87R12565 KLA-D
By: Johnson S.B. No. 1751
A BILL TO BE ENTITLED
AN ACT
relating to improvements to access to health care in this state,
including increased access to and scope of coverage under health
benefit plans and Medicaid, and to improvements in health outcomes;
authorizing an assessment; imposing penalties.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
ARTICLE 1. HEALTH BENEFIT PLAN AVAILABILITY AND SCOPE OF COVERAGE
SECTION 1.01. (a) Subtitle I, Title 4, Government Code, is
amended by adding Chapter 537A to read as follows:
CHAPTER 537A. LIVE WELL TEXAS PROGRAM
SUBCHAPTER A. GENERAL PROVISIONS
Sec. 537A.0001. DEFINITIONS. In this chapter:
(1) "Basic plan" means the program health benefit plan
described by Section 537A.0202.
(2) "Eligible individual" means an individual who is
eligible to participate in the program.
(3) "MyHealth account" means a personal wellness and
responsibility account established for a participant under Section
537A.0251.
(4) "Participant" means an individual who is:
(A) enrolled in a program health benefit plan; or
(B) receiving health care financial assistance
under Subchapter H.
(5) "Plus plan" means the program health benefit plan
described by Section 537A.0203.
(6) "Program" means the Live Well Texas program
established under this chapter.
(7) "Program health benefit plan" includes:
(A) the basic plan; and
(B) the plus plan.
(8) "Program health benefit plan provider" means a
health benefit plan provider that contracts with the commission
under Section 537A.0107 to arrange for the provision of health care
services through a program health benefit plan.
SUBCHAPTER B. FEDERAL WAIVER FOR LIVE WELL TEXAS PROGRAM
Sec. 537A.0051. FEDERAL AUTHORIZATION FOR PROGRAM. (a)
Notwithstanding any other law, the executive commissioner shall
develop and seek a waiver under Section 1115 of the Social Security
Act (42 U.S.C. Section 1315) to the state Medicaid plan to implement
the Live Well Texas program to assist individuals in obtaining
health benefit coverage through a program health benefit plan or
health care financial assistance.
(b) The terms of a waiver the executive commissioner seeks
under this section must:
(1) be designed to:
(A) provide health benefit coverage options for
eligible individuals;
(B) produce better health outcomes for
participants;
(C) create incentives for participants to
transition from receiving public assistance benefits to achieving
stable employment;
(D) promote personal responsibility and engage
participants in making decisions regarding health care based on
cost and quality;
(E) support participants' self-sufficiency by
requiring unemployed participants to be referred to work search and
job training programs;
(F) support participants who become ineligible
to participate in a program health benefit plan in transitioning to
private health benefit coverage; and
(G) leverage enhanced federal medical assistance
percentage funding to minimize or eliminate the need for a program
enrollment cap; and
(2) allow for the operation of the program consistent
with the requirements of this chapter, except to the extent
deviation from the requirements is necessary to obtain federal
authorization of the waiver.
Sec. 537A.0052. FUNDING. Subject to approval of the waiver
described by Section 537A.0051, the commission shall implement the
program using enhanced federal medical assistance percentage
funding available under the Patient Protection and Affordable Care
Act (Pub. L. No. 111-148) as amended by the Health Care and
Education Reconciliation Act of 2010 (Pub. L. No. 111-152).
Sec. 537A.0053. NOT AN ENTITLEMENT; TERMINATION OF PROGRAM.
(a) This chapter does not establish an entitlement to health
benefit coverage or health care financial assistance under the
program for eligible individuals.
(b) The program terminates at the time federal funding
terminates under the Patient Protection and Affordable Care Act
(Pub. L. No. 111-148) as amended by the Health Care and Education
Reconciliation Act of 2010 (Pub. L. No. 111-152), unless a
successor program providing federal funding is created.
SUBCHAPTER C. PROGRAM ADMINISTRATION
Sec. 537A.0101. PROGRAM OBJECTIVE. The principal objective
of the program is to provide primary and preventative health care
through high deductible program health benefit plans to eligible
individuals.
Sec. 537A.0102. PROGRAM PROMOTION. The commission shall
promote and provide information about the program to individuals
who:
(1) are potentially eligible to participate in the
program; and
(2) live in medically underserved areas of this state.
Sec. 537A.0103. COMMISSION'S AUTHORITY RELATED TO HEALTH
BENEFIT PLAN PROVIDER CONTRACTS. The commission may:
(1) enter into contracts with health benefit plan
providers under Section 537A.0107;
(2) monitor program health benefit plan providers
through reporting requirements and other means to ensure contract
performance and quality delivery of services;
(3) monitor the quality of services delivered to
participants through outcome measurements; and
(4) provide payment under the contracts to program
health benefit plan providers.
Sec. 537A.0104. COMMISSION'S AUTHORITY RELATED TO
ELIGIBILITY AND MEDICAID COORDINATION. The commission may:
(1) accept applications for health benefit coverage
under the program and implement program eligibility screening and
enrollment procedures;
(2) resolve grievances related to eligibility
determinations; and
(3) to the extent possible, coordinate the program
with Medicaid.
Sec. 537A.0105. THIRD-PARTY ADMINISTRATOR CONTRACT FOR
PROGRAM IMPLEMENTATION. (a) In administering the program, the
commission may contract with a third-party administrator to provide
enrollment and related services.
(b) If the commission contracts with a third-party
administrator under this section, the commission may:
(1) monitor the third-party administrator through
reporting requirements and other means to ensure contract
performance and quality delivery of services; and
(2) provide payment under the contract to the
third-party administrator.
(c) The executive commissioner shall retain all
policymaking authority over the program.
(d) The commission shall procure each contract with a
third-party administrator, as applicable, through a competitive
procurement process that complies with all federal and state laws.
Sec. 537A.0106. TEXAS DEPARTMENT OF INSURANCE DUTIES. (a)
At the commission's request, the Texas Department of Insurance
shall provide any necessary assistance with the program. The
department shall monitor the quality of the services provided by
program health benefit plan providers and resolve grievances
related to those providers.
(b) The commission and the Texas Department of Insurance may
adopt a memorandum of understanding that addresses the
responsibilities of each agency with respect to the program.
(c) The Texas Department of Insurance, in consultation with
the commission, shall adopt rules as necessary to implement this
section.
Sec. 537A.0107. HEALTH BENEFIT PLAN PROVIDER CONTRACTS.
The commission shall select through a competitive procurement
process that complies with all federal and state laws and contract
with health benefit plan providers to provide health care services
under the program. To be eligible for a contract under this section,
an entity must:
(1) be a Medicaid managed care organization;
(2) hold a certificate of authority issued by the
Texas Department of Insurance that authorizes the entity to provide
the types of health care services offered under the program; and
(3) satisfy, except as provided by this chapter, any
applicable requirement of the Insurance Code or another insurance
law of this state.
Sec. 537A.0108. HEALTH CARE PROVIDERS. (a) A health care
provider who provides health care services under the program must
meet certification and licensure requirements required by
commission rules and other law.
(b) In adopting rules governing the program, the executive
commissioner shall ensure that a health care provider who provides
health care services under the program is reimbursed at a rate that
is at least equal to the rate paid under Medicare for the provision
of the same or substantially similar services.
Sec. 537A.0109. PROHIBITION ON CERTAIN HEALTH CARE
PROVIDERS. The executive commissioner shall adopt rules that
prohibit a health care provider from providing health care services
under the program for a reasonable period, as determined by the
executive commissioner, if the health care provider:
(1) fails to repay overpayments made under the
program; or
(2) owns, controls, manages, or is otherwise
affiliated with and has financial, managerial, or administrative
influence over a health care provider who has been suspended or
prohibited from providing health care services under the program.
SUBCHAPTER D. ELIGIBILITY FOR PROGRAM HEALTH BENEFIT COVERAGE
Sec. 537A.0151. ELIGIBILITY REQUIREMENTS. (a) An
individual is eligible to enroll in a program health benefit plan
if:
(1) the individual is:
(A) a resident of this state; and
(B) a citizen of the United States or is
otherwise legally authorized to be present in the United States;
(2) the individual is 19 years of age or older but
younger than 65 years of age;
(3) applying the eligibility criteria in effect in
this state on December 31, 2020, the individual is not eligible for
Medicaid; and
(4) federal matching funds are available under the
Patient Protection and Affordable Care Act (Pub. L. No. 111-148) as
amended by the Health Care and Education Reconciliation Act of 2010
(Pub. L. No. 111-152) to provide benefits to the individual under
the federal medical assistance program established under Title XIX,
Social Security Act (42 U.S.C. Section 1396 et seq.).
(b) An individual who is a parent or caretaker relative to
whom 42 C.F.R. Section 435.110 applies is eligible to enroll in a
program health benefit plan.
Sec. 537A.0152. CONTINUOUS COVERAGE. The commission shall
ensure that an individual who is initially determined or
redetermined to be eligible to participate in the program and
enroll in a program health benefit plan will remain eligible for
coverage under the plan for a period of 12 months beginning on the
first day of the month following the date eligibility was
determined or redetermined, subject to Section 537A.0252(f).
Sec. 537A.0153. APPLICATION FORM AND PROCEDURES. (a) The
executive commissioner shall adopt an application form and
application procedures for the program. The form and procedures
must be coordinated with forms and procedures under Medicaid to
ensure that there is a single consolidated application process to
seek health benefit coverage under the program or Medicaid.
(b) To the extent possible, the commission shall make the
application form available in languages other than English.
(c) The executive commissioner may permit an individual to
apply by mail, over the telephone, or through the Internet.
Sec. 537A.0154. ELIGIBILITY SCREENING AND ENROLLMENT. (a)
The executive commissioner shall adopt eligibility screening and
enrollment procedures or use the Texas Integrated Enrollment
Services eligibility determination system or a compatible system to
screen individuals and enroll eligible individuals in the program.
