Texas 2021 - 87th Regular

Texas Senate Bill SB1751 Compare Versions

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1	1	87R12565 KLA-D
2	2	By: Johnson S.B. No. 1751
3	3
4	4
5	5	A BILL TO BE ENTITLED
6	6	AN ACT
7	7	relating to improvements to access to health care in this state,
8	8	including increased access to and scope of coverage under health
9	9	benefit plans and Medicaid, and to improvements in health outcomes;
10	10	authorizing an assessment; imposing penalties.
11	11	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
12	12	ARTICLE 1. HEALTH BENEFIT PLAN AVAILABILITY AND SCOPE OF COVERAGE
13	13	SECTION 1.01. (a) Subtitle I, Title 4, Government Code, is
14	14	amended by adding Chapter 537A to read as follows:
15	15	CHAPTER 537A. LIVE WELL TEXAS PROGRAM
16	16	SUBCHAPTER A. GENERAL PROVISIONS
17	17	Sec. 537A.0001. DEFINITIONS. In this chapter:
18	18	(1) "Basic plan" means the program health benefit plan
19	19	described by Section 537A.0202.
20	20	(2) "Eligible individual" means an individual who is
21	21	eligible to participate in the program.
22	22	(3) "MyHealth account" means a personal wellness and
23	23	responsibility account established for a participant under Section
24	24	537A.0251.
25	25	(4) "Participant" means an individual who is:
26	26	(A) enrolled in a program health benefit plan; or
27	27	(B) receiving health care financial assistance
28	28	under Subchapter H.
29	29	(5) "Plus plan" means the program health benefit plan
30	30	described by Section 537A.0203.
31	31	(6) "Program" means the Live Well Texas program
32	32	established under this chapter.
33	33	(7) "Program health benefit plan" includes:
34	34	(A) the basic plan; and
35	35	(B) the plus plan.
36	36	(8) "Program health benefit plan provider" means a
37	37	health benefit plan provider that contracts with the commission
38	38	under Section 537A.0107 to arrange for the provision of health care
39	39	services through a program health benefit plan.
40	40	SUBCHAPTER B. FEDERAL WAIVER FOR LIVE WELL TEXAS PROGRAM
41	41	Sec. 537A.0051. FEDERAL AUTHORIZATION FOR PROGRAM. (a)
42	42	Notwithstanding any other law, the executive commissioner shall
43	43	develop and seek a waiver under Section 1115 of the Social Security
44	44	Act (42 U.S.C. Section 1315) to the state Medicaid plan to implement
45	45	the Live Well Texas program to assist individuals in obtaining
46	46	health benefit coverage through a program health benefit plan or
47	47	health care financial assistance.
48	48	(b) The terms of a waiver the executive commissioner seeks
49	49	under this section must:
50	50	(1) be designed to:
51	51	(A) provide health benefit coverage options for
52	52	eligible individuals;
53	53	(B) produce better health outcomes for
54	54	participants;
55	55	(C) create incentives for participants to
56	56	transition from receiving public assistance benefits to achieving
57	57	stable employment;
58	58	(D) promote personal responsibility and engage
59	59	participants in making decisions regarding health care based on
60	60	cost and quality;
61	61	(E) support participants' self-sufficiency by
62	62	requiring unemployed participants to be referred to work search and
63	63	job training programs;
64	64	(F) support participants who become ineligible
65	65	to participate in a program health benefit plan in transitioning to
66	66	private health benefit coverage; and
67	67	(G) leverage enhanced federal medical assistance
68	68	percentage funding to minimize or eliminate the need for a program
69	69	enrollment cap; and
70	70	(2) allow for the operation of the program consistent
71	71	with the requirements of this chapter, except to the extent
72	72	deviation from the requirements is necessary to obtain federal
73	73	authorization of the waiver.
74	74	Sec. 537A.0052. FUNDING. Subject to approval of the waiver
75	75	described by Section 537A.0051, the commission shall implement the
76	76	program using enhanced federal medical assistance percentage
77	77	funding available under the Patient Protection and Affordable Care
78	78	Act (Pub. L. No. 111-148) as amended by the Health Care and
79	79	Education Reconciliation Act of 2010 (Pub. L. No. 111-152).
80	80	Sec. 537A.0053. NOT AN ENTITLEMENT; TERMINATION OF PROGRAM.
