Texas 2021 - 87th Regular

Texas House Bill HB4143 Compare Versions

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

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1	1	87R3701 RDS-F
2	2	By: Coleman H.B. No. 4143
3	3
4	4
5	5	A BILL TO BE ENTITLED
6	6	AN ACT
7	7	relating to health benefit plan coverage in this state.
8	8	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
9	9	ARTICLE 1. HEALTH BENEFIT COVERAGE AVAILABILITY
10	10	SECTION 1.01. Subtitle G, Title 8, Insurance Code, is
11	11	amended by adding Chapter 1511 to read as follows:
12	12	CHAPTER 1511. HEALTH BENEFIT COVERAGE AVAILABILITY
13	13	SUBCHAPTER A. GENERAL PROVISIONS
14	14	Sec. 1511.001. APPLICABILITY OF CHAPTER. (a) Except as
15	15	otherwise provided by this chapter, this chapter applies only to a
16	16	health benefit plan that provides benefits for medical or surgical
17	17	expenses incurred as a result of a health condition, accident, or
18	18	sickness, including an individual, group, blanket, or franchise
19	19	insurance policy or insurance agreement, a group hospital service
20	20	contract, or an individual or group evidence of coverage or similar
21	21	coverage document that is issued by:
22	22	(1) an insurance company;
23	23	(2) a group hospital service corporation operating
24	24	under Chapter 842;
25	25	(3) a health maintenance organization operating under
26	26	Chapter 843;
27	27	(4) an approved nonprofit health corporation that
28	28	holds a certificate of authority under Chapter 844;
29	29	(5) a multiple employer welfare arrangement that holds
30	30	a certificate of authority under Chapter 846;
31	31	(6) a stipulated premium company operating under
32	32	Chapter 884;
33	33	(7) a fraternal benefit society operating under
34	34	Chapter 885;
35	35	(8) a Lloyd's plan operating under Chapter 941; or
36	36	(9) an exchange operating under Chapter 942.
37	37	(b) Notwithstanding any other law, this chapter applies to:
38	38	(1) a small employer health benefit plan subject to
39	39	Chapter 1501, including coverage provided through a health group
40	40	cooperative under Subchapter B of that chapter; and
41	41	(2) a standard health benefit plan issued under
42	42	Chapter 1507.
43	43	(c) This chapter applies to coverage under a group health
44	44	benefit plan provided to a resident of this state regardless of
45	45	whether the group policy, agreement, or contract is delivered,
46	46	issued for delivery, or renewed in this state.
47	47	Sec. 1511.002. EXCEPTIONS. (a) This chapter does not apply
48	48	to:
49	49	(1) a plan that provides coverage:
50	50	(A) for wages or payments in lieu of wages for a
51	51	period during which an employee is absent from work because of
52	52	sickness or injury;
53	53	(B) as a supplement to a liability insurance
54	54	policy;
55	55	(C) for credit insurance;
56	56	(D) only for dental or vision care;
57	57	(E) only for a specified disease or for another
58	58	limited benefit; or
59	59	(F) only for accidental death or dismemberment;
60	60	(2) a Medicare supplemental policy as defined by
61	61	Section 1882(g)(1), Social Security Act (42 U.S.C. Section
62	62	1395ss(g)(1));
63	63	(3) a workers' compensation insurance policy;
64	64	(4) medical payment insurance coverage provided under
65	65	a motor vehicle insurance policy; or
66	66	(5) a long-term care policy, including a nursing home
67	67	fixed indemnity policy, unless the commissioner determines that the
68	68	policy provides benefit coverage so comprehensive that the policy
69	69	is a health benefit plan as described by Section 1511.001.
70	70	(b) This chapter does not apply to an individual health
71	71	benefit plan issued on or before March 23, 2010, that has not had
72	72	any significant changes since that date that reduce benefits or
73	73	increase costs to the individual.
74	74	Sec. 1511.003. CONFLICT WITH OTHER LAW. If there is a
75	75	conflict between this chapter and other law, this chapter prevails.
76	76	Sec. 1511.004. RULES. (a) Subject to Subsection (b), the
77	77	commissioner may adopt rules as necessary to implement this
78	78	chapter.
79	79	(b) Rules adopted by the commissioner to implement this
80	80	chapter must be consistent with the Patient Protection and
81	81	Affordable Care Act (Pub. L. No. 111-148), as that Act existed on
82	82	January 1, 2017.
83	83	SUBCHAPTER B. GUARANTEED ISSUE AND RENEWABILITY
84	84	Sec. 1511.051. GUARANTEED ISSUE. A health benefit plan
85	85	issuer shall issue a group or individual health benefit plan chosen
86	86	by a group plan sponsor or individual to each group plan sponsor or
87	87	individual that elects to be covered under the plan and agrees to
88	88	satisfy the requirements of the plan.
89	89	Sec. 1511.052. RENEWABILITY AND CONTINUATION OF HEALTH
90	90	BENEFIT PLANS. (a) Except as provided by Subsection (b), a health
91	91	benefit plan issuer shall renew or continue a group or individual
92	92	health benefit plan at the option of the group plan sponsor or
93	93	individual, as applicable.
94	94	(b) A health benefit plan issuer may decline to renew or
95	95	continue a group or individual health benefit plan:
96	96	(1) for failure to pay a premium or contribution in
97	97	accordance with the terms of the plan;
98	98	(2) for fraud or intentional misrepresentation;
99	99	(3) because the issuer is ceasing to offer coverage in
100	100	the relevant market in accordance with rules adopted by the
101	101	commissioner;
102	102	(4) with respect to an individual plan, because an
103	103	individual no longer resides, lives, or works in an area in which
104	104	the issuer is authorized to provide coverage, but only if all plans
105	105	are not renewed or not continued under this subdivision uniformly
106	106	without regard to any health status related factor of covered
107	107	individuals; or
108	108	(5) in accordance with federal law, including
109	109	regulations.