(b) The eligibility screening and enrollment procedures
must ensure that an individual applying for the program who appears
eligible for Medicaid is identified and assisted with obtaining
Medicaid coverage. If the individual is denied Medicaid coverage
but is determined eligible to enroll in a program health benefit
plan, the commission shall enroll the individual in a program
health benefit plan of the individual's choosing and for which the
individual is eligible without further application or
qualification.
(c) Not later than the 30th day after the date an individual
submits a complete application form and unless the individual is
identified and assisted with obtaining Medicaid coverage under
Subsection (b), the commission shall ensure that the individual's
eligibility to participate in the program is determined and that
the individual is provided with information on program health
benefit plans and program health benefit plan providers. The
commission shall enroll the individual in the program health
benefit plan and with the program health benefit plan provider of
the individual's choosing in a timely manner, as determined by the
commission.
(d) The executive commissioner may establish enrollment
periods for the program.
Sec. 537A.0155. ELIGIBILITY REDETERMINATION PROCESS;
DISENROLLMENT. (a) Not later than the 90th day before the
expiration of a participant's coverage period, the commission shall
notify the participant regarding the eligibility redetermination
process and request documentation necessary to redetermine the
participant's eligibility.
(b) The commission shall provide written notice of
termination of eligibility to a participant not later than the 30th
day before the date the participant's eligibility will terminate.
The commission shall disenroll the participant from the program if:
(1) the participant does not submit the requested
eligibility redetermination documentation before the last day of
the participant's coverage period; or
(2) the commission, based on the submitted
documentation, determines the participant is no longer eligible for
the program, subject to Subchapter H.
(c) An individual may submit the requested eligibility
redetermination documentation not later than the 90th day after the
date the individual is disenrolled from the program. If the
commission determines that the individual continues to meet program
eligibility requirements, the commission shall reenroll the
individual in the program without any additional application
requirements.
(d) An individual who does not complete the eligibility
redetermination process in accordance with this section and who is
disenrolled from the program may not participate in the program for
a period of 180 days beginning on the date of disenrollment. This
subsection does not apply to an individual described by Section
537A.0206 or 537A.0208 or an individual who is pregnant or is
younger than 21 years of age.
(e) At the time a participant is disenrolled from the
program under this section, the commission shall provide to the
participant:
(1) notice that the participant may be eligible to
receive health care financial assistance under Subchapter H in
transitioning to private health benefit coverage; and
(2) information on and the eligibility requirements
for that financial assistance.
SUBCHAPTER E. BASIC AND PLUS PLANS
Sec. 537A.0201. BASIC AND PLUS PLAN COVERAGE GENERALLY.
(a) The basic and plus plans offered under the program must:
(1) comply with this subchapter and coverage
requirements prescribed by other law; and
(2) at a minimum, provide coverage for essential
health benefits required under 42 U.S.C. Section 18022(b).
(b) In modifying covered health benefits under the basic and
plus plans, the executive commissioner shall consider the health
care needs of healthy individuals and individuals with special
health care needs.
(c) The basic and plus plans must allow a participant with a
chronic, disabling, or life-threatening illness to select an
appropriate specialist as the participant's primary care
physician.
Sec. 537A.0202. BASIC PLAN: COVERAGE AND INCOME
ELIGIBILITY. (a) The program must include a basic plan that is
sufficient to meet the basic health care needs of individuals who
enroll in the plan.
(b) The covered health benefits under the basic plan must
include:
(1) primary care physician services;
(2) prenatal and postpartum care;
(3) specialty care physician visits;
(4) home health services, not to exceed 100 visits per
year;
(5) outpatient surgery;
(6) allergy testing;
(7) chemotherapy;
(8) intravenous infusion services;
(9) radiation therapy;
(10) dialysis;
(11) emergency care hospital services;
(12) emergency transportation, including ambulance
and air ambulance;
(13) urgent care clinic services;
(14) hospitalization, including for:
(A) general inpatient hospital care;
(B) inpatient physician services;
(C) inpatient surgical services;
(D) non-cosmetic reconstructive surgery;
(E) a transplant;
(F) treatment for a congenital abnormality;
(G) anesthesia;
(H) hospice care; and
(I) care in a skilled nursing facility for a
period not to exceed 100 days per occurrence;
(15) inpatient and outpatient behavioral health
services;
(16) inpatient, outpatient, and residential substance
use treatment;
(17) prescription drugs, including tobacco cessation
drugs;
(18) inpatient and outpatient rehabilitative and
habilitative care, including physical, occupational, and speech
therapy, not to exceed 60 combined visits per year;
(19) medical equipment, appliances, and assistive
technology, including prosthetics and hearing aids, and the repair,
technical support, and customization needed for individual use;
(20) laboratory and pathology tests and services;
(21) diagnostic imaging, including x-rays, magnetic
resonance imaging, computed tomography, and positron emission
tomography;
(22) preventative care services as described by
Section 537A.0204; and
(23) services under the early and periodic screening,
diagnostic, and treatment program for participants who are younger
than 21 years of age.
(c) To be eligible for health care benefits under the basic
plan, an individual who is eligible for the program must have an
annual household income that is equal to or less than 100 percent of
the federal poverty level.
Sec. 537A.0203. PLUS PLAN: COVERAGE AND INCOME ELIGIBILITY.
(a) The program must include a plus plan that includes the covered
health benefits listed in Section 537A.0202 and the following
additional enhanced health benefits:
(1) services related to the treatment of conditions
affecting the temporomandibular joint;
(2) dental care;
(3) vision care;
(4) notwithstanding Section 537A.0202(b)(18),
inpatient and outpatient rehabilitative and habilitative care,
including physical, occupational, and speech therapy, not to exceed
75 combined visits per year;
(5) bariatric surgery; and
(6) other services the commission considers
appropriate.
(b) An individual who is eligible for the program and whose
annual household income exceeds 100 percent of the federal poverty
level will automatically be enrolled in and receive health benefits
under the plus plan. An individual who is eligible for the program
and whose annual household income is equal to or less than 100
percent of the federal poverty level may choose to enroll in the
plus plan.
(c) A participant enrolled in the plus plan is required to
make MyHealth account contributions in accordance with Section
537A.0252.
Sec. 537A.0204. PREVENTATIVE CARE SERVICES. (a) The
commission shall provide to each participant a list of health care
services that qualify as preventative care services based on the
age, gender, and preexisting conditions of the participant. In
developing the list, the commission shall consult with the federal
Centers for Disease Control and Prevention.
(b) A program health benefit plan shall, at no cost to the
participant, provide coverage for:
(1) preventative care services described by 42 U.S.C.
Section 300gg-13; and
(2) a maximum of $500 per year of preventative care
services other than those described by Subdivision (1).
(c) A participant who receives preventative care services
not described by Subsection (b) that are covered under the
participant's program health benefit plan is subject to deductible
and copayment requirements for the services in accordance with the
terms of the plan.
Sec. 537A.0205. COPAYMENTS. (a) A participant enrolled in
the basic plan shall pay a copayment for each covered health benefit
except for a preventative care or family planning service. The
executive commissioner by rule shall adopt a copayment schedule for
basic plan services, subject to Subsection (c).
(b) Except as provided by Subsection (c), a participant
enrolled in the plus plan may not be required to pay a copayment for
a covered service.
(c) A participant enrolled in the basic or plus plan shall
pay a copayment in an amount set by commission rule not to exceed
$25 for nonemergency use of hospital emergency department services
unless:
(1) the participant has met the cost-sharing maximum
for the calendar quarter, as prescribed by commission rule;
(2) the participant is referred to the hospital
emergency department by a health care provider;
(3) the visit is a true emergency, as defined by
commission rule; or
(4) the participant is pregnant.
Sec. 537A.0206. CERTAIN PARTICIPANTS ELIGIBLE FOR STATE
MEDICAID PLAN BENEFITS. (a) A participant described by 42 C.F.R.
Section 440.315 who is enrolled in the basic or plus plan is
entitled to receive under the program all health benefits that
would be available under the state Medicaid plan.
(b) A participant to which this section applies is subject
to the cost-sharing requirements, including copayment and MyHealth
account contribution requirements, of the program health benefit
plan in which the participant is enrolled.
(c) The commission shall develop screening measures to
identify participants to which this section applies.
Sec. 537A.0207. PREGNANT PARTICIPANTS. (a) A participant
who becomes pregnant while enrolled in the program and who meets the
eligibility requirements for Medicaid may choose to remain in the
program or enroll in Medicaid.
(b) A pregnant participant described by Subsection (a) who
is enrolled in the basic or plus plan and who remains in the program
is:
(1) notwithstanding Section 537A.0205, not subject to
any cost-sharing requirements, including copayment and MyHealth
account contribution requirements, of the program health benefit
plan in which the participant is enrolled until the expiration of
the second month following the month in which the pregnancy ends;
(2) entitled to receive as a Medicaid wrap-around
benefit all Medicaid services a pregnant woman enrolled in Medicaid
is entitled to receive, including a pharmacy benefit, when the
participant exceeds coverage limits under the participant's
program health benefit plan or if a service is not covered by the
plan; and
(3) eligible for additional vision and dental care
benefits.
Sec. 537A.0208. PARENTS AND CARETAKER RELATIVES. (a) A
parent or caretaker relative to whom 42 C.F.R. Section 435.110
applies is entitled to receive as a Medicaid wrap-around benefit
all Medicaid services to which the individual would be entitled
under the state Medicaid plan that are not covered under the
individual's program health benefit plan or exceed the plan's
coverage limits.
(b) An individual described by Subsection (a) who chooses to
participate in the program is subject to the cost-sharing
requirements, including copayment and MyHealth account
contribution requirements, of the program health benefit plan in
which the individual is enrolled.