81	81	(a) This chapter does not establish an entitlement to health
82	82	benefit coverage or health care financial assistance under the
83	83	program for eligible individuals.
84	84	(b) The program terminates at the time federal funding
85	85	terminates under the Patient Protection and Affordable Care Act
86	86	(Pub. L. No. 111-148) as amended by the Health Care and Education
87	87	Reconciliation Act of 2010 (Pub. L. No. 111-152), unless a
88	88	successor program providing federal funding is created.
89	89	SUBCHAPTER C. PROGRAM ADMINISTRATION
90	90	Sec. 537A.0101. PROGRAM OBJECTIVE. The principal objective
91	91	of the program is to provide primary and preventative health care
92	92	through high deductible program health benefit plans to eligible
93	93	individuals.
94	94	Sec. 537A.0102. PROGRAM PROMOTION. The commission shall
95	95	promote and provide information about the program to individuals
96	96	who:
97	97	(1) are potentially eligible to participate in the
98	98	program; and
99	99	(2) live in medically underserved areas of this state.
100	100	Sec. 537A.0103. COMMISSION'S AUTHORITY RELATED TO HEALTH
101	101	BENEFIT PLAN PROVIDER CONTRACTS. The commission may:
102	102	(1) enter into contracts with health benefit plan
103	103	providers under Section 537A.0107;
104	104	(2) monitor program health benefit plan providers
105	105	through reporting requirements and other means to ensure contract
106	106	performance and quality delivery of services;
107	107	(3) monitor the quality of services delivered to
108	108	participants through outcome measurements; and
109	109	(4) provide payment under the contracts to program
110	110	health benefit plan providers.
111	111	Sec. 537A.0104. COMMISSION'S AUTHORITY RELATED TO
112	112	ELIGIBILITY AND MEDICAID COORDINATION. The commission may:
113	113	(1) accept applications for health benefit coverage
114	114	under the program and implement program eligibility screening and
115	115	enrollment procedures;
116	116	(2) resolve grievances related to eligibility
117	117	determinations; and
118	118	(3) to the extent possible, coordinate the program
119	119	with Medicaid.
120	120	Sec. 537A.0105. THIRD-PARTY ADMINISTRATOR CONTRACT FOR
121	121	PROGRAM IMPLEMENTATION. (a) In administering the program, the
122	122	commission may contract with a third-party administrator to provide
123	123	enrollment and related services.
124	124	(b) If the commission contracts with a third-party
125	125	administrator under this section, the commission may:
126	126	(1) monitor the third-party administrator through
127	127	reporting requirements and other means to ensure contract
128	128	performance and quality delivery of services; and
129	129	(2) provide payment under the contract to the
130	130	third-party administrator.
131	131	(c) The executive commissioner shall retain all
132	132	policymaking authority over the program.
133	133	(d) The commission shall procure each contract with a
134	134	third-party administrator, as applicable, through a competitive
135	135	procurement process that complies with all federal and state laws.
136	136	Sec. 537A.0106. TEXAS DEPARTMENT OF INSURANCE DUTIES. (a)
137	137	At the commission's request, the Texas Department of Insurance
138	138	shall provide any necessary assistance with the program. The
139	139	department shall monitor the quality of the services provided by
140	140	program health benefit plan providers and resolve grievances
141	141	related to those providers.
142	142	(b) The commission and the Texas Department of Insurance may
143	143	adopt a memorandum of understanding that addresses the
144	144	responsibilities of each agency with respect to the program.
145	145	(c) The Texas Department of Insurance, in consultation with
146	146	the commission, shall adopt rules as necessary to implement this
147	147	section.
148	148	Sec. 537A.0107. HEALTH BENEFIT PLAN PROVIDER CONTRACTS.
149	149	The commission shall select through a competitive procurement
150	150	process that complies with all federal and state laws and contract
151	151	with health benefit plan providers to provide health care services
152	152	under the program. To be eligible for a contract under this section,
153	153	an entity must:
154	154	(1) be a Medicaid managed care organization;
155	155	(2) hold a certificate of authority issued by the
156	156	Texas Department of Insurance that authorizes the entity to provide
157	157	the types of health care services offered under the program; and
158	158	(3) satisfy, except as provided by this chapter, any
159	159	applicable requirement of the Insurance Code or another insurance
160	160	law of this state.
