaid;
54	54	(9) a governmental plan that by law provides benefits
55	55	that are in excess of those of any private insurance plan or other
56	56	nongovernmental plan; or
57	57	(10) an individual accident and health insurance
58	58	policy that is designed to fully integrate with other policies
59	59	through a variable deductible.
60	60	Sec. 1203.052. MANDATED COORDINATION OF BENEFITS. (a)
61	61	This subchapter applies if:
62	62	(1) an insured or enrollee is covered by two or more
63	63	insurance policies or other coverage documents; and
64	64	(2) each policy or other coverage document provides
65	65	the insured or enrollee benefits for medical, surgical, or dental
66	66	expenses.
67	67	(b) The primary health benefit plan issuer, as determined
68	68	under Section 1203.053, is responsible for expenses covered under
69	69	the insurance policy or other coverage document issued by the
70	70	primary health benefit plan issuer up to the full amount of the
71	71	applicable policy or document limit.
72	72	(c) Before the limit described by Subsection (b) is reached,
73	73	the secondary health benefit plan issuer, as determined under
74	74	Section 1203.053, is responsible only for the expenses covered
75	75	under the insurance policy or other coverage document issued by the
76	76	secondary health benefit plan issuer that are not covered under the
77	77	policy or document issued by the primary health benefit plan
78	78	issuer.
79	79	(d) After the limit described by Subsection (b) has been
80	80	reached, the secondary health benefit plan issuer, in addition to
81	81	the responsibility described by Subsection (c), is responsible for
82	82	any expenses covered by both policies or documents that exceed the
83	83	limit described by Subsection (b), up to the full amount of the
84	84	applicable limit of the insurance policy or other coverage document
85	85	issued by the secondary health benefit plan issuer.
86	86	Sec. 1203.053. DETERMINATION OF ORDER OF BENEFITS. (a)
87	87	Except as provided by Subsections (b) and (c), if the person
88	88	receiving benefits under an insurance policy or other coverage
89	89	document:
90	90	(1) is named as insured or enrollee, the policy or
91	91	coverage document is primary; or
92	92	(2) is not named as insured or enrollee, the policy or
93	93	coverage document is secondary to a primary policy or coverage
94	94	document.
95	95	(b) If a dependent child is covered under two or more
96	96	insurance policies or coverage documents:
97	97	(1) the primary policy or coverage document is the
98	98	policy or coverage document of the insured or enrollee whose
99	99	birthday is earlier in the calendar year than the insured or
100	100	enrollee of other policies or coverage documents that provide
101	101	coverage to the child; or
102	102	(2) if the insureds or enrollees under the policies or
103	103	coverage documents have the same birthday, the policy or coverage
104	104	document that has been in effect longest is primary.
105	105	(c) A determination of the order of benefits made under
106	106	Subsection (a) or (b) may be superseded by a court order under
107	107	Section 154.182, Family Code.
108	108	Sec. 1203.054. CERTAIN COORDINATION OF BENEFITS PROVISIONS
109	109	PROHIBITED. An insurance policy or other coverage document subject
110	110	to this subchapter may not be delivered, issued for delivery, or
111	111	renewed in this state if:
112	112	(1) a provision of the policy or document excludes or
113	113	reduces the payment of benefits for medical, surgical, or dental
114	114	expenses to or on behalf of an insured or enrollee;
115	115	(2) the reason for the exclusion or reduction is that
116	116	benefits are payable or have been paid to or on behalf of the
117	117	insured or enrollee under another insurance policy or coverage
118	118	document; and
119	119	(3) the exclusion or reduction applies before the full
120	120	amount of the expenses incurred by the insured or enrollee and
121	121	covered by both policies has been paid or reimbursed or the full
122	122	amount of the applicable limit of the policy or document containing
123	123	the exclusion or reduction is reached.
124	124	Sec. 1203.055. RESTRICTION ON COORDINATION OF BENEFITS
125	125	VOID. A provision of an insurance policy or other coverage document
126	126	that violates this subchapter is void.
127	127	SECTION 2. Chapter 1203, Insurance Code, is amended by
128	128	designating Sections 1203.001 through 1203.003 as Subchapter A and
129	129	adding a subchapter heading to read as follows:
130	130	SUBCHAPTER A. SUPPLEMENTAL INSURANCE POLICIES
131	131	SECTION 3. Section 1203.001, Insurance Code, is amended to
132	132	read as follows:
133	133	Sec. 1203.001. APPLICABILITY OF SUBCHAPTER [CHAPTER]. (a)
134	134	This subchapter [chapter] applies only to:
135	135	(1) a policy of group accident and health insurance as
136	136	described by Chapter 1251;
137	137	(2) a policy of blanket accident and health insurance
138	138	as described by Chapter 1251;
139	139	(3) a policy of individual accident and health
140	140	insurance as defined by Section 1201.001; or
141	141	(4) an evidence of coverage as defined by Section
142	142	843.002.
143	143	(b) This subchapter [chapter] does not apply to an
144	144	individual accident and health insurance policy that is designed to
145	145	fully integrate with other policies through a variable deductible.
146	146	SECTION 4. The change in law made by this Act applies only
147	147	to an insurance policy or other coverage document that is
148	148	delivered, issued for delivery, or renewed on or after January 1,
149	149	2016. A policy or document delivered, issued for delivery, or
150	150	renewed before January 1, 2016, is governed by the law as it existed
151	151	immediately before the effective date of this Act, and that law is
152	152	continued in effect for that purpose.
153	153	SECTION 5. This Act takes effect September 1, 2015.