SUBCHAPTER F. MYHEALTH ACCOUNTS
Sec. 537A.0251. ESTABLISHMENT AND OPERATION OF MYHEALTH
ACCOUNTS. (a) The commission shall establish a MyHealth account
for each participant who is enrolled in a program health benefit
plan that is funded with money contributed in accordance with this
subchapter.
(b) The commission shall enable each participant to access
and manage money in and information regarding the participant's
MyHealth account through an electronic system. The commission may
contract with an entity that has appropriate experience and
expertise to establish, implement, or administer the electronic
system.
(c) Except as otherwise provided by Section 537A.0252, the
commission shall require each participant to contribute to the
participant's MyHealth account in amounts described by that
section.
Sec. 537A.0252. MYHEALTH ACCOUNT CONTRIBUTIONS;
DEDUCTIBLE. (a) The executive commissioner by rule shall
establish an annual universal deductible for each participant
enrolled in the basic or plus plan.
(b) To ensure each participant's MyHealth account contains
a sufficient amount of money at the beginning of a coverage period,
the commission shall, before the beginning of that period, fund
each account with the following amounts:
(1) for a participant enrolled in the basic plan, the
annual universal deductible amount; and
(2) for a participant enrolled in the plus plan, the
difference between the annual universal deductible amount and the
participant's required annual contribution as determined by the
schedule established under Subsection (c).
(c) The executive commissioner by rule shall establish a
graduated annual MyHealth account contribution schedule for
participants enrolled in the plus plan that:
(1) is based on a participant's annual household
income, with participants whose annual household incomes are less
than the federal poverty level paying progressively less and
participants whose annual household incomes are equal to or greater
than the federal poverty level paying progressively more; and
(2) may not require a participant to contribute more
than a total of five percent of the participant's annual household
income to the participant's MyHealth account.
(d) A participant's employer may contribute on behalf of the
participant any amount of the participant's annual MyHealth account
contribution. A nonprofit organization may contribute on behalf of
a participant any amount of the participant's annual MyHealth
account contribution.
(e) Subject to the contribution cap described by Subsection
(c)(2) and not before the expiration of the participant's first
coverage period, the commission shall require a participant who
uses one or more tobacco products to contribute to the
participant's MyHealth account an annual MyHealth account
contribution amount that is one percent more than the participant
would otherwise be required to contribute under the schedule
established under Subsection (c).
(f) An annual MyHealth account contribution must be paid by
or on behalf of a participant monthly in installments that are at
least equal to one-twelfth of the total required contribution. The
coverage period for a participant whose annual household income
exceeds 100 percent of the federal poverty level may not begin until
the first day of the first month following the month in which the
first monthly installment is received.
Sec. 537A.0253. USE OF MYHEALTH ACCOUNT MONEY. A
participant may use money in the participant's MyHealth account to
pay copayments and deductible costs required under the
participant's program health benefit plan. The commission shall
issue to each participant an electronic payment card that allows
the participant to use the card to pay the program health benefit
plan costs.
Sec. 537A.0254. PROGRAM HEALTH BENEFIT PLAN PROVIDER
REWARDS PROGRAM FOR ENGAGEMENT IN CERTAIN HEALTHY BEHAVIORS;
SMOKING CESSATION INITIATIVE. (a) A program health benefit plan
provider shall establish a rewards program through which a
participant receiving health care through a program health benefit
plan offered by the program health benefit plan provider may earn
money to be contributed to the participant's MyHealth account.
(b) Under a rewards program, a program health benefit plan
provider shall contribute money to a participant's MyHealth account
if the participant engages in certain healthy behaviors. The
executive commissioner by rule shall determine:
(1) the behaviors in which a participant must engage
to receive a contribution, which must include behaviors related to:
(A) completion of a health risk assessment;
(B) smoking cessation; and
(C) as applicable, chronic disease management;
and
(2) the amount of money a program health benefit plan
provider shall contribute for each behavior described by
Subdivision (1).
(c) Subsection (b) does not prevent a program health benefit
plan provider from contributing money to a participant's MyHealth
account if the participant engages in a behavior not specified by
that subsection or a rule adopted in accordance with that
subsection. If a program health benefit plan provider chooses to
contribute money under this subsection, the program health benefit
plan provider shall determine the amount of money to be contributed
for the behavior.
(d) A participant may use contributions a program health
benefit plan provider makes under a rewards program to offset a
maximum of 50 percent of the participant's required annual MyHealth
account contribution established under Section 537A.0252.
(e) Contributions a program health benefit plan provider
makes under a rewards program that result in a participant's
MyHealth account balance exceeding the participant's required
annual MyHealth account contribution may be rolled over into the
next coverage period in accordance with Section 537A.0256.
(f) During the first coverage period of a participant who
uses one or more tobacco products, a program health benefit plan
provider shall actively attempt to engage the participant in and
provide educational materials to the participant on:
(1) smoking cessation activities for which the
participant may receive a monetary contribution under this section;
and
(2) other smoking cessation programs or resources
available to the participant.
Sec. 537A.0255. MONTHLY STATEMENTS. The commission shall
distribute to each participant with a MyHealth account a monthly
statement that includes information on:
(1) the participant's MyHealth account activity during
the preceding month, including information on the cost of health
care services delivered to the participant during that month;
(2) the balance of money available in the MyHealth
account at the time the statement is issued; and
(3) the amount of any contributions due from the
participant.
Sec. 537A.0256. MYHEALTH ACCOUNT ROLL OVER. (a) The
executive commissioner by rule shall establish a process in
accordance with this section to roll over money in a participant's
MyHealth account to the succeeding coverage period. The commission
shall calculate the amount to be rolled over at the time the
participant's program eligibility is redetermined.
(b) For a participant enrolled in the basic plan, the
commission shall calculate the amount to be rolled over to a
subsequent coverage period MyHealth account from the participant's
current coverage period MyHealth account based on:
(1) the amount of money remaining in the participant's
MyHealth account from the current coverage period; and
(2) whether the participant received recommended
preventative care services during the current coverage period.
(c) For a participant enrolled in the plus plan who, as
determined by the commission, timely makes MyHealth account
contributions in accordance with this subchapter, the commission
shall calculate the amount to be rolled over to a subsequent
coverage period MyHealth account from the participant's current
coverage period MyHealth account based on:
(1) the amount of money remaining in the participant's
MyHealth account from the current coverage period;
(2) the total amount of money the participant
contributed to the participant's MyHealth account during the
current coverage period; and
(3) whether the participant received recommended
preventative care services during the current coverage period.
(d) Except as provided by Subsection (e), a participant may
use money rolled over into the participant's MyHealth account for
the succeeding coverage period to offset required annual MyHealth
account contributions, as applicable, during that coverage period.
(e) A participant enrolled in the basic plan who rolls over
money into the participant's MyHealth account for the succeeding
coverage period and who chooses to enroll in the plus plan for that
coverage period may use the money rolled over to offset a maximum of
50 percent of the required annual MyHealth account contributions
for that coverage period.
Sec. 537A.0257. REFUND. If at the end of a participant's
coverage period the participant chooses to cease participating in a
program health benefit plan or is no longer eligible to participate
in a program health benefit plan, or if a participant is terminated
from the program health benefit plan under Section 537A.0258 for
failure to pay required contributions, the commission shall refund
to the participant any money the participant contributed that
remains in the participant's MyHealth account at the end of the
coverage period or on the termination date.
Sec. 537A.0258. PENALTIES FOR FAILURE TO MAKE MYHEALTH
ACCOUNT CONTRIBUTIONS. (a) For a participant whose annual
household income exceeds 100 percent of the federal poverty level
and who fails to make a contribution in accordance with Section
537A.0252, the commission shall provide a 60-day grace period
during which the participant may make the contribution without
penalty. If the participant fails to make the contribution during
the grace period, the participant will be disenrolled from the
program health benefit plan in which the participant is enrolled
and may not reenroll in a program health benefit plan until:
(1) the 181st day after the date the participant is
disenrolled; and
(2) the participant pays any debt accrued due to the
participant's failure to make the contribution.
(b) For a participant enrolled in the plus plan whose annual
household income is equal to or less than 100 percent of the federal
poverty level and who fails to make a contribution in accordance
with Section 537A.0252, the commission shall disenroll the
participant from the plus plan and enroll the participant in the
basic plan. A participant enrolled in the basic plan under this
subsection may not change enrollment to the plus plan until the
participant's program eligibility is redetermined.
SUBCHAPTER G. EMPLOYMENT INITIATIVE
Sec. 537A.0301. GATEWAY TO WORK PROGRAM. (a) The
commission shall develop and implement a gateway to work program
to:
(1) integrate existing job training and job search
programs available in this state through the Texas Workforce
Commission or other appropriate state agencies with the Live Well
Texas program; and
(2) provide each participant with general information
on the job training and job search programs.
(b) Under the gateway to work program, the commission shall
refer each participant who is unemployed or working less than 20
hours a week to available job search and job training programs.
SUBCHAPTER H. HEALTH CARE FINANCIAL ASSISTANCE FOR CERTAIN
PARTICIPANTS
Sec. 537A.0351. HEALTH CARE FINANCIAL ASSISTANCE FOR
CONTINUITY OF CARE. (a) The commission shall ensure continuity of
care by providing health care financial assistance in accordance
with and in the manner described by this subchapter for a
participant who:
(1) is disenrolled from a program health benefit plan
in accordance with Section 537A.0155 because the participant's
annual household income exceeds the income eligibility
requirements for enrollment in a program health benefit plan; and
(2) seeks and obtains private health benefit coverage
within 12 months following the date of disenrollment.
(b) To receive health care financial assistance under this
subchapter, a participant must provide to the commission, in the
form and manner required by the commission, documentation showing
the participant has obtained or is actively seeking private health
benefit coverage.
(c) The commission may not impose an upper income
eligibility limit on a participant to receive health care financial
assistance under this subchapter.