161	161	Sec. 537A.0108. HEALTH CARE PROVIDERS. (a) A health care
162	162	provider who provides health care services under the program must
163	163	meet certification and licensure requirements required by
164	164	commission rules and other law.
165	165	(b) In adopting rules governing the program, the executive
166	166	commissioner shall ensure that a health care provider who provides
167	167	health care services under the program is reimbursed at a rate that
168	168	is at least equal to the rate paid under Medicare for the provision
169	169	of the same or substantially similar services.
170	170	Sec. 537A.0109. PROHIBITION ON CERTAIN HEALTH CARE
171	171	PROVIDERS. The executive commissioner shall adopt rules that
172	172	prohibit a health care provider from providing health care services
173	173	under the program for a reasonable period, as determined by the
174	174	executive commissioner, if the health care provider:
175	175	(1) fails to repay overpayments made under the
176	176	program; or
177	177	(2) owns, controls, manages, or is otherwise
178	178	affiliated with and has financial, managerial, or administrative
179	179	influence over a health care provider who has been suspended or
180	180	prohibited from providing health care services under the program.
181	181	SUBCHAPTER D. ELIGIBILITY FOR PROGRAM HEALTH BENEFIT COVERAGE
182	182	Sec. 537A.0151. ELIGIBILITY REQUIREMENTS. (a) An
183	183	individual is eligible to enroll in a program health benefit plan
184	184	if:
185	185	(1) the individual is:
186	186	(A) a resident of this state; and
187	187	(B) a citizen of the United States or is
188	188	otherwise legally authorized to be present in the United States;
189	189	(2) the individual is 19 years of age or older but
190	190	younger than 65 years of age;
191	191	(3) applying the eligibility criteria in effect in
192	192	this state on December 31, 2020, the individual is not eligible for
193	193	Medicaid; and
194	194	(4) federal matching funds are available under the
195	195	Patient Protection and Affordable Care Act (Pub. L. No. 111-148) as
196	196	amended by the Health Care and Education Reconciliation Act of 2010
197	197	(Pub. L. No. 111-152) to provide benefits to the individual under
198	198	the federal medical assistance program established under Title XIX,
199	199	Social Security Act (42 U.S.C. Section 1396 et seq.).
200	200	(b) An individual who is a parent or caretaker relative to
201	201	whom 42 C.F.R. Section 435.110 applies is eligible to enroll in a
202	202	program health benefit plan.
203	203	Sec. 537A.0152. CONTINUOUS COVERAGE. The commission shall
204	204	ensure that an individual who is initially determined or
205	205	redetermined to be eligible to participate in the program and
206	206	enroll in a program health benefit plan will remain eligible for
207	207	coverage under the plan for a period of 12 months beginning on the
208	208	first day of the month following the date eligibility was
209	209	determined or redetermined, subject to Section 537A.0252(f).
210	210	Sec. 537A.0153. APPLICATION FORM AND PROCEDURES. (a) The
211	211	executive commissioner shall adopt an application form and
212	212	application procedures for the program. The form and procedures
213	213	must be coordinated with forms and procedures under Medicaid to
214	214	ensure that there is a single consolidated application process to
215	215	seek health benefit coverage under the program or Medicaid.
216	216	(b) To the extent possible, the commission shall make the
217	217	application form available in languages other than English.
218	218	(c) The executive commissioner may permit an individual to
219	219	apply by mail, over the telephone, or through the Internet.
220	220	Sec. 537A.0154. ELIGIBILITY SCREENING AND ENROLLMENT. (a)
221	221	The executive commissioner shall adopt eligibility screening and
222	222	enrollment procedures or use the Texas Integrated Enrollment
223	223	Services eligibility determination system or a compatible system to
224	224	screen individuals and enroll eligible individuals in the program.
225	225	(b) The eligibility screening and enrollment procedures
226	226	must ensure that an individual applying for the program who appears
227	227	eligible for Medicaid is identified and assisted with obtaining
228	228	Medicaid coverage. If the individual is denied Medicaid coverage
229	229	but is determined eligible to enroll in a program health benefit
230	230	plan, the commission shall enroll the individual in a program
231	231	health benefit plan of the individual's choosing and for which the
232	232	individual is eligible without further application or
233	233	qualification.