110	110	Sec. 1511.053. RESCISSION PROHIBITED; EXCEPTION. (a)
111	111	Notwithstanding any other law, except as provided by Subsection
112	112	(b), a health benefit plan issuer may not rescind coverage under a
113	113	health benefit plan with respect to an enrollee in the plan.
114	114	(b) A health benefit plan issuer may rescind coverage under
115	115	a health benefit plan with respect to an enrollee if the enrollee
116	116	engages in conduct that constitutes fraud or makes an intentional
117	117	misrepresentation of a material fact.
118	118	Sec. 1511.054. EXCESSIVE WAITING PERIODS PROHIBITED. A
119	119	health benefit plan issuer issuing a group or individual health
120	120	benefit plan may not require a waiting period for coverage that
121	121	exceeds 90 days.
122	122	Sec. 1511.055. OPEN AND SPECIAL ENROLLMENT PERIODS. (a) A
123	123	health benefit plan issuer issuing an individual health benefit
124	124	plan may restrict enrollment in coverage to an annual open
125	125	enrollment period and special enrollment periods.
126	126	(b) An individual or an individual's dependent qualified to
127	127	enroll in an individual health benefit plan may enroll anytime
128	128	during the open enrollment period or during a special enrollment
129	129	period designated by the commissioner.
130	130	(c) A health benefit plan issuer issuing a group health
131	131	benefit plan may not limit enrollment to an open or special
132	132	enrollment period.
133	133	(d) The commissioner shall adopt rules as necessary to
134	134	administer this section, including rules designating enrollment
135	135	periods.
136	136	SUBCHAPTER C. PREEXISTING CONDITIONS AND HEALTH STATUS
137	137	Sec. 1511.101. DEFINITIONS. In this subchapter:
138	138	(1) "Dependent" has the meaning assigned by Section
139	139	1501.002.
140	140	(2) "Health status related factor" has the meaning
141	141	assigned by Section 1501.002.
142	142	(3) "Preexisting condition" means a condition present
143	143	before the effective date of an individual's coverage under a
144	144	health benefit plan.
145	145	Sec. 1511.102. APPLICABILITY OF SUBCHAPTER.
146	146	Notwithstanding any other law, in addition to a health benefit plan
147	147	to which this chapter applies under Subchapter A, this subchapter
148	148	applies to:
149	149	(1) a basic coverage plan under Chapter 1551;
150	150	(2) a basic plan under Chapter 1575;
151	151	(3) a primary care coverage plan under Chapter 1579;
152	152	(4) a plan providing basic coverage under Chapter
153	153	1601;
154	154	(5) health benefits provided by or through a church
155	155	benefits board under Subchapter I, Chapter 22, Business
156	156	Organizations Code;
157	157	(6) group health coverage made available by a school
158	158	district in accordance with Section 22.004, Education Code;
159	159	(7) the state Medicaid program, including the Medicaid
160	160	managed care program operated under Chapter 533, Government Code;
161	161	(8) the child health plan program under Chapter 62,
162	162	Health and Safety Code;
163	163	(9) a regional or local health care program operated
164	164	under Section 75.104, Health and Safety Code;
165	165	(10) a self-funded health benefit plan sponsored by a
166	166	professional employer organization under Chapter 91, Labor Code;
167	167	(11) county employee group health benefits provided
168	168	under Chapter 157, Local Government Code; and
169	169	(12) health and accident coverage provided by a risk
170	170	pool created under Chapter 172, Local Government Code.
171	171	Sec. 1511.103. PREEXISTING CONDITION AND HEALTH STATUS
172	172	RESTRICTIONS PROHIBITED. Notwithstanding any other law, a health
173	173	benefit plan issuer may not:
174	174	(1) deny coverage to or refuse to enroll a group, an
175	175	individual, or an individual's dependent in a health benefit plan
176	176	on the basis of a preexisting condition or health status related
177	177	factor;
178	178	(2) limit or exclude, or require a waiting period for,
179	179	coverage under the health benefit plan for treatment of a
180	180	preexisting condition otherwise covered under the plan; or
181	181	(3) charge a group, individual, or dependent more for
182	182	coverage than the health benefit plan issuer charges a group,
183	183	individual, or dependent who does not have a preexisting condition
184	184	or health status related factor.
185	185	SUBCHAPTER D. PROHIBITED DISCRIMINATION
186	186	Sec. 1511.151. DISCRIMINATORY BENEFIT DESIGN PROHIBITED.
187	187	(a) A health benefit plan issuer may not, through the plan's
188	188	benefit design, discriminate against an enrollee on the basis of
189	189	race, color, national origin, age, sex, expected length of life,
190	190	present or predicted disability, degree of medical dependency,
191	191	quality of life, or other health condition.
192	192	(b) A health benefit plan issuer may not use a health
193	193	benefit design that will have the effect of discouraging the
194	194	enrollment of individuals with significant health needs in the
195	195	health benefit plan.
196	196	(c) This section may not be construed to prevent a health
197	197	benefit plan issuer from appropriately utilizing reasonable
198	198	medical management techniques.
199	199	Sec. 1511.152. DISCRIMINATORY MARKETING PROHIBITED. A
200	200	health benefit plan issuer may not use a marketing practice that
201	201	will have the effect of discouraging the enrollment of individuals
202	202	with significant health needs in the health benefit plan or that
203	203	discriminates on the basis of race, color, national origin, age,
204	204	sex, expected length of life, present or predicted disability,
205	205	degree of medical dependency, quality of life, or other health
206	206	condition.
