By: Coleman H.B. No. 565
A BILL TO BE ENTITLED
AN ACT
relating to healthcare coverage in this state.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
ARTICLE 1. STATE MEDICAID PROGRAM
SECTION 1.01. Subtitle I, Title 4, Government Code, is
amended by adding Chapter 540 to read as follows:
SUBCHAPTER A. ACUTE CARE
Sec. 540.051. ELIGIBILITY FOR MEDICAID ACUTE CARE. (a) An
individual is eligible to receive acute care benefits under the
state Medicaid program if the individual:
(1) has a household income at or below 100 percent of
the federal poverty level;
(2) is under 19 years of age and:
(A) is receiving Supplemental Security Income
(SSI) under 42 U.S.C. Section 1381 et seq.; or
(B) is in foster care or resides in another
residential care setting under the conservatorship of the
Department of Family and Protective Services; or
(3) meets the eligibility requirements that were in
effect on September 1, 2013.
(b) The commission shall provide acute care benefits under
the state Medicaid program to each individual eligible under this
section through the most cost-effective means, as determined by the
commission.
(c) If an individual is not eligible for the state Medicaid
program under Subsection (a), the commission shall refer the
individual to the program established under Chapter 541 that helps
connect eligible residents with health benefit plan coverage
through private market solutions, a health benefit exchange, or any
other resource the commission determines appropriate.
Sec. 540.052. MEDICAID SLIDING SCALE SUBSIDIES. (a) An
individual who is eligible for the state Medicaid program under
Section 540.051 may receive a Medicaid sliding scale subsidy to
purchase a health benefit plan from an authorized health benefit
plan issuer.
(b) A sliding scale subsidy provided to an individual under
this section must:
(1) be based on:
(A) the average premium in the market; and
(B) a realistic assessment of the
individual's ability to pay a portion of the premium; and
(2) include an enhancement for individuals who choose
a high deductible health plan with a health savings account.
(c) The commission shall ensure that counselors are made
available to individuals receiving a subsidy to advise the
individuals on selecting a health benefit plan that meets the
individuals' needs.
(d) An individual receiving a subsidy under this section is
responsible for paying:
(1) any difference between the premium costs
associated with the purchase of a health benefit plan and the amount
of the individual's subsidy under this section; and
(2) any copayments associated with the health benefit
plan.
(e) If the amount of a subsidy received by an individual
under this section exceeds the premium costs associated with the
individual's purchase of a health benefit plan, the individual may
deposit the excess amount in a health savings account that may be
used only in the manner described by Section 540.054(b).
Sec. 540.053. ADDITIONAL COST-SHARING SUBSIDIES. In
addition to providing a subsidy to an individual under Section
540.052, the commission shall provide additional subsidies for
coinsurance payments, copayments, deductibles, and other
cost-sharing requirements associated with the individual's health
benefit plan. The commission shall provide the additional
subsidies on a sliding scale based on income.
Sec. 540.054. DELIVERY OF SUBSIDIES; HEALTH SAVINGS
ACCOUNTS. (a) The commission shall determine the most appropriate
manner for delivering and administering subsidies provided under
Sections 540.052 and 540.053. In determining the most appropriate
manner, the commission shall consider depositing subsidy amounts
for an individual in a health savings account established for that
individual.
(b) A health savings account established under this section
may be used only to:
(1) pay health benefit plan premiums and cost-sharing
amounts; and
(2) if appropriate, purchase health care-related
goods and services.
Sec. 540.055. MEDICAID HEALTH BENEFIT PLAN ISSUERS AND
MINIMUM COVERAGE. The commission shall allow any health benefit
plan issuer authorized to write health benefit plans in this state
to participate in the state Medicaid program. The commission in
consultation with the commissioner of insurance shall establish
minimum coverage requirements for a health benefit plan to be
eligible for purchase under the state Medicaid program, subject to
the requirements specified by this chapter.
