87R3701 RDS-F
By: Coleman H.B. No. 4143
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 COVERAGE AVAILABILITY
SECTION 1.01. Subtitle G, Title 8, Insurance Code, is
amended by adding Chapter 1511 to read as follows:
CHAPTER 1511. HEALTH BENEFIT COVERAGE AVAILABILITY
SUBCHAPTER A. GENERAL PROVISIONS
Sec. 1511.001. APPLICABILITY OF CHAPTER. (a) Except as
otherwise provided by this chapter, 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; and
(2) a standard health benefit plan issued under
Chapter 1507.
(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. 1511.002. 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 a specified disease or for another
limited benefit; or
(F) only for accidental death or dismemberment;
(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 1511.001.
(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. 1511.003. CONFLICT WITH OTHER LAW. If there is a
conflict between this chapter and other law, this chapter prevails.
Sec. 1511.004. RULES. (a) Subject to Subsection (b), the
commissioner may adopt rules as necessary to implement this
chapter.
(b) Rules adopted by the commissioner to implement this
chapter must be consistent with the Patient Protection and
Affordable Care Act (Pub. L. No. 111-148), as that Act existed on
January 1, 2017.
SUBCHAPTER B. GUARANTEED ISSUE AND RENEWABILITY
Sec. 1511.051. GUARANTEED ISSUE. A health benefit plan
issuer shall issue a group or individual health benefit plan chosen
by a group plan sponsor or individual to each group plan sponsor or
individual that elects to be covered under the plan and agrees to
satisfy the requirements of the plan.
Sec. 1511.052. RENEWABILITY AND CONTINUATION OF HEALTH
BENEFIT PLANS. (a) Except as provided by Subsection (b), a health
benefit plan issuer shall renew or continue a group or individual
health benefit plan at the option of the group plan sponsor or
individual, as applicable.
(b) A health benefit plan issuer may decline to renew or
continue a group or individual health benefit plan:
(1) for failure to pay a premium or contribution in
accordance with the terms of the plan;
(2) for fraud or intentional misrepresentation;
(3) because the issuer is ceasing to offer coverage in
the relevant market in accordance with rules adopted by the
commissioner;
(4) with respect to an individual plan, because an
individual no longer resides, lives, or works in an area in which
the issuer is authorized to provide coverage, but only if all plans
are not renewed or not continued under this subdivision uniformly
without regard to any health status related factor of covered
individuals; or
(5) in accordance with federal law, including
regulations.
Sec. 1511.053. RESCISSION PROHIBITED; EXCEPTION. (a)
Notwithstanding any other law, except as provided by Subsection
(b), a health benefit plan issuer may not rescind coverage under a
health benefit plan with respect to an enrollee in the plan.
(b) A health benefit plan issuer may rescind coverage under
a health benefit plan with respect to an enrollee if the enrollee
engages in conduct that constitutes fraud or makes an intentional
misrepresentation of a material fact.
Sec. 1511.054. EXCESSIVE WAITING PERIODS PROHIBITED. A
health benefit plan issuer issuing a group or individual health
benefit plan may not require a waiting period for coverage that
exceeds 90 days.
Sec. 1511.055. OPEN AND SPECIAL ENROLLMENT PERIODS. (a) A
health benefit plan issuer issuing an individual health benefit
plan may restrict enrollment in coverage to an annual open
enrollment period and special enrollment periods.
(b) An individual or an individual's dependent qualified to
enroll in an individual health benefit plan may enroll anytime
during the open enrollment period or during a special enrollment
period designated by the commissioner.
(c) A health benefit plan issuer issuing a group health
benefit plan may not limit enrollment to an open or special
enrollment period.
(d) The commissioner shall adopt rules as necessary to
administer this section, including rules designating enrollment
periods.
SUBCHAPTER C. PREEXISTING CONDITIONS AND HEALTH STATUS
Sec. 1511.101. DEFINITIONS. In this subchapter:
(1) "Dependent" has the meaning assigned by Section
1501.002.
