Texas 2021 - 87th Regular

Texas House Bill HB1541 Compare Versions

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

Old	New	Differences
1	1	87R3426 RDS-D
2	2	By: Johnson of Dallas H.B. No. 1541
3	3
4	4
5	5	A BILL TO BE ENTITLED
6	6	AN ACT
7	7	relating to availability of and benefits provided under health
8	8	benefit plan coverage.
9	9	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
10	10	ARTICLE 1. HEALTH BENEFIT COVERAGE AVAILABILITY
11	11	SECTION 1.01. Subtitle G, Title 8, Insurance Code, is
12	12	amended by adding Chapter 1511 to read as follows:
13	13	CHAPTER 1511. HEALTH BENEFIT COVERAGE AVAILABILITY
14	14	SUBCHAPTER A. GENERAL PROVISIONS
15	15	Sec. 1511.001. APPLICABILITY OF CHAPTER. (a) Except as
16	16	otherwise provided by this chapter, this chapter applies only to a
17	17	health benefit plan that provides benefits for medical or surgical
18	18	expenses incurred as a result of a health condition, accident, or
19	19	sickness, including an individual, group, blanket, or franchise
20	20	insurance policy or insurance agreement, a group hospital service
21	21	contract, or an individual or group evidence of coverage or similar
22	22	coverage document that is issued by:
23	23	(1) an insurance company;
24	24	(2) a group hospital service corporation operating
25	25	under Chapter 842;
26	26	(3) a health maintenance organization operating under
27	27	Chapter 843;
28	28	(4) an approved nonprofit health corporation that
29	29	holds a certificate of authority under Chapter 844;
30	30	(5) a multiple employer welfare arrangement that holds
31	31	a certificate of authority under Chapter 846;
32	32	(6) a stipulated premium company operating under
33	33	Chapter 884;
34	34	(7) a fraternal benefit society operating under
35	35	Chapter 885;
36	36	(8) a Lloyd's plan operating under Chapter 941; or
37	37	(9) an exchange operating under Chapter 942.
38	38	(b) Notwithstanding any other law, this chapter applies to:
39	39	(1) a small employer health benefit plan subject to
40	40	Chapter 1501, including coverage provided through a health group
41	41	cooperative under Subchapter B of that chapter; and
42	42	(2) a standard health benefit plan issued under
43	43	Chapter 1507.
44	44	(c) This chapter applies to coverage under a group health
45	45	benefit plan provided to a resident of this state regardless of
46	46	whether the group policy, agreement, or contract is delivered,
47	47	issued for delivery, or renewed in this state.
48	48	Sec. 1511.002. EXCEPTIONS. (a) This chapter does not apply
49	49	to:
50	50	(1) a plan that provides coverage:
51	51	(A) for wages or payments in lieu of wages for a
52	52	period during which an employee is absent from work because of
53	53	sickness or injury;
54	54	(B) as a supplement to a liability insurance
55	55	policy;
56	56	(C) for credit insurance;
57	57	(D) only for dental or vision care;
58	58	(E) only for a specified disease or for another
59	59	limited benefit; or
60	60	(F) only for accidental death or dismemberment;
61	61	(2) a Medicare supplemental policy as defined by
62	62	Section 1882(g)(1), Social Security Act (42 U.S.C. Section
63	63	1395ss(g)(1));
64	64	(3) a workers' compensation insurance policy;
65	65	(4) medical payment insurance coverage provided under
66	66	a motor vehicle insurance policy; or
67	67	(5) a long-term care policy, including a nursing home
68	68	fixed indemnity policy, unless the commissioner determines that the
69	69	policy provides benefit coverage so comprehensive that the policy
70	70	is a health benefit plan as described by Section 1511.001.
71	71	(b) This chapter does not apply to an individual health
72	72	benefit plan issued on or before March 23, 2010, that has not had
73	73	any significant changes since that date that reduce benefits or
74	74	increase costs to the individual.
75	75	Sec. 1511.003. CONFLICT WITH OTHER LAW. If there is a
76	76	conflict between this chapter and other law, this chapter prevails.
