Texas 2019 - 86th Regular

Texas House Bill HB565 Compare Versions

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1	1	By: Coleman H.B. No. 565
2	2
3	3
4	4	A BILL TO BE ENTITLED
5	5	AN ACT
6	6	relating to healthcare coverage in this state.
7	7	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
8	8	ARTICLE 1. STATE MEDICAID PROGRAM
9	9	SECTION 1.01. Subtitle I, Title 4, Government Code, is
10	10	amended by adding Chapter 540 to read as follows:
11	11	SUBCHAPTER A. ACUTE CARE
12	12	Sec. 540.051. ELIGIBILITY FOR MEDICAID ACUTE CARE. (a) An
13	13	individual is eligible to receive acute care benefits under the
14	14	state Medicaid program if the individual:
15	15	(1) has a household income at or below 100 percent of
16	16	the federal poverty level;
17	17	(2) is under 19 years of age and:
18	18	(A) is receiving Supplemental Security Income
19	19	(SSI) under 42 U.S.C. Section 1381 et seq.; or
20	20	(B) is in foster care or resides in another
21	21	residential care setting under the conservatorship of the
22	22	Department of Family and Protective Services; or
23	23	(3) meets the eligibility requirements that were in
24	24	effect on September 1, 2013.
25	25	(b) The commission shall provide acute care benefits under
26	26	the state Medicaid program to each individual eligible under this
27	27	section through the most cost-effective means, as determined by the
28	28	commission.
29	29	(c) If an individual is not eligible for the state Medicaid
30	30	program under Subsection (a), the commission shall refer the
31	31	individual to the program established under Chapter 541 that helps
32	32	connect eligible residents with health benefit plan coverage
33	33	through private market solutions, a health benefit exchange, or any
34	34	other resource the commission determines appropriate.
35	35	Sec. 540.052. MEDICAID SLIDING SCALE SUBSIDIES. (a) An
36	36	individual who is eligible for the state Medicaid program under
37	37	Section 540.051 may receive a Medicaid sliding scale subsidy to
38	38	purchase a health benefit plan from an authorized health benefit
39	39	plan issuer.
40	40	(b) A sliding scale subsidy provided to an individual under
41	41	this section must:
42	42	(1) be based on:
43	43	(A) the average premium in the market; and
44	44	(B) a realistic assessment of the
45	45	individual's ability to pay a portion of the premium; and
46	46	(2) include an enhancement for individuals who choose
47	47	a high deductible health plan with a health savings account.
48	48	(c) The commission shall ensure that counselors are made
49	49	available to individuals receiving a subsidy to advise the
50	50	individuals on selecting a health benefit plan that meets the
51	51	individuals' needs.
52	52	(d) An individual receiving a subsidy under this section is
53	53	responsible for paying:
54	54	(1) any difference between the premium costs
55	55	associated with the purchase of a health benefit plan and the amount
56	56	of the individual's subsidy under this section; and
57	57	(2) any copayments associated with the health benefit
58	58	plan.
59	59	(e) If the amount of a subsidy received by an individual
60	60	under this section exceeds the premium costs associated with the
61	61	individual's purchase of a health benefit plan, the individual may
62	62	deposit the excess amount in a health savings account that may be
63	63	used only in the manner described by Section 540.054(b).
64	64	Sec. 540.053. ADDITIONAL COST-SHARING SUBSIDIES. In
65	65	addition to providing a subsidy to an individual under Section
66	66	540.052, the commission shall provide additional subsidies for
67	67	coinsurance payments, copayments, deductibles, and other
68	68	cost-sharing requirements associated with the individual's health
69	69	benefit plan. The commission shall provide the additional
70	70	subsidies on a sliding scale based on income.
71	71	Sec. 540.054. DELIVERY OF SUBSIDIES; HEALTH SAVINGS
72	72	ACCOUNTS. (a) The commission shall determine the most appropriate
73	73	manner for delivering and administering subsidies provided under
74	74	Sections 540.052 and 540.053. In determining the most appropriate
75	75	manner, the commission shall consider depositing subsidy amounts
76	76	for an individual in a health savings account established for that
77	77	individual.
78	78	(b) A health savings account established under this section
79	79	may be used only to:
80	80	(1) pay health benefit plan premiums and cost-sharing
81	81	amounts; and
82	82	(2) if appropriate, purchase health care-related
83	83	goods and services.
84	84	Sec. 540.055. MEDICAID HEALTH BENEFIT PLAN ISSUERS AND
85	85	MINIMUM COVERAGE. The commission shall allow any health benefit
86	86	plan issuer authorized to write health benefit plans in this state
87	87	to participate in the state Medicaid program. The commission in
88	88	consultation with the commissioner of insurance shall establish
89	89	minimum coverage requirements for a health benefit plan to be
90	90	eligible for purchase under the state Medicaid program, subject to
91	91	the requirements specified by this chapter.
92	92	Sec. 540.056. REINSURANCE FOR PARTICIPATING HEALTH BENEFIT
93	93	PLAN ISSUERS. (a) The commission in consultation with the
94	94	commissioner of insurance shall study a reinsurance program to
95	95	reinsure participating health benefit plan issuers.