(2) "Health status related factor" has the meaning
assigned by Section 1501.002.
(3) "Preexisting condition" means a condition present
before the effective date of an individual's coverage under a
health benefit plan.
Sec. 1511.102. APPLICABILITY OF SUBCHAPTER.
Notwithstanding any other law, in addition to a health benefit plan
to which this chapter applies under Subchapter A, 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.
Sec. 1511.103. PREEXISTING CONDITION AND HEALTH STATUS
RESTRICTIONS PROHIBITED. Notwithstanding any other law, a health
benefit plan issuer may not:
(1) deny coverage to or refuse to enroll a group, an
individual, or an individual's dependent in a health benefit plan
on the basis of a preexisting condition or health status related
factor;
(2) limit or exclude, or require a waiting period for,
coverage under the health benefit plan for treatment of a
preexisting condition otherwise covered under the plan; or
(3) charge a group, individual, or dependent more for
coverage than the health benefit plan issuer charges a group,
individual, or dependent who does not have a preexisting condition
or health status related factor.
SUBCHAPTER D. PROHIBITED DISCRIMINATION
Sec. 1511.151. DISCRIMINATORY BENEFIT DESIGN PROHIBITED.
(a) A health benefit plan issuer may not, through the plan's
benefit design, discriminate against an enrollee on the basis of
race, color, national origin, age, sex, expected length of life,
present or predicted disability, degree of medical dependency,
quality of life, or other health condition.
(b) A health benefit plan issuer may not use a health
benefit design that will have the effect of discouraging the
enrollment of individuals with significant health needs in the
health benefit plan.
(c) This section may not be construed to prevent a health
benefit plan issuer from appropriately utilizing reasonable
medical management techniques.
Sec. 1511.152. DISCRIMINATORY MARKETING PROHIBITED. A
health benefit plan issuer may not use a marketing practice that
will have the effect of discouraging the enrollment of individuals
with significant health needs in the health benefit plan or that
discriminates on the basis of race, color, national origin, age,
sex, expected length of life, present or predicted disability,
degree of medical dependency, quality of life, or other health
condition.
Sec. 1511.153. 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 E. CHOICE OF HEALTH CARE PROFESSIONAL; EMERGENCY
SERVICES
Sec. 1511.201. CHOICE OF PRIMARY CARE PROFESSIONAL. (a)
Notwithstanding any other law, a health benefit plan that requires
or provides for the designation by an enrollee of a participating
primary care provider must allow the enrollee to designate any
available participating primary care provider as the enrollee's
primary care provider.
(b) For an enrollee who is a child, the health benefit plan
must allow the child's parent or guardian to designate any
available participating primary care provider, including
participating primary care providers specializing in pediatrics,
as the primary care provider for the child.
Sec. 1511.202. CHOICE OF HEALTH CARE PROFESSIONAL
SPECIALIZING IN OBSTETRICAL AND GYNECOLOGICAL CARE. (a) A health
benefit plan may not require that a female individual covered by a
health benefit plan obtain authorization or a referral before
seeking obstetrical or gynecological care from a participating
health care professional specializing in obstetrics or gynecology.
(b) A health care professional specializing in obstetrics
or gynecology must adhere to the health benefit plan issuer's
policies and procedures.
Sec. 1511.203. COVERAGE FOR EMERGENCY SERVICES. (a) In
this section, "emergency services" means bona fide emergency
services provided after the sudden onset of a medical condition
manifesting itself by acute symptoms of sufficient severity,
including severe pain, such that the absence of immediate medical
attention could reasonably be expected to result in:
(1) placing the patient's health in serious jeopardy;
(2) serious impairment to bodily functions; or
(3) serious dysfunction of any bodily organ or part.
(b) A health benefit plan that provides coverage for
emergency services may not:
(1) require prior authorization for those services;
(2) impose requirements or limitations on coverage of
emergency services provided by a health care professional who does
not have a contractual relationship with the health benefit plan
that are more restrictive than the requirements or limitations
imposed on coverage of emergency services provided by health care
professionals who do have a contractual relationship with the
health benefit plan; or
(3) apply a different cost-sharing requirement for
emergency services provided by an out-of-network health care
professional.