Sec. 537A.0352. DURATION AND AMOUNT OF HEALTH CARE
FINANCIAL ASSISTANCE. (a) A participant described by Section
537A.0351 may receive health care financial assistance under this
subchapter until the first anniversary of the date the participant
was disenrolled from a program health benefit plan.
(b) Health care financial assistance made available to a
participant under this subchapter:
(1) may not exceed the amount described by Section
537A.0353; and
(2) is limited to payment for eligible services
described by Section 537A.0354.
Sec. 537A.0353. BRIDGE ACCOUNT; FUNDING. (a) The
commission shall establish a bridge account for each participant
eligible to receive health care financial assistance under Section
537A.0351. The account is funded with money the commission
contributes in accordance with this section.
(b) The commission shall enable each participant for whom a
bridge account is established to access and manage money in and
information regarding the participant's account through an
electronic system. The commission may contract with the same
entity described by Section 537A.0251(b) or another entity with
appropriate experience and expertise to establish, implement, or
administer the electronic system.
(c) The commission shall fund each bridge account in an
amount equal to $1,000 using money the commission retains or
recoups during the roll over process described by Section 537A.0256
or following the issuance of a refund as described by Section
537A.0257.
(d) The commission may not require a participant to
contribute money to the participant's bridge account.
(e) The commission shall retain or recoup any unexpended
money in a participant's bridge account at the end of the period for
which the participant is eligible to receive health care financial
assistance under this subchapter for the purpose of funding another
participant's MyHealth account under Subchapter F or bridge account
under this subchapter.
Sec. 537A.0354. USE OF BRIDGE ACCOUNT MONEY. (a) The
commission shall issue to each participant for whom a bridge
account is established an electronic payment card that allows the
participant to use the card to pay costs for eligible services
described by Subsection (b).
(b) A participant may use money in the participant's bridge
account to pay:
(1) premium costs incurred during the private health
benefit coverage enrollment process and coverage period; and
(2) copayments, deductible costs, and coinsurance
associated with the private health benefit coverage obtained by the
participant for health care services that would otherwise be
reimbursable under Medicaid.
(c) Costs described by Subsection (b)(2) associated with
eligible services delivered to a participant may be paid by:
(1) a participant using the electronic payment card
issued under Subsection (a); or
(2) a health care provider directly charging and
receiving payment from the participant's bridge account.
Sec. 537A.0355. ENROLLMENT COUNSELING. The commission
shall provide enrollment counseling to an individual who is seeking
private health benefit coverage and who is otherwise eligible to
receive health care financial assistance under this subchapter.
(b) As soon as practicable after the effective date of this
Act, the executive commissioner of the Health and Human Services
Commission shall apply for and actively pursue from the appropriate
federal agency the waiver as required by Section 537A.0051,
Government Code, as added by this section. The commission may delay
implementing this section until the waiver applied for under
Section 537.0051 is granted, subject to Subsection (c) of this
section.
(c) To maximize budget savings, not later than the 90th day
after the effective date of this Act, the executive commissioner of
the Health and Human Services Commission shall seek from the
appropriate federal agency an amendment to the state Medicaid plan
to implement the provisions of this section that the commission
would otherwise be authorized to implement under the state Medicaid
plan without the waiver described by Subsection (b) of this
section. The commission shall implement the provisions described by
this subsection as soon as practicable after the state Medicaid
plan amendment is approved.
SECTION 1.02. (a) 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 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. 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.
(b) Subtitle G, Title 8, Insurance Code, is amended by
adding Chapter 1512 to read as follows:
CHAPTER 1512. HEALTH BENEFIT COVERAGE AVAILABILITY
SUBCHAPTER A. GENERAL PROVISIONS
Sec. 1512.001. 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. 1512.002. 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 1512.001.
(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. 1512.003. CONFLICT WITH OTHER LAW. If there is a
conflict between this chapter and other law, this chapter prevails.
Sec. 1512.004. 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. 1512.051. 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. 1512.052. 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. 1512.053. 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. 1512.101. 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. 1512.102. 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. 1512.103. 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. 1512.151. 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. 1512.152. 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.
(c) 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.
(d) 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 1512; and
(8) Subchapters A, B, and G, Chapter 1451.
(e) 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 1512.052;
(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.
(f) 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 1512.052;
(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.
(g) 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.
(h) Subchapter B, Chapter 1202, Insurance Code, is
repealed.
(i) The change in law made by this section 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.
ARTICLE 2. TEXAS HEALTH INSURANCE EXCHANGE AUTHORITY AND
REINSURANCE PROGRAM
SECTION 2.01. (a) This section establishes the Texas
Health Insurance Exchange Authority governed by a board of
directors to implement the Texas Health Insurance Exchange as an
American Health Benefit Exchange authorized by Section 1311,
Patient Protection and Affordable Care Act (42 U.S.C. Section
18031).
(b) The purpose of the Texas Health Insurance Exchange
Authority created under this section is to create, manage, and
maintain the exchange in order to:
(1) benefit the state health insurance market and
individuals enrolling in health benefit plans; and
(2) facilitate or assist in facilitating the
purchasing of qualified plans on the exchange by qualified
enrollees in the individual market or the individual and small
group markets.
(c) In carrying out the purposes of this section, the Texas
Health Exchange Authority shall:
(1) educate consumers, including through outreach, a
navigator program, and postenrollment support;
(2) assist individuals in accessing income-based
assistance for which the individual may be eligible, including
premium tax credits, cost-sharing reductions, and government
programs;
(3) negotiate premium rates with health benefit plan
issuers on the exchange;
(4) contract selectively with health benefit plan
issuers to drive value and promote improvement in the delivery
system;
(5) standardize health benefit plan designs and
cost-sharing;
(6) leverage quality improvement and delivery system
reforms by encouraging participating health benefit plans to
implement strategies to promote the delivery of better coordinated,
more efficient health care services;
(7) consider the need for consumer choice in rural,
urban, and suburban areas of the state;
(8) assess and collect fees from health benefit plan
issuers on the Texas Health Insurance Exchange to support the
operation of the exchange and the reinsurance program; and
(9) distribute receipted fees, including to benefit
the reinsurance program.
(d) As soon as practicable after the effective date of this
Act, the board of directors of the Texas Health Insurance Exchange
Authority shall adopt rules and procedures necessary to implement
this section.
SECTION 2.02. (a) The Texas Department of Insurance may
apply to the United States secretary of health and human services to
obtain a waiver under 42 U.S.C. Section 18052 to:
(1) waive any applicable provisions of the Patient
Protection and Affordable Care Act (Pub. L. No. 111-148) with
respect to health benefit plan coverage in this state;
(2) establish a reinsurance program in accordance with
an approved waiver; and
(3) maximize federal funding for the reinsurance
program for plan years beginning on or after the effective date of
the implementation of the program.
(b) On approval by the United States secretary of health and
human services of the Texas Department of Insurance's application
waiver under Subsection (a) of this section, the department shall
establish and implement a reinsurance program for the purposes of:
(1) stabilizing rates and premiums for health benefit
plans in the individual market; and
(2) providing greater financial certainty to
consumers of health benefit plans in this state.
ARTICLE 3. HEALTH BENEFIT PLAN RATES
SECTION 3.01. Title 8, Insurance Code, is amended by adding
Subtitle N to read as follows:
SUBTITLE N. RATES
CHAPTER 1698. RATES FOR CERTAIN COVERAGE
SUBCHAPTER A. GENERAL PROVISIONS
Sec. 1698.001. APPLICABILITY OF CHAPTER. This chapter
applies only to rates for the following health benefit plans:
(1) an individual major medical expense insurance
policy to which Chapter 1201 applies;
(2) individual health maintenance organization
coverage;
(3) a group accident and health insurance policy
issued to an association under Section 1251.052;
(4) a blanket accident and health insurance policy
issued to an association under Section 1251.358;
(5) group health maintenance organization coverage
issued to an association described by Section 1251.052 or 1251.358;
or
(6) a small employer health benefit plan provided
under Chapter 1501.
Sec. 1698.002. APPLICABILITY OF OTHER LAWS GOVERNING RATES.
The requirements of this chapter are in addition to any other
provision of this code governing health benefit plan rates. Except
as otherwise provided by this chapter, in the case of a conflict
between this chapter and another provision of this code, this
chapter controls.
SUBCHAPTER B. RATE STANDARDS
Sec. 1698.051. EXCESSIVE, INADEQUATE, AND UNFAIRLY
DISCRIMINATORY RATES. (a) A rate is excessive, inadequate, or
unfairly discriminatory for purposes of this chapter as provided by
this section.
(b) A rate is excessive if the rate is likely to produce a
long-term profit that is unreasonably high in relation to the
health benefit plan coverage provided.
(c) A rate is inadequate if:
(1) the rate is insufficient to sustain projected
losses and expenses to which the rate applies; and
(2) continued use of the rate:
(A) endangers the solvency of a health benefit
plan issuer using the rate; or
(B) has the effect of substantially lessening
competition or creating a monopoly in a market.
(d) A rate is unfairly discriminatory if the rate:
(1) is not based on sound actuarial principles;
(2) does not bear a reasonable relationship to the
expected loss and expense experience among risks or is based on
unreasonable administrative expenses; or
(3) is based wholly or partly on the race, creed,
color, ethnicity, or national origin of an individual or group
sponsoring coverage under or covered by the health benefit plan.
SUBCHAPTER C. DISAPPROVAL OF RATES
Sec. 1698.101. REVIEW OF PREMIUM RATES. (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) The commissioner by rule shall establish a process under
which the commissioner:
(1) reviews health benefit plan rates and rate changes
for compliance with this chapter and other applicable law; and
(2) disapproves rates that do not comply with this
chapter not later than the 60th day after the date the department
receives a complete filing.