Sec. 540.056. REINSURANCE FOR PARTICIPATING HEALTH BENEFIT
PLAN ISSUERS. (a) The commission in consultation with the
commissioner of insurance shall study a reinsurance program to
reinsure participating health benefit plan issuers.
(b) In examining options for a reinsurance program, the
commission and commissioner of insurance shall consider a plan
design under which:
(1) a participating health benefit plan is not charged
a premium for the reinsurance; and
(2) the health benefit plan issuer retains risk on a
sliding scale.
SUBCHAPTER B. LONG-TERM SERVICES AND SUPPORTS
Sec. 540.101. PLAN TO REFORM DELIVERY OF LONG-TERM SERVICES
AND SUPPORTS. The commission shall develop a comprehensive plan to
reform the delivery of long-term services and supports that is
designed to achieve the following objectives under the state
Medicaid program or any other program created as an alternative to
the state Medicaid program:
(1) encourage consumer direction;
(2) simplify and streamline the provision of services;
(3) provide flexibility to design benefits packages
that meet the needs of individuals receiving long-term services and
supports under the program;
(4) improve the cost-effectiveness and sustainability
of the provision of long-term services and supports;
(5) reduce reliance on institutional settings; and
(6) encourage cost sharing by family members when
appropriate.
ARTICLE 2. IMMEDIATE REFORM: PROGRAM TO ENSURE HEALTH BENEFIT
COVERAGE FOR CERTAIN INDIVIDUALS THROUGH PRIVATE MARKETPLACE
SECTION 2.01. Subtitle I, Title 4, Government Code, is
amended by adding Chapter 541 to read as follows:
CHAPTER 541. PROGRAM TO ENSURE HEALTH BENEFIT PLAN COVERAGE FOR
CERTAIN INDIVIDUALS THROUGH PRIVATE MARKET SOLUTIONS
SUBCHAPTER A. GENERAL PROVISIONS
Sec. 541.001. DEFINITION. In this chapter, "medical
assistance program" means the program established under Chapter 32,
Human Resources Code.
Sec. 541.002. CONFLICT WITH OTHER LAW. (a) Except as
provided by Subsection (b), to the extent of a conflict between a
provision of this chapter and:
(1) another provision of state law, the provision of
this chapter controls; and
(2) a provision of federal law or any authorization
described under Subchapter B, the federal law or authorization
controls.
(b) The program operated under this chapter is in addition
to any medical assistance program operated under a block grant
funding system under Chapter 540.
Sec. 541.003. PROGRAM FOR HEALTH BENEFIT PLAN COVERAGE
THROUGH PRIVATE MARKET SOLUTIONS. Subject to the requirements of
this chapter, the commission in consultation with the Texas
Department of Insurance shall develop and implement a program that
helps connect certain low-income residents of this state with
health benefit plan coverage through private market solutions.
Sec. 541.004. NOT AN ENTITLEMENT. This chapter does not
establish an entitlement to assistance in obtaining health benefit
plan coverage.
Sec. 541.005. RULES. The executive commissioner shall
adopt rules necessary to implement this chapter.
SUBCHAPTER B. FEDERAL AUTHORIZATION
Sec. 541.051. FEDERAL AUTHORIZATION FOR FLEXIBILITY TO
ESTABLISH PROGRAM. (a) The commission in consultation with the
Texas Department of Insurance shall negotiate with the United
States secretary of health and human services, the federal Centers
for Medicare and Medicaid Services, and other appropriate persons
for purposes of seeking a waiver or other authorization necessary
to obtain the flexibility to use federal matching funds to help
provide, in accordance with Subchapter C, health benefit plan
coverage to certain low-income individuals through private market
solutions.