77	77	Sec. 1511.004. RULES. (a) Subject to Subsection (b), the
78	78	commissioner may adopt rules as necessary to implement this
79	79	chapter.
80	80	(b) Rules adopted by the commissioner to implement this
81	81	chapter must be consistent with the Patient Protection and
82	82	Affordable Care Act (Pub. L. No. 111-148), as that Act existed on
83	83	January 1, 2017.
84	84	SUBCHAPTER B. GUARANTEED ISSUE AND RENEWABILITY
85	85	Sec. 1511.051. GUARANTEED ISSUE. A health benefit plan
86	86	issuer shall issue a group or individual health benefit plan chosen
87	87	by a group plan sponsor or individual to each group plan sponsor or
88	88	individual that elects to be covered under the plan and agrees to
89	89	satisfy the requirements of the plan.
90	90	Sec. 1511.052. RENEWABILITY AND CONTINUATION OF HEALTH
91	91	BENEFIT PLANS. (a) Except as provided by Subsection (b), a health
92	92	benefit plan issuer shall renew or continue a group or individual
93	93	health benefit plan at the option of the group plan sponsor or
94	94	individual, as applicable.
95	95	(b) A health benefit plan issuer may decline to renew or
96	96	continue a group or individual health benefit plan:
97	97	(1) for failure to pay a premium or contribution in
98	98	accordance with the terms of the plan;
99	99	(2) for fraud or intentional misrepresentation;
100	100	(3) because the issuer is ceasing to offer coverage in
101	101	the relevant market in accordance with rules adopted by the
102	102	commissioner;
103	103	(4) with respect to an individual plan, because an
104	104	individual no longer resides, lives, or works in an area in which
105	105	the issuer is authorized to provide coverage, but only if all plans
106	106	are not renewed or not continued under this subdivision uniformly
107	107	without regard to any health status related factor of covered
108	108	individuals; or
109	109	(5) in accordance with federal law, including
110	110	regulations.
111	111	Sec. 1511.053. OPEN AND SPECIAL ENROLLMENT PERIODS. (a) A
112	112	health benefit plan issuer issuing an individual health benefit
113	113	plan may restrict enrollment in coverage to an annual open
114	114	enrollment period and special enrollment periods.
115	115	(b) An individual or an individual's dependent qualified to
116	116	enroll in an individual health benefit plan may enroll anytime
117	117	during the open enrollment period or during a special enrollment
118	118	period designated by the commissioner.
119	119	(c) A health benefit plan issuer issuing a group health
120	120	benefit plan may not limit enrollment to an open or special
121	121	enrollment period.
122	122	(d) The commissioner shall adopt rules as necessary to
123	123	administer this section, including rules designating enrollment
124	124	periods.
125	125	SUBCHAPTER C. PREEXISTING CONDITIONS AND HEALTH STATUS
126	126	Sec. 1511.101. DEFINITIONS. In this subchapter:
127	127	(1) "Dependent" has the meaning assigned by Section
128	128	1501.002.
129	129	(2) "Health status related factor" has the meaning
130	130	assigned by Section 1501.002.
131	131	(3) "Preexisting condition" means a condition present
132	132	before the effective date of an individual's coverage under a
133	133	health benefit plan.
134	134	Sec. 1511.102. APPLICABILITY OF SUBCHAPTER.
135	135	Notwithstanding any other law, in addition to a health benefit plan
136	136	to which this chapter applies under Subchapter A, this subchapter
137	137	applies to:
138	138	(1) a basic coverage plan under Chapter 1551;
139	139	(2) a basic plan under Chapter 1575;
140	140	(3) a primary care coverage plan under Chapter 1579;
141	141	(4) a plan providing basic coverage under Chapter
142	142	1601;
143	143	(5) health benefits provided by or through a church
144	144	benefits board under Subchapter I, Chapter 22, Business
145	145	Organizations Code;
146	146	(6) group health coverage made available by a school
147	147	district in accordance with Section 22.004, Education Code;
148	148	(7) the state Medicaid program, including the Medicaid
149	149	managed care program operated under Chapter 533, Government Code;
150	150	(8) the child health plan program under Chapter 62,
151	151	Health and Safety Code;
152	152	(9) a regional or local health care program operated
153	153	under Section 75.104, Health and Safety Code;
154	154	(10) a self-funded health benefit plan sponsored by a
155	155	professional employer organization under Chapter 91, Labor Code;
156	156	(11) county employee group health benefits provided
157	157	under Chapter 157, Local Government Code; and
158	158	(12) health and accident coverage provided by a risk
159	159	pool created under Chapter 172, Local Government Code.