207	207	Sec. 1511.153. DISCRIMINATION BASED ON GENDER PROHIBITED.
208	208	A health benefit plan issuer may not charge an individual a higher
209	209	premium rate based on the individual's gender.
210	210	SUBCHAPTER E. CHOICE OF HEALTH CARE PROFESSIONAL; EMERGENCY
211	211	SERVICES
212	212	Sec. 1511.201. CHOICE OF PRIMARY CARE PROFESSIONAL. (a)
213	213	Notwithstanding any other law, a health benefit plan that requires
214	214	or provides for the designation by an enrollee of a participating
215	215	primary care provider must allow the enrollee to designate any
216	216	available participating primary care provider as the enrollee's
217	217	primary care provider.
218	218	(b) For an enrollee who is a child, the health benefit plan
219	219	must allow the child's parent or guardian to designate any
220	220	available participating primary care provider, including
221	221	participating primary care providers specializing in pediatrics,
222	222	as the primary care provider for the child.
223	223	Sec. 1511.202. CHOICE OF HEALTH CARE PROFESSIONAL
224	224	SPECIALIZING IN OBSTETRICAL AND GYNECOLOGICAL CARE. (a) A health
225	225	benefit plan may not require that a female individual covered by a
226	226	health benefit plan obtain authorization or a referral before
227	227	seeking obstetrical or gynecological care from a participating
228	228	health care professional specializing in obstetrics or gynecology.
229	229	(b) A health care professional specializing in obstetrics
230	230	or gynecology must adhere to the health benefit plan issuer's
231	231	policies and procedures.
232	232	Sec. 1511.203. COVERAGE FOR EMERGENCY SERVICES. (a) In
233	233	this section, "emergency services" means bona fide emergency
234	234	services provided after the sudden onset of a medical condition
235	235	manifesting itself by acute symptoms of sufficient severity,
236	236	including severe pain, such that the absence of immediate medical
237	237	attention could reasonably be expected to result in:
238	238	(1) placing the patient's health in serious jeopardy;
239	239	(2) serious impairment to bodily functions; or
240	240	(3) serious dysfunction of any bodily organ or part.
241	241	(b) A health benefit plan that provides coverage for
242	242	emergency services may not:
243	243	(1) require prior authorization for those services;
244	244	(2) impose requirements or limitations on coverage of
245	245	emergency services provided by a health care professional who does
246	246	not have a contractual relationship with the health benefit plan
247	247	that are more restrictive than the requirements or limitations
248	248	imposed on coverage of emergency services provided by health care
249	249	professionals who do have a contractual relationship with the
250	250	health benefit plan; or
251	251	(3) apply a different cost-sharing requirement for
252	252	emergency services provided by an out-of-network health care
253	253	professional.
254	254	SUBCHAPTER F. COVERAGE AND PREMIUMS FOR INDIVIDUAL AND SMALL
255	255	EMPLOYER HEALTH BENEFIT PLANS
256	256	Sec. 1511.251. DEFINITIONS. In this subchapter:
257	257	(1) "Individual health benefit plan" means:
258	258	(A) an individual accident and health insurance
259	259	policy to which Chapter 1201 applies; or
260	260	(B) individual health maintenance organization
261	261	coverage.
262	262	(2) "Small employer health benefit plan" has the
263	263	meaning assigned by Section 1501.002.
264	264	Sec. 1511.252. PREMIUM RATE VARIATION; RATING FACTORS. (a)
265	265	Notwithstanding any other law, an individual or small employer
266	266	health benefit plan issuer may not vary premium rates for those
267	267	plans based on a factor other than:
268	268	(1) the geographic area in which an individual
269	269	resides;
270	270	(2) the age of an individual;
271	271	(3) the use of one or more tobacco products by an
272	272	individual; and
273	273	(4) the individual's family size.
274	274	(b) Premium rates for an individual or small employer health
275	275	benefit plan may not vary by a ratio greater than:
276	276	(1) three to one based on the factor described by
277	277	Subsection (a)(2); or
278	278	(2) 1.5 to one based on the factor described by
279	279	Subsection (a)(3).
280	280	Sec. 1511.253. PREMIUM RATE REVIEW BY COMMISSIONER. (a)
281	281	The commissioner by rule shall establish a process to annually
282	282	review increases in premium rates charged by individual or small
283	283	employer health benefit plan issuers.
284	284	(b) The rules must require:
285	285	(1) an individual or small employer health benefit
286	286	plan issuer to:
287	287	(A) submit to the commissioner a justification
288	288	for a premium rate increase that results in an increase equal to or
289	289	greater than 10 percent prior to implementing the increase; and
290	290	(B) post information regarding the premium rate
291	291	increase on the health benefit plan issuer's Internet website; and
292	292	(2) the commissioner to make available to the public
293	293	information on premium increases and justifications submitted by
294	294	health benefit plan issuers under Subdivision (1).
295	295	Sec. 1511.254. SINGLE RISK POOL FOR INDIVIDUAL AND SMALL
296	296	EMPLOYER HEALTH BENEFIT PLANS. In establishing premium rates, a
297	297	health benefit plan issuer must consider:
298	298	(1) all individuals enrolled in individual health
299	299	benefit plans as members of one risk pool; and
300	300	(2) all individuals enrolled in small employer health
301	301	benefit plans as members of one risk pool.
302	302	Sec. 1511.255. LEVELS OF COVERAGE. (a) Except as provided
303	303	by Subsection (b), an individual or small employer health benefit
304	304	plan must provide one of the following levels of coverage:
305	305	(1) a bronze level of coverage that is designed to
306	306	provide benefits that are actuarially equivalent to 60 percent of
307	307	the full actuarial value of the benefits provided under the plan;
308	308	(2) a silver level of coverage that is designed to
309	309	provide benefits that are actuarially equivalent to 70 percent of
310	310	the full actuarial value of the benefits provided under the plan;
311	311	(3) a gold level of coverage that is designed to
312	312	provide benefits that are actuarially equivalent to 80 percent of
313	313	the full actuarial value of the benefits provided under the plan;
314	314	and
315	315	(4) a platinum level of coverage that is designed to
316	316	provide benefits that are actuarially equivalent to 90 percent of
317	317	the full actuarial value of the benefits provided under the plan.