234	234	(c) Not later than the 30th day after the date an individual
235	235	submits a complete application form and unless the individual is
236	236	identified and assisted with obtaining Medicaid coverage under
237	237	Subsection (b), the commission shall ensure that the individual's
238	238	eligibility to participate in the program is determined and that
239	239	the individual is provided with information on program health
240	240	benefit plans and program health benefit plan providers. The
241	241	commission shall enroll the individual in the program health
242	242	benefit plan and with the program health benefit plan provider of
243	243	the individual's choosing in a timely manner, as determined by the
244	244	commission.
245	245	(d) The executive commissioner may establish enrollment
246	246	periods for the program.
247	247	Sec. 537A.0155. ELIGIBILITY REDETERMINATION PROCESS;
248	248	DISENROLLMENT. (a) Not later than the 90th day before the
249	249	expiration of a participant's coverage period, the commission shall
250	250	notify the participant regarding the eligibility redetermination
251	251	process and request documentation necessary to redetermine the
252	252	participant's eligibility.
253	253	(b) The commission shall provide written notice of
254	254	termination of eligibility to a participant not later than the 30th
255	255	day before the date the participant's eligibility will terminate.
256	256	The commission shall disenroll the participant from the program if:
257	257	(1) the participant does not submit the requested
258	258	eligibility redetermination documentation before the last day of
259	259	the participant's coverage period; or
260	260	(2) the commission, based on the submitted
261	261	documentation, determines the participant is no longer eligible for
262	262	the program, subject to Subchapter H.
263	263	(c) An individual may submit the requested eligibility
264	264	redetermination documentation not later than the 90th day after the
265	265	date the individual is disenrolled from the program. If the
266	266	commission determines that the individual continues to meet program
267	267	eligibility requirements, the commission shall reenroll the
268	268	individual in the program without any additional application
269	269	requirements.
270	270	(d) An individual who does not complete the eligibility
271	271	redetermination process in accordance with this section and who is
272	272	disenrolled from the program may not participate in the program for
273	273	a period of 180 days beginning on the date of disenrollment. This
274	274	subsection does not apply to an individual described by Section
275	275	537A.0206 or 537A.0208 or an individual who is pregnant or is
276	276	younger than 21 years of age.
277	277	(e) At the time a participant is disenrolled from the
278	278	program under this section, the commission shall provide to the
279	279	participant:
280	280	(1) notice that the participant may be eligible to
281	281	receive health care financial assistance under Subchapter H in
282	282	transitioning to private health benefit coverage; and
283	283	(2) information on and the eligibility requirements
284	284	for that financial assistance.
285	285	SUBCHAPTER E. BASIC AND PLUS PLANS
286	286	Sec. 537A.0201. BASIC AND PLUS PLAN COVERAGE GENERALLY.
287	287	(a) The basic and plus plans offered under the program must:
288	288	(1) comply with this subchapter and coverage
289	289	requirements prescribed by other law; and
290	290	(2) at a minimum, provide coverage for essential
291	291	health benefits required under 42 U.S.C. Section 18022(b).
292	292	(b) In modifying covered health benefits under the basic and
293	293	plus plans, the executive commissioner shall consider the health
294	294	care needs of healthy individuals and individuals with special
295	295	health care needs.
296	296	(c) The basic and plus plans must allow a participant with a
297	297	chronic, disabling, or life-threatening illness to select an
298	298	appropriate specialist as the participant's primary care
299	299	physician.
300	300	Sec. 537A.0202. BASIC PLAN: COVERAGE AND INCOME
301	301	ELIGIBILITY. (a) The program must include a basic plan that is
302	302	sufficient to meet the basic health care needs of individuals who
303	303	enroll in the plan.