160	160	Sec. 1511.103. PREEXISTING CONDITION AND HEALTH STATUS
161	161	RESTRICTIONS PROHIBITED. Notwithstanding any other law, a health
162	162	benefit plan issuer may not:
163	163	(1) deny coverage to or refuse to enroll a group, an
164	164	individual, or an individual's dependent in a health benefit plan
165	165	on the basis of a preexisting condition or health status related
166	166	factor;
167	167	(2) limit or exclude, or require a waiting period for,
168	168	coverage under the health benefit plan for treatment of a
169	169	preexisting condition otherwise covered under the plan; or
170	170	(3) charge a group, individual, or dependent more for
171	171	coverage than the health benefit plan issuer charges a group,
172	172	individual, or dependent who does not have a preexisting condition
173	173	or health status related factor.
174	174	SUBCHAPTER D. PROHIBITED DISCRIMINATION
175	175	Sec. 1511.151. DISCRIMINATORY BENEFIT DESIGN PROHIBITED.
176	176	(a) A health benefit plan issuer may not, through the plan's
177	177	benefit design, discriminate against an enrollee on the basis of
178	178	race, color, national origin, age, sex, expected length of life,
179	179	present or predicted disability, degree of medical dependency,
180	180	quality of life, or other health condition.
181	181	(b) A health benefit plan issuer may not use a health
182	182	benefit design that will have the effect of discouraging the
183	183	enrollment of individuals with significant health needs in the
184	184	health benefit plan.
185	185	(c) This section may not be construed to prevent a health
186	186	benefit plan issuer from appropriately utilizing reasonable
187	187	medical management techniques.
188	188	Sec. 1511.152. DISCRIMINATORY MARKETING PROHIBITED. A
189	189	health benefit plan issuer may not use a marketing practice that
190	190	will have the effect of discouraging the enrollment of individuals
191	191	with significant health needs in the health benefit plan or that
192	192	discriminates on the basis of race, color, national origin, age,
193	193	sex, expected length of life, present or predicted disability,
194	194	degree of medical dependency, quality of life, or other health
195	195	condition.
196	196	ARTICLE 2. COVERAGE OF ESSENTIAL HEALTH BENEFITS
197	197	SECTION 2.01. Subtitle E, Title 8, Insurance Code, is
198	198	amended by adding Chapter 1380 to read as follows:
199	199	CHAPTER 1380. COVERAGE OF ESSENTIAL HEALTH BENEFITS
200	200	Sec. 1380.001. APPLICABILITY OF CHAPTER. (a) This chapter
201	201	applies only to a health benefit plan that provides benefits for
202	202	medical or surgical expenses incurred as a result of a health
203	203	condition, accident, or sickness, including an individual, group,
204	204	blanket, or franchise insurance policy or insurance agreement, a
205	205	group hospital service contract, or an individual or group evidence
206	206	of coverage or similar coverage document that is issued by:
207	207	(1) an insurance company;
208	208	(2) a group hospital service corporation operating
209	209	under Chapter 842;
210	210	(3) a health maintenance organization operating under
211	211	Chapter 843;
212	212	(4) an approved nonprofit health corporation that
213	213	holds a certificate of authority under Chapter 844;
214	214	(5) a multiple employer welfare arrangement that holds
215	215	a certificate of authority under Chapter 846;
216	216	(6) a stipulated premium company operating under
217	217	Chapter 884;
218	218	(7) a fraternal benefit society operating under
219	219	Chapter 885;
220	220	(8) a Lloyd's plan operating under Chapter 941; or
221	221	(9) an exchange operating under Chapter 942.