318	318	(b) An individual health benefit plan may provide a level of
319	319	coverage other than a level of coverage described in Subsection (a)
320	320	if:
321	321	(1) the individual enrolled in the health benefit plan
322	322	is:
323	323	(A) younger than 30 years of age as of the first
324	324	day of the plan year; or
325	325	(B) exempt from the requirement to maintain
326	326	minimum essential coverage under 26 U.S.C. Section 5000A(e)(1) or
327	327	(5); and
328	328	(2) the health benefit plan provides coverage for:
329	329	(A) essential health benefits as required by
330	330	Section 1380.003, except that the plan provides no benefits for any
331	331	plan year until the individual has incurred cost-sharing expenses
332	332	in an amount equal to the annual limitation under Section 1380.005
333	333	for the plan year, subject to Section 1380.006; and
334	334	(B) at least three primary care visits.
335	335	SUBCHAPTER G. SUMMARY OF BENEFITS AND COVERAGE
336	336	Sec. 1511.301. SUMMARY OF BENEFITS AND COVERAGE. (a) A
337	337	health benefit plan issuer must provide to an individual a summary
338	338	of benefits and coverage explanation that accurately describes the
339	339	benefits and coverage under the health benefit plan:
340	340	(1) at the time of the individual's application for
341	341	coverage;
342	342	(2) prior to a period of enrollment or reenrollment;
343	343	and
344	344	(3) at the time the health benefit plan is issued.
345	345	(b) The commissioner shall adopt rules that establish
346	346	standards for the disclosures required in a summary described by
347	347	Subsection (a).
348	348	SUBCHAPTER H. REVIEW AND APPEALS PROCEDURES
349	349	Sec. 1511.351. EXTERNAL REVIEW MODEL ACT RULES. (a) The
350	350	department shall adopt rules as necessary to conform Texas law with
351	351	the requirements of the NAIC Uniform Health Carrier External Review
352	352	Model Act (April 2010).
353	353	(b) To the extent that the rules adopted under this section
354	354	conflict with Chapter 843 or Title 14, the rules control.
355	355	Sec. 1511.352. APPEALS. A health benefit plan issuer must
356	356	implement an effective appeals process for appeals of coverage
357	357	determinations and claims. The appeals process must:
358	358	(1) include an internal claims appeal process;
359	359	(2) provide for notice to individuals enrolled in a
360	360	health benefit plan, in a culturally and linguistically appropriate
361	361	manner, of available internal and external appeals processes and
362	362	the availability of any consumer assistance from the department;
363	363	and
364	364	(3) allow an individual enrolled in a health benefit
365	365	plan to review the individual's file, present evidence and
366	366	testimony as part of the appeals process, and receive continued
367	367	coverage pending the outcome of the appeals process.
368	368	SUBCHAPTER I. REBATE
369	369	Sec. 1511.401. DEFINITIONS. In this subchapter:
370	370	(1) "Individual health benefit plan" means:
371	371	(A) an individual accident and health insurance
372	372	policy to which Chapter 1201 applies; or
373	373	(B) individual health maintenance organization
374	374	coverage.
375	375	(2) "Large employer health benefit plan" and "small
376	376	employer health benefit plan" have the meanings assigned by Section
377	377	1501.002.
378	378	Sec. 1511.402. MEDICAL LOSS RATIO. (a) A health benefit
379	379	plan issuer must calculate, with respect to each plan year:
380	380	(1) the amount of premium revenue expended on medical
381	381	claims, including reimbursement for clinical services provided to
382	382	individuals under a health benefit plan;
383	383	(2) the amount of premium revenue expended on
384	384	activities that improve health care quality; and
385	385	(3) after accounting for payments or receipts for risk
386	386	adjustment, risk corridors, and reinsurance, the total amount of
387	387	premium revenue received excluding federal and state taxes and
388	388	licensing or regulatory fees.
389	389	(b) A health benefit plan issuer must determine the ratio of
390	390	the combined amounts in Subsections (a)(1) and (a)(2) to the amount
391	391	in Subsection (a)(3).
392	392	Sec. 1511.403. REBATE. (a) This section applies only to:
393	393	(1) an individual or small employer health benefit
394	394	plan issuer with a ratio calculated under Section 1511.402(b) that
395	395	is greater than 80 percent; or
396	396	(2) a large group health benefit plan issuer with a
397	397	ratio calculated under Section 1511.402(b) that is greater than 85
398	398	percent.
399	399	(b) A health benefit plan issuer must, with respect to each
400	400	plan year for which this section applies to the issuer, provide each
401	401	enrolled individual a rebate, on a pro rata basis, as provided by
402	402	Subsection (c).
403	403	(c) The total amount of an annual rebate must be equal to the
404	404	product of the total amount of premium revenue calculated under
405	405	Section 1511.402(a)(3) and:
406	406	(1) with respect to an individual or small employer
407	407	plan, the amount by which the ratio described in Section
408	408	1511.402(b) exceeds 80 percent; or
409	409	(2) with respect to a large group plan, the amount by
410	410	which the ratio described in Section 1511.402(b) exceeds 85
411	411	percent.