96	96	(b) In examining options for a reinsurance program, the
97	97	commission and commissioner of insurance shall consider a plan
98	98	design under which:
99	99	(1) a participating health benefit plan is not charged
100	100	a premium for the reinsurance; and
101	101	(2) the health benefit plan issuer retains risk on a
102	102	sliding scale.
103	103	SUBCHAPTER B. LONG-TERM SERVICES AND SUPPORTS
104	104	Sec. 540.101. PLAN TO REFORM DELIVERY OF LONG-TERM SERVICES
105	105	AND SUPPORTS. The commission shall develop a comprehensive plan to
106	106	reform the delivery of long-term services and supports that is
107	107	designed to achieve the following objectives under the state
108	108	Medicaid program or any other program created as an alternative to
109	109	the state Medicaid program:
110	110	(1) encourage consumer direction;
111	111	(2) simplify and streamline the provision of services;
112	112	(3) provide flexibility to design benefits packages
113	113	that meet the needs of individuals receiving long-term services and
114	114	supports under the program;
115	115	(4) improve the cost-effectiveness and sustainability
116	116	of the provision of long-term services and supports;
117	117	(5) reduce reliance on institutional settings; and
118	118	(6) encourage cost sharing by family members when
119	119	appropriate.
120	120	ARTICLE 2. IMMEDIATE REFORM: PROGRAM TO ENSURE HEALTH BENEFIT
121	121	COVERAGE FOR CERTAIN INDIVIDUALS THROUGH PRIVATE MARKETPLACE
122	122	SECTION 2.01. Subtitle I, Title 4, Government Code, is
123	123	amended by adding Chapter 541 to read as follows:
124	124	CHAPTER 541. PROGRAM TO ENSURE HEALTH BENEFIT PLAN COVERAGE FOR
125	125	CERTAIN INDIVIDUALS THROUGH PRIVATE MARKET SOLUTIONS
126	126	SUBCHAPTER A. GENERAL PROVISIONS
127	127	Sec. 541.001. DEFINITION. In this chapter, "medical
128	128	assistance program" means the program established under Chapter 32,
129	129	Human Resources Code.
130	130	Sec. 541.002. CONFLICT WITH OTHER LAW. (a) Except as
131	131	provided by Subsection (b), to the extent of a conflict between a
132	132	provision of this chapter and:
133	133	(1) another provision of state law, the provision of
134	134	this chapter controls; and
135	135	(2) a provision of federal law or any authorization
136	136	described under Subchapter B, the federal law or authorization
137	137	controls.
138	138	(b) The program operated under this chapter is in addition
139	139	to any medical assistance program operated under a block grant
140	140	funding system under Chapter 540.
141	141	Sec. 541.003. PROGRAM FOR HEALTH BENEFIT PLAN COVERAGE
142	142	THROUGH PRIVATE MARKET SOLUTIONS. Subject to the requirements of
143	143	this chapter, the commission in consultation with the Texas
144	144	Department of Insurance shall develop and implement a program that
145	145	helps connect certain low-income residents of this state with
146	146	health benefit plan coverage through private market solutions.
147	147	Sec. 541.004. NOT AN ENTITLEMENT. This chapter does not
148	148	establish an entitlement to assistance in obtaining health benefit
149	149	plan coverage.
150	150	Sec. 541.005. RULES. The executive commissioner shall
151	151	adopt rules necessary to implement this chapter.
152	152	SUBCHAPTER B. FEDERAL AUTHORIZATION
153	153	Sec. 541.051. FEDERAL AUTHORIZATION FOR FLEXIBILITY TO
154	154	ESTABLISH PROGRAM. (a) The commission in consultation with the
155	155	Texas Department of Insurance shall negotiate with the United
156	156	States secretary of health and human services, the federal Centers
157	157	for Medicare and Medicaid Services, and other appropriate persons
158	158	for purposes of seeking a waiver or other authorization necessary
159	159	to obtain the flexibility to use federal matching funds to help
160	160	provide, in accordance with Subchapter C, health benefit plan
161	161	coverage to certain low-income individuals through private market
162	162	solutions.
163	163	(b) Any agreement reached under this section must:
164	164	(1) create a program that is made cost neutral to this
165	165	state by:
166	166	(A) leveraging premium tax revenues; and
167	167	(B) achieving cost savings through offsets to
168	168	general revenue health care costs or the implementation of other
169	169	cost savings mechanisms;
170	170	(2) create more efficient health benefit plan coverage
171	171	options for eligible individuals through:
172	172	(A) program changes that may be made without the
173	173	need for additional federal approval; and
174	174	(B) program changes that require additional
175	175	federal approval;
176	176	(3) require the commission to achieve efficiency and
177	177	reduce unnecessary utilization, including duplication, of health
178	178	care services;
179	179	(4) be designed with the goals of:
180	180	(A) relieving local tax burdens;
181	181	(B) reducing general revenue reliance so as to
182	182	make general revenue available for other state priorities; and
183	183	(C) minimizing the impact of any federal health
184	184	care laws on Texas-based businesses; and
185	185	(5) afford this state the opportunity to develop a
186	186	state-specific way with benefits that specifically meet the unique
187	187	needs of this state's population.