(c) The rules must:
(1) require an individual or small employer health
benefit plan issuer to:
(A) submit to the commissioner a justification
for a rate increase that results in an increase equal to or greater
than 10 percent; and
(B) post information regarding the rate increase
on the health benefit plan issuer's Internet website;
(2) require the commissioner to make available to the
public information on rate increases and justifications submitted
by health benefit plan issuers under Subdivision (1);
(3) provide a mechanism for receiving public comment
on proposed rate increases; and
(4) provide for the results of rate reviews to be
reported to the Centers for Medicare and Medicaid Services.
Sec. 1698.102. DISAPPROVAL OF RATE CHANGE AUTHORIZED. (a)
In this section, "qualified health plan" has the meaning assigned
by Section 1301(a), Patient Protection and Affordable Care Act (42
U.S.C. Section 18021).
(b) The commissioner may disapprove a rate or rate change
filed with the department by a health benefit plan issuer not later
than the 60th day after the date the department receives a complete
filing if:
(1) the commissioner determines that the proposed rate
is excessive, inadequate, or unfairly discriminatory; or
(2) the required rate filing is incomplete.
(c) In making a determination under this section, the
commissioner shall consider the following factors:
(1) the reasonableness and soundness of the actuarial
assumptions, calculations, projections, and other factors used by
the plan issuer to arrive at the proposed rate or rate change;
(2) the historical trends for medical claims
experienced by the plan issuer;
(3) the reasonableness of the plan issuer's historical
and projected administrative expenses;
(4) the plan issuer's compliance with medical loss
ratio standards applicable under state or federal law;
(5) whether the rate applies to an open or closed block
of business;
(6) whether the plan issuer has complied with all
requirements for pooling risk and participating in risk adjustment
programs in effect under state or federal law;
(7) the financial condition of the plan issuer for at
least the previous five years, or for the plan issuer's time in
existence, if less than five years, including profitability,
surplus, reserves, investment income, reinsurance, dividends, and
transfers of funds to affiliates or parent companies;
(8) for a rate change, the financial performance for
at least the previous five years of the block of business subject to
the proposed rate change, or for the block's time in existence, if
less than five years, including past and projected profits,
surplus, reserves, investment income, and reinsurance applicable
to the block;
(9) the covered benefits or health benefit plan design
or, for a rate change, any changes to the benefits or design;
(10) the allowable variations for case
characteristics, risk classifications, and participation in
programs promoting wellness;
(11) whether the proposed rate is necessary to
maintain the plan issuer's solvency or maintain rate stability and
prevent excessive rate increases in the future; and
(12) any other factor listed in 45 C.F.R. Section
154.301(a)(4) to the extent applicable.
(d) In making a determination under this section regarding a
proposed rate for a qualified health plan, the commissioner shall
consider, in addition to the factors under Subsection (c), the
following factors:
(1) the purchasing power of consumers who are eligible
for a premium subsidy under the Patient Protection and Affordable
Care Act (Pub. L. No. 111-148);
(2) if the plan is in the silver level, as described by
42 U.S.C. Section 18022(d), whether the rate is appropriate for the
plan in relation to the rates charged for qualified health plans
offering different levels of coverage, taking into account lack of
funding for cost-sharing reductions and the covered benefits for
each level of coverage; and
(3) whether the plan issuer utilized the induced
demand factors developed by the Centers for Medicare and Medicaid
Services for the risk adjustment program established under 42
U.S.C. Section 18063 for the level of coverage offered by the plan,
and, if the plan did not utilize those factors, whether the plan
issuer provided objective evidence showing why those factors are
inappropriate for the rate.
(e) In making a determination under this section, the
commissioner may consider the following factors:
(1) if the commissioner determines appropriate for
comparison purposes, medical claims trends reported by plan issuers
in this state or in a region of this country or the country as a
whole; and
(2) inflation indexes.
Sec. 1698.103. DISPUTE RESOLUTION. The commissioner by
rule shall establish a method for a health benefit plan issuer to
dispute the disapproval of a rate under this subchapter, which may
include an informal method for the plan issuer and the commissioner
to reach an agreement about an appropriate rate.
Sec. 1698.104. USE OF DISAPPROVED RATE PENDING DISPUTE
RESOLUTION. (a) If the commissioner disapproves a rate under this
subchapter and the plan issuer objects to the disapproval, the plan
issuer may use the disapproved rate pending the completion of:
(1) the dispute resolution process established under
this subchapter; and
(2) any other appeal of the disapproval authorized by
law and pursued by the plan issuer.
(b) The commissioner shall adopt rules establishing the
conditions under which any excess premiums will be refunded or
credited to the persons who paid the premiums if the plan issuer
uses a disapproved rate while an appeal is pending and the rate
dispute is not resolved in the plan issuer's favor.
Sec. 1698.105. FEDERAL FUNDING. The commissioner shall
seek all available federal funding to cover the cost to the
department of reviewing rates and resolving rate disputes under
this subchapter.
SECTION 3.02. Subtitle N, Title 8, Insurance Code, as added
by this article, applies only to rates for health benefit plan
coverage delivered, issued for delivery, or renewed on or after
January 1, 2022. Rates for health benefit plan coverage delivered,
issued for delivery, or renewed before January 1, 2022, are
governed by the law in effect immediately before the effective date
of this Act, and that law is continued in effect for that purpose.
ARTICLE 4. HEALTH INSURANCE RISK POOL
SECTION 4.01. Subtitle G, Title 8, Insurance Code, is
amended by adding Chapter 1511 to read as follows:
CHAPTER 1511. HEALTH INSURANCE RISK POOL
SUBCHAPTER A. GENERAL PROVISIONS
Sec. 1511.0001. DEFINITIONS. In this chapter:
(1) "Board" means the board of directors appointed
under this chapter.
(2) "Pool" means a health insurance risk pool
established under this chapter and administered by the board.
Sec. 1511.0002. WAIVER. The commissioner shall:
(1) apply to the United States secretary of health and
human services under 42 U.S.C. Section 18052 for a waiver of Section
1312(c)(1) of the Patient Protection and Affordable Care Act (Pub.
L. No. 111-148) and any applicable regulations or guidance
beginning with the 2022 plan year;
(2) take any action the commissioner considers
appropriate to make an application under Subdivision (1); and
(3) implement a state plan that meets the requirements
of a waiver granted in response to an application under Subdivision
(1) if the plan is:
(A) consistent with state and federal law; and
(B) approved by the United States secretary of
health and human services.
Sec. 1511.0003. EXEMPTION FROM STATE TAXES AND FEES.
Notwithstanding any other law, a program created under this chapter
is not subject to any state tax, regulatory fee, or surcharge,
including a premium or maintenance tax or fee.
Sec. 1511.0004. NOTICE AND COMMENT. Following the grant of
a waiver under Section 1511.0002 and before the commissioner
implements a state plan under that section, the commissioner shall
hold a public hearing to solicit stakeholder comments regarding the
establishment of a health insurance risk pool under this chapter.
SUBCHAPTER B. ESTABLISHMENT AND PURPOSE
Sec. 1511.0051. ESTABLISHMENT OF HEALTH INSURANCE RISK
POOL. To the extent that federal money is available and only if the
United States secretary of health and human services grants the
waiver application submitted under Section 1511.0002, the
commissioner shall:
(1) apply for the federal money;
(2) use the federal money to establish a pool for the
purpose of this chapter; and
(3) authorize the board to use the federal money to
administer a pool for the purpose of this chapter.
Sec. 1511.0052. PURPOSE OF POOL. The purpose of the pool is
to provide a reinsurance mechanism to:
(1) meaningfully reduce health benefit plan premiums
in the individual market by mitigating the impact of high-risk
individuals on rates;
(2) maximize available federal money to assist
residents of this state to obtain guaranteed issue health benefit
coverage without increasing the federal deficit; and
(3) increase enrollment in guaranteed issue,
individual market health benefit plans that provide benefits and
coverage and cost-sharing protections against out-of-pocket costs
comparable to and as comprehensive as health benefit plans that
would be available without the pool.
SUBCHAPTER C. ADMINISTRATION
Sec. 1511.0101. BOARD OF DIRECTORS. (a) The pool is
governed by a board of directors.
(b) The board consists of nine members appointed by the
commissioner as follows:
(1) at least two, but not more than four, members must
be individuals who are affiliated with a health benefit plan issuer
authorized to write health benefit plans in this state;
(2) at least two members must be:
(A) individuals or the parents of individuals who
are covered by the pool or are reasonably expected to qualify for
coverage by the pool; or
(B) individuals who work as advocates for
individuals described by Paragraph (A); and
(3) the other members may be selected from individuals
such as:
(A) a physician licensed to practice in this
state by the Texas State Board of Medical Examiners;
(B) a hospital administrator;
(C) an advanced nurse practitioner; or
(D) a representative of the public who is not:
(i) employed by or affiliated with an
insurance company or insurance plan, group hospital service
corporation, or health maintenance organization;
(ii) related within the first degree of
consanguinity or affinity to an individual described by
Subparagraph (i); or
(iii) licensed as, employed by, or
affiliated with a physician, hospital, or other health care
provider.
(c) For purposes of Subsection (b), an individual who is
required to register under Chapter 305, Government Code, because of
the individual's activities with respect to health benefit
plan-related matters is affiliated with a health benefit plan
issuer.
(d) An individual is not disqualified under Subsection
(b)(3)(D)(i) from representing the public if the individual's only
affiliation with an insurance company or insurance plan, group
hospital service corporation, or health maintenance organization
is as an insured or as an individual who has coverage through a plan
provided by the corporation or organization.
Sec. 1511.0102. TERMS; VACANCY. (a) Board members serve
staggered six-year terms.
(b) The commissioner shall fill a vacancy on the board by
appointing, for the unexpired term, an individual who has the
appropriate qualifications to fill that position.
Sec. 1511.0103. PRESIDING OFFICER. The commissioner shall
designate one board member to serve as presiding officer at the
pleasure of the commissioner.