(b) Any agreement reached under this section must:
(1) create a program that is made cost neutral to this
state by:
(A) leveraging premium tax revenues; and
(B) achieving cost savings through offsets to
general revenue health care costs or the implementation of other
cost savings mechanisms;
(2) create more efficient health benefit plan coverage
options for eligible individuals through:
(A) program changes that may be made without the
need for additional federal approval; and
(B) program changes that require additional
federal approval;
(3) require the commission to achieve efficiency and
reduce unnecessary utilization, including duplication, of health
care services;
(4) be designed with the goals of:
(A) relieving local tax burdens;
(B) reducing general revenue reliance so as to
make general revenue available for other state priorities; and
(C) minimizing the impact of any federal health
care laws on Texas-based businesses; and
(5) afford this state the opportunity to develop a
state-specific way with benefits that specifically meet the unique
needs of this state's population.
(c) An agreement reached under this section may be:
(1) limited in duration; and
(2) contingent on continued funding by the federal
government.
SUBCHAPTER C. PROGRAM REQUIREMENTS
Sec. 541.101. ENROLLMENT ELIGIBILITY. (a) Subject to
Subsection (b), an individual may be eligible to enroll in a program
designed and established under this chapter if the person:
(1) is younger than 65;
(2) has a household income at or below 133 percent of
the federal poverty level; and
(3) is not otherwise eligible to receive benefits
under the medical assistance program, including through a program
operated under Chapter 540 through a block grant funding system or a
waiver, other than one granted under this chapter, to the program.
(b) The executive commissioner may amend or further define
the eligibility requirements of this section if the commission
determines it necessary to reach an agreement under Subchapter B.
Sec. 541.102. MINIMUM PROGRAM REQUIREMENTS. A program
designed and established under this chapter must:
(1) if cost-effective for this state, provide premium
assistance to purchase health benefit plan coverage in the private
market, including health benefit plan coverage offered through a
managed care delivery model;
(2) provide enrollees with access to health benefits,
including benefits provided through a managed care delivery model,
that:
(A) are tailored to the enrollees;
(B) provide levels of coverage that are
customized to meet health care needs of individuals within defined
categories of the enrolled population; and
(C) emphasize personal responsibility and
accountability through flexible and meaningful cost-sharing
requirements and wellness initiatives, including through
incentives for compliance with health, wellness, and treatment
strategies and disincentives for noncompliance;
(3) include pay-for-performance initiatives for
private health benefit plan issuers that participate in the
program;
(4) use technology to maximize the efficiency with
which the commission and any health benefit plan issuer, health
care provider, or managed care organization participating in the
program manages enrollee participation;
(5) allow recipients under the medical assistance
program to enroll in the program to receive premium assistance as an
alternative to the medical assistance program;
(6) encourage eligible individuals to enroll in other
private or employer-sponsored health benefit plan coverage, if
available and appropriate;
(7) encourage the utilization of health care services
in the most appropriate low-cost settings; and
(8) establish health savings accounts for enrollees,
as appropriate.
SECTION 2.02. The Health and Human Services Commission in
consultation with the Texas Department of Insurance and the
Medicaid Reform Task Force shall actively develop a proposal for
the authorization from the appropriate federal entity as required
by Subchapter B, Chapter 541, Government Code, as added by this
article. As soon as possible after the effective date of this Act,
the Health and Human Services Commission shall request and actively
pursue obtaining the authorization from the appropriate federal
entity.
ARTICLE 3. FEDERAL AUTHORIZATION
SECTION 3.01. Subject to Section 2.02 of this Act, if before
implementing any provision of this Act a state agency determines
that a waiver or authorization from a federal agency is necessary
for implementation of that provision, the agency affected by the
provision shall request the waiver or authorization and may delay
implementing that provision until the waiver or authorization is
granted.