222	222	(b) Notwithstanding any other law, this chapter applies to:
223	223	(1) a small employer health benefit plan subject to
224	224	Chapter 1501, including coverage provided through a health group
225	225	cooperative under Subchapter B of that chapter;
226	226	(2) a standard health benefit plan issued under
227	227	Chapter 1507;
228	228	(3) a basic coverage plan under Chapter 1551;
229	229	(4) a basic plan under Chapter 1575;
230	230	(5) a primary care coverage plan under Chapter 1579;
231	231	(6) a plan providing basic coverage under Chapter
232	232	1601;
233	233	(7) health benefits provided by or through a church
234	234	benefits board under Subchapter I, Chapter 22, Business
235	235	Organizations Code;
236	236	(8) group health coverage made available by a school
237	237	district in accordance with Section 22.004, Education Code;
238	238	(9) the state Medicaid program, including the Medicaid
239	239	managed care program operated under Chapter 533, Government Code;
240	240	(10) the child health plan program under Chapter 62,
241	241	Health and Safety Code;
242	242	(11) a regional or local health care program operated
243	243	under Section 75.104, Health and Safety Code;
244	244	(12) a self-funded health benefit plan sponsored by a
245	245	professional employer organization under Chapter 91, Labor Code;
246	246	(13) county employee group health benefits provided
247	247	under Chapter 157, Local Government Code; and
248	248	(14) health and accident coverage provided by a risk
249	249	pool created under Chapter 172, Local Government Code.
250	250	(c) This chapter applies to coverage under a group health
251	251	benefit plan provided to a resident of this state regardless of
252	252	whether the group policy, agreement, or contract is delivered,
253	253	issued for delivery, or renewed in this state.
254	254	Sec. 1380.002. EXCEPTION. This chapter does not apply to an
255	255	individual health benefit plan issued on or before March 23, 2010,
256	256	that has not had any significant changes since that date that reduce
257	257	benefits or increase costs to the individual.
258	258	Sec. 1380.003. REQUIRED COVERAGE FOR ESSENTIAL HEALTH
259	259	BENEFITS. (a) In this section:
260	260	(1) "Individual health benefit plan" means:
261	261	(A) an individual accident and health insurance
262	262	policy to which Chapter 1201 applies; or
263	263	(B) individual health maintenance organization
264	264	coverage.
265	265	(2) "Small employer health benefit plan" has the
266	266	meaning assigned by Section 1501.002.
267	267	(b) An individual or small employer health benefit plan must
268	268	provide coverage for the essential health benefits listed in 42
269	269	U.S.C. Section 18022(b)(1), as that section existed on January 1,
270	270	2017, and other benefits identified by the United States secretary
271	271	of health and human services as essential health benefits as of that
272	272	date.
273	273	Sec. 1380.004. CERTAIN ANNUAL AND LIFETIME LIMITS
274	274	PROHIBITED. A health benefit plan issuer may not establish an
275	275	annual or lifetime benefit amount for an enrollee in relation to
276	276	essential health benefits listed in 42 U.S.C. Section 18022(b)(1),
277	277	as that section existed on January 1, 2017, and other benefits
278	278	identified by the United States secretary of health and human
279	279	services as essential health benefits as of that date.
280	280	Sec. 1380.005. LIMITATIONS ON COST-SHARING. A health
281	281	benefit plan issuer may not impose cost-sharing requirements that
282	282	exceed the limits established in 42 U.S.C. Section 18022(c)(1) in
283	283	relation to essential health benefits listed in 42 U.S.C. Section
284	284	18022(b)(1), as those sections existed on January 1, 2017, and
285	285	other benefits identified by the United States secretary of health
286	286	and human services as essential health benefits as of that date.
287	287	Sec. 1380.006. RULES. (a) Subject to Subsection (b), the
288	288	commissioner may adopt rules as necessary to implement this
289	289	chapter.