SUBCHAPTER F. COVERAGE AND PREMIUMS FOR INDIVIDUAL AND SMALL
EMPLOYER HEALTH BENEFIT PLANS
Sec. 1511.251. DEFINITIONS. In this subchapter:
(1) "Individual health benefit plan" means:
(A) an individual accident and health insurance
policy to which Chapter 1201 applies; or
(B) individual health maintenance organization
coverage.
(2) "Small employer health benefit plan" has the
meaning assigned by Section 1501.002.
Sec. 1511.252. PREMIUM RATE VARIATION; RATING FACTORS. (a)
Notwithstanding any other law, an individual or small employer
health benefit plan issuer may not vary premium rates for those
plans based on a factor other than:
(1) the geographic area in which an individual
resides;
(2) the age of an individual;
(3) the use of one or more tobacco products by an
individual; and
(4) the individual's family size.
(b) Premium rates for an individual or small employer health
benefit plan may not vary by a ratio greater than:
(1) three to one based on the factor described by
Subsection (a)(2); or
(2) 1.5 to one based on the factor described by
Subsection (a)(3).
Sec. 1511.253. PREMIUM RATE REVIEW BY COMMISSIONER. (a)
The commissioner by rule shall establish a process to annually
review increases in premium rates charged by individual or small
employer health benefit plan issuers.
(b) The rules must require:
(1) an individual or small employer health benefit
plan issuer to:
(A) submit to the commissioner a justification
for a premium rate increase that results in an increase equal to or
greater than 10 percent prior to implementing the increase; and
(B) post information regarding the premium rate
increase on the health benefit plan issuer's Internet website; and
(2) the commissioner to make available to the public
information on premium increases and justifications submitted by
health benefit plan issuers under Subdivision (1).
Sec. 1511.254. SINGLE RISK POOL FOR INDIVIDUAL AND SMALL
EMPLOYER HEALTH BENEFIT PLANS. In establishing premium rates, a
health benefit plan issuer must consider:
(1) all individuals enrolled in individual health
benefit plans as members of one risk pool; and
(2) all individuals enrolled in small employer health
benefit plans as members of one risk pool.
Sec. 1511.255. LEVELS OF COVERAGE. (a) Except as provided
by Subsection (b), an individual or small employer health benefit
plan must provide one of the following levels of coverage:
(1) a bronze level of coverage that is designed to
provide benefits that are actuarially equivalent to 60 percent of
the full actuarial value of the benefits provided under the plan;
(2) a silver level of coverage that is designed to
provide benefits that are actuarially equivalent to 70 percent of
the full actuarial value of the benefits provided under the plan;
(3) a gold level of coverage that is designed to
provide benefits that are actuarially equivalent to 80 percent of
the full actuarial value of the benefits provided under the plan;
and
(4) a platinum level of coverage that is designed to
provide benefits that are actuarially equivalent to 90 percent of
the full actuarial value of the benefits provided under the plan.
(b) An individual health benefit plan may provide a level of
coverage other than a level of coverage described in Subsection (a)
if:
(1) the individual enrolled in the health benefit plan
is:
(A) younger than 30 years of age as of the first
day of the plan year; or
(B) exempt from the requirement to maintain
minimum essential coverage under 26 U.S.C. Section 5000A(e)(1) or
(5); and
(2) the health benefit plan provides coverage for:
(A) essential health benefits as required by
Section 1380.003, except that the plan provides no benefits for any
plan year until the individual has incurred cost-sharing expenses
in an amount equal to the annual limitation under Section 1380.005
for the plan year, subject to Section 1380.006; and
(B) at least three primary care visits.