412	412	ARTICLE 2. COVERAGE OF ESSENTIAL HEALTH BENEFITS
413	413	SECTION 2.01. Subtitle E, Title 8, Insurance Code, is
414	414	amended by adding Chapter 1380 to read as follows:
415	415	CHAPTER 1380. COVERAGE OF ESSENTIAL HEALTH BENEFITS
416	416	Sec. 1380.001. APPLICABILITY OF CHAPTER. (a) This chapter
417	417	applies only to a health benefit plan that provides benefits for
418	418	medical or surgical expenses incurred as a result of a health
419	419	condition, accident, or sickness, including an individual, group,
420	420	blanket, or franchise insurance policy or insurance agreement, a
421	421	group hospital service contract, or an individual or group evidence
422	422	of coverage or similar coverage document that is issued by:
423	423	(1) an insurance company;
424	424	(2) a group hospital service corporation operating
425	425	under Chapter 842;
426	426	(3) a health maintenance organization operating under
427	427	Chapter 843;
428	428	(4) an approved nonprofit health corporation that
429	429	holds a certificate of authority under Chapter 844;
430	430	(5) a multiple employer welfare arrangement that holds
431	431	a certificate of authority under Chapter 846;
432	432	(6) a stipulated premium company operating under
433	433	Chapter 884;
434	434	(7) a fraternal benefit society operating under
435	435	Chapter 885;
436	436	(8) a Lloyd's plan operating under Chapter 941; or
437	437	(9) an exchange operating under Chapter 942.
438	438	(b) Notwithstanding any other law, this chapter applies to:
439	439	(1) a small employer health benefit plan subject to
440	440	Chapter 1501, including coverage provided through a health group
441	441	cooperative under Subchapter B of that chapter;
442	442	(2) a standard health benefit plan issued under
443	443	Chapter 1507;
444	444	(3) a basic coverage plan under Chapter 1551;
445	445	(4) a basic plan under Chapter 1575;
446	446	(5) a primary care coverage plan under Chapter 1579;
447	447	(6) a plan providing basic coverage under Chapter
448	448	1601;
449	449	(7) health benefits provided by or through a church
450	450	benefits board under Subchapter I, Chapter 22, Business
451	451	Organizations Code;
452	452	(8) group health coverage made available by a school
453	453	district in accordance with Section 22.004, Education Code;
454	454	(9) the state Medicaid program, including the Medicaid
455	455	managed care program operated under Chapter 533, Government Code;
456	456	(10) the child health plan program under Chapter 62,
457	457	Health and Safety Code;
458	458	(11) a regional or local health care program operated
459	459	under Section 75.104, Health and Safety Code;
460	460	(12) a self-funded health benefit plan sponsored by a
461	461	professional employer organization under Chapter 91, Labor Code;
462	462	(13) county employee group health benefits provided
463	463	under Chapter 157, Local Government Code; and
464	464	(14) health and accident coverage provided by a risk
465	465	pool created under Chapter 172, Local Government Code.
466	466	(c) This chapter applies to coverage under a group health
467	467	benefit plan provided to a resident of this state regardless of
468	468	whether the group policy, agreement, or contract is delivered,
469	469	issued for delivery, or renewed in this state.
470	470	Sec. 1380.002. EXCEPTION. This chapter does not apply to an
471	471	individual health benefit plan issued on or before March 23, 2010,
472	472	that has not had any significant changes since that date that reduce
473	473	benefits or increase costs to the individual.
474	474	Sec. 1380.003. REQUIRED COVERAGE FOR ESSENTIAL HEALTH
475	475	BENEFITS. (a) In this section:
476	476	(1) "Individual health benefit plan" means:
477	477	(A) an individual accident and health insurance
478	478	policy to which Chapter 1201 applies; or
479	479	(B) individual health maintenance organization
480	480	coverage.
481	481	(2) "Small employer health benefit plan" has the
482	482	meaning assigned by Section 1501.002.
483	483	(b) An individual or small employer health benefit plan must
484	484	provide coverage for the essential health benefits listed in 42
485	485	U.S.C. Section 18022(b)(1), as that section existed on January 1,
486	486	2017, and other benefits identified by the United States secretary
487	487	of health and human services as essential health benefits as of that
488	488	date.
489	489	Sec. 1380.004. CERTAIN ANNUAL AND LIFETIME LIMITS
490	490	PROHIBITED. A health benefit plan issuer may not establish an
491	491	annual or lifetime benefit amount for an enrollee in relation to
492	492	essential health benefits listed in 42 U.S.C. Section 18022(b)(1),
493	493	as that section existed on January 1, 2017, and other benefits
494	494	identified by the United States secretary of health and human
495	495	services as essential health benefits as of that date.
496	496	Sec. 1380.005. LIMITATIONS ON COST-SHARING. A health
497	497	benefit plan issuer may not impose cost-sharing requirements that
498	498	exceed the annual limits established in 42 U.S.C. Section
499	499	18022(c)(1) in relation to essential health benefits listed in 42
500	500	U.S.C. Section 18022(b)(1), as those sections existed on January 1,
501	501	2017, and other benefits identified by the United States secretary
502	502	of health and human services as essential health benefits as of that
503	503	date.
504	504	Sec. 1380.006. CERTAIN COST-SHARING PROVISIONS FOR
505	505	PREVENTIVE SERVICES PROHIBITED. A health benefit plan issuer may
506	506	not impose a deductible, copayment, coinsurance, or other
507	507	cost-sharing provision applicable to benefits for:
508	508	(1) a preventive item or service that has in effect a
509	509	rating of "A" or "B" in the most recent recommendations of the
510	510	United States Preventive Services Task Force;
511	511	(2) an immunization recommended for routine use in the
512	512	most recent immunization schedules published by the United States
513	513	Centers for Disease Control and Prevention of the United States
514	514	Public Health Service; or
515	515	(3) preventive care and screenings supported by the
516	516	most recent comprehensive guidelines adopted by the United States
517	517	Health Resources and Services Administration, including additional
518	518	preventive care and screenings for women not described in
519	519	Subdivision (1).