188	188	(c) An agreement reached under this section may be:
189	189	(1) limited in duration; and
190	190	(2) contingent on continued funding by the federal
191	191	government.
192	192	SUBCHAPTER C. PROGRAM REQUIREMENTS
193	193	Sec. 541.101. ENROLLMENT ELIGIBILITY. (a) Subject to
194	194	Subsection (b), an individual may be eligible to enroll in a program
195	195	designed and established under this chapter if the person:
196	196	(1) is younger than 65;
197	197	(2) has a household income at or below 133 percent of
198	198	the federal poverty level; and
199	199	(3) is not otherwise eligible to receive benefits
200	200	under the medical assistance program, including through a program
201	201	operated under Chapter 540 through a block grant funding system or a
202	202	waiver, other than one granted under this chapter, to the program.
203	203	(b) The executive commissioner may amend or further define
204	204	the eligibility requirements of this section if the commission
205	205	determines it necessary to reach an agreement under Subchapter B.
206	206	Sec. 541.102. MINIMUM PROGRAM REQUIREMENTS. A program
207	207	designed and established under this chapter must:
208	208	(1) if cost-effective for this state, provide premium
209	209	assistance to purchase health benefit plan coverage in the private
210	210	market, including health benefit plan coverage offered through a
211	211	managed care delivery model;
212	212	(2) provide enrollees with access to health benefits,
213	213	including benefits provided through a managed care delivery model,
214	214	that:
215	215	(A) are tailored to the enrollees;
216	216	(B) provide levels of coverage that are
217	217	customized to meet health care needs of individuals within defined
218	218	categories of the enrolled population; and
219	219	(C) emphasize personal responsibility and
220	220	accountability through flexible and meaningful cost-sharing
221	221	requirements and wellness initiatives, including through
222	222	incentives for compliance with health, wellness, and treatment
223	223	strategies and disincentives for noncompliance;
224	224	(3) include pay-for-performance initiatives for
225	225	private health benefit plan issuers that participate in the
226	226	program;
227	227	(4) use technology to maximize the efficiency with
228	228	which the commission and any health benefit plan issuer, health
229	229	care provider, or managed care organization participating in the
230	230	program manages enrollee participation;
231	231	(5) allow recipients under the medical assistance
232	232	program to enroll in the program to receive premium assistance as an
233	233	alternative to the medical assistance program;
234	234	(6) encourage eligible individuals to enroll in other
235	235	private or employer-sponsored health benefit plan coverage, if
236	236	available and appropriate;
237	237	(7) encourage the utilization of health care services
238	238	in the most appropriate low-cost settings; and
239	239	(8) establish health savings accounts for enrollees,
240	240	as appropriate.
241	241	SECTION 2.02. The Health and Human Services Commission in
242	242	consultation with the Texas Department of Insurance and the
243	243	Medicaid Reform Task Force shall actively develop a proposal for
244	244	the authorization from the appropriate federal entity as required
245	245	by Subchapter B, Chapter 541, Government Code, as added by this
246	246	article. As soon as possible after the effective date of this Act,
247	247	the Health and Human Services Commission shall request and actively
248	248	pursue obtaining the authorization from the appropriate federal
249	249	entity.
250	250	ARTICLE 3. FEDERAL AUTHORIZATION
251	251	SECTION 3.01. Subject to Section 2.02 of this Act, if before
252	252	implementing any provision of this Act a state agency determines
253	253	that a waiver or authorization from a federal agency is necessary
254	254	for implementation of that provision, the agency affected by the
255	255	provision shall request the waiver or authorization and may delay
256	256	implementing that provision until the waiver or authorization is
257	257	granted.
258	258	ARTICLE 4. HEALTH BENEFIT AFFORDABILITY AND ACCESSIBILITY
259	259	SECTION 4.01. Subtitle A, Title 8, Insurance Code, is
260	260	amended by adding Chapter 1218 to read as follows:
261	261	CHAPTER 1218. HEALTH BENEFIT AFFORDABILITY AND ACCESSIBILITY
262	262	SUBCHAPTER A. GENERAL PROVISIONS
263	263	Sec. 1218.001. APPLICABILITY OF CHAPTER. (a) This chapter
264	264	applies only to a health benefit plan that provides benefits for
265	265	medical or surgical expenses incurred as a result of a health
266	266	condition, accident, or sickness, including an individual, group,
267	267	blanket, or franchise insurance policy or insurance agreement, a
268	268	group hospital service contract, or an individual or group evidence
269	269	of coverage or similar coverage document that is issued by:
270	270	(1) an insurance company;
271	271	(2) a group hospital service corporation operating
272	272	under Chapter 842;
273	273	(3) a health maintenance organization operating under
274	274	Chapter 843;
275	275	(4) an approved nonprofit health corporation that
276	276	holds a certificate of authority under Chapter 844;
277	277	(5) a multiple employer welfare arrangement that holds
278	278	a certificate of authority under Chapter 846;
279	279	(6) a stipulated premium company operating under
280	280	Chapter 884;
281	281	(7) a fraternal benefit society operating under
282	282	Chapter 885;
283	283	(8) a Lloyd's plan operating under Chapter 941; or
284	284	(9) an exchange operating under Chapter 942.