SUBCHAPTER G. SUMMARY OF BENEFITS AND COVERAGE
Sec. 1511.301. SUMMARY OF BENEFITS AND COVERAGE. (a) A
health benefit plan issuer must provide to an individual a summary
of benefits and coverage explanation that accurately describes the
benefits and coverage under the health benefit plan:
(1) at the time of the individual's application for
coverage;
(2) prior to a period of enrollment or reenrollment;
and
(3) at the time the health benefit plan is issued.
(b) The commissioner shall adopt rules that establish
standards for the disclosures required in a summary described by
Subsection (a).
SUBCHAPTER H. REVIEW AND APPEALS PROCEDURES
Sec. 1511.351. 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.
Sec. 1511.352. APPEALS. A health benefit plan issuer must
implement an effective appeals process for appeals of coverage
determinations and claims. The appeals process must:
(1) include an internal claims appeal process;
(2) provide for notice to individuals enrolled in a
health benefit plan, in a culturally and linguistically appropriate
manner, of available internal and external appeals processes and
the availability of any consumer assistance from the department;
and
(3) allow an individual enrolled in a health benefit
plan to review the individual's file, present evidence and
testimony as part of the appeals process, and receive continued
coverage pending the outcome of the appeals process.
SUBCHAPTER I. REBATE
Sec. 1511.401. DEFINITIONS. In this subchapter:
(1) "Individual health benefit plan" means:
(A) an individual accident and health insurance
policy to which Chapter 1201 applies; or
(B) individual health maintenance organization
coverage.
(2) "Large employer health benefit plan" and "small
employer health benefit plan" have the meanings assigned by Section
1501.002.
Sec. 1511.402. MEDICAL LOSS RATIO. (a) A health benefit
plan issuer must calculate, with respect to each plan year:
(1) the amount of premium revenue expended on medical
claims, including reimbursement for clinical services provided to
individuals under a health benefit plan;
(2) the amount of premium revenue expended on
activities that improve health care quality; and
(3) after accounting for payments or receipts for risk
adjustment, risk corridors, and reinsurance, the total amount of
premium revenue received excluding federal and state taxes and
licensing or regulatory fees.
(b) A health benefit plan issuer must determine the ratio of
the combined amounts in Subsections (a)(1) and (a)(2) to the amount
in Subsection (a)(3).
Sec. 1511.403. REBATE. (a) This section applies only to:
(1) an individual or small employer health benefit
plan issuer with a ratio calculated under Section 1511.402(b) that
is greater than 80 percent; or
(2) a large group health benefit plan issuer with a
ratio calculated under Section 1511.402(b) that is greater than 85
percent.
(b) A health benefit plan issuer must, with respect to each
plan year for which this section applies to the issuer, provide each
enrolled individual a rebate, on a pro rata basis, as provided by
Subsection (c).
(c) The total amount of an annual rebate must be equal to the
product of the total amount of premium revenue calculated under
Section 1511.402(a)(3) and:
(1) with respect to an individual or small employer
plan, the amount by which the ratio described in Section
1511.402(b) exceeds 80 percent; or
(2) with respect to a large group plan, the amount by
which the ratio described in Section 1511.402(b) exceeds 85
percent.
ARTICLE 2. COVERAGE OF ESSENTIAL HEALTH BENEFITS
SECTION 2.01. 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) In this section:
(1) "Individual health benefit plan" means:
(A) an individual accident and health insurance
policy to which Chapter 1201 applies; or
(B) individual health maintenance organization
coverage.
(2) "Small employer health benefit plan" has the
meaning assigned by Section 1501.002.
(b) An individual or small employer 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.
Sec. 1380.004. 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. 1380.005. LIMITATIONS ON COST-SHARING. A health
benefit plan issuer may not impose cost-sharing requirements that
exceed the annual 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. 1380.006. 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, including additional
preventive care and screenings for women not described in
Subdivision (1).
Sec. 1380.007. RULES. (a) Subject to Subsection (b), the
commissioner may adopt rules as necessary to implement this
chapter.
(b) Rules adopted by the commissioner to implement this
chapter must be consistent with the Patient Protection and
Affordable Care Act (Pub. L. No. 111-148), as that Act existed on
January 1, 2017.