520	520	Sec. 1380.007. RULES. (a) Subject to Subsection (b), the
521	521	commissioner may adopt rules as necessary to implement this
522	522	chapter.
523	523	(b) Rules adopted by the commissioner to implement this
524	524	chapter must be consistent with the Patient Protection and
525	525	Affordable Care Act (Pub. L. No. 111-148), as that Act existed on
526	526	January 1, 2017.
527	527	ARTICLE 3. HEALTH BENEFIT PLAN COVERAGE FOR CERTAIN YOUNG ADULTS
528	528	SECTION 3.01. Subchapter A, Chapter 533, Government Code,
529	529	is amended by adding Section 533.0057 to read as follows:
530	530	Sec. 533.0057. ELIGIBILITY AGE FOR STAR HEALTH COVERAGE. A
531	531	child enrolled in the STAR Health Medicaid managed care program is
532	532	eligible to receive health care services under the program until
533	533	the child is 26 years of age.
534	534	SECTION 3.02. Section 846.260, Insurance Code, is amended
535	535	to read as follows:
536	536	Sec. 846.260. LIMITING AGE APPLICABLE TO [UNMARRIED] CHILD.
537	537	If children are eligible for coverage under the terms of a multiple
538	538	employer welfare arrangement's plan document, any limiting age
539	539	applicable to a [an unmarried] child of an enrollee is 26 [25] years
540	540	of age.
541	541	SECTION 3.03. Section 1201.053(b), Insurance Code, is
542	542	amended to read as follows:
543	543	(b) On the application of an adult member of a family, an
544	544	individual accident and health insurance policy may, at the time of
545	545	original issuance or by subsequent amendment, insure two or more
546	546	eligible members of the adult's family, including a spouse,
547	547	[unmarried] children younger than 26 [25] years of age, including a
548	548	grandchild of the adult as described by Section 1201.062(a)(1), a
549	549	child the adult is required to insure under a medical support order
550	550	or dental support order, if the policy provides dental coverage,
551	551	issued under Chapter 154, Family Code, or enforceable by a court in
552	552	this state, and any other individual dependent on the adult.
553	553	SECTION 3.04. Section 1201.062(a), Insurance Code, is
554	554	amended to read as follows:
555	555	(a) An individual or group accident and health insurance
556	556	policy that is delivered, issued for delivery, or renewed in this
557	557	state, including a policy issued by a corporation operating under
558	558	Chapter 842, or a self-funded or self-insured welfare or benefit
559	559	plan or program, to the extent that regulation of the plan or
560	560	program is not preempted by federal law, that provides coverage for
561	561	a child of an insured or group member, on payment of a premium, must
562	562	provide coverage for:
563	563	(1) each grandchild of the insured or group member if
564	564	the grandchild is:
565	565	(A) [unmarried;
566	566	[(B)] younger than 26 [25] years of age; and
567	567	(B) [(C)] a dependent of the insured or group
568	568	member for federal income tax purposes at the time application for
569	569	coverage of the grandchild is made; and
570	570	(2) each child for whom the insured or group member
571	571	must provide medical support or dental support, if the policy
572	572	provides dental coverage, under an order issued under Chapter 154,
573	573	Family Code, or enforceable by a court in this state.
574	574	SECTION 3.05. Section 1201.065(a), Insurance Code, is
575	575	amended to read as follows:
576	576	(a) An individual or group accident and health insurance
577	577	policy may contain criteria relating to a maximum age or enrollment
578	578	in school to establish continued eligibility for coverage of a
579	579	child 26 [25] years of age or older.
580	580	SECTION 3.06. Section 1251.151(a), Insurance Code, is
581	581	amended to read as follows:
582	582	(a) A group policy or contract of insurance for hospital,
583	583	surgical, or medical expenses incurred as a result of accident or
584	584	sickness, including a group contract issued by a group hospital
585	585	service corporation, that provides coverage under the policy or
586	586	contract for a child of an insured must, on payment of a premium,
587	587	provide coverage for any grandchild of the insured if the
588	588	grandchild is:
589	589	(1) [unmarried;
590	590	[(2)] younger than 26 [25] years of age; and
591	591	(2) [(3)] a dependent of the insured for federal
592	592	income tax purposes at the time the application for coverage of the
593	593	grandchild is made.
594	594	SECTION 3.07. Section 1251.152(a), Insurance Code, is
595	595	amended to read as follows:
596	596	(a) For purposes of this section, "dependent" includes:
597	597	(1) a child of an employee or member who is[:
598	598	[(A) unmarried; and
599	599	[(B)] younger than 26 [25] years of age; and
600	600	(2) a grandchild of an employee or member who is:
601	601	(A) [unmarried;
602	602	[(B)] younger than 26 [25] years of age; and
603	603	(B) [(C)] a dependent of the insured for federal
604	604	income tax purposes at the time the application for coverage of the
605	605	grandchild is made.
606	606	SECTION 3.08. Section 1271.006(a), Insurance Code, is
607	607	amended to read as follows:
608	608	(a) If children are eligible for coverage under the terms of
609	609	an evidence of coverage, any limiting age applicable to a [an
610	610	unmarried] child of an enrollee, including a [an unmarried]
611	611	grandchild of an enrollee, is 26 [25] years of age. The limiting
612	612	age applicable to a child must be stated in the evidence of
613	613	coverage.