285	285	(b) Notwithstanding any other law, this chapter applies to:
286	286	(1) a small employer health benefit plan subject to
287	287	Chapter 1501, including coverage provided through a health group
288	288	cooperative under Subchapter B of that chapter;
289	289	(2) a standard health benefit plan issued under
290	290	Chapter 1507;
291	291	(3) a basic coverage plan under Chapter 1551;
292	292	(4) a basic plan under Chapter 1575;
293	293	(5) a primary care coverage plan under Chapter 1579;
294	294	(6) a plan providing basic coverage under Chapter
295	295	1601;
296	296	(7) health benefits provided by or through a church
297	297	benefits board under Subchapter I, Chapter 22, Business
298	298	Organizations Code;
299	299	(8) group health coverage made available by a school
300	300	district in accordance with Section 22.004, Education Code;
301	301	(9) the state Medicaid program, including the Medicaid
302	302	managed care program operated under Chapter 533, Government Code;
303	303	(10) the child health plan program under Chapter 62,
304	304	Health and Safety Code;
305	305	(11) a regional or local health care program operated
306	306	under Section 75.104, Health and Safety Code;
307	307	(12) a self-funded health benefit plan sponsored by a
308	308	professional employer organization under Chapter 91, Labor Code;
309	309	(13) county employee group health benefits provided
310	310	under Chapter 157, Local Government Code; and
311	311	(14) health and accident coverage provided by a risk
312	312	pool created under Chapter 172, Local Government Code.
313	313	(c) This chapter applies to coverage under a group health
314	314	benefit plan provided to a resident of this state regardless of
315	315	whether the group policy, agreement, or contract is delivered,
316	316	issued for delivery, or renewed in this state.
317	317	Sec. 1218.002. EXCEPTIONS. (a) This chapter does not apply
318	318	to:
319	319	(1) a plan that provides coverage:
320	320	(A) for wages or payments in lieu of wages for a
321	321	period during which an employee is absent from work because of
322	322	sickness or injury;
323	323	(B) as a supplement to a liability insurance
324	324	policy;
325	325	(C) for credit insurance;
326	326	(D) only for dental or vision care;
327	327	(E) only for hospital expenses; or
328	328	(F) only for indemnity for hospital confinement;
329	329	(2) a Medicare supplemental policy as defined by
330	330	Section 1882(g)(1), Social Security Act (42 U.S.C. Section
331	331	1395ss(g)(1));
332	332	(3) a workers' compensation insurance policy;
333	333	(4) medical payment insurance coverage provided under
334	334	a motor vehicle insurance policy; or
335	335	(5) a long-term care policy, including a nursing home
336	336	fixed indemnity policy, unless the commissioner determines that the
337	337	policy provides benefit coverage so comprehensive that the policy
338	338	is a health benefit plan as described by Section 1218.001.
339	339	(b) This chapter does not apply to an individual health
340	340	benefit plan issued on or before March 23, 2010, that has not had
341	341	any significant changes since that date that reduce benefits or
342	342	increase costs to the individual.
343	343	Sec. 1218.003. CONFLICT WITH OTHER LAW. If this chapter
344	344	conflicts with another law relating to lifetime or annual benefit
345	345	limits or the imposition of a premium, deductible, copayment,
346	346	coinsurance, or other cost-sharing provision, this chapter
347	347	controls.
348	348	SUBCHAPTER B. CERTAIN COST-SHARING AND COVERAGE AMOUNT LIMITS
349	349	PROHIBITED
350	350	Sec. 1218.051. CERTAIN COST-SHARING PROVISIONS FOR
351	351	PREVENTIVE SERVICES PROHIBITED. A health benefit plan issuer may
352	352	not impose a deductible, copayment, coinsurance, or other
353	353	cost-sharing provision applicable to benefits for:
354	354	(1) a preventive item or service that has in effect a
355	355	rating of "A" or "B" in the most recent recommendations of the
356	356	United States Preventive Services Task Force;
357	357	(2) an immunization recommended for routine use in the
358	358	most recent immunization schedules published by the United States
359	359	Centers for Disease Control and Prevention of the United States
360	360	Public Health Service; or
361	361	(3) preventive care and screenings supported by the
362	362	most recent comprehensive guidelines adopted by the United States
363	363	Health Resources and Services Administration.
364	364	Sec. 1218.052. CERTAIN ANNUAL AND LIFETIME LIMITS
365	365	PROHIBITED. A health benefit plan issuer may not establish an
366	366	annual or lifetime benefit amount for an enrollee in relation to
367	367	essential health benefits listed in 42 U.S.C. Section 18022(b)(1),
368	368	as that section existed on January 1, 2019, and other benefits
369	369	identified by the United States secretary of health and human
370	370	services as essential health benefits as of that date.
371	371	Sec. 1218.053. LIMITATIONS ON COST-SHARING. A health
372	372	benefit plan issuer may not impose cost-sharing requirements that
373	373	exceed the limits established in 42 U.S.C. Section 18022(c)(1) in
374	374	relation to essential health benefits listed in 42 U.S.C. Section
375	375	18022(b)(1), as those sections existed on January 1, 2019, and
376	376	other benefits identified by the United States secretary of health
377	377	and human services as essential health benefits as of that date.