ARTICLE 4. HEALTH BENEFIT AFFORDABILITY AND ACCESSIBILITY
SECTION 4.01. Subtitle A, Title 8, Insurance Code, is
amended by adding Chapter 1218 to read as follows:
CHAPTER 1218. HEALTH BENEFIT AFFORDABILITY AND ACCESSIBILITY
SUBCHAPTER A. GENERAL PROVISIONS
Sec. 1218.001. 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 issued by:
(1) an insurance company;
(2) a group hospital service corporation operating
under Chapter 842;
(3) a health maintenance organization operating under
Chapter 843;
(4) an approved nonprofit health corporation that
holds a certificate of authority under Chapter 844;
(5) a multiple employer welfare arrangement that holds
a certificate of authority under Chapter 846;
(6) a stipulated premium company operating under
Chapter 884;
(7) a fraternal benefit society operating under
Chapter 885;
(8) a Lloyd's plan operating under Chapter 941; or
(9) an exchange operating under Chapter 942.
(b) Notwithstanding any other law, this chapter applies to:
(1) a small employer health benefit plan subject to
Chapter 1501, including coverage provided through a health group
cooperative under Subchapter B of that chapter;
(2) a standard health benefit plan issued under
Chapter 1507;
(3) a basic coverage plan under Chapter 1551;
(4) a basic plan under Chapter 1575;
(5) a primary care coverage plan under Chapter 1579;
(6) a plan providing basic coverage under Chapter
1601;
(7) health benefits provided by or through a church
benefits board under Subchapter I, Chapter 22, Business
Organizations Code;
(8) group health coverage made available by a school
district in accordance with Section 22.004, Education Code;
(9) the state Medicaid program, including the Medicaid
managed care program operated under Chapter 533, Government Code;
(10) the child health plan program under Chapter 62,
Health and Safety Code;
(11) a regional or local health care program operated
under Section 75.104, Health and Safety Code;
(12) a self-funded health benefit plan sponsored by a
professional employer organization under Chapter 91, Labor Code;
(13) county employee group health benefits provided
under Chapter 157, Local Government Code; and
(14) health and accident coverage provided by a risk
pool created under Chapter 172, Local Government Code.
(c) This chapter applies to coverage under a group health
benefit plan provided to a resident of this state regardless of
whether the group policy, agreement, or contract is delivered,
issued for delivery, or renewed in this state.
Sec. 1218.002. EXCEPTIONS. (a) 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(g)(1));
(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 1218.001.
(b) This chapter does not apply to an individual health
benefit plan issued on or before March 23, 2010, that has not had
any significant changes since that date that reduce benefits or
increase costs to the individual.
Sec. 1218.003. CONFLICT WITH OTHER LAW. If this chapter
conflicts with another law relating to lifetime or annual benefit
limits or the imposition of a premium, deductible, copayment,
coinsurance, or other cost-sharing provision, this chapter
controls.
SUBCHAPTER B. CERTAIN COST-SHARING AND COVERAGE AMOUNT LIMITS
PROHIBITED
Sec. 1218.051. CERTAIN COST-SHARING PROVISIONS FOR
PREVENTIVE SERVICES 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. 1218.052. CERTAIN ANNUAL AND LIFETIME LIMITS
PROHIBITED. A health benefit plan issuer may not establish an
annual or lifetime benefit amount for an enrollee in relation to
essential health benefits listed in 42 U.S.C. Section 18022(b)(1),
as that section existed on January 1, 2019, and other benefits
identified by the United States secretary of health and human
services as essential health benefits as of that date.
Sec. 1218.053. LIMITATIONS ON COST-SHARING. A health
benefit plan issuer may not impose cost-sharing requirements that
exceed the limits established in 42 U.S.C. Section 18022(c)(1) in
relation to essential health benefits listed in 42 U.S.C. Section
18022(b)(1), as those sections existed on January 1, 2019, and
other benefits identified by the United States secretary of health
and human services as essential health benefits as of that date.
Sec. 1218.054. DISCRIMINATION BASED ON GENDER PROHIBITED. A
health benefit plan issuer may not charge an individual a higher
premium rate based on the individual's gender.
