84R13564 PMO-D
By: Herrero H.B. No. 4016
A BILL TO BE ENTITLED
AN ACT
relating to coordination of health benefits under certain insurance
policies.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Chapter 1203, Insurance Code, is amended by
adding Subchapter B to read as follows:
SUBCHAPTER B. MANDATED COORDINATION OF HEALTH BENEFITS
Sec. 1203.051. APPLICABILITY OF SUBCHAPTER. (a) This
subchapter applies only to a health benefit plan that provides
benefits for medical, surgical, or dental expenses incurred as a
result of a health condition, accident, or sickness, including an
individual, group, blanket, or franchise insurance policy or
insurance agreement, or 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; or
(7) a health maintenance organization operating under
Chapter 843.
(b) This subchapter applies to group insurance contracts,
individual insurance contracts, and subscriber contracts that pay
or reimburse for the cost of dental care.
(c) This subchapter applies to the medical care components
of individual and group long-term care contracts.
(d) This subchapter does not apply to:
(1) workers' compensation insurance coverage;
(2) hospital indemnity coverage benefits or other
fixed indemnity coverage;
(3) accident-only coverage;
(4) specified disease or specified accident coverage;
(5) school accident-type coverages that cover
students for accidents only, including athletic injuries, either on
a "24-hour" or a "to and from school" basis;
(6) benefits provided in long-term care insurance
policies for nonmedical services, including personal care, adult
day care, homemaker services, assistance with activities of daily
living, respite care, custodial care, or payment of a fixed daily
benefit without regard to expenses incurred or the receipt of
services;
(7) Medicare supplement policies;
(8) a state plan under Medicaid;
(9) a governmental plan that by law provides benefits
that are in excess of those of any private insurance plan or other
nongovernmental plan; or
(10) an individual accident and health insurance
policy that is designed to fully integrate with other policies
through a variable deductible.
Sec. 1203.052. MANDATED COORDINATION OF BENEFITS. (a)
This subchapter applies if:
(1) an insured or enrollee is covered by two or more
insurance policies or other coverage documents; and
(2) each policy or other coverage document provides
the insured or enrollee benefits for medical, surgical, or dental
expenses.
(b) The primary health benefit plan issuer, as determined
under Section 1203.053, is responsible for expenses covered under
the insurance policy or other coverage document issued by the
primary health benefit plan issuer up to the full amount of the
applicable policy or document limit.
(c) Before the limit described by Subsection (b) is reached,
the secondary health benefit plan issuer, as determined under
Section 1203.053, is responsible only for the expenses covered
under the insurance policy or other coverage document issued by the
secondary health benefit plan issuer that are not covered under the
policy or document issued by the primary health benefit plan
issuer.
(d) After the limit described by Subsection (b) has been
reached, the secondary health benefit plan issuer, in addition to
the responsibility described by Subsection (c), is responsible for
any expenses covered by both policies or documents that exceed the
limit described by Subsection (b), up to the full amount of the
applicable limit of the insurance policy or other coverage document
issued by the secondary health benefit plan issuer.
Sec. 1203.053. DETERMINATION OF ORDER OF BENEFITS. (a)
Except as provided by Subsections (b) and (c), if the person
receiving benefits under an insurance policy or other coverage
document:
(1) is named as insured or enrollee, the policy or
coverage document is primary; or
(2) is not named as insured or enrollee, the policy or
coverage document is secondary to a primary policy or coverage
document.
(b) If a dependent child is covered under two or more
insurance policies or coverage documents:
(1) the primary policy or coverage document is the
policy or coverage document of the insured or enrollee whose
birthday is earlier in the calendar year than the insured or
enrollee of other policies or coverage documents that provide
coverage to the child; or
(2) if the insureds or enrollees under the policies or
coverage documents have the same birthday, the policy or coverage
document that has been in effect longest is primary.
(c) A determination of the order of benefits made under
Subsection (a) or (b) may be superseded by a court order under
Section 154.182, Family Code.
Sec. 1203.054. CERTAIN COORDINATION OF BENEFITS PROVISIONS
PROHIBITED. An insurance policy or other coverage document subject
to this subchapter may not be delivered, issued for delivery, or
renewed in this state if:
(1) a provision of the policy or document excludes or
reduces the payment of benefits for medical, surgical, or dental
expenses to or on behalf of an insured or enrollee;
(2) the reason for the exclusion or reduction is that
benefits are payable or have been paid to or on behalf of the
insured or enrollee under another insurance policy or coverage
document; and
(3) the exclusion or reduction applies before the full
amount of the expenses incurred by the insured or enrollee and
covered by both policies has been paid or reimbursed or the full
amount of the applicable limit of the policy or document containing
the exclusion or reduction is reached.
Sec. 1203.055. RESTRICTION ON COORDINATION OF BENEFITS
VOID. A provision of an insurance policy or other coverage document
that violates this subchapter is void.
SECTION 2. Chapter 1203, Insurance Code, is amended by
designating Sections 1203.001 through 1203.003 as Subchapter A and
adding a subchapter heading to read as follows:
SUBCHAPTER A. SUPPLEMENTAL INSURANCE POLICIES
SECTION 3. Section 1203.001, Insurance Code, is amended to
read as follows:
Sec. 1203.001. APPLICABILITY OF SUBCHAPTER [CHAPTER]. (a)
This subchapter [chapter] applies only to:
(1) a policy of group accident and health insurance as
described by Chapter 1251;
(2) a policy of blanket accident and health insurance
as described by Chapter 1251;
(3) a policy of individual accident and health
insurance as defined by Section 1201.001; or
(4) an evidence of coverage as defined by Section
843.002.
(b) This subchapter [chapter] does not apply to an
individual accident and health insurance policy that is designed to
fully integrate with other policies through a variable deductible.
SECTION 4. The change in law made by this Act applies only
to an insurance policy or other coverage document that is
delivered, issued for delivery, or renewed on or after January 1,
2016. A policy or document delivered, issued for delivery, or
renewed before January 1, 2016, 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.
SECTION 5. This Act takes effect September 1, 2015.