290	290	(b) Rules adopted by the commissioner to implement this
291	291	chapter must be consistent with the Patient Protection and
292	292	Affordable Care Act (Pub. L. No. 111-148), as that Act existed on
293	293	January 1, 2017.
294	294	ARTICLE 3. CONFORMING AMENDMENTS; REPEALER
295	295	SECTION 3.01. Section 841.002, Insurance Code, is amended
296	296	to read as follows:
297	297	Sec. 841.002. APPLICABILITY OF CHAPTER AND OTHER
298	298	LAW. Except as otherwise expressly provided by this code, each
299	299	insurance company incorporated or engaging in business in this
300	300	state as a life insurance company, an accident insurance company, a
301	301	life and accident insurance company, a health and accident
302	302	insurance company, or a life, health, and accident insurance
303	303	company is subject to:
304	304	(1) this chapter;
305	305	(2) Chapter 3;
306	306	(3) Chapters 425 and 493;
307	307	(4) Title 7;
308	308	(5) Sections [1202.051,] 1204.151, 1204.153, and
309	309	1204.154;
310	310	(6) Subchapter A, Chapter 1202, Subchapters A and F,
311	311	Chapter 1204, Subchapter A, Chapter 1273, Subchapters A, B, and D,
312	312	Chapter 1355, and Subchapter A, Chapter 1366;
313	313	(7) Subchapter A, Chapter 1507;
314	314	(8) Chapters 1203, 1210, 1251-1254, 1301, 1351, 1354,
315	315	1359, 1364, 1368, 1505, 1651, 1652, and 1701; and
316	316	(9) Chapter 177, Local Government Code.
317	317	SECTION 3.02. Section 1201.005, Insurance Code, is amended
318	318	to read as follows:
319	319	Sec. 1201.005. REFERENCES TO CHAPTER. In this chapter, a
320	320	reference to this chapter includes a reference to:
321	321	(1) [Section 1202.052;
322	322	[(2)] Section 1271.005(a), to the extent that the
323	323	subsection relates to the applicability of Section 1201.105, and
324	324	Sections 1271.005(d) and (e);
325	325	(2) [(3)] Chapter 1351;
326	326	(3) [(4)] Subchapters C and E, Chapter 1355;
327	327	(4) [(5)] Chapter 1356;
328	328	(5) [(6)] Chapter 1365;
329	329	(6) [(7)] Subchapter A, Chapter 1367;
330	330	(7) Subchapter B, Chapter 1511; and
331	331	(8) Subchapters A, B, and G, Chapter 1451.
332	332	SECTION 3.03. Section 1507.003(b), Insurance Code, is
333	333	amended to read as follows:
334	334	(b) For purposes of this subchapter, "state-mandated health
335	335	benefits" does not include benefits that are mandated by federal
336	336	law or standard provisions or rights required under this code or
337	337	other laws of this state to be provided in an individual, blanket,
338	338	or group policy for accident and health insurance that are
339	339	unrelated to a specific health illness, injury, or condition of an
340	340	insured, including provisions related to:
341	341	(1) continuation of coverage under:
342	342	(A) Subchapters F and G, Chapter 1251;
343	343	(B) Section 1201.059; and
344	344	(C) Subchapter B, Chapter 1253;
345	345	(2) termination of coverage under Sections [1202.051
346	346	and] 1501.108 and 1511.052;
347	347	(3) preexisting conditions under Subchapter D,
348	348	Chapter 1201, and Sections 1501.102-1501.105;
349	349	(4) coverage of children, including newborn or adopted
350	350	children, under:
351	351	(A) Subchapter D, Chapter 1251;
352	352	(B) Sections 1201.053, 1201.061,
353	353	1201.063-1201.065, and Subchapter A, Chapter 1367;
354	354	(C) Chapter 1504;
355	355	(D) Chapter 1503;
356	356	(E) Section 1501.157;
357	357	(F) Section 1501.158; and
358	358	(G) Sections 1501.607-1501.609;
359	359	(5) services of practitioners under:
360	360	(A) Subchapters A, B, and C, Chapter 1451; or
361	361	(B) Section 1301.052;
362	362	(6) supplies and services associated with the
363	363	treatment of diabetes under Subchapter B, Chapter 1358;
364	364	(7) coverage for serious mental illness under
365	365	Subchapter A, Chapter 1355;
366	366	(8) coverage for childhood immunizations and hearing
367	367	screening as required by Subchapters B and C, Chapter 1367, other
368	368	than Section 1367.053(c) and Chapter 1353;
369	369	(9) coverage for reconstructive surgery for certain
370	370	craniofacial abnormalities of children as required by Subchapter D,
371	371	Chapter 1367;
372	372	(10) coverage for the dietary treatment of
373	373	phenylketonuria as required by Chapter 1359;
374	374	(11) coverage for referral to a non-network physician
375	375	or provider when medically necessary covered services are not
376	376	available through network physicians or providers, as required by
377	377	Section 1271.055; and
378	378	(12) coverage for cancer screenings under:
379	379	(A) Chapter 1356;
380	380	(B) Chapter 1362;
381	381	(C) Chapter 1363; and
382	382	(D) Chapter 1370.
