Texas 2021 - 87th Regular

Texas House Bill HB3851 Compare Versions

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1	1	87R5124 SMT-F
2	2	By: Martinez Fischer H.B. No. 3851
3	3
4	4
5	5	A BILL TO BE ENTITLED
6	6	AN ACT
7	7	relating to the creation of a health insurance risk pool for certain
8	8	health benefit plan enrollees; authorizing an assessment.
9	9	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
10	10	SECTION 1. Subtitle G, Title 8, Insurance Code, is amended
11	11	by adding Chapter 1511 to read as follows:
12	12	CHAPTER 1511. HEALTH INSURANCE RISK POOL
13	13	SUBCHAPTER A. GENERAL PROVISIONS
14	14	Sec. 1511.0001. DEFINITIONS. In this chapter:
15	15	(1) "Board" means the board of directors appointed
16	16	under this chapter.
17	17	(2) "Pool" means a health insurance risk pool
18	18	established under this chapter and administered by the board.
19	19	Sec. 1511.0002. WAIVER. The commissioner shall:
20	20	(1) apply to the United States secretary of health and
21	21	human services under 42 U.S.C. Section 18052 for a waiver of Section
22	22	1312(c)(1) of the Patient Protection and Affordable Care Act (Pub.
23	23	L. No. 111-148) and any applicable regulations or guidance
24	24	beginning with the 2022 plan year;
25	25	(2) take any action the commissioner considers
26	26	appropriate to make an application under Subdivision (1); and
27	27	(3) implement a state plan that meets the requirements
28	28	of a waiver granted in response to an application under Subdivision
29	29	(1) if the plan is:
30	30	(A) consistent with state and federal law; and
31	31	(B) approved by the United States secretary of
32	32	health and human services.
33	33	Sec. 1511.0003. EXEMPTION FROM STATE TAXES AND FEES.
34	34	Notwithstanding any other law, a program created under this chapter
35	35	is not subject to any state tax, regulatory fee, or surcharge,
36	36	including a premium or maintenance tax or fee.
37	37	Sec. 1511.0004. NOTICE AND COMMENT. Following the grant of
38	38	a waiver under Section 1511.0002 and before the commissioner
39	39	implements a state plan under that section, the commissioner shall
40	40	hold a public hearing to solicit stakeholder comments regarding the
41	41	establishment of a health insurance risk pool under this chapter.
42	42	SUBCHAPTER B. ESTABLISHMENT AND PURPOSE
43	43	Sec. 1511.0051. ESTABLISHMENT OF HEALTH INSURANCE RISK
44	44	POOL. To the extent that federal money is available and only if the
45	45	United States secretary of health and human services grants the
46	46	waiver application submitted under Section 1511.0002, the
47	47	commissioner shall:
48	48	(1) apply for the federal money;
49	49	(2) use the federal money to establish a pool for the
50	50	purpose of this chapter; and
51	51	(3) authorize the board to use the federal money to
52	52	administer a pool for the purpose of this chapter.
53	53	Sec. 1511.0052. PURPOSE OF POOL. The purpose of the pool is
54	54	to provide a reinsurance mechanism to:
55	55	(1) meaningfully reduce health benefit plan premiums
56	56	in the individual market by mitigating the impact of high-risk
57	57	individuals on rates;
58	58	(2) maximize available federal money to assist
59	59	residents of this state to obtain guaranteed issue health benefit
60	60	coverage without increasing the federal deficit; and
61	61	(3) increase enrollment in guaranteed issue,
62	62	individual market health benefit plans that provide benefits and
63	63	coverage and cost-sharing protections against out-of-pocket costs
64	64	comparable to and as comprehensive as health benefit plans that
65	65	would be available without the pool.
66	66	SUBCHAPTER C. ADMINISTRATION
67	67	Sec. 1511.0101. BOARD OF DIRECTORS. (a) The pool is
68	68	governed by a board of directors.
