Texas 2019 - 86th Regular

Texas Senate Bill SB145 Compare Versions

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

Old	New	Differences
1	1	86R1744 MEW-F
2	2	By: Rodríguez S.B. No. 145
3	3
4	4
5	5	A BILL TO BE ENTITLED
6	6	AN ACT
7	7	relating to health benefit plan coverage in this state.
8	8	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
9	9	ARTICLE 1. HEALTH BENEFIT AFFORDABILITY AND ACCESSIBILITY
10	10	SECTION 1.01. Subtitle A, Title 8, Insurance Code, is
11	11	amended by adding Chapter 1219 to read as follows:
12	12	CHAPTER 1219. HEALTH BENEFIT AFFORDABILITY AND ACCESSIBILITY
13	13	SUBCHAPTER A. GENERAL PROVISIONS
14	14	Sec. 1219.001. APPLICABILITY OF CHAPTER. (a) This chapter
15	15	applies only to a health benefit plan that provides benefits for
16	16	medical or surgical expenses incurred as a result of a health
17	17	condition, accident, or sickness, including an individual, group,
18	18	blanket, or franchise insurance policy or insurance agreement, a
19	19	group hospital service contract, or an individual or group evidence
20	20	of coverage or similar coverage document that is issued 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 health maintenance organization operating under
25	25	Chapter 843;
26	26	(4) an approved nonprofit health corporation that
27	27	holds a certificate of authority under Chapter 844;
28	28	(5) a multiple employer welfare arrangement that holds
29	29	a certificate of authority under Chapter 846;
30	30	(6) a stipulated premium company operating under
31	31	Chapter 884;
32	32	(7) a fraternal benefit society operating under
33	33	Chapter 885;
34	34	(8) a Lloyd's plan operating under Chapter 941; or
35	35	(9) an exchange operating under Chapter 942.
36	36	(b) Notwithstanding any other law, this chapter applies to:
37	37	(1) a small employer health benefit plan subject to
38	38	Chapter 1501, including coverage provided through a health group
39	39	cooperative under Subchapter B of that chapter;
40	40	(2) a standard health benefit plan issued under
41	41	Chapter 1507;
42	42	(3) a basic coverage plan under Chapter 1551;
43	43	(4) a basic plan under Chapter 1575;
44	44	(5) a primary care coverage plan under Chapter 1579;
45	45	(6) a plan providing basic coverage under Chapter
46	46	1601;
47	47	(7) health benefits provided by or through a church
48	48	benefits board under Subchapter I, Chapter 22, Business
49	49	Organizations Code;
50	50	(8) group health coverage made available by a school
51	51	district in accordance with Section 22.004, Education Code;
52	52	(9) the state Medicaid program, including the Medicaid
53	53	managed care program operated under Chapter 533, Government Code;
54	54	(10) the child health plan program under Chapter 62,
55	55	Health and Safety Code;
56	56	(11) a regional or local health care program operated
57	57	under Section 75.104, Health and Safety Code;
58	58	(12) a self-funded health benefit plan sponsored by a
59	59	professional employer organization under Chapter 91, Labor Code;
60	60	(13) county employee group health benefits provided
61	61	under Chapter 157, Local Government Code; and
62	62	(14) health and accident coverage provided by a risk
63	63	pool created under Chapter 172, Local Government Code.
64	64	(c) This chapter applies to coverage under a group health
65	65	benefit plan provided to a resident of this state regardless of
66	66	whether the group policy, agreement, or contract is delivered,
67	67	issued for delivery, or renewed in this state.