378	378	Sec. 1218.054. DISCRIMINATION BASED ON GENDER PROHIBITED. A
379	379	health benefit plan issuer may not charge an individual a higher
380	380	premium rate based on the individual's gender.
381	381	SUBCHAPTER C. COVERAGE OF PREEXISTING CONDITIONS
382	382	Sec. 1218.101. DEFINITION. In this subchapter,
383	383	"preexisting condition" means a condition present before the
384	384	effective date of an individual's coverage under a health benefit
385	385	plan.
386	386	Sec. 1218.102. PREEXISTING CONDITION RESTRICTIONS
387	387	PROHIBITED. Notwithstanding any other law, a health benefit plan
388	388	issuer may not:
389	389	(1) deny an individual's application for coverage or
390	390	refuse to enroll an individual in a health benefit plan due to a
391	391	preexisting condition;
392	392	(2) limit or exclude coverage under the health benefit
393	393	plan for the treatment of a preexisting condition otherwise covered
394	394	under the plan; or
395	395	(3) charge the individual more for coverage than the
396	396	health benefit plan issuer charges an individual who does not have a
397	397	preexisting condition.
398	398	SUBCHAPTER D. EXTERNAL REVIEW PROCEDURE
399	399	Sec. 1218.151. EXTERNAL REVIEW MODEL ACT RULES. (a) The
400	400	department shall adopt rules as necessary to conform Texas law with
401	401	the requirements of the NAIC Uniform Health Carrier External Review
402	402	Model Act (April 2010).
403	403	(b) To the extent that the rules adopted under this section
404	404	conflict with Chapter 843 or Title 14, the rules control.
405	405	ARTICLE 5. HEALTH BENEFIT PLAN COVERAGE FOR MENTAL HEALTH
406	406	CONDITIONS AND SUBSTANCE USE DISORDERS
407	407	SECTION 5.01. Chapter 1355, Insurance Code, is amended by
408	408	adding Subchapter F to read as follows:
409	409	SUBCHAPTER F. COVERAGE FOR MENTAL HEALTH CONDITIONS AND SUBSTANCE
410	410	USE DISORDERS
411	411	Sec. 1355.251. DEFINITIONS. In this subchapter:
412	412	(1) "Financial requirement" includes a requirement
413	413	relating to a deductible, copayment, coinsurance, or other
414	414	out-of-pocket expense or an annual or lifetime limit.
415	415	(2) "Mental health benefit" means a benefit relating
416	416	to an item or service for a mental health condition, as defined
417	417	under the terms of a health benefit plan and in accordance with
418	418	applicable federal and state law.
419	419	(3) "Nonquantitative treatment limitation" includes:
420	420	(A) a medical management standard limiting or
421	421	excluding benefits based on medical necessity or medical
422	422	appropriateness or based on whether a treatment is experimental or
423	423	investigational;
424	424	(B) formulary design for prescription drugs;
425	425	(C) network tier design;
426	426	(D) a standard for provider participation in a
427	427	network, including reimbursement rates;
428	428	(E) a method used by a health benefit plan to
429	429	determine usual, customary, and reasonable charges;
430	430	(F) a step therapy protocol;
431	431	(G) an exclusion based on failure to complete a
432	432	course of treatment; and
433	433	(H) a restriction based on geographic location,
434	434	facility type, provider specialty, and other criteria that limit
435	435	the scope or duration of a benefit.
436	436	(4) "Substance use disorder benefit" means a benefit
437	437	relating to an item or service for a substance use disorder, as
438	438	defined under the terms of a health benefit plan and in accordance
439	439	with applicable federal and state law.
440	440	(5) "Treatment limitation" includes a limit on the
441	441	frequency of treatment, number of visits, days of coverage, or
442	442	other similar limit on the scope or duration of treatment. The term
443	443	includes a nonquantitative treatment limitation.
444	444	Sec. 1355.252. APPLICABILITY OF SUBCHAPTER. (a) This
445	445	subchapter applies only to a health benefit plan that provides
446	446	benefits for medical or surgical expenses incurred as a result of a
447	447	health condition, accident, or sickness, including an individual,
448	448	group, blanket, or franchise insurance policy or insurance
449	449	agreement, a group hospital service contract, or an individual or
450	450	group evidence of coverage or similar coverage document that is
451	451	issued by:
452	452	(1) an insurance company;
453	453	(2) a group hospital service corporation operating
454	454	under Chapter 842;
455	455	(3) a health maintenance organization operating under
456	456	Chapter 843;
457	457	(4) an approved nonprofit health corporation that
458	458	holds a certificate of authority under Chapter 844;
459	459	(5) a multiple employer welfare arrangement that holds
460	460	a certificate of authority under Chapter 846;
461	461	(6) a stipulated premium company operating under
462	462	Chapter 884;
463	463	(7) a fraternal benefit society operating under
464	464	Chapter 885;
465	465	(8) a Lloyd's plan operating under Chapter 941; or
466	466	(9) an exchange operating under Chapter 942.