304	304	(b) The covered health benefits under the basic plan must
305	305	include:
306	306	(1) primary care physician services;
307	307	(2) prenatal and postpartum care;
308	308	(3) specialty care physician visits;
309	309	(4) home health services, not to exceed 100 visits per
310	310	year;
311	311	(5) outpatient surgery;
312	312	(6) allergy testing;
313	313	(7) chemotherapy;
314	314	(8) intravenous infusion services;
315	315	(9) radiation therapy;
316	316	(10) dialysis;
317	317	(11) emergency care hospital services;
318	318	(12) emergency transportation, including ambulance
319	319	and air ambulance;
320	320	(13) urgent care clinic services;
321	321	(14) hospitalization, including for:
322	322	(A) general inpatient hospital care;
323	323	(B) inpatient physician services;
324	324	(C) inpatient surgical services;
325	325	(D) non-cosmetic reconstructive surgery;
326	326	(E) a transplant;
327	327	(F) treatment for a congenital abnormality;
328	328	(G) anesthesia;
329	329	(H) hospice care; and
330	330	(I) care in a skilled nursing facility for a
331	331	period not to exceed 100 days per occurrence;
332	332	(15) inpatient and outpatient behavioral health
333	333	services;
334	334	(16) inpatient, outpatient, and residential substance
335	335	use treatment;
336	336	(17) prescription drugs, including tobacco cessation
337	337	drugs;
338	338	(18) inpatient and outpatient rehabilitative and
339	339	habilitative care, including physical, occupational, and speech
340	340	therapy, not to exceed 60 combined visits per year;
341	341	(19) medical equipment, appliances, and assistive
342	342	technology, including prosthetics and hearing aids, and the repair,
343	343	technical support, and customization needed for individual use;
344	344	(20) laboratory and pathology tests and services;
345	345	(21) diagnostic imaging, including x-rays, magnetic
346	346	resonance imaging, computed tomography, and positron emission
347	347	tomography;
348	348	(22) preventative care services as described by
349	349	Section 537A.0204; and
350	350	(23) services under the early and periodic screening,
351	351	diagnostic, and treatment program for participants who are younger
352	352	than 21 years of age.
353	353	(c) To be eligible for health care benefits under the basic
354	354	plan, an individual who is eligible for the program must have an
355	355	annual household income that is equal to or less than 100 percent of
356	356	the federal poverty level.
357	357	Sec. 537A.0203. PLUS PLAN: COVERAGE AND INCOME ELIGIBILITY.
358	358	(a) The program must include a plus plan that includes the covered
359	359	health benefits listed in Section 537A.0202 and the following
360	360	additional enhanced health benefits:
361	361	(1) services related to the treatment of conditions
362	362	affecting the temporomandibular joint;
363	363	(2) dental care;
364	364	(3) vision care;
365	365	(4) notwithstanding Section 537A.0202(b)(18),
366	366	inpatient and outpatient rehabilitative and habilitative care,
367	367	including physical, occupational, and speech therapy, not to exceed
368	368	75 combined visits per year;
369	369	(5) bariatric surgery; and
370	370	(6) other services the commission considers
371	371	appropriate.
372	372	(b) An individual who is eligible for the program and whose
373	373	annual household income exceeds 100 percent of the federal poverty
374	374	level will automatically be enrolled in and receive health benefits
375	375	under the plus plan. An individual who is eligible for the program
376	376	and whose annual household income is equal to or less than 100
377	377	percent of the federal poverty level may choose to enroll in the
378	378	plus plan.
379	379	(c) A participant enrolled in the plus plan is required to
380	380	make MyHealth account contributions in accordance with Section
381	381	537A.0252.
382	382	Sec. 537A.0204. PREVENTATIVE CARE SERVICES. (a) The
383	383	commission shall provide to each participant a list of health care
384	384	services that qualify as preventative care services based on the
385	385	age, gender, and preexisting conditions of the participant. In
386	386	developing the list, the commission shall consult with the federal
387	387	Centers for Disease Control and Prevention.
388	388	(b) A program health benefit plan shall, at no cost to the
389	389	participant, provide coverage for:
390	390	(1) preventative care services described by 42 U.S.C.
391	391	Section 300gg-13; and
392	392	(2) a maximum of $500 per year of preventative care
393	393	services other than those described by Subdivision (1).
394	394	(c) A participant who receives preventative care services
395	395	not described by Subsection (b) that are covered under the
396	396	participant's program health benefit plan is subject to deductible
397	397	and copayment requirements for the services in accordance with the
398	398	terms of the plan.
399	399	Sec. 537A.0205. COPAYMENTS. (a) A participant enrolled in
400	400	the basic plan shall pay a copayment for each covered health benefit
401	401	except for a preventative care or family planning service. The
402	402	executive commissioner by rule shall adopt a copayment schedule for
403	403	basic plan services, subject to Subsection (c).
404	404	(b) Except as provided by Subsection (c), a participant
405	405	enrolled in the plus plan may not be required to pay a copayment for
406	406	a covered service.