68	68	Sec. 1219.002. EXCEPTIONS. (a) This chapter does not apply
69	69	to:
70	70	(1) a plan that provides coverage:
71	71	(A) for wages or payments in lieu of wages for a
72	72	period during which an employee is absent from work because of
73	73	sickness or injury;
74	74	(B) as a supplement to a liability insurance
75	75	policy;
76	76	(C) for credit insurance;
77	77	(D) only for dental or vision care;
78	78	(E) only for hospital expenses; or
79	79	(F) only for indemnity for hospital confinement;
80	80	(2) a Medicare supplemental policy as defined by
81	81	Section 1882(g)(1), Social Security Act (42 U.S.C. Section
82	82	1395ss(g)(1));
83	83	(3) a workers' compensation insurance policy;
84	84	(4) medical payment insurance coverage provided under
85	85	a motor vehicle insurance policy; or
86	86	(5) a long-term care policy, including a nursing home
87	87	fixed indemnity policy, unless the commissioner determines that the
88	88	policy provides benefit coverage so comprehensive that the policy
89	89	is a health benefit plan as described by Section 1219.001.
90	90	(b) This chapter does not apply to an individual health
91	91	benefit plan issued on or before March 23, 2010, that has not had
92	92	any significant changes since that date that reduce benefits or
93	93	increase costs to the individual.
94	94	Sec. 1219.003. CONFLICT WITH OTHER LAW. If this chapter
95	95	conflicts with another law relating to lifetime or annual benefit
96	96	limits or the imposition of a premium, deductible, copayment,
97	97	coinsurance, or other cost-sharing provision, this chapter
98	98	controls.
99	99	SUBCHAPTER B. CERTAIN COST-SHARING AND COVERAGE AMOUNT LIMITS
100	100	PROHIBITED
101	101	Sec. 1219.051. CERTAIN COST-SHARING PROVISIONS FOR
102	102	PREVENTIVE SERVICES PROHIBITED. A health benefit plan issuer may
103	103	not impose a deductible, copayment, coinsurance, or other
104	104	cost-sharing provision applicable to benefits for:
105	105	(1) a preventive item or service that has in effect a
106	106	rating of "A" or "B" in the most recent recommendations of the
107	107	United States Preventive Services Task Force;
108	108	(2) an immunization recommended for routine use in the
109	109	most recent immunization schedules published by the United States
110	110	Centers for Disease Control and Prevention of the United States
111	111	Public Health Service; or
112	112	(3) preventive care and screenings supported by the
113	113	most recent comprehensive guidelines adopted by the United States
114	114	Health Resources and Services Administration.
115	115	Sec. 1219.052. CERTAIN ANNUAL AND LIFETIME LIMITS
116	116	PROHIBITED. A health benefit plan issuer may not establish an
117	117	annual or lifetime benefit amount for an enrollee in relation to
118	118	essential health benefits listed in 42 U.S.C. Section 18022(b)(1),
119	119	as that section existed on January 1, 2017, and other benefits
120	120	identified by the United States secretary of health and human
121	121	services as essential health benefits as of that date.
122	122	Sec. 1219.053. LIMITATIONS ON COST-SHARING. A health
123	123	benefit plan issuer may not impose cost-sharing requirements that
124	124	exceed the limits established in 42 U.S.C. Section 18022(c)(1) in
125	125	relation to essential health benefits listed in 42 U.S.C. Section
126	126	18022(b)(1), as those sections existed on January 1, 2017, and
127	127	other benefits identified by the United States secretary of health
128	128	and human services as essential health benefits as of that date.
129	129	Sec. 1219.054. DISCRIMINATION BASED ON GENDER PROHIBITED.
130	130	A health benefit plan issuer may not charge an individual a higher
131	131	premium rate based on the individual's gender.
132	132	SUBCHAPTER C. COVERAGE OF PREEXISTING CONDITIONS
133	133	Sec. 1219.101. DEFINITION. In this subchapter,
134	134	"preexisting condition" means a condition present before the
135	135	effective date of an individual's coverage under a health benefit
136	136	plan.