ARTICLE 3. HEALTH BENEFIT PLAN COVERAGE FOR CERTAIN YOUNG ADULTS
SECTION 3.01. 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 3.02. 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 a [an unmarried] child of an enrollee is 26 [25] years
of age.
SECTION 3.03. 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 3.04. 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
(B) [(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 3.05. 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 3.06. 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
(2) [(3)] a dependent of the insured for federal
income tax purposes at the time the application for coverage of the
grandchild is made.
SECTION 3.07. 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
(B) [(C)] a dependent of the insured for federal
income tax purposes at the time the application for coverage of the
grandchild is made.
SECTION 3.08. 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 a [an
unmarried] child of an enrollee, including a [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 3.09. 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 3.10. The heading to Section 1501.609, Insurance
Code, is amended to read as follows:
Sec. 1501.609. COVERAGE FOR [UNMARRIED] CHILDREN.
SECTION 3.11. 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 a [an unmarried] child of an enrollee is 26
[25] years of age.
SECTION 3.12. 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 3.13. Section 1551.004(a), Insurance Code, is
amended to read as follows:
(a) In this chapter, "dependent" with respect to an
individual eligible to participate in the group benefits program
means the individual's:
(1) spouse;
(2) [unmarried] child younger than 26 years of age;
(3) child of any age who the board of trustees
determines lives with or has the child's care provided by the
individual on a regular basis if the child is mentally or physically
incapacitated to the extent that the child is dependent on the
individual for care or support, as determined by the board of
trustees;
(4) child of any age who is unmarried, for purposes of
health benefit coverage under this chapter, on expiration of the
child's continuation coverage under the Consolidated Omnibus
Budget Reconciliation Act of 1985 (Pub. L. No. 99-272) and its
subsequent amendments; and
(5) ward, as that term is defined by Chapter 1002,
Estates Code, who is 26 years of age or younger.
SECTION 3.14. 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 4. CONFORMING AMENDMENTS; REPEALER
SECTION 4.01. Section 841.002, Insurance Code, is amended
to read as follows:
Sec. 841.002. APPLICABILITY OF CHAPTER AND OTHER
LAW. Except as otherwise expressly provided by this code, each
insurance company incorporated or engaging in business in this
state as a life insurance company, an accident insurance company, a
life and accident insurance company, a health and accident
insurance company, or a life, health, and accident insurance
company is subject to:
(1) this chapter;
(2) Chapter 3;
(3) Chapters 425 and 493;
(4) Title 7;
(5) Sections [1202.051,] 1204.151, 1204.153, and
1204.154;
(6) Subchapter A, Chapter 1202, Subchapters A and F,
Chapter 1204, Subchapter A, Chapter 1273, Subchapters A, B, and D,
Chapter 1355, and Subchapter A, Chapter 1366;
(7) Subchapter A, Chapter 1507;
(8) Chapters 1203, 1210, 1251-1254, 1301, 1351, 1354,
1359, 1364, 1368, 1505, 1651, 1652, and 1701; and
(9) Chapter 177, Local Government Code.
SECTION 4.02. Section 1201.005, Insurance Code, is amended
to read as follows:
Sec. 1201.005. REFERENCES TO CHAPTER. In this chapter, a
reference to this chapter includes a reference to:
(1) [Section 1202.052;
[(2)] Section 1271.005(a), to the extent that the
subsection relates to the applicability of Section 1201.105, and
Sections 1271.005(d) and (e);
(2) [(3)] Chapter 1351;
(3) [(4)] Subchapters C and E, Chapter 1355;
(4) [(5)] Chapter 1356;
(5) [(6)] Chapter 1365;
(6) [(7)] Subchapter A, Chapter 1367;
(7) Subchapter B, Chapter 1511; and
(8) Subchapters A, B, and G, Chapter 1451.