614	614	SECTION 3.09. Section 1501.002(2), Insurance Code, is
615	615	amended to read as follows:
616	616	(2) "Dependent" means:
617	617	(A) a spouse;
618	618	(B) a child younger than 26 [25] years of age,
619	619	including a newborn child;
620	620	(C) a child of any age who is:
621	621	(i) medically certified as disabled; and
622	622	(ii) dependent on the parent;
623	623	(D) an individual who must be covered under:
624	624	(i) Section 1251.154; or
625	625	(ii) Section 1201.062; and
626	626	(E) any other child eligible under an employer's
627	627	health benefit plan, including a child described by Section
628	628	1503.003.
629	629	SECTION 3.10. The heading to Section 1501.609, Insurance
630	630	Code, is amended to read as follows:
631	631	Sec. 1501.609. COVERAGE FOR [UNMARRIED] CHILDREN.
632	632	SECTION 3.11. Section 1501.609(b), Insurance Code, is
633	633	amended to read as follows:
634	634	(b) Any limiting age applicable under a large employer
635	635	health benefit plan to a [an unmarried] child of an enrollee is 26
636	636	[25] years of age.
637	637	SECTION 3.12. Sections 1503.003(a) and (b), Insurance Code,
638	638	are amended to read as follows:
639	639	(a) A health benefit plan may not condition coverage for a
640	640	child younger than 26 [25] years of age on the child's being
641	641	enrolled at an educational institution.
642	642	(b) A health benefit plan that requires as a condition of
643	643	coverage for a child 26 [25] years of age or older that the child be
644	644	a full-time student at an educational institution must provide the
645	645	coverage:
646	646	(1) for the entire academic term during which the
647	647	child begins as a full-time student and remains enrolled,
648	648	regardless of whether the number of hours of instruction for which
649	649	the child is enrolled is reduced to a level that changes the child's
650	650	academic status to less than that of a full-time student; and
651	651	(2) continuously until the 10th day of instruction of
652	652	the subsequent academic term, on which date the health benefit plan
653	653	may terminate coverage for the child if the child does not return to
654	654	full-time student status before that date.
655	655	SECTION 3.13. Section 1551.004(a), Insurance Code, is
656	656	amended to read as follows:
657	657	(a) In this chapter, "dependent" with respect to an
658	658	individual eligible to participate in the group benefits program
659	659	means the individual's:
660	660	(1) spouse;
661	661	(2) [unmarried] child younger than 26 years of age;
662	662	(3) child of any age who the board of trustees
663	663	determines lives with or has the child's care provided by the
664	664	individual on a regular basis if the child is mentally or physically
665	665	incapacitated to the extent that the child is dependent on the
666	666	individual for care or support, as determined by the board of
667	667	trustees;
668	668	(4) child of any age who is unmarried, for purposes of
669	669	health benefit coverage under this chapter, on expiration of the
670	670	child's continuation coverage under the Consolidated Omnibus
671	671	Budget Reconciliation Act of 1985 (Pub. L. No. 99-272) and its
672	672	subsequent amendments; and
673	673	(5) ward, as that term is defined by Chapter 1002,
674	674	Estates Code, who is 26 years of age or younger.
675	675	SECTION 3.14. Section 1601.004(a), Insurance Code, is
676	676	amended to read as follows:
677	677	(a) In this chapter, "dependent," with respect to an
678	678	individual eligible to participate in the uniform program under
679	679	Section 1601.101 or 1601.102, means the individual's:
680	680	(1) spouse;
681	681	(2) [unmarried] child younger than 26 [25] years of
682	682	age; and
683	683	(3) child of any age who lives with or has the child's
684	684	care provided by the individual on a regular basis if the child has
685	685	a mental disability or is [mentally retarded or] physically
686	686	incapacitated to the extent that the child is dependent on the
687	687	individual for care or support, as determined by the system.
688	688	ARTICLE 4. CONFORMING AMENDMENTS; REPEALER
689	689	SECTION 4.01. Section 841.002, Insurance Code, is amended
690	690	to read as follows:
691	691	Sec. 841.002. APPLICABILITY OF CHAPTER AND OTHER
692	692	LAW. Except as otherwise expressly provided by this code, each
693	693	insurance company incorporated or engaging in business in this
694	694	state as a life insurance company, an accident insurance company, a
695	695	life and accident insurance company, a health and accident
696	696	insurance company, or a life, health, and accident insurance
697	697	company is subject to:
698	698	(1) this chapter;
699	699	(2) Chapter 3;
700	700	(3) Chapters 425 and 493;
701	701	(4) Title 7;
702	702	(5) Sections [1202.051,] 1204.151, 1204.153, and
703	703	1204.154;
704	704	(6) Subchapter A, Chapter 1202, Subchapters A and F,
705	705	Chapter 1204, Subchapter A, Chapter 1273, Subchapters A, B, and D,
706	706	Chapter 1355, and Subchapter A, Chapter 1366;
707	707	(7) Subchapter A, Chapter 1507;
708	708	(8) Chapters 1203, 1210, 1251-1254, 1301, 1351, 1354,
709	709	1359, 1364, 1368, 1505, 1651, 1652, and 1701; and
710	710	(9) Chapter 177, Local Government Code.
711	711	SECTION 4.02. Section 1201.005, Insurance Code, is amended
712	712	to read as follows:
713	713	Sec. 1201.005. REFERENCES TO CHAPTER. In this chapter, a
714	714	reference to this chapter includes a reference to:
715	715	(1) [Section 1202.052;
716	716	[(2)] Section 1271.005(a), to the extent that the
717	717	subsection relates to the applicability of Section 1201.105, and
718	718	Sections 1271.005(d) and (e);
719	719	(2) [(3)] Chapter 1351;
720	720	(3) [(4)] Subchapters C and E, Chapter 1355;
721	721	(4) [(5)] Chapter 1356;
722	722	(5) [(6)] Chapter 1365;
723	723	(6) [(7)] Subchapter A, Chapter 1367;
724	724	(7) Subchapter B, Chapter 1511; and
725	725	(8) Subchapters A, B, and G, Chapter 1451.