137	137	Sec. 1219.102. PREEXISTING CONDITION RESTRICTIONS
138	138	PROHIBITED. Notwithstanding any other law, a health benefit plan
139	139	issuer may not:
140	140	(1) deny an individual's application for coverage or
141	141	refuse to enroll an individual in a health benefit plan due to a
142	142	preexisting condition;
143	143	(2) limit or exclude coverage under the health benefit
144	144	plan for the treatment of a preexisting condition otherwise covered
145	145	under the plan; or
146	146	(3) charge the individual more for coverage than the
147	147	health benefit plan issuer charges an individual who does not have a
148	148	preexisting condition.
149	149	SUBCHAPTER D. EXTERNAL REVIEW PROCEDURE
150	150	Sec. 1219.151. EXTERNAL REVIEW MODEL ACT RULES. (a) The
151	151	department shall adopt rules as necessary to conform Texas law with
152	152	the requirements of the NAIC Uniform Health Carrier External Review
153	153	Model Act (April 2010).
154	154	(b) To the extent that the rules adopted under this section
155	155	conflict with Chapter 843 or Title 14, the rules control.
156	156	ARTICLE 2. HEALTH BENEFIT PLAN COVERAGE FOR MENTAL HEALTH
157	157	CONDITIONS AND SUBSTANCE USE DISORDERS
158	158	SECTION 2.01. Section 1355.252, Insurance Code, is amended
159	159	by adding Subsections (d) and (e) to read as follows:
160	160	(d) Notwithstanding any other law, this subchapter applies
161	161	to:
162	162	(1) a basic coverage plan under Chapter 1551;
163	163	(2) a basic plan under Chapter 1575;
164	164	(3) a primary care coverage plan under Chapter 1579;
165	165	(4) a plan providing basic coverage under Chapter
166	166	1601;
167	167	(5) health benefits provided by or through a church
168	168	benefits board under Subchapter I, Chapter 22, Business
169	169	Organizations Code;
170	170	(6) group health coverage made available by a school
171	171	district in accordance with Section 22.004, Education Code;
172	172	(7) the state Medicaid program, including the Medicaid
173	173	managed care program operated under Chapter 533, Government Code;
174	174	(8) the child health plan program under Chapter 62,
175	175	Health and Safety Code;
176	176	(9) a regional or local health care program operated
177	177	under Section 75.104, Health and Safety Code;
178	178	(10) a self-funded health benefit plan sponsored by a
179	179	professional employer organization under Chapter 91, Labor Code;
180	180	(11) county employee group health benefits provided
181	181	under Chapter 157, Local Government Code; and
182	182	(12) health and accident coverage provided by a risk
183	183	pool created under Chapter 172, Local Government Code.
184	184	(e) This subchapter applies to coverage under a group health
185	185	benefit plan provided to a resident of this state regardless of
186	186	whether the group policy, agreement, or contract is delivered,
187	187	issued for delivery, or renewed in this state.
188	188	SECTION 2.02. Section 1355.253, Insurance Code, is amended
189	189	by amending Subsection (b) and adding Subsection (c) to read as
190	190	follows:
191	191	(b) To the extent that this section would otherwise require
192	192	this state to make a payment under 42 U.S.C. Section
193	193	18031(d)(3)(B)(ii), a qualified health plan, as defined by 45
194	194	C.F.R. Section 155.20, is not required to provide a benefit under
195	195	this subchapter that exceeds the specified essential health
196	196	benefits required under 42 U.S.C. Section 18022(b), as that section
197	197	existed on January 1, 2017.
198	198	(c) This subchapter does not apply to an individual health
199	199	benefit plan issued on or before March 23, 2010, that has not had
200	200	any significant changes since that date that reduce benefits or
201	201	increase costs to the individual.