SUBCHAPTER C. COVERAGE OF PREEXISTING CONDITIONS
Sec. 1218.101. DEFINITION. In this subchapter,
"preexisting condition" means a condition present before the
effective date of an individual's coverage under a health benefit
plan.
Sec. 1218.102. PREEXISTING CONDITION RESTRICTIONS
PROHIBITED. Notwithstanding any other law, a health benefit plan
issuer may not:
(1) deny an individual's application for coverage or
refuse to enroll an individual in a health benefit plan due to a
preexisting condition;
(2) limit or exclude coverage under the health benefit
plan for the treatment of a preexisting condition otherwise covered
under the plan; or
(3) charge the individual more for coverage than the
health benefit plan issuer charges an individual who does not have a
preexisting condition.
SUBCHAPTER D. EXTERNAL REVIEW PROCEDURE
Sec. 1218.151. EXTERNAL REVIEW MODEL ACT RULES. (a) The
department shall adopt rules as necessary to conform Texas law with
the requirements of the NAIC Uniform Health Carrier External Review
Model Act (April 2010).
(b) To the extent that the rules adopted under this section
conflict with Chapter 843 or Title 14, the rules control.
ARTICLE 5. HEALTH BENEFIT PLAN COVERAGE FOR MENTAL HEALTH
CONDITIONS AND SUBSTANCE USE DISORDERS
SECTION 5.01. Chapter 1355, Insurance Code, is amended by
adding Subchapter F to read as follows:
SUBCHAPTER F. COVERAGE FOR MENTAL HEALTH CONDITIONS AND SUBSTANCE
USE DISORDERS
Sec. 1355.251. DEFINITIONS. In this subchapter:
(1) "Financial requirement" includes a requirement
relating to a deductible, copayment, coinsurance, or other
out-of-pocket expense or an annual or lifetime limit.
(2) "Mental health benefit" means a benefit relating
to an item or service for a mental health condition, as defined
under the terms of a health benefit plan and in accordance with
applicable federal and state law.
(3) "Nonquantitative treatment limitation" includes:
(A) a medical management standard limiting or
excluding benefits based on medical necessity or medical
appropriateness or based on whether a treatment is experimental or
investigational;
(B) formulary design for prescription drugs;
(C) network tier design;
(D) a standard for provider participation in a
network, including reimbursement rates;
(E) a method used by a health benefit plan to
determine usual, customary, and reasonable charges;
(F) a step therapy protocol;
(G) an exclusion based on failure to complete a
course of treatment; and
(H) a restriction based on geographic location,
facility type, provider specialty, and other criteria that limit
the scope or duration of a benefit.
(4) "Substance use disorder benefit" means a benefit
relating to an item or service for a substance use disorder, as
defined under the terms of a health benefit plan and in accordance
with applicable federal and state law.
(5) "Treatment limitation" includes a limit on the
frequency of treatment, number of visits, days of coverage, or
other similar limit on the scope or duration of treatment. The term
includes a nonquantitative treatment limitation.
Sec. 1355.252. APPLICABILITY OF SUBCHAPTER. (a) This
subchapter 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
issued by:
(1) an insurance company;
(2) a group hospital service corporation operating
under Chapter 842;
(3) a health maintenance organization operating under
Chapter 843;
(4) an approved nonprofit health corporation that
holds a certificate of authority under Chapter 844;
(5) a multiple employer welfare arrangement that holds
a certificate of authority under Chapter 846;
(6) a stipulated premium company operating under
Chapter 884;
(7) a fraternal benefit society operating under
Chapter 885;
(8) a Lloyd's plan operating under Chapter 941; or
(9) an exchange operating under Chapter 942.