69	69	(b) The board consists of nine members appointed by the
70	70	commissioner as follows:
71	71	(1) at least two, but not more than four, members must
72	72	be individuals who are affiliated with a health benefit plan issuer
73	73	authorized to write health benefit plans in this state;
74	74	(2) at least two members must be:
75	75	(A) individuals or the parents of individuals who
76	76	are covered by the pool or are reasonably expected to qualify for
77	77	coverage by the pool; or
78	78	(B) individuals who work as advocates for
79	79	individuals described by Paragraph (A); and
80	80	(3) the other members may be selected from individuals
81	81	such as:
82	82	(A) a physician licensed to practice in this
83	83	state by the Texas State Board of Medical Examiners;
84	84	(B) a hospital administrator;
85	85	(C) an advanced nurse practitioner; or
86	86	(D) a representative of the public who is not:
87	87	(i) employed by or affiliated with an
88	88	insurance company or insurance plan, group hospital service
89	89	corporation, or health maintenance organization;
90	90	(ii) related within the first degree of
91	91	consanguinity or affinity to an individual described by
92	92	Subparagraph (i); or
93	93	(iii) licensed as, employed by, or
94	94	affiliated with a physician, hospital, or other health care
95	95	provider.
96	96	(c) For purposes of Subsection (b), an individual who is
97	97	required to register under Chapter 305, Government Code, because of
98	98	the individual's activities with respect to health benefit
99	99	plan-related matters is affiliated with a health benefit plan
100	100	issuer.
101	101	(d) An individual is not disqualified under Subsection
102	102	(b)(3)(D)(i) from representing the public if the individual's only
103	103	affiliation with an insurance company or insurance plan, group
104	104	hospital service corporation, or health maintenance organization
105	105	is as an insured or as an individual who has coverage through a plan
106	106	provided by the corporation or organization.
107	107	Sec. 1511.0102. TERMS; VACANCY. (a) Board members serve
108	108	staggered six-year terms.
109	109	(b) The commissioner shall fill a vacancy on the board by
110	110	appointing, for the unexpired term, an individual who has the
111	111	appropriate qualifications to fill that position.
112	112	Sec. 1511.0103. PRESIDING OFFICER. The commissioner shall
113	113	designate one board member to serve as presiding officer at the
114	114	pleasure of the commissioner.
115	115	Sec. 1511.0104. PER DIEM; REIMBURSEMENT. A board member is
116	116	not entitled to compensation for service on the board but is
117	117	entitled to:
118	118	(1) a per diem in the amount provided by the General
119	119	Appropriations Act for state officials for each day the member
120	120	performs duties as a board member; and
121	121	(2) reimbursement of expenses incurred while
122	122	performing duties as a board member in the amount provided by the
123	123	General Appropriations Act for state officials.
124	124	Sec. 1511.0105. MEMBER'S IMMUNITY. (a) A board member is
125	125	not liable for an act or omission made in good faith in the
126	126	performance of powers and duties under this chapter.
127	127	(b) A cause of action does not arise against a board member
128	128	for an act or omission described by Subsection (a).
129	129	Sec. 1511.0106. ADDITIONAL POWERS AND DUTIES. The
130	130	commissioner by rule may establish powers and duties of the board in
131	131	addition to those provided by this chapter.
132	132	Sec. 1511.0107. PLAN OF OPERATION. (a) Operation and
133	133	management of the pool are governed by a plan of operation adopted
134	134	by the board and approved by the commissioner. The plan of
135	135	operation includes the articles, bylaws, and operating rules of the
136	136	pool.
137	137	(b) The plan of operation must ensure the fair, reasonable,
138	138	and equitable administration of the pool.
139	139	(c) The board shall amend the plan of operation as necessary
140	140	to carry out this chapter. An amendment to the plan of operation
141	141	must be approved by the commissioner before the board may adopt the
142	142	amendment.
143	143	SUBCHAPTER D. POWERS AND DUTIES
144	144	Sec. 1511.0151. METHODS TO REDUCE PREMIUM IN INDIVIDUAL
145	145	MARKET. Subject to any requirements to obtain federal money for the
146	146	pool, the board may use pool money to achieve lower enrollee premium
147	147	rates by establishing a reinsurance mechanism for health benefit
148	148	plan issuers writing comprehensive, guaranteed issue coverage in
149	149	the individual market.
150	150	Sec. 1511.0152. INCREASED ACCESS TO GUARANTEED ISSUE
151	151	COVERAGE. The board shall use pool money to increase enrollment in
152	152	guaranteed issue coverage in the individual market in a manner that
153	153	ensures that the benefits and cost-sharing protections available in
154	154	the individual market are maintained in the same manner the
155	155	benefits and protections would be maintained without the waiver
156	156	described by Section 1511.0002.