SECTION 4.03. Section 1507.003(b), Insurance Code, is
amended to read as follows:
(b) For purposes of this subchapter, "state-mandated health
benefits" does not include benefits that are mandated by federal
law or standard provisions or rights required under this code or
other laws of this state to be provided in an individual, blanket,
or group policy for accident and health insurance that are
unrelated to a specific health illness, injury, or condition of an
insured, including provisions related to:
(1) continuation of coverage under:
(A) Subchapters F and G, Chapter 1251;
(B) Section 1201.059; and
(C) Subchapter B, Chapter 1253;
(2) termination of coverage under Sections [1202.051
and] 1501.108 and 1511.052;
(3) preexisting conditions under Subchapter D,
Chapter 1201, and Sections 1501.102-1501.105;
(4) coverage of children, including newborn or adopted
children, under:
(A) Subchapter D, Chapter 1251;
(B) Sections 1201.053, 1201.061,
1201.063-1201.065, and Subchapter A, Chapter 1367;
(C) Chapter 1504;
(D) Chapter 1503;
(E) Section 1501.157;
(F) Section 1501.158; and
(G) Sections 1501.607-1501.609;
(5) services of practitioners under:
(A) Subchapters A, B, and C, Chapter 1451; or
(B) Section 1301.052;
(6) supplies and services associated with the
treatment of diabetes under Subchapter B, Chapter 1358;
(7) coverage for serious mental illness under
Subchapter A, Chapter 1355;
(8) coverage for childhood immunizations and hearing
screening as required by Subchapters B and C, Chapter 1367, other
than Section 1367.053(c) and Chapter 1353;
(9) coverage for reconstructive surgery for certain
craniofacial abnormalities of children as required by Subchapter D,
Chapter 1367;
(10) coverage for the dietary treatment of
phenylketonuria as required by Chapter 1359;
(11) coverage for referral to a non-network physician
or provider when medically necessary covered services are not
available through network physicians or providers, as required by
Section 1271.055; and
(12) coverage for cancer screenings under:
(A) Chapter 1356;
(B) Chapter 1362;
(C) Chapter 1363; and
(D) Chapter 1370.
SECTION 4.04. Section 1507.053(b), Insurance Code, is
amended to read as follows:
(b) For purposes of this subchapter, "state-mandated health
benefits" does not include coverage that is mandated by federal law
or standard provisions or rights required under this code or other
laws of this state to be provided in an evidence of coverage that
are unrelated to a specific health illness, injury, or condition of
an enrollee, including provisions related to:
(1) continuation of coverage under Subchapter G,
Chapter 1251;
(2) termination of coverage under Sections [1202.051
and] 1501.108 and 1511.052;
(3) preexisting conditions under Subchapter D,
Chapter 1201, and Sections 1501.102-1501.105;
(4) coverage of children, including newborn or adopted
children, under:
(A) Chapter 1504;
(B) Chapter 1503;
(C) Section 1501.157;
(D) Section 1501.158; and
(E) Sections 1501.607-1501.609;
(5) services of providers under Section 843.304;
(6) coverage for serious mental health illness under
Subchapter A, Chapter 1355; and
(7) coverage for cancer screenings under:
(A) Chapter 1356;
(B) Chapter 1362;
(C) Chapter 1363; and
(D) Chapter 1370.
SECTION 4.05. Section 1501.602(a), Insurance Code, is
amended to read as follows:
(a) A large employer health benefit plan issuer[:
[(1) may refuse to provide coverage to a large
employer in accordance with the issuer's underwriting standards and
criteria;
[(2) shall accept or reject the entire group of
individuals who meet the participation criteria and choose
coverage; and
[(3)] may exclude only those employees or dependents
who decline coverage.
SECTION 4.06. Subchapter B, Chapter 1202, Insurance Code,
is repealed.
ARTICLE 5. IMPLEMENTATION; TRANSITION; EFFECTIVE DATE
SECTION 5.01. 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 5.02. 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, 2022. A health benefit
plan that is delivered, issued for delivery, or renewed before
January 1, 2022, 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 5.03. This Act takes effect September 1, 2021.