(b) Notwithstanding any other law, this subchapter applies
to:
(1) a small employer health benefit plan subject to
Chapter 1501, including coverage provided through a health group
cooperative under Subchapter B of that chapter;
(2) a standard health benefit plan issued under
Chapter 1507;
(3) a basic coverage plan under Chapter 1551;
(4) a basic plan under Chapter 1575;
(5) a primary care coverage plan under Chapter 1579;
(6) a plan providing basic coverage under Chapter
1601;
(7) health benefits provided by or through a church
benefits board under Subchapter I, Chapter 22, Business
Organizations Code;
(8) group health coverage made available by a school
district in accordance with Section 22.004, Education Code;
(9) the state Medicaid program, including the Medicaid
managed care program operated under Chapter 533, Government Code;
(10) the child health plan program under Chapter 62,
Health and Safety Code;
(11) a regional or local health care program operated
under Section 75.104, Health and Safety Code;
(12) a self-funded health benefit plan sponsored by a
professional employer organization under Chapter 91, Labor Code;
(13) county employee group health benefits provided
under Chapter 157, Local Government Code; and
(14) health and accident coverage provided by a risk
pool created under Chapter 172, Local Government Code.
(c) This subchapter applies to coverage under a group health
benefit plan provided to a resident of this state regardless of
whether the group policy, agreement, or contract is delivered,
issued for delivery, or renewed in this state.
Sec. 1355.253. EXCEPTION. This subchapter does not apply
to an individual health benefit plan issued on or before March 23,
2010, that has not had any significant changes since that date that
reduce benefits or increase costs to the individual.
Sec. 1355.254. REQUIRED COVERAGE FOR MENTAL HEALTH
CONDITIONS AND SUBSTANCE USE DISORDERS. (a) A health benefit plan
must provide benefits for mental health conditions and substance
use disorders under the same terms and conditions applicable to
benefits for medical or surgical expenses.
(b) Coverage under Subsection (a) may not impose treatment
limitations or financial requirements on benefits for a mental
health condition or substance use disorder that are generally more
restrictive than treatment limitations or financial requirements
imposed on coverage of benefits for medical or surgical expenses.
Sec. 1355.255. DEFINITIONS UNDER PLAN. (a) A health
benefit plan must define a condition to be a mental health condition
or not a mental health condition in a manner consistent with
generally recognized independent standards of medical practice.
(b) A health benefit plan must define a condition to be a
substance use disorder or not a substance use disorder in a manner
consistent with generally recognized independent standards of
medical practice.
Sec. 1355.256. COORDINATION WITH OTHER LAW; INTENT OF
LEGISLATURE. This subchapter supplements Subchapters A and B of
this chapter and Chapter 1368 and the department rules adopted
under those statutes. It is the intent of the legislature that
Subchapter A or B of this chapter or Chapter 1368 or the department
rules adopted under those statutes controls in any circumstance in
which that other law requires:
(1) a benefit that is not required by this subchapter;
or
(2) a more extensive benefit than is required by this
subchapter.
Sec. 1355.257. RULES. The commissioner shall adopt rules
necessary to implement this subchapter.
ARTICLE 6. COVERAGE OF ESSENTIAL HEALTH BENEFITS
SECTION 6.01. Subtitle E, Title 8, Insurance Code, is
amended by adding Chapter 1380 to read as follows:
CHAPTER 1380. COVERAGE OF ESSENTIAL HEALTH BENEFITS
Sec. 1380.001. 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 issued by:
(1) an insurance company;
(2) a group hospital service corporation operating
under Chapter 842;
(3) a health maintenance organization operating under
Chapter 843;
(4) an approved nonprofit health corporation that
holds a certificate of authority under Chapter 844;
(5) a multiple employer welfare arrangement that holds
a certificate of authority under Chapter 846;
(6) a stipulated premium company operating under
Chapter 884;
(7) a fraternal benefit society operating under
Chapter 885;
(8) a Lloyd's plan operating under Chapter 941; or
(9) an exchange operating under Chapter 942.