157	157	Sec. 1511.0153. CONTRACTS AND AGREEMENTS. The board may
158	158	enter into a contract or agreement that the board determines is
159	159	appropriate to carry out this chapter, including a contract or
160	160	agreement with:
161	161	(1) a similar pool in another state for the joint
162	162	performance of common administrative functions;
163	163	(2) another organization for the performance of
164	164	administrative functions; or
165	165	(3) a federal agency.
166	166	Sec. 1511.0154. RULES. The commissioner and board may
167	167	adopt rules necessary to implement this chapter, including rules to
168	168	administer the pool and distribute pool money.
169	169	Sec. 1511.0155. PROCEDURES, CRITERIA, AND FORMS. The board
170	170	by rule shall provide the procedures, criteria, and forms necessary
171	171	to implement, collect, and deposit assessments under Subchapter E.
172	172	Sec. 1511.0156. PUBLIC EDUCATION AND OUTREACH. (a) The
173	173	board may develop and implement public education, outreach, and
174	174	facilitated enrollment strategies under this chapter.
175	175	(b) The board may contract with marketing organizations to
176	176	perform or provide assistance with the strategies described by
177	177	Subsection (a).
178	178	Sec. 1511.0157. AUTHORITY TO ACT AS REINSURER. In addition
179	179	to the powers granted to the board under this chapter, the board may
180	180	exercise any authority that may be exercised under the law of this
181	181	state by a reinsurer.
182	182	SUBCHAPTER E. FUNDING
183	183	Sec. 1511.0201. FUNDING. The commissioner may use money
184	184	appropriated to the department to:
185	185	(1) apply for federal money and grants; and
186	186	(2) implement this chapter.
187	187	Sec. 1511.0202. ASSESSMENTS. (a) The board may assess
188	188	health benefit plan issuers, including making advance interim
189	189	assessments, as reasonable and necessary for the pool's
190	190	organizational and interim operating expenses.
191	191	(b) The board shall credit an interim assessment as an
192	192	offset against any regular assessment that is due after the end of
193	193	the fiscal year.
194	194	(c) The regular assessment is the amount calculated under
195	195	Section 1511.0204.
196	196	(d) The board shall deposit money from the interim and
197	197	regular assessments described by this section in an account
198	198	established outside the treasury and administered by the board.
199	199	Money in the account may be spent without an appropriation and may
200	200	be used only for purposes authorized by this chapter.
201	201	Sec. 1511.0203. DETERMINATION OF POOL FUNDING
202	202	REQUIREMENTS. After the end of each fiscal year, the board shall
203	203	determine for the next calendar year the amount of money required by
204	204	the pool to reduce enrollee premiums in accordance with this
205	205	chapter after applying the federal money obtained under this
206	206	chapter.
207	207	Sec. 1511.0204. ASSESSMENTS TO COVER POOL FUNDING
208	208	REQUIREMENTS. (a) The board shall recover an amount equal to the
209	209	funding required as determined under Section 1511.0203 by assessing
210	210	each health benefit plan issuer an amount determined annually by
211	211	the board based on information in annual statements, the health
212	212	benefit plan issuer's annual report to the board under Sections
213	213	1511.0251 and 1511.0252, and any other reports required by and
214	214	filed with the board.