467	467	(b) Notwithstanding any other law, this subchapter applies
468	468	to:
469	469	(1) a small employer health benefit plan subject to
470	470	Chapter 1501, including coverage provided through a health group
471	471	cooperative under Subchapter B of that chapter;
472	472	(2) a standard health benefit plan issued under
473	473	Chapter 1507;
474	474	(3) a basic coverage plan under Chapter 1551;
475	475	(4) a basic plan under Chapter 1575;
476	476	(5) a primary care coverage plan under Chapter 1579;
477	477	(6) a plan providing basic coverage under Chapter
478	478	1601;
479	479	(7) health benefits provided by or through a church
480	480	benefits board under Subchapter I, Chapter 22, Business
481	481	Organizations Code;
482	482	(8) group health coverage made available by a school
483	483	district in accordance with Section 22.004, Education Code;
484	484	(9) the state Medicaid program, including the Medicaid
485	485	managed care program operated under Chapter 533, Government Code;
486	486	(10) the child health plan program under Chapter 62,
487	487	Health and Safety Code;
488	488	(11) a regional or local health care program operated
489	489	under Section 75.104, Health and Safety Code;
490	490	(12) a self-funded health benefit plan sponsored by a
491	491	professional employer organization under Chapter 91, Labor Code;
492	492	(13) county employee group health benefits provided
493	493	under Chapter 157, Local Government Code; and
494	494	(14) health and accident coverage provided by a risk
495	495	pool created under Chapter 172, Local Government Code.
496	496	(c) This subchapter applies to coverage under a group health
497	497	benefit plan provided to a resident of this state regardless of
498	498	whether the group policy, agreement, or contract is delivered,
499	499	issued for delivery, or renewed in this state.
500	500	Sec. 1355.253. EXCEPTION. This subchapter does not apply
501	501	to an individual health benefit plan issued on or before March 23,
502	502	2010, that has not had any significant changes since that date that
503	503	reduce benefits or increase costs to the individual.
504	504	Sec. 1355.254. REQUIRED COVERAGE FOR MENTAL HEALTH
505	505	CONDITIONS AND SUBSTANCE USE DISORDERS. (a) A health benefit plan
506	506	must provide benefits for mental health conditions and substance
507	507	use disorders under the same terms and conditions applicable to
508	508	benefits for medical or surgical expenses.
509	509	(b) Coverage under Subsection (a) may not impose treatment
510	510	limitations or financial requirements on benefits for a mental
511	511	health condition or substance use disorder that are generally more
512	512	restrictive than treatment limitations or financial requirements
513	513	imposed on coverage of benefits for medical or surgical expenses.
514	514	Sec. 1355.255. DEFINITIONS UNDER PLAN. (a) A health
515	515	benefit plan must define a condition to be a mental health condition
516	516	or not a mental health condition in a manner consistent with
517	517	generally recognized independent standards of medical practice.
518	518	(b) A health benefit plan must define a condition to be a
519	519	substance use disorder or not a substance use disorder in a manner
520	520	consistent with generally recognized independent standards of
521	521	medical practice.
522	522	Sec. 1355.256. COORDINATION WITH OTHER LAW; INTENT OF
523	523	LEGISLATURE. This subchapter supplements Subchapters A and B of
524	524	this chapter and Chapter 1368 and the department rules adopted
525	525	under those statutes. It is the intent of the legislature that
526	526	Subchapter A or B of this chapter or Chapter 1368 or the department
527	527	rules adopted under those statutes controls in any circumstance in
528	528	which that other law requires:
529	529	(1) a benefit that is not required by this subchapter;
530	530	or
531	531	(2) a more extensive benefit than is required by this
532	532	subchapter.
533	533	Sec. 1355.257. RULES. The commissioner shall adopt rules
534	534	necessary to implement this subchapter.
535	535	ARTICLE 6. COVERAGE OF ESSENTIAL HEALTH BENEFITS
536	536	SECTION 6.01. Subtitle E, Title 8, Insurance Code, is
537	537	amended by adding Chapter 1380 to read as follows:
538	538	CHAPTER 1380. COVERAGE OF ESSENTIAL HEALTH BENEFITS
539	539	Sec. 1380.001. APPLICABILITY OF CHAPTER. (a) This chapter
540	540	applies only to a health benefit plan that provides benefits for
541	541	medical or surgical expenses incurred as a result of a health
542	542	condition, accident, or sickness, including an individual, group,
543	543	blanket, or franchise insurance policy or insurance agreement, a
544	544	group hospital service contract, or an individual or group evidence
545	545	of coverage or similar coverage document that is issued by:
546	546	(1) an insurance company;
547	547	(2) a group hospital service corporation operating
548	548	under Chapter 842;
549	549	(3) a health maintenance organization operating under
550	550	Chapter 843;
551	551	(4) an approved nonprofit health corporation that
552	552	holds a certificate of authority under Chapter 844;
553	553	(5) a multiple employer welfare arrangement that holds
554	554	a certificate of authority under Chapter 846;
555	555	(6) a stipulated premium company operating under
556	556	Chapter 884;
557	557	(7) a fraternal benefit society operating under
558	558	Chapter 885;
559	559	(8) a Lloyd's plan operating under Chapter 941; or
560	560	(9) an exchange operating under Chapter 942.