726	726	SECTION 4.03. Section 1507.003(b), Insurance Code, is
727	727	amended to read as follows:
728	728	(b) For purposes of this subchapter, "state-mandated health
729	729	benefits" does not include benefits that are mandated by federal
730	730	law or standard provisions or rights required under this code or
731	731	other laws of this state to be provided in an individual, blanket,
732	732	or group policy for accident and health insurance that are
733	733	unrelated to a specific health illness, injury, or condition of an
734	734	insured, including provisions related to:
735	735	(1) continuation of coverage under:
736	736	(A) Subchapters F and G, Chapter 1251;
737	737	(B) Section 1201.059; and
738	738	(C) Subchapter B, Chapter 1253;
739	739	(2) termination of coverage under Sections [1202.051
740	740	and] 1501.108 and 1511.052;
741	741	(3) preexisting conditions under Subchapter D,
742	742	Chapter 1201, and Sections 1501.102-1501.105;
743	743	(4) coverage of children, including newborn or adopted
744	744	children, under:
745	745	(A) Subchapter D, Chapter 1251;
746	746	(B) Sections 1201.053, 1201.061,
747	747	1201.063-1201.065, and Subchapter A, Chapter 1367;
748	748	(C) Chapter 1504;
749	749	(D) Chapter 1503;
750	750	(E) Section 1501.157;
751	751	(F) Section 1501.158; and
752	752	(G) Sections 1501.607-1501.609;
753	753	(5) services of practitioners under:
754	754	(A) Subchapters A, B, and C, Chapter 1451; or
755	755	(B) Section 1301.052;
756	756	(6) supplies and services associated with the
757	757	treatment of diabetes under Subchapter B, Chapter 1358;
758	758	(7) coverage for serious mental illness under
759	759	Subchapter A, Chapter 1355;
760	760	(8) coverage for childhood immunizations and hearing
761	761	screening as required by Subchapters B and C, Chapter 1367, other
762	762	than Section 1367.053(c) and Chapter 1353;
763	763	(9) coverage for reconstructive surgery for certain
764	764	craniofacial abnormalities of children as required by Subchapter D,
765	765	Chapter 1367;
766	766	(10) coverage for the dietary treatment of
767	767	phenylketonuria as required by Chapter 1359;
768	768	(11) coverage for referral to a non-network physician
769	769	or provider when medically necessary covered services are not
770	770	available through network physicians or providers, as required by
771	771	Section 1271.055; and
772	772	(12) coverage for cancer screenings under:
773	773	(A) Chapter 1356;
774	774	(B) Chapter 1362;
775	775	(C) Chapter 1363; and
776	776	(D) Chapter 1370.
777	777	SECTION 4.04. Section 1507.053(b), Insurance Code, is
778	778	amended to read as follows:
779	779	(b) For purposes of this subchapter, "state-mandated health
780	780	benefits" does not include coverage that is mandated by federal law
781	781	or standard provisions or rights required under this code or other
782	782	laws of this state to be provided in an evidence of coverage that
783	783	are unrelated to a specific health illness, injury, or condition of
784	784	an enrollee, including provisions related to:
785	785	(1) continuation of coverage under Subchapter G,
786	786	Chapter 1251;
787	787	(2) termination of coverage under Sections [1202.051
788	788	and] 1501.108 and 1511.052;
789	789	(3) preexisting conditions under Subchapter D,
790	790	Chapter 1201, and Sections 1501.102-1501.105;
791	791	(4) coverage of children, including newborn or adopted
792	792	children, under:
793	793	(A) Chapter 1504;
794	794	(B) Chapter 1503;
795	795	(C) Section 1501.157;
796	796	(D) Section 1501.158; and
797	797	(E) Sections 1501.607-1501.609;
798	798	(5) services of providers under Section 843.304;
799	799	(6) coverage for serious mental health illness under
800	800	Subchapter A, Chapter 1355; and
801	801	(7) coverage for cancer screenings under:
802	802	(A) Chapter 1356;
803	803	(B) Chapter 1362;
804	804	(C) Chapter 1363; and
805	805	(D) Chapter 1370.
806	806	SECTION 4.05. Section 1501.602(a), Insurance Code, is
807	807	amended to read as follows:
808	808	(a) A large employer health benefit plan issuer[:
809	809	[(1) may refuse to provide coverage to a large
810	810	employer in accordance with the issuer's underwriting standards and
811	811	criteria;
812	812	[(2) shall accept or reject the entire group of
813	813	individuals who meet the participation criteria and choose
814	814	coverage; and
815	815	[(3)] may exclude only those employees or dependents
816	816	who decline coverage.
817	817	SECTION 4.06. Subchapter B, Chapter 1202, Insurance Code,
818	818	is repealed.
819	819	ARTICLE 5. IMPLEMENTATION; TRANSITION; EFFECTIVE DATE
820	820	SECTION 5.01. If before implementing any provision of this
821	821	Act a state agency determines that a waiver or authorization from a
822	822	federal agency is necessary for implementation of that provision,
823	823	the agency affected by the provision shall request the waiver or
824	824	authorization and may delay implementing that provision until the
825	825	waiver or authorization is granted.
826	826	SECTION 5.02. The change in law made by this Act applies
827	827	only to a health benefit plan that is delivered, issued for
828	828	delivery, or renewed on or after January 1, 2022. A health benefit
829	829	plan that is delivered, issued for delivery, or renewed before
830	830	January 1, 2022, is governed by the law as it existed immediately
831	831	before the effective date of this Act, and that law is continued in
832	832	effect for that purpose.
833	833	SECTION 5.03. This Act takes effect September 1, 2021.