215	215	(b) The board shall use the total number of enrolled
216	216	individuals reported by all health benefit plan issuers under
217	217	Section 1511.0252 as of the preceding December 31 to compute the
218	218	amount of a health benefit plan issuer's assessment, if any, in
219	219	accordance with this subsection. The board shall allocate the
220	220	total amount to be assessed based on the total number of enrolled
221	221	individuals covered by excess loss, stop-loss, or reinsurance
222	222	policies and on the total number of other enrolled individuals as
223	223	determined under Section 1511.0252. To compute the amount of a
224	224	health benefit plan issuer's assessment:
225	225	(1) for the issuer's enrolled individuals covered by
226	226	an excess loss, stop-loss, or reinsurance policy, the board shall:
227	227	(A) divide the allocated amount to be assessed by
228	228	the total number of enrolled individuals covered by excess loss,
229	229	stop-loss, or reinsurance policies, as determined under Section
230	230	1511.0252, to determine the per capita amount; and
231	231	(B) multiply the number of a health benefit plan
232	232	issuer's enrolled individuals covered by an excess loss, stop-loss,
233	233	or reinsurance policy, as determined under Section 1511.0252, by
234	234	the per capita amount to determine the amount assessed to that
235	235	health benefit plan issuer; and
236	236	(2) for the issuer's enrolled individuals not covered
237	237	by excess loss, stop-loss, or reinsurance policies, the board,
238	238	using the gross health benefit plan premiums reported for the
239	239	preceding calendar year by health benefit plan issuers under
240	240	Section 1511.0253, shall:
241	241	(A) divide the gross premium collected by a
242	242	health benefit plan issuer by the gross premium collected by all
243	243	health benefit plan issuers; and
244	244	(B) multiply the allocated amount to be assessed
245	245	by the fraction computed under Paragraph (A) to determine the
246	246	amount assessed to that health benefit plan issuer.
247	247	(c) A small employer health benefit plan described by
248	248	Chapter 1501 is not subject to an assessment under this section.
249	249	Sec. 1511.0205. ASSESSMENT DUE DATE; INTEREST. (a) An
250	250	assessment is due on the date specified by the board that is not
251	251	earlier than the 30th day after the date written notice of the
252	252	assessment is transmitted to the health benefit plan issuer.
253	253	(b) Interest accrues on the unpaid amount of an assessment
254	254	at a rate equal to the prime lending rate, as published in the most
255	255	recent issue of the Wall Street Journal and determined as of the
256	256	first day of each month during which the assessment is delinquent,
257	257	plus three percent.
258	258	Sec. 1511.0206. ABATEMENT OR DEFERMENT OF ASSESSMENT. (a)
259	259	A health benefit plan issuer may petition the board for an abatement
260	260	or deferment of all or part of an assessment imposed by the board.
261	261	The board may abate or defer all or part of the assessment if the
262	262	board determines that payment of the assessment would endanger the
263	263	ability of the health benefit plan issuer to fulfill its
264	264	contractual obligations.
265	265	(b) If all or part of an assessment against a health benefit
266	266	plan issuer is abated or deferred, the amount of the abatement or
267	267	deferment shall be assessed against the other health benefit plan
268	268	issuers in a manner consistent with the method for computing
269	269	assessments under this chapter.
270	270	(c) A health benefit plan issuer receiving an abatement or
271	271	deferment under this section remains liable to the pool for the
272	272	deficiency.
273	273	Sec. 1511.0207. USE OF EXCESS FROM ASSESSMENTS. If the
274	274	total amount of the assessments exceeds the pool's actual losses
275	275	and administrative expenses, the board shall credit each health
276	276	benefit plan issuer with the excess in an amount proportionate to
277	277	the amount the health benefit plan issuer paid in assessments. The
278	278	credit may be paid to the health benefit plan issuer or applied to
279	279	future assessments under this chapter.
280	280	Sec. 1511.0208. COLLECTION OF ASSESSMENTS. The pool may
281	281	recover or collect assessments made under this subchapter.
282	282	SUBCHAPTER F. REPORTING
283	283	Sec. 1511.0251. ANNUAL ISSUER REPORT TO BOARD: REQUESTED
284	284	INFORMATION. Each health benefit plan issuer shall report to the
285	285	board the information requested by the board, as of December 31 of
286	286	the preceding year.
287	287	Sec. 1511.0252. ANNUAL ISSUER REPORT TO BOARD: ENROLLED
288	288	INDIVIDUALS. (a) Each health benefit plan issuer shall report to
289	289	the board the number of residents of this state enrolled, as of
290	290	December 31 of the preceding year, in the issuer's health benefit
291	291	plans providing coverage for residents in this state, as:
292	292	(1) an employee under a group health benefit plan; or
293	293	(2) an individual policyholder or subscriber.
294	294	(b) In determining the number of individuals to report under
295	295	Subsection (a)(1), the health benefit plan issuer shall include
296	296	each employee for whom a premium is paid and coverage is provided
297	297	under an excess loss, stop-loss, or reinsurance policy issued by
298	298	the issuer to an employer or group health benefit plan providing
299	299	coverage for employees in this state. A health benefit plan issuer
300	300	providing excess loss insurance, stop-loss insurance, or
301	301	reinsurance, as described by this subsection, for a primary health
302	302	benefit plan issuer may not report individuals reported by the
303	303	primary health benefit plan issuer.