Sec. 1511.0104. PER DIEM; REIMBURSEMENT. A board member is
not entitled to compensation for service on the board but is
entitled to:
(1) a per diem in the amount provided by the General
Appropriations Act for state officials for each day the member
performs duties as a board member; and
(2) reimbursement of expenses incurred while
performing duties as a board member in the amount provided by the
General Appropriations Act for state officials.
Sec. 1511.0105. MEMBER'S IMMUNITY. (a) A board member is
not liable for an act or omission made in good faith in the
performance of powers and duties under this chapter.
(b) A cause of action does not arise against a board member
for an act or omission described by Subsection (a).
Sec. 1511.0106. ADDITIONAL POWERS AND DUTIES. The
commissioner by rule may establish powers and duties of the board in
addition to those provided by this chapter.
Sec. 1511.0107. PLAN OF OPERATION. (a) Operation and
management of the pool are governed by a plan of operation adopted
by the board and approved by the commissioner. The plan of
operation includes the articles, bylaws, and operating rules of the
pool.
(b) The plan of operation must ensure the fair, reasonable,
and equitable administration of the pool.
(c) The board shall amend the plan of operation as necessary
to carry out this chapter. An amendment to the plan of operation
must be approved by the commissioner before the board may adopt the
amendment.
SUBCHAPTER D. POWERS AND DUTIES
Sec. 1511.0151. METHODS TO REDUCE PREMIUM IN INDIVIDUAL
MARKET. Subject to any requirements to obtain federal money for the
pool, the board may use pool money to achieve lower enrollee premium
rates by establishing a reinsurance mechanism for health benefit
plan issuers writing comprehensive, guaranteed issue coverage in
the individual market.
Sec. 1511.0152. INCREASED ACCESS TO GUARANTEED ISSUE
COVERAGE. The board shall use pool money to increase enrollment in
guaranteed issue coverage in the individual market in a manner that
ensures that the benefits and cost-sharing protections available in
the individual market are maintained in the same manner the
benefits and protections would be maintained without the waiver
described by Section 1511.0002.
Sec. 1511.0153. CONTRACTS AND AGREEMENTS. The board may
enter into a contract or agreement that the board determines is
appropriate to carry out this chapter, including a contract or
agreement with:
(1) a similar pool in another state for the joint
performance of common administrative functions;
(2) another organization for the performance of
administrative functions; or
(3) a federal agency.
Sec. 1511.0154. RULES. The commissioner and board may
adopt rules necessary to implement this chapter, including rules to
administer the pool and distribute pool money.
Sec. 1511.0155. PROCEDURES, CRITERIA, AND FORMS. The board
by rule shall provide the procedures, criteria, and forms necessary
to implement, collect, and deposit assessments under Subchapter E.
Sec. 1511.0156. PUBLIC EDUCATION AND OUTREACH. (a) The
board may develop and implement public education, outreach, and
facilitated enrollment strategies under this chapter.
(b) The board may contract with marketing organizations to
perform or provide assistance with the strategies described by
Subsection (a).
Sec. 1511.0157. AUTHORITY TO ACT AS REINSURER. In addition
to the powers granted to the board under this chapter, the board may
exercise any authority that may be exercised under the law of this
state by a reinsurer.
SUBCHAPTER E. FUNDING
Sec. 1511.0201. FUNDING. The commissioner may use money
appropriated to the department to:
(1) apply for federal money and grants; and
(2) implement this chapter.
Sec. 1511.0202. ASSESSMENTS. (a) The board may assess
health benefit plan issuers, including making advance interim
assessments, as reasonable and necessary for the pool's
organizational and interim operating expenses.
(b) The board shall credit an interim assessment as an
offset against any regular assessment that is due after the end of
the fiscal year.
(c) The regular assessment is the amount calculated under
Section 1511.0204.
(d) The board shall deposit money from the interim and
regular assessments described by this section in an account
established outside the treasury and administered by the board.
Money in the account may be spent without an appropriation and may
be used only for purposes authorized by this chapter.
Sec. 1511.0203. DETERMINATION OF POOL FUNDING
REQUIREMENTS. After the end of each fiscal year, the board shall
determine for the next calendar year the amount of money required by
the pool to reduce enrollee premiums in accordance with this
chapter after applying the federal money obtained under this
chapter.
Sec. 1511.0204. ASSESSMENTS TO COVER POOL FUNDING
REQUIREMENTS. (a) The board shall recover an amount equal to the
funding required as determined under Section 1511.0203 by assessing
each health benefit plan issuer an amount determined annually by
the board based on information in annual statements, the health
benefit plan issuer's annual report to the board under Sections
1511.0251 and 1511.0252, and any other reports required by and
filed with the board.
(b) The board shall use the total number of enrolled
individuals reported by all health benefit plan issuers under
Section 1511.0252 as of the preceding December 31 to compute the
amount of a health benefit plan issuer's assessment, if any, in
accordance with this subsection. The board shall allocate the
total amount to be assessed based on the total number of enrolled
individuals covered by excess loss, stop-loss, or reinsurance
policies and on the total number of other enrolled individuals as
determined under Section 1511.0252. To compute the amount of a
health benefit plan issuer's assessment:
(1) for the issuer's enrolled individuals covered by
an excess loss, stop-loss, or reinsurance policy, the board shall:
(A) divide the allocated amount to be assessed by
the total number of enrolled individuals covered by excess loss,
stop-loss, or reinsurance policies, as determined under Section
1511.0252, to determine the per capita amount; and
(B) multiply the number of a health benefit plan
issuer's enrolled individuals covered by an excess loss, stop-loss,
or reinsurance policy, as determined under Section 1511.0252, by
the per capita amount to determine the amount assessed to that
health benefit plan issuer; and
(2) for the issuer's enrolled individuals not covered
by excess loss, stop-loss, or reinsurance policies, the board,
using the gross health benefit plan premiums reported for the
preceding calendar year by health benefit plan issuers under
Section 1511.0253, shall:
(A) divide the gross premium collected by a
health benefit plan issuer by the gross premium collected by all
health benefit plan issuers; and
(B) multiply the allocated amount to be assessed
by the fraction computed under Paragraph (A) to determine the
amount assessed to that health benefit plan issuer.
(c) A small employer health benefit plan described by
Chapter 1501 is not subject to an assessment under this section.
Sec. 1511.0205. ASSESSMENT DUE DATE; INTEREST. (a) An
assessment is due on the date specified by the board that is not
earlier than the 30th day after the date written notice of the
assessment is transmitted to the health benefit plan issuer.
(b) Interest accrues on the unpaid amount of an assessment
at a rate equal to the prime lending rate, as published in the most
recent issue of the Wall Street Journal and determined as of the
first day of each month during which the assessment is delinquent,
plus three percent.
Sec. 1511.0206. ABATEMENT OR DEFERMENT OF ASSESSMENT. (a)
A health benefit plan issuer may petition the board for an abatement
or deferment of all or part of an assessment imposed by the board.
The board may abate or defer all or part of the assessment if the
board determines that payment of the assessment would endanger the
ability of the health benefit plan issuer to fulfill its
contractual obligations.
(b) If all or part of an assessment against a health benefit
plan issuer is abated or deferred, the amount of the abatement or
deferment shall be assessed against the other health benefit plan
issuers in a manner consistent with the method for computing
assessments under this chapter.
(c) A health benefit plan issuer receiving an abatement or
deferment under this section remains liable to the pool for the
deficiency.
Sec. 1511.0207. USE OF EXCESS FROM ASSESSMENTS. If the
total amount of the assessments exceeds the pool's actual losses
and administrative expenses, the board shall credit each health
benefit plan issuer with the excess in an amount proportionate to
the amount the health benefit plan issuer paid in assessments. The
credit may be paid to the health benefit plan issuer or applied to
future assessments under this chapter.
Sec. 1511.0208. COLLECTION OF ASSESSMENTS. The pool may
recover or collect assessments made under this subchapter.
SUBCHAPTER F. REPORTING
Sec. 1511.0251. ANNUAL ISSUER REPORT TO BOARD: REQUESTED
INFORMATION. Each health benefit plan issuer shall report to the
board the information requested by the board, as of December 31 of
the preceding year.
Sec. 1511.0252. ANNUAL ISSUER REPORT TO BOARD: ENROLLED
INDIVIDUALS. (a) Each health benefit plan issuer shall report to
the board the number of residents of this state enrolled, as of
December 31 of the preceding year, in the issuer's health benefit
plans providing coverage for residents in this state, as:
(1) an employee under a group health benefit plan; or
(2) an individual policyholder or subscriber.
(b) In determining the number of individuals to report under
Subsection (a)(1), the health benefit plan issuer shall include
each employee for whom a premium is paid and coverage is provided
under an excess loss, stop-loss, or reinsurance policy issued by
the issuer to an employer or group health benefit plan providing
coverage for employees in this state. A health benefit plan issuer
providing excess loss insurance, stop-loss insurance, or
reinsurance, as described by this subsection, for a primary health
benefit plan issuer may not report individuals reported by the
primary health benefit plan issuer.
(c) Ten employees covered by a health benefit plan issuer
under a policy of excess loss insurance, stop-loss insurance, or
reinsurance count as one employee for purposes of determining that
health benefit plan issuer's assessment.
(d) In determining the number of individuals to report under
this section, the health benefit plan issuer shall exclude:
(1) the dependents of the employee or an individual
policyholder or subscriber; and
(2) individuals who are covered by the health benefit
plan issuer under a Medicare supplement benefit plan subject to
Chapter 1652.
(e) In determining the number of enrolled individuals to
report under this section, the health benefit plan issuer shall
exclude individuals who are retired employees 65 years of age or
older.
Sec. 1511.0253. ANNUAL ISSUER REPORT TO BOARD: GROSS
PREMIUMS. (a) Each health benefit plan issuer shall report to the
board the gross premiums collected for the preceding calendar year
for health benefit plans.