202	202	ARTICLE 3. COVERAGE OF ESSENTIAL HEALTH BENEFITS
203	203	SECTION 3.01. Subtitle E, Title 8, Insurance Code, is
204	204	amended by adding Chapter 1380 to read as follows:
205	205	CHAPTER 1380. COVERAGE OF ESSENTIAL HEALTH BENEFITS
206	206	Sec. 1380.001. APPLICABILITY OF CHAPTER. (a) This chapter
207	207	applies only to a health benefit plan that provides benefits for
208	208	medical or surgical expenses incurred as a result of a health
209	209	condition, accident, or sickness, including an individual, group,
210	210	blanket, or franchise insurance policy or insurance agreement, a
211	211	group hospital service contract, or an individual or group evidence
212	212	of coverage or similar coverage document that is issued by:
213	213	(1) an insurance company;
214	214	(2) a group hospital service corporation operating
215	215	under Chapter 842;
216	216	(3) a health maintenance organization operating under
217	217	Chapter 843;
218	218	(4) an approved nonprofit health corporation that
219	219	holds a certificate of authority under Chapter 844;
220	220	(5) a multiple employer welfare arrangement that holds
221	221	a certificate of authority under Chapter 846;
222	222	(6) a stipulated premium company operating under
223	223	Chapter 884;
224	224	(7) a fraternal benefit society operating under
225	225	Chapter 885;
226	226	(8) a Lloyd's plan operating under Chapter 941; or
227	227	(9) an exchange operating under Chapter 942.
228	228	(b) Notwithstanding any other law, this chapter applies to:
229	229	(1) a small employer health benefit plan subject to
230	230	Chapter 1501, including coverage provided through a health group
231	231	cooperative under Subchapter B of that chapter;
232	232	(2) a standard health benefit plan issued under
233	233	Chapter 1507;
234	234	(3) a basic coverage plan under Chapter 1551;
235	235	(4) a basic plan under Chapter 1575;
236	236	(5) a primary care coverage plan under Chapter 1579;
237	237	(6) a plan providing basic coverage under Chapter
238	238	1601;
239	239	(7) health benefits provided by or through a church
240	240	benefits board under Subchapter I, Chapter 22, Business
241	241	Organizations Code;
242	242	(8) group health coverage made available by a school
243	243	district in accordance with Section 22.004, Education Code;
244	244	(9) the state Medicaid program, including the Medicaid
245	245	managed care program operated under Chapter 533, Government Code;
246	246	(10) the child health plan program under Chapter 62,
247	247	Health and Safety Code;
248	248	(11) a regional or local health care program operated
249	249	under Section 75.104, Health and Safety Code;
250	250	(12) a self-funded health benefit plan sponsored by a
251	251	professional employer organization under Chapter 91, Labor Code;
252	252	(13) county employee group health benefits provided
253	253	under Chapter 157, Local Government Code; and
254	254	(14) health and accident coverage provided by a risk
255	255	pool created under Chapter 172, Local Government Code.
256	256	(c) This chapter applies to coverage under a group health
257	257	benefit plan provided to a resident of this state regardless of
258	258	whether the group policy, agreement, or contract is delivered,
259	259	issued for delivery, or renewed in this state.
260	260	Sec. 1380.002. EXCEPTION. This chapter does not apply to an
261	261	individual health benefit plan issued on or before March 23, 2010,
262	262	that has not had any significant changes since that date that reduce
263	263	benefits or increase costs to the individual.
264	264	Sec. 1380.003. REQUIRED COVERAGE FOR ESSENTIAL HEALTH
265	265	BENEFITS. A health benefit plan must provide coverage for the
266	266	essential health benefits listed in 42 U.S.C. Section 18022(b)(1),
267	267	as that section existed on January 1, 2017, and other benefits
268	268	identified by the United States secretary of health and human
269	269	services as essential health benefits as of that date.
270	270	ARTICLE 4. HEALTH BENEFIT PLAN COVERAGE FOR CERTAIN YOUNG ADULTS
271	271	SECTION 4.01. Subchapter A, Chapter 533, Government Code,
272	272	is amended by adding Section 533.0057 to read as follows:
273	273	Sec. 533.0057. ELIGIBILITY AGE FOR STAR HEALTH COVERAGE. A
274	274	child enrolled in the STAR Health Medicaid managed care program is
275	275	eligible to receive health care services under the program until
276	276	the child is 26 years of age.