561	561	(b) Notwithstanding any other law, this chapter applies to:
562	562	(1) a small employer health benefit plan subject to
563	563	Chapter 1501, including coverage provided through a health group
564	564	cooperative under Subchapter B of that chapter;
565	565	(2) a standard health benefit plan issued under
566	566	Chapter 1507;
567	567	(3) a basic coverage plan under Chapter 1551;
568	568	(4) a basic plan under Chapter 1575;
569	569	(5) a primary care coverage plan under Chapter 1579;
570	570	(6) a plan providing basic coverage under Chapter
571	571	1601;
572	572	(7) health benefits provided by or through a church
573	573	benefits board under Subchapter I, Chapter 22, Business
574	574	Organizations Code;
575	575	(8) group health coverage made available by a school
576	576	district in accordance with Section 22.004, Education Code;
577	577	(9) the state Medicaid program, including the Medicaid
578	578	managed care program operated under Chapter 533, Government Code;
579	579	(10) the child health plan program under Chapter 62,
580	580	Health and Safety Code;
581	581	(11) a regional or local health care program operated
582	582	under Section 75.104, Health and Safety Code;
583	583	(12) a self-funded health benefit plan sponsored by a
584	584	professional employer organization under Chapter 91, Labor Code;
585	585	(13) county employee group health benefits provided
586	586	under Chapter 157, Local Government Code; and
587	587	(14) health and accident coverage provided by a risk
588	588	pool created under Chapter 172, Local Government Code.
589	589	(c) This chapter applies to coverage under a group health
590	590	benefit plan provided to a resident of this state regardless of
591	591	whether the group policy, agreement, or contract is delivered,
592	592	issued for delivery, or renewed in this state.
593	593	Sec. 1380.002. EXCEPTION. This chapter does not apply to an
594	594	individual health benefit plan issued on or before March 23, 2010,
595	595	that has not had any significant changes since that date that reduce
596	596	benefits or increase costs to the individual.
597	597	Sec. 1380.003. REQUIRED COVERAGE FOR ESSENTIAL HEALTH
598	598	BENEFITS. A health benefit plan must provide coverage for the
599	599	essential health benefits listed in 42 U.S.C. Section 18022(b)(1),
600	600	as that section existed on January 1, 2019, and other benefits
601	601	identified by the United States secretary of health and human
602	602	services as essential health benefits as of that date.
603	603	ARTICLE 7. HEALTH BENEFIT PLAN COVERAGE FOR CERTAIN YOUNG ADULTS
604	604	SECTION 7.01. Subchapter A, Chapter 533, Government Code,
605	605	is amended by adding Section 533.0054 to read as follows:
606	606	Sec. 533.0054. ELIGIBILITY AGE FOR STAR HEALTH COVERAGE. A
607	607	child enrolled in the STAR Health Medicaid managed care program is
608	608	eligible to receive health care services under the program until
609	609	the child is 26 years of age.
610	610	SECTION 7.02. Section 846.260, Insurance Code, is amended
611	611	to read as follows:
612	612	Sec. 846.260. LIMITING AGE APPLICABLE TO UNMARRIED CHILD.
613	613	If children are eligible for coverage under the terms of a multiple
614	614	employer welfare arrangement's plan document, any limiting age
615	615	applicable to an unmarried child of an enrollee is 26 [25] years of
616	616	age.
617	617	SECTION 7.03. Section 1201.053(b), Insurance Code, is
618	618	amended to read as follows:
619	619	(b) On the application of an adult member of a family, an
620	620	individual accident and health insurance policy may, at the time of
621	621	original issuance or by subsequent amendment, insure two or more
622	622	eligible members of the adult's family, including a spouse,
623	623	unmarried children younger than 26 [25] years of age, including a
624	624	grandchild of the adult as described by Section 1201.062(a)(1), a
625	625	child the adult is required to insure under a medical support order
626	626	or dental support order, if the policy provides dental coverage,
627	627	issued under Chapter 154, Family Code, or enforceable by a court in
628	628	this state, and any other individual dependent on the adult.
629	629	SECTION 7.04. Section 1201.062(a), Insurance Code, is
630	630	amended to read as follows:
631	631	(a) An individual or group accident and health insurance
632	632	policy that is delivered, issued for delivery, or renewed in this
633	633	state, including a policy issued by a corporation operating under
634	634	Chapter 842, or a self-funded or self-insured welfare or benefit
635	635	plan or program, to the extent that regulation of the plan or
636	636	program is not preempted by federal law, that provides coverage for
637	637	a child of an insured or group member, on payment of a premium, must
638	638	provide coverage for:
639	639	(1) each grandchild of the insured or group member if
640	640	the grandchild is:
641	641	(A) unmarried;
642	642	(B) younger than 26 [25] years of age; and
643	643	(C) a dependent of the insured or group member
644	644	for federal income tax purposes at the time application for
645	645	coverage of the grandchild is made; and
646	646	(2) each child for whom the insured or group member
647	647	must provide medical support or dental support, if the policy
648	648	provides dental coverage, under an order issued under Chapter 154,
649	649	Family Code, or enforceable by a court in this state.
650	650	SECTION 7.05. Section 1201.065(a), Insurance Code, is
651	651	amended to read as follows:
652	652	(a) An individual or group accident and health insurance
653	653	policy may contain criteria relating to a maximum age or enrollment
654	654	in school to establish continued eligibility for coverage of a
655	655	child 26 [25] years of age or older.