407	407	(c) A participant enrolled in the basic or plus plan shall
408	408	pay a copayment in an amount set by commission rule not to exceed
409	409	$25 for nonemergency use of hospital emergency department services
410	410	unless:
411	411	(1) the participant has met the cost-sharing maximum
412	412	for the calendar quarter, as prescribed by commission rule;
413	413	(2) the participant is referred to the hospital
414	414	emergency department by a health care provider;
415	415	(3) the visit is a true emergency, as defined by
416	416	commission rule; or
417	417	(4) the participant is pregnant.
418	418	Sec. 537A.0206. CERTAIN PARTICIPANTS ELIGIBLE FOR STATE
419	419	MEDICAID PLAN BENEFITS. (a) A participant described by 42 C.F.R.
420	420	Section 440.315 who is enrolled in the basic or plus plan is
421	421	entitled to receive under the program all health benefits that
422	422	would be available under the state Medicaid plan.
423	423	(b) A participant to which this section applies is subject
424	424	to the cost-sharing requirements, including copayment and MyHealth
425	425	account contribution requirements, of the program health benefit
426	426	plan in which the participant is enrolled.
427	427	(c) The commission shall develop screening measures to
428	428	identify participants to which this section applies.
429	429	Sec. 537A.0207. PREGNANT PARTICIPANTS. (a) A participant
430	430	who becomes pregnant while enrolled in the program and who meets the
431	431	eligibility requirements for Medicaid may choose to remain in the
432	432	program or enroll in Medicaid.
433	433	(b) A pregnant participant described by Subsection (a) who
434	434	is enrolled in the basic or plus plan and who remains in the program
435	435	is:
436	436	(1) notwithstanding Section 537A.0205, not subject to
437	437	any cost-sharing requirements, including copayment and MyHealth
438	438	account contribution requirements, of the program health benefit
439	439	plan in which the participant is enrolled until the expiration of
440	440	the second month following the month in which the pregnancy ends;
441	441	(2) entitled to receive as a Medicaid wrap-around
442	442	benefit all Medicaid services a pregnant woman enrolled in Medicaid
443	443	is entitled to receive, including a pharmacy benefit, when the
444	444	participant exceeds coverage limits under the participant's
445	445	program health benefit plan or if a service is not covered by the
446	446	plan; and
447	447	(3) eligible for additional vision and dental care
448	448	benefits.
449	449	Sec. 537A.0208. PARENTS AND CARETAKER RELATIVES. (a) A
450	450	parent or caretaker relative to whom 42 C.F.R. Section 435.110
451	451	applies is entitled to receive as a Medicaid wrap-around benefit
452	452	all Medicaid services to which the individual would be entitled
453	453	under the state Medicaid plan that are not covered under the
454	454	individual's program health benefit plan or exceed the plan's
455	455	coverage limits.
456	456	(b) An individual described by Subsection (a) who chooses to
457	457	participate in the program is subject to the cost-sharing
458	458	requirements, including copayment and MyHealth account
459	459	contribution requirements, of the program health benefit plan in
460	460	which the individual is enrolled.
461	461	SUBCHAPTER F. MYHEALTH ACCOUNTS
462	462	Sec. 537A.0251. ESTABLISHMENT AND OPERATION OF MYHEALTH
463	463	ACCOUNTS. (a) The commission shall establish a MyHealth account
464	464	for each participant who is enrolled in a program health benefit
465	465	plan that is funded with money contributed in accordance with this
466	466	subchapter.
467	467	(b) The commission shall enable each participant to access
468	468	and manage money in and information regarding the participant's
469	469	MyHealth account through an electronic system. The commission may
470	470	contract with an entity that has appropriate experience and
471	471	expertise to establish, implement, or administer the electronic
472	472	system.
473	473	(c) Except as otherwise provided by Section 537A.0252, the
474	474	commission shall require each participant to contribute to the
475	475	participant's MyHealth account in amounts described by that
476	476	section.
477	477	Sec. 537A.0252. MYHEALTH ACCOUNT CONTRIBUTIONS;
478	478	DEDUCTIBLE. (a) The executive commissioner by rule shall
479	479	establish an annual universal deductible for each participant
480	480	enrolled in the basic or plus plan.
481	481	(b) To ensure each participant's MyHealth account contains
482	482	a sufficient amount of money at the beginning