277	277	SECTION 4.02. Section 846.260, Insurance Code, is amended
278	278	to read as follows:
279	279	Sec. 846.260. LIMITING AGE APPLICABLE TO UNMARRIED CHILD.
280	280	If children are eligible for coverage under the terms of a multiple
281	281	employer welfare arrangement's plan document, any limiting age
282	282	applicable to an unmarried child of an enrollee is 26 [25] years of
283	283	age.
284	284	SECTION 4.03. Section 1201.053(b), Insurance Code, is
285	285	amended to read as follows:
286	286	(b) On the application of an adult member of a family, an
287	287	individual accident and health insurance policy may, at the time of
288	288	original issuance or by subsequent amendment, insure two or more
289	289	eligible members of the adult's family, including a spouse,
290	290	unmarried children younger than 26 [25] years of age, including a
291	291	grandchild of the adult as described by Section 1201.062(a)(1), a
292	292	child the adult is required to insure under a medical support order
293	293	or dental support order, if the policy provides dental coverage,
294	294	issued under Chapter 154, Family Code, or enforceable by a court in
295	295	this state, and any other individual dependent on the adult.
296	296	SECTION 4.04. Section 1201.062(a), Insurance Code, is
297	297	amended to read as follows:
298	298	(a) An individual or group accident and health insurance
299	299	policy that is delivered, issued for delivery, or renewed in this
300	300	state, including a policy issued by a corporation operating under
301	301	Chapter 842, or a self-funded or self-insured welfare or benefit
302	302	plan or program, to the extent that regulation of the plan or
303	303	program is not preempted by federal law, that provides coverage for
304	304	a child of an insured or group member, on payment of a premium, must
305	305	provide coverage for:
306	306	(1) each grandchild of the insured or group member if
307	307	the grandchild is:
308	308	(A) unmarried;
309	309	(B) younger than 26 [25] years of age; and
310	310	(C) a dependent of the insured or group member
311	311	for federal income tax purposes at the time application for
312	312	coverage of the grandchild is made; and
313	313	(2) each child for whom the insured or group member
314	314	must provide medical support or dental support, if the policy
315	315	provides dental coverage, under an order issued under Chapter 154,
316	316	Family Code, or enforceable by a court in this state.
317	317	SECTION 4.05. Section 1201.065(a), Insurance Code, is
318	318	amended to read as follows:
319	319	(a) An individual or group accident and health insurance
320	320	policy may contain criteria relating to a maximum age or enrollment
321	321	in school to establish continued eligibility for coverage of a
322	322	child 26 [25] years of age or older.
323	323	SECTION 4.06. Section 1251.151(a), Insurance Code, is
324	324	amended to read as follows:
325	325	(a) A group policy or contract of insurance for hospital,
326	326	surgical, or medical expenses incurred as a result of accident or
327	327	sickness, including a group contract issued by a group hospital
328	328	service corporation, that provides coverage under the policy or
329	329	contract for a child of an insured must, on payment of a premium,
330	330	provide coverage for any grandchild of the insured if the
331	331	grandchild is:
332	332	(1) unmarried;
333	333	(2) younger than 26 [25] years of age; and
334	334	(3) a dependent of the insured for federal income tax
335	335	purposes at the time the application for coverage of the grandchild
336	336	is made.
337	337	SECTION 4.07. Section 1251.152(a), Insurance Code, is
338	338	amended to read as follows:
339	339	(a) For purposes of this section, "dependent" includes:
340	340	(1) a child of an employee or member who is:
341	341	(A) unmarried; and
342	342	(B) younger than 26 [25] years of age; and
343	343	(2) a grandchild of an employee or member who is:
344	344	(A) unmarried;
345	345	(B) younger than 26 [25] years of age; and
346	346	(C) a dependent of the insured for federal income
347	347	tax purposes at the time the application for coverage of the
348	348	grandchild is made.