(b) For purposes of this section, gross health benefit plan
premiums do not include premiums collected for:
(1) coverage under a Medicare supplement benefit plan
subject to Chapter 1652;
(2) coverage under a small employer health benefit
plan subject to Chapter 1501;
(3) coverage:
(A) for wages or payments in lieu of wages for a
period during which an employee is absent from work because of
accident or disability;
(B) as a supplement to a liability insurance
policy;
(C) for credit insurance;
(D) only for dental or vision care; or
(E) only for a specified disease or illness;
(4) a workers' compensation insurance policy;
(5) medical payment insurance coverage provided under
a motor vehicle insurance policy;
(6) a long-term care policy, including a nursing home
fixed indemnity policy, unless the commissioner determines that the
policy provides comprehensive health benefit plan coverage;
(7) liability insurance coverage, including general
liability insurance and automobile liability insurance;
(8) coverage for on-site medical clinics;
(9) insurance coverage under which benefits are
payable with or without regard to fault and that is statutorily
required to be contained in a liability insurance policy or
equivalent self-insurance; or
(10) other similar insurance coverage, as specified by
federal regulations issued under the Health Insurance Portability
and Accountability Act of 1996 (Pub. L. No. 104-191), under which
benefits for medical care are secondary or incidental to other
insurance benefits.
Sec. 1511.0254. ANNUAL BOARD REPORT OF POOL ACTIVITIES.
(a) Beginning June 1, 2022, not later than June 1 of each year, the
board shall submit a report to the governor, lieutenant governor,
and speaker of the house of representatives.
(b) The report submitted under Subsection (a) must include:
(1) a summary of the activities conducted under this
chapter in the calendar year preceding the year in which the report
is submitted;
(2) the average amount by which health benefit plan
premiums were reduced in this state and in each rating region;
(3) the average change in each rating region in the
amount of health benefit plan premiums paid by individuals who
receive a premium subsidy under the Patient Protection and
Affordable Care Act (Pub. L. No. 111-148); and
(4) an estimate of the change in each rating region in
enrollment in health benefit plans due to the reduction in
premiums.
SEC. 4.02. Notwithstanding Section 1511.0002(1), Insurance
Code, as added by this article, the commissioner of insurance may
not apply for the waiver as required by that subdivision until the
commissioner determines that the commissioner has completed a
review under Chapter 1698, Insurance Code, as added by this Act, of
all health benefit plan rates in effect for compliance with that
chapter and other applicable law.
ARTICLE 5. ADMINISTRATION OF, ELIGIBILITY FOR, AND BENEFITS
PROVIDED UNDER MEDICAID
SECTION 5.01. Section 533.001, Government Code, is amended
by adding Subdivision (6-a) to read as follows:
(6-a) "Social determinants of health" means the
environmental conditions in which a person is born, lives, learns,
works, plays, worships, and ages that affect a range of health,
functional, and quality of life outcomes and risks.
SECTION 5.02. (a) Section 533.003(a), Government Code, is
amended to read as follows:
(a) In awarding contracts to managed care organizations,
the commission shall:
(1) give preference to organizations that have
significant participation in the organization's provider network
from each health care provider in the region who has traditionally
provided care to Medicaid and charity care patients;
(2) give extra consideration to organizations that
agree to assure continuity of care for at least three months beyond
the period of Medicaid eligibility for recipients;
(3) consider the need to use different managed care
plans to meet the needs of different populations;
(4) consider the ability of organizations to process
Medicaid claims electronically; and
(5) give extra consideration to organizations that use
enriched data sets incorporating social determinants of health to
manage socially complex populations in a manner that achieves:
(A) cost savings through implementation of
appropriate interventions for those populations; and
(B) favorable health outcomes for those
populations by reducing preventable emergency room visits,
hospitalizations, and institutionalizations [in the initial
implementation of managed care in the South Texas service region,
give extra consideration to an organization that either:
[(A) is locally owned, managed, and operated, if
one exists; or
[(B) is in compliance with the requirements of
Section 533.004].
(b) Section 533.003(a), Government Code, as amended by this
section, applies to a contract entered into or renewed on or after
the effective date of this Act. A contract entered into or renewed
before that date is governed by the law in effect on the date the
contract was entered into or renewed, and that law is continued in
effect for that purpose.
SECTION 5.03. Subchapter A, Chapter 533, Government Code,
is amended by adding Sections 533.021 and 533.022 to read as
follows:
Sec. 533.021. PROMOTORAS AND COMMUNITY HEALTH WORKERS. (a)
In this section, "promotora" and "community health worker" have the
meaning assigned by Section 48.001, Health and Safety Code.
(b) The commission shall allow each Medicaid managed care
organization providing health care services under the STAR Medicaid
managed care program to categorize services provided by a promotora
or community health worker as a quality improvement cost, as
authorized by federal law, instead of as an administrative expense.
Sec. 533.022. ANNUAL REPORT ON USE OF SOCIAL DETERMINANTS
OF HEALTH. Each Medicaid managed care organization that uses
enriched data sets described by Section 533.003(a)(5) shall submit
to the commission an annual report that assesses any cost savings
and favorable health outcomes achieved by using those data sets.
SECTION 5.04. (a) Chapter 533, Government Code, is amended
by adding Subchapter F to read as follows:
SUBCHAPTER F. PILOT PROJECT TO ADDRESS CERTAIN SOCIAL DETERMINANTS
OF HEALTH
Sec. 533.101. DEFINITIONS. In this subchapter:
(1) "Pilot project" means the pilot project
established under Section 533.102.
(2) "Project participant" means an individual who
participates in the pilot project.
(3) "Social determinants of health" means the
environmental conditions in which an individual lives that affect
the individual's health and quality of life.
Sec. 533.102. PILOT PROJECT FOR PROVIDING ENHANCED CASE
MANAGEMENT AND OTHER SERVICES TO ADDRESS SOCIAL DETERMINANTS OF
HEALTH. (a) The executive commissioner shall seek a waiver under
Section 1115 of the federal Social Security Act (42 U.S.C. Section
1315) to the state Medicaid plan to develop and implement a
five-year pilot project to improve the health care outcomes of
Medicaid recipients and reduce associated health care costs by
providing enhanced case management and other coordinated,
evidence-based, nonmedical intervention services designed to
directly address recipient needs related to the following social
determinants of health:
(1) housing instability;
(2) food insecurity;
(3) transportation insecurity;
(4) interpersonal violence; and
(5) toxic stress.
(b) The commission shall develop and implement the pilot
project with the assistance and involvement of Medicaid managed
care organizations, public or private stakeholders, and other
persons the commission determines appropriate.
(c) A pilot project established under this section shall be
conducted in one or more regions of this state as selected by the
commission.
Sec. 533.103. BENEFITS: CASE MANAGEMENT AND INTERVENTION
SERVICES. (a) The pilot project must assign a case manager to each
project participant. The case manager will determine, authorize,
and coordinate individualized nonmedical intervention services for
participants that directly address and improve the participants'
quality of life respecting one or more of the social determinants of
health described by Section 533.102.
(b) The commission shall prescribe the nonmedical
intervention services that may be provided to project participants,
which may include:
(1) the following services to address housing
instability:
(A) tenancy support and sustaining services;
(B) housing quality and safety improvement
services;
(C) legal assistance with connecting
participants to community resources to address legal issues, other
than providing legal representation or paying for legal
representation;
(D) one-time financial assistance to secure
housing; and
(E) short-term post-hospitalization housing;
(2) the following services to address food insecurity:
(A) assistance applying for benefits under the
supplemental nutrition assistance program or the federal special
supplemental nutrition program for women, infants, and children
administered by 42 U.S.C. Section 1786;
(B) assistance accessing school-based meal
programs;
(C) assistance locating and accessing food banks
or community-based summer and after-school food programs;
(D) nutrition counseling; and
(E) financial assistance for targeted nutritious
food or meal delivery services for individuals with medically
related special dietary needs if funding cannot be obtained through
other sources;
(3) the following services to address transportation
insecurity:
(A) educational assistance to gain access to
public and private forms of transportation, including
ride-sharing; and
(B) financial assistance for public
transportation or, if public transportation is not available,
private transportation to support participants' ability to access
pilot project services; and
(4) the following services to address interpersonal
violence and toxic stress:
(A) assistance with locating and accessing
community-based social services and mental health agencies with
expertise in addressing interpersonal violence;
(B) assistance with locating and accessing
high-quality child-care and after-school programs;
(C) assistance with locating and accessing
community engagement activities;
(D) navigational services focused on identifying
and improving existing factors posing a risk to the safety and
health of victims transitioning from traumatic situations,
including:
(i) obtaining a new phone number or mailing
address;
(ii) securing immediate shelter and
long-term housing;
(iii) making school arrangements to
minimize disruption of school schedules; and
(iv) connecting participants to
medical-legal partnerships to address overlap between health care
and legal needs;
(E) legal assistance for interpersonal
violence-related issues, including assistance securing a
protection order, other than providing legal representation or
paying for legal representation;
(F) assistance accessing evidence-based
parenting support; and
(G) assistance accessing evidence-based
maternal, infant, and early home visiting services.
Sec. 533.104. PARTICIPANT ELIGIBILITY. An individual is
eligible to participate in the pilot project if the individual:
(1) is a Medicaid recipient and receives benefits
through a Medicaid managed care model or arrangement under this
chapter;
(2) resides in a region in which the pilot project is
implemented; and
(3) meets other eligibility criteria established by
the commission for project participation, including:
(A) having or being at a higher risk than the
general population of developing a chronic or serious health
condition; and
(B) experiencing at least one of the social
determinants of health described by Section 533.102.
Sec. 533.105. RULES. The executive commissioner may adopt
rules to implement this subchapter.
Sec. 533.106. REPORT. Not later than September 1 of each
even-numbered year, the commission shall submit to the legislature
a report on the pilot project. The report must include:
(1) an evaluation of the pilot project's success in
reducing or eliminating poor health outcomes and reducing
associated health care costs; and
(2) a recommendation on whether the pilot project
should be continued, expanded, or terminated.