304	304	(c) Ten employees covered by a health benefit plan issuer
305	305	under a policy of excess loss insurance, stop-loss insurance, or
306	306	reinsurance count as one employee for purposes of determining that
307	307	health benefit plan issuer's assessment.
308	308	(d) In determining the number of individuals to report under
309	309	this section, the health benefit plan issuer shall exclude:
310	310	(1) the dependents of the employee or an individual
311	311	policyholder or subscriber; and
312	312	(2) individuals who are covered by the health benefit
313	313	plan issuer under a Medicare supplement benefit plan subject to
314	314	Chapter 1652.
315	315	(e) In determining the number of enrolled individuals to
316	316	report under this section, the health benefit plan issuer shall
317	317	exclude individuals who are retired employees 65 years of age or
318	318	older.
319	319	Sec. 1511.0253. ANNUAL ISSUER REPORT TO BOARD: GROSS
320	320	PREMIUMS. (a) Each health benefit plan issuer shall report to the
321	321	board the gross premiums collected for the preceding calendar year
322	322	for health benefit plans.
323	323	(b) For purposes of this section, gross health benefit plan
324	324	premiums do not include premiums collected for:
325	325	(1) coverage under a Medicare supplement benefit plan
326	326	subject to Chapter 1652;
327	327	(2) coverage under a small employer health benefit
328	328	plan subject to Chapter 1501;
329	329	(3) coverage:
330	330	(A) for wages or payments in lieu of wages for a
331	331	period during which an employee is absent from work because of
332	332	accident or disability;
333	333	(B) as a supplement to a liability insurance
334	334	policy;
335	335	(C) for credit insurance;
336	336	(D) only for dental or vision care; or
337	337	(E) only for a specified disease or illness;
338	338	(4) a workers' compensation insurance policy;
339	339	(5) medical payment insurance coverage provided under
340	340	a motor vehicle insurance policy;
341	341	(6) a long-term care policy, including a nursing home
342	342	fixed indemnity policy, unless the commissioner determines that the
343	343	policy provides comprehensive health benefit plan coverage;
344	344	(7) liability insurance coverage, including general
345	345	liability insurance and automobile liability insurance;
346	346	(8) coverage for on-site medical clinics;
347	347	(9) insurance coverage under which benefits are
348	348	payable with or without regard to fault and that is statutorily
349	349	required to be contained in a liability insurance policy or
350	350	equivalent self-insurance; or
351	351	(10) other similar insurance coverage, as specified by
352	352	federal regulations issued under the Health Insurance Portability
353	353	and Accountability Act of 1996 (Pub. L. No. 104-191), under which
354	354	benefits for medical care are secondary or incidental to other
355	355	insurance benefits.
356	356	Sec. 1511.0254. ANNUAL BOARD REPORT OF POOL ACTIVITIES.
357	357	(a) Beginning June 1, 2022, not later than June 1 of each year, the
358	358	board shall submit a report to the governor, lieutenant governor,
359	359	and speaker of the house of representatives.
360	360	(b) The report submitted under Subsection (a) must include:
361	361	(1) a summary of the activities conducted under this
362	362	chapter in the calendar year preceding the year in which the report
363	363	is submitted;
364	364	(2) the average amount by which health benefit plan
365	365	premiums were reduced in this state and in each rating region;
366	366	(3) the average change in each rating region in the
367	367	amount of health benefit plan premiums paid by individuals who
368	368	receive a premium subsidy under the Patient Protection and
369	369	Affordable Care Act (Pub. L. No. 111-148); and
370	370	(4) an estimate of the change in each rating region in
371	371	enrollment in health benefit plans due to the reduction in
372	372	premiums.
373	373	SECTION 2. This Act takes effect immediately if it receives
374	374	a vote of two-thirds of all the members elected to each house, as
375	375	provided by Section 39, Article III, Texas Constitution. If this
376	376	Act does not receive the vote necessary for immediate effect, this
377	377	Act takes effect September 1, 2021.