349	349	SECTION 4.08. Section 1271.006(a), Insurance Code, is
350	350	amended to read as follows:
351	351	(a) If children are eligible for coverage under the terms of
352	352	an evidence of coverage, any limiting age applicable to an
353	353	unmarried child of an enrollee, including an unmarried grandchild
354	354	of an enrollee, is 26 [25] years of age. The limiting age
355	355	applicable to a child must be stated in the evidence of coverage.
356	356	SECTION 4.09. Section 1501.002(2), Insurance Code, is
357	357	amended to read as follows:
358	358	(2) "Dependent" means:
359	359	(A) a spouse;
360	360	(B) a child younger than 26 [25] years of age,
361	361	including a newborn child;
362	362	(C) a child of any age who is:
363	363	(i) medically certified as disabled; and
364	364	(ii) dependent on the parent;
365	365	(D) an individual who must be covered under:
366	366	(i) Section 1251.154; or
367	367	(ii) Section 1201.062; and
368	368	(E) any other child eligible under an employer's
369	369	health benefit plan, including a child described by Section
370	370	1503.003.
371	371	SECTION 4.10. Section 1501.609(b), Insurance Code, is
372	372	amended to read as follows:
373	373	(b) Any limiting age applicable under a large employer
374	374	health benefit plan to an unmarried child of an enrollee is 26 [25]
375	375	years of age.
376	376	SECTION 4.11. Sections 1503.003(a) and (b), Insurance Code,
377	377	are amended to read as follows:
378	378	(a) A health benefit plan may not condition coverage for a
379	379	child younger than 26 [25] years of age on the child's being
380	380	enrolled at an educational institution.
381	381	(b) A health benefit plan that requires as a condition of
382	382	coverage for a child 26 [25] years of age or older that the child be
383	383	a full-time student at an educational institution must provide the
384	384	coverage:
385	385	(1) for the entire academic term during which the
386	386	child begins as a full-time student and remains enrolled,
387	387	regardless of whether the number of hours of instruction for which
388	388	the child is enrolled is reduced to a level that changes the child's
389	389	academic status to less than that of a full-time student; and
390	390	(2) continuously until the 10th day of instruction of
391	391	the subsequent academic term, on which date the health benefit plan
392	392	may terminate coverage for the child if the child does not return to
393	393	full-time student status before that date.
394	394	SECTION 4.12. Section 1601.004(a), Insurance Code, is
395	395	amended to read as follows:
396	396	(a) In this chapter, "dependent," with respect to an
397	397	individual eligible to participate in the uniform program under
398	398	Section 1601.101 or 1601.102, means the individual's:
399	399	(1) spouse;
400	400	(2) unmarried child younger than 26 [25] years of age;
401	401	and
402	402	(3) child of any age who lives with or has the child's
403	403	care provided by the individual on a regular basis if the child has
404	404	a mental disability or is [mentally retarded or] physically
405	405	incapacitated to the extent that the child is dependent on the
406	406	individual for care or support, as determined by the system.
407	407	ARTICLE 5. TRANSITION; EFFECTIVE DATE
408	408	SECTION 5.01. The change in law made by this Act applies
409	409	only to a health benefit plan that is delivered, issued for
410	410	delivery, or renewed on or after January 1, 2020. A health benefit
411	411	plan that is delivered, issued for delivery, or renewed before
412	412	January 1, 2020, is governed by the law as it existed immediately
413	413	before the effective date of this Act, and that law is continued in
414	414	effect for that purpose.
415	415	SECTION 5.02. If before implementing any provision of this
416	416	Act a state agency determines that a waiver or authorization from a
417	417	federal agency is necessary for implementation of that provision,
418	418	the agency affected by the provision shall request the waiver or
419	419	authorization and may delay implementing that provision until the
420	420	waiver or authorization is granted.
421	421	SECTION 5.03. This Act takes effect September 1, 2019.