Sec. 533.107. EXPIRATION. This subchapter expires
September 1, 2027.
(b) As soon as practicable after the effective date of this
Act, the executive commissioner of the Health and Human Services
Commission shall apply for and actively pursue a waiver under
Section 1115 of the federal Social Security Act (42 U.S.C. Section
1315) to the state Medicaid plan from the Centers for Medicare and
Medicaid Services or any other federal agency to implement
Subchapter F, Chapter 533, Government Code, as added by this
section. The commission may delay implementing Subchapter F,
Chapter 533, Government Code, as added by this section, until the
waiver applied for under this subsection is granted.
SECTION 5.05. Section 32.024, Human Resources Code, is
amended by adding Subsections (l-1) and (oo) to read as follows:
(l-1) The commission shall continue to provide medical
assistance to a woman who is eligible for medical assistance for
pregnant women for a period of not less than 12 months following the
last month of the woman's pregnancy.
(oo) The commission shall provide medical assistance
reimbursement to a treating health care provider who participates
in Medicaid for the provision to a child or adult medical assistance
recipient of behavioral health services that are classified by a
Current Procedural Terminology code as collaborative care
management services.
SECTION 5.06. (a) Subchapter B, Chapter 32, Human
Resources Code, is amended by adding Section 32.02472 to read as
follows:
Sec. 32.02472. ELIGIBILITY OF CERTAIN PERSONS LAWFULLY
PRESENT IN THE UNITED STATES. (a) The commission shall provide
medical assistance in accordance with 8 U.S.C. Section 1612(b) to a
person who:
(1) is a qualified alien, as defined by 8 U.S.C.
Sections 1641(b) and (c);
(2) meets the eligibility requirements of the medical
assistance program;
(3) entered the United States on or after August 22,
1996; and
(4) has resided in the United States for a period of
five years after the date the person entered as a qualified alien.
(b) To the extent allowed by federal law, the commission
shall provide medical assistance for pregnant women to a person who
is pregnant and is lawfully present, or lawfully residing in the
United States as defined by the Centers for Medicare and Medicaid
Services, including a battered alien under 8 U.S.C. Section
1641(c), regardless of the date the person entered the United
States.
(b) Not later than October 1, 2021, the executive
commissioner of the Health and Human Services Commission shall seek
an amendment to the state Medicaid plan or a waiver or other
authorization from a federal agency as necessary to implement
Section 32.02472, Human Resources Code, as added by this section.
SECTION 5.07. Subchapter B, Chapter 32, Human Resources
Code, is amended by adding Section 32.02605 to read as follows:
Sec. 32.02605. PRESUMPTIVE ELIGIBILITY OF CERTAIN ELDERLY
INDIVIDUALS FOR HOME AND COMMUNITY-BASED SERVICES. (a) In this
section, "elderly" means an individual who is at least 65 years of
age.
(b) The executive commissioner shall by rule adopt a program
providing for:
(1) the determination and certification of
presumptive eligibility for medical assistance of an elderly
individual who requires a skilled level of nursing care; and
(2) the provision through the medical assistance
program to the individual of that care in a home or community-based
setting instead of in an institutional setting, provided the
individual applies for and meets the basic eligibility requirements
for medical assistance.
(c) The program established under this section must:
(1) provide medical assistance benefits under a
presumptive eligibility determination for a period of not more than
90 days;
(2) establish eligibility criteria and a process for
determining the entities authorized to make determinations of
presumptive eligibility under the program;
(3) provide a preliminary screening tool to entities
described by Subdivision (2) that will allow representatives of
those entities to:
(A) make a determination as to whether an
applicant is:
(i) functionally able to live at home or in
a community setting; and
(ii) likely to be financially eligible for
medical assistance;
(B) make the determination under Paragraph
(A)(ii) not later than the fourth day after the date a determination
is made under Paragraph (A)(i); and
(C) initiate the provision of medical assistance
benefits not later than the fifth day after the date an applicant is
determined eligible under Paragraph (A)(i); and
(4) require an applicant to sign a written agreement:
(A) attesting to the accuracy of financial and
other information the applicant provides and on which presumptive
eligibility is based; and
(B) acknowledging that:
(i) state-funded services are subject to
the period prescribed by Subdivision (1); and
(ii) the applicant is required to comply
with Subsection (d).
(d) An applicant who is determined presumptively eligible
for medical assistance under the program established by this
section must complete an application for medical assistance not
later than the 10th day after the date the applicant is screened for
functional eligibility under Subsection (c)(3)(A)(i).
(e) Not later than the 45th day after the date the
commission receives an application under Subsection (d), the
commission shall make a final determination of eligibility for
medical assistance.
(f) To the extent permitted by federal law, the commission
shall retroactively apply a final determination of eligibility for
medical assistance under Subsection (e) for a period that does not
precede the 90th day before the date the application was filed under
Subsection (d).
(g) The commission shall submit an annual report to the
standing committees of the senate and house of representatives
having jurisdiction over the medical assistance program that
details:
(1) the number of individuals determined
presumptively eligible for medical assistance under the program
established under this section;
(2) the savings to the state based on how much
institutional care would have cost for individuals determined
presumptively eligible for medical assistance under the program
established under this section who were later determined eligible
for medical assistance; and
(3) the number of individuals determined
presumptively eligible for medical assistance under the program
established under this section who were later determined not
eligible for medical assistance and the cost to the state to provide
those individuals with home or community-based services before the
final determination of eligibility for medical assistance.
(h) The report required under Subsection (g) may be combined
with any other report required by this chapter or other law.
SECTION 5.08. Section 32.0261, Human Resources Code, is
amended to read as follows:
Sec. 32.0261. CONTINUOUS ELIGIBILITY. The executive
commissioner shall adopt rules in accordance with 42 U.S.C. Section
1396a(e)(12), as amended, to provide for a period of continuous
eligibility for a child under 19 years of age who is determined to
be eligible for medical assistance under this chapter. The rules
shall provide that the child remains eligible for medical
assistance, without additional review by the commission and
regardless of changes in the child's resources or income, until the
earlier of:
(1) the first anniversary of [end of the six-month
period following] the date on which the child's eligibility was
determined; or
(2) the child's 19th birthday.
ARTICLE 6. HEALTH LITERACY
SECTION 6.01. Section 104.002, Health and Safety Code, is
amended by adding Subdivision (6) to read as follows:
(6) "Health literacy" means the degree to which an
individual has the capacity to obtain and understand basic health
information and services to make appropriate health decisions.
SECTION 6.02. Subchapter B, Chapter 104, Health and Safety
Code, is amended by adding Section 104.0157 to read as follows:
Sec. 104.0157. HEALTH LITERACY ADVISORY COMMITTEE. (a)
The statewide health coordinating council shall establish an
advisory committee on health literacy composed of representatives
of relevant interest groups, including the academic community,
consumer groups, health plans, pharmacies, and associations of
physicians, dentists, hospitals, and nurses.
(b) Members of the advisory committee shall elect one member
as presiding officer.
(c) The advisory committee shall develop a long-range plan
for improving health literacy in this state. The committee shall
update the plan at least once every two years.
(d) In developing the long-range plan, the advisory
committee shall study the economic impact low health literacy has
on state health programs and health insurance coverage for
residents of this state. The advisory committee shall:
(1) identify primary risk factors contributing to low
health literacy;
(2) examine methods for health care practitioners,
health care facilities, and others to address the health literacy
of patients and the public;
(3) examine the effectiveness of using quality
measures in state health programs to improve health literacy;
(4) identify strategies for expanding the use of plain
language instructions for patients; and
(5) examine the impact improved health literacy has on
enhancing patient safety, reducing preventable events, and
increasing medication adherence to attain greater
cost-effectiveness and better patient outcomes in the provision of
health care.
(e) Not later than December 1 of each even-numbered year,
the advisory committee shall submit the long-range plan developed
or updated under this section to the governor, the lieutenant
governor, the speaker of the house of representatives, and each
member of the legislature.
(f) An advisory committee member serves without
compensation but is entitled to reimbursement for the member's
travel expenses as provided by Chapter 660, Government Code, and
the General Appropriations Act.
(g) Sections 2110.002, 2110.003, and 2110.008, Government
Code, do not apply to the advisory committee.
(h) Meetings of the advisory committee under this section
are subject to Chapter 551, Government Code.
SECTION 6.03. Sections 104.022(e) and (f), Health and
Safety Code, are amended to read as follows:
(e) The state health plan shall be developed and used in
accordance with applicable state and federal law. The plan must
identify:
(1) major statewide health concerns, including the
prevalence of low health literacy among health care consumers;
(2) the availability and use of current health
resources of the state, including resources associated with
information technology and state-supported institutions of higher
education; and
(3) future health service, information technology,
and facility needs of the state.
(f) The state health plan must:
(1) propose strategies for the correction of major
deficiencies in the service delivery system;
(2) propose strategies for improving health literacy
to attain greater cost-effectiveness and better patient outcomes in
the provision of health care;
(3) [(2)] propose strategies for incorporating
information technology in the service delivery system;
(4) [(3)] propose strategies for involving
state-supported institutions of higher education in providing
health services and for coordinating those efforts with health and
human services agencies in order to close gaps in services; and
(5) [(4)] provide direction for the state's
legislative and executive decision-making processes to implement
the strategies proposed by the plan.
ARTICLE 7. FEDERAL AUTHORIZATION AND EFFECTIVE DATE
SEC. 7.01. (a) Except as provided by Subsection (b) of this
section, 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.
(b) Subsection (a) of this section does not apply to the
extent another provision of this Act specifically authorizes or
requires a state agency to seek a waiver, state Medicaid plan
amendment, or other authorization from a federal agency.
SEC. 7.02. This Act takes effect September 1, 2021.