86R1744 MEW-F
By: RodrÃguez S.B. No. 145
A BILL TO BE ENTITLED
AN ACT
relating to health benefit plan coverage in this state.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
ARTICLE 1. HEALTH BENEFIT AFFORDABILITY AND ACCESSIBILITY
SECTION 1.01. Subtitle A, Title 8, Insurance Code, is
amended by adding Chapter 1219 to read as follows:
CHAPTER 1219. HEALTH BENEFIT AFFORDABILITY AND ACCESSIBILITY
SUBCHAPTER A. GENERAL PROVISIONS
Sec. 1219.001. 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. 1219.002. 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 1219.001.
(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. 1219.003. 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. 1219.051. 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. 1219.052. 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, 2017, and other benefits
identified by the United States secretary of health and human
services as essential health benefits as of that date.
Sec. 1219.053. 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, 2017, and
other benefits identified by the United States secretary of health
and human services as essential health benefits as of that date.
Sec. 1219.054. 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. 1219.101. 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. 1219.102. 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. 1219.151. 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 2. HEALTH BENEFIT PLAN COVERAGE FOR MENTAL HEALTH
CONDITIONS AND SUBSTANCE USE DISORDERS
SECTION 2.01. Section 1355.252, Insurance Code, is amended
by adding Subsections (d) and (e) to read as follows:
(d) Notwithstanding any other law, this subchapter applies
to:
(1) a basic coverage plan under Chapter 1551;
(2) a basic plan under Chapter 1575;
(3) a primary care coverage plan under Chapter 1579;
(4) a plan providing basic coverage under Chapter
1601;
(5) health benefits provided by or through a church
benefits board under Subchapter I, Chapter 22, Business
Organizations Code;
(6) group health coverage made available by a school
district in accordance with Section 22.004, Education Code;
(7) the state Medicaid program, including the Medicaid
managed care program operated under Chapter 533, Government Code;
(8) the child health plan program under Chapter 62,
Health and Safety Code;
(9) a regional or local health care program operated
under Section 75.104, Health and Safety Code;
(10) a self-funded health benefit plan sponsored by a
professional employer organization under Chapter 91, Labor Code;
(11) county employee group health benefits provided
under Chapter 157, Local Government Code; and
(12) health and accident coverage provided by a risk
pool created under Chapter 172, Local Government Code.
(e) 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.
SECTION 2.02. Section 1355.253, Insurance Code, is amended
by amending Subsection (b) and adding Subsection (c) to read as
follows:
(b) To the extent that this section would otherwise require
this state to make a payment under 42 U.S.C. Section
18031(d)(3)(B)(ii), a qualified health plan, as defined by 45
C.F.R. Section 155.20, is not required to provide a benefit under
this subchapter that exceeds the specified essential health
benefits required under 42 U.S.C. Section 18022(b), as that section
existed on January 1, 2017.
(c) 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.
ARTICLE 3. COVERAGE OF ESSENTIAL HEALTH BENEFITS
SECTION 3.01. 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, 2017, and other benefits
identified by the United States secretary of health and human
services as essential health benefits as of that date.
ARTICLE 4. HEALTH BENEFIT PLAN COVERAGE FOR CERTAIN YOUNG ADULTS
SECTION 4.01. Subchapter A, Chapter 533, Government Code,
is amended by adding Section 533.0057 to read as follows:
Sec. 533.0057. 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 4.02. 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 4.03. 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 4.04. 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 4.05. 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 4.06. 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 4.07. 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 4.08. 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 4.09. 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 4.10. 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 4.11. 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 4.12. 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 5. TRANSITION; EFFECTIVE DATE
SECTION 5.01. 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 5.02. 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 5.03. This Act takes effect September 1, 2019.