383	383	SECTION 3.04. Section 1507.053(b), Insurance Code, is
384	384	amended to read as follows:
385	385	(b) For purposes of this subchapter, "state-mandated health
386	386	benefits" does not include coverage that is mandated by federal law
387	387	or standard provisions or rights required under this code or other
388	388	laws of this state to be provided in an evidence of coverage that
389	389	are unrelated to a specific health illness, injury, or condition of
390	390	an enrollee, including provisions related to:
391	391	(1) continuation of coverage under Subchapter G,
392	392	Chapter 1251;
393	393	(2) termination of coverage under Sections [1202.051
394	394	and] 1501.108 and 1511.052;
395	395	(3) preexisting conditions under Subchapter D,
396	396	Chapter 1201, and Sections 1501.102-1501.105;
397	397	(4) coverage of children, including newborn or adopted
398	398	children, under:
399	399	(A) Chapter 1504;
400	400	(B) Chapter 1503;
401	401	(C) Section 1501.157;
402	402	(D) Section 1501.158; and
403	403	(E) Sections 1501.607-1501.609;
404	404	(5) services of providers under Section 843.304;
405	405	(6) coverage for serious mental health illness under
406	406	Subchapter A, Chapter 1355; and
407	407	(7) coverage for cancer screenings under:
408	408	(A) Chapter 1356;
409	409	(B) Chapter 1362;
410	410	(C) Chapter 1363; and
411	411	(D) Chapter 1370.
412	412	SECTION 3.05. Section 1501.602(a), Insurance Code, is
413	413	amended to read as follows:
414	414	(a) A large employer health benefit plan issuer[:
415	415	[(1) may refuse to provide coverage to a large
416	416	employer in accordance with the issuer's underwriting standards and
417	417	criteria;
418	418	[(2) shall accept or reject the entire group of
419	419	individuals who meet the participation criteria and choose
420	420	coverage; and
421	421	[(3)] may exclude only those employees or dependents
422	422	who decline coverage.
423	423	SECTION 3.06. Subchapter B, Chapter 1202, Insurance Code,
424	424	is repealed.
425	425	ARTICLE 4. IMPLEMENTATION; TRANSITION; EFFECTIVE DATE
426	426	SECTION 4.01. If before implementing any provision of this
427	427	Act a state agency determines that a waiver or authorization from a
428	428	federal agency is necessary for implementation of that provision,
429	429	the agency affected by the provision shall request the waiver or
430	430	authorization and may delay implementing that provision until the
431	431	waiver or authorization is granted.
432	432	SECTION 4.02. The change in law made by this Act applies
433	433	only to a health benefit plan that is delivered, issued for
434	434	delivery, or renewed on or after January 1, 2022. A health benefit
435	435	plan that is delivered, issued for delivery, or renewed before
436	436	January 1, 2022, is governed by the law as it existed immediately
437	437	before the effective date of this Act, and that law is continued in
438	438	effect for that purpose.
439	439	SECTION 4.03. This Act takes effect September 1, 2021.