(b) Notwithstanding any other law, this chapter applies to:
(1) a small employer health benefit plan subject to
Chapter 1501, including coverage provided through a health group
cooperative under Subchapter B of that chapter;
(2) a standard health benefit plan issued under
Chapter 1507;
(3) a basic coverage plan under Chapter 1551;
(4) a basic plan under Chapter 1575;
(5) a primary care coverage plan under Chapter 1579;
(6) a plan providing basic coverage under Chapter
1601;
(7) health benefits provided by or through a church
benefits board under Subchapter I, Chapter 22, Business
Organizations Code;
(8) group health coverage made available by a school
district in accordance with Section 22.004, Education Code;
(9) the state Medicaid program, including the Medicaid
managed care program operated under Chapter 533, Government Code;
(10) the child health plan program under Chapter 62,
Health and Safety Code;
(11) a regional or local health care program operated
under Section 75.104, Health and Safety Code;
(12) a self-funded health benefit plan sponsored by a
professional employer organization under Chapter 91, Labor Code;
(13) county employee group health benefits provided
under Chapter 157, Local Government Code; and
(14) health and accident coverage provided by a risk
pool created under Chapter 172, Local Government Code.
(c) This chapter applies to coverage under a group health
benefit plan provided to a resident of this state regardless of
whether the group policy, agreement, or contract is delivered,
issued for delivery, or renewed in this state.
Sec. 1380.002. EXCEPTION. This chapter does not apply to an
individual health benefit plan issued on or before March 23, 2010,
that has not had any significant changes since that date that reduce
benefits or increase costs to the individual.
Sec. 1380.003. REQUIRED COVERAGE FOR ESSENTIAL HEALTH
BENEFITS. A health benefit plan must provide coverage for the
essential health benefits listed in 42 U.S.C. Section 18022(b)(1),
as that section existed on January 1, 2019, and other benefits
identified by the United States secretary of health and human
services as essential health benefits as of that date.
ARTICLE 7. HEALTH BENEFIT PLAN COVERAGE FOR CERTAIN YOUNG ADULTS
SECTION 7.01. Subchapter A, Chapter 533, Government Code,
is amended by adding Section 533.0054 to read as follows:
Sec. 533.0054. ELIGIBILITY AGE FOR STAR HEALTH COVERAGE. A
child enrolled in the STAR Health Medicaid managed care program is
eligible to receive health care services under the program until
the child is 26 years of age.
SECTION 7.02. 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 7.03. 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
or dental support order, if the policy provides dental coverage,
issued under Chapter 154, Family Code, or enforceable by a court in
this state, and any other individual dependent on the adult.
SECTION 7.04. 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 or dental support, if the policy
provides dental coverage, under an order issued under Chapter 154,
Family Code, or enforceable by a court in this state.
SECTION 7.05. 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 7.06. 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 7.07. Section 1251.152(a), Insurance Code, is
amended to read as follows:
(a) For purposes of this section, "dependent" includes:
(1) a child of an employee or member who is:
(A) unmarried; and
(B) younger than 26 [25] years of age; and
(2) a grandchild of an employee or member who is:
(A) unmarried;
(B) younger than 26 [25] years of age; and
(C) a dependent of the insured for federal income
tax purposes at the time the application for coverage of the
grandchild is made.
SECTION 7.08. 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, is 26 [25] years of age. The limiting age
applicable to a child must be stated in the evidence of coverage.
SECTION 7.09. 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.
SECTION 7.10. 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 7.11. 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 7.12. 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 has
a mental disability or 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.
ARTICLE 8. TRANSITION; EFFECTIVE DATE
SECTION 8.01. The change in law made by this Act applies
only to a health benefit plan that is delivered, issued for
delivery, or renewed on or after January 1, 2020. A health benefit
plan that is delivered, issued for delivery, or renewed before
January 1, 2020, 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 8.02. If before implementing any provision of this
Act a state agency determines that a waiver or authorization from a
federal agency is necessary for implementation of that provision,
the agency affected by the provision shall request the waiver or
authorization and may delay implementing that provision until the
waiver or authorization is granted.
SECTION 8.03. This Act takes effect September 1, 2019.