656	656	SECTION 7.06. Section 1251.151(a), Insurance Code, is
657	657	amended to read as follows:
658	658	(a) A group policy or contract of insurance for hospital,
659	659	surgical, or medical expenses incurred as a result of accident or
660	660	sickness, including a group contract issued by a group hospital
661	661	service corporation, that provides coverage under the policy or
662	662	contract for a child of an insured must, on payment of a premium,
663	663	provide coverage for any grandchild of the insured if the
664	664	grandchild is:
665	665	(1) unmarried;
666	666	(2) younger than 26 [25] years of age; and
667	667	(3) a dependent of the insured for federal income tax
668	668	purposes at the time the application for coverage of the grandchild
669	669	is made.
670	670	SECTION 7.07. Section 1251.152(a), Insurance Code, is
671	671	amended to read as follows:
672	672	(a) For purposes of this section, "dependent" includes:
673	673	(1) a child of an employee or member who is:
674	674	(A) unmarried; and
675	675	(B) younger than 26 [25] years of age; and
676	676	(2) a grandchild of an employee or member who is:
677	677	(A) unmarried;
678	678	(B) younger than 26 [25] years of age; and
679	679	(C) a dependent of the insured for federal income
680	680	tax purposes at the time the application for coverage of the
681	681	grandchild is made.
682	682	SECTION 7.08. Section 1271.006(a), Insurance Code, is
683	683	amended to read as follows:
684	684	(a) If children are eligible for coverage under the terms of
685	685	an evidence of coverage, any limiting age applicable to an
686	686	unmarried child of an enrollee, including an unmarried grandchild
687	687	of an enrollee, is 26 [25] years of age. The limiting age
688	688	applicable to a child must be stated in the evidence of coverage.
689	689	SECTION 7.09. Section 1501.002(2), Insurance Code, is
690	690	amended to read as follows:
691	691	(2) "Dependent" means:
692	692	(A) a spouse;
693	693	(B) a child younger than 26 [25] years of age,
694	694	including a newborn child;
695	695	(C) a child of any age who is:
696	696	(i) medically certified as disabled; and
697	697	(ii) dependent on the parent;
698	698	(D) an individual who must be covered under:
699	699	(i) Section 1251.154; or
700	700	(ii) Section 1201.062; and
701	701	(E) any other child eligible under an employer's
702	702	health benefit plan, including a child described by Section
703	703	1503.003.
704	704	SECTION 7.10. Section 1501.609(b), Insurance Code, is
705	705	amended to read as follows:
706	706	(b) Any limiting age applicable under a large employer
707	707	health benefit plan to an unmarried child of an enrollee is 26 [25]
708	708	years of age.
709	709	SECTION 7.11. Sections 1503.003(a) and (b), Insurance Code,
710	710	are amended to read as follows:
711	711	(a) A health benefit plan may not condition coverage for a
712	712	child younger than 26 [25] years of age on the child's being
713	713	enrolled at an educational institution.
714	714	(b) A health benefit plan that requires as a condition of
715	715	coverage for a child 26 [25] years of age or older that the child be
716	716	a full-time student at an educational institution must provide the
717	717	coverage:
718	718	(1) for the entire academic term during which the
719	719	child begins as a full-time student and remains enrolled,
720	720	regardless of whether the number of hours of instruction for which
721	721	the child is enrolled is reduced to a level that changes the child's
722	722	academic status to less than that of a full-time student; and
723	723	(2) continuously until the 10th day of instruction of
724	724	the subsequent academic term, on which date the health benefit plan
725	725	may terminate coverage for the child if the child does not return to
726	726	full-time student status before that date.
727	727	SECTION 7.12. Section 1601.004(a), Insurance Code, is
728	728	amended to read as follows:
729	729	(a) In this chapter, "dependent," with respect to an
730	730	individual eligible to participate in the uniform program under
731	731	Section 1601.101 or 1601.102, means the individual's:
732	732	(1) spouse;
733	733	(2) unmarried child younger than 26
734	734	[25] years of age;
735	735	and
736	736	(3) child of any age who lives with or has the child's
737	737	care provided by the individual on a regular basis if the child has
738	738	a mental disability or is [mentally retarded or] physically
739	739	incapacitated to the extent that the child is dependent on the
740	740	individual for care or support, as determined by the system.
741	741	ARTICLE 8. TRANSITION; EFFECTIVE DATE
742	742	SECTION 8.01. The change in law made by this Act applies
743	743	only to a health benefit plan that is delivered, issued for
744	744	delivery, or renewed on or after January 1, 2020. A health benefit
745	745	plan that is delivered, issued for delivery, or renewed before
746	746	January 1, 2020, is governed by the law as it existed immediately
747	747	before the effective date of this Act, and that law is continued in
748	748	effect for that purpose.
749	749	SECTION 8.02. If before implementing any provision of this
750	750	Act a state agency determines that a waiver or authorization from a
751	751	federal agency is necessary for implementation of that provision,
752	752	the agency affected by the provision shall request the waiver or
753	753	authorization and may delay implementing that provision until the
754	754	waiver or authorization is granted.
755	755	SECTION 8.03. This Act takes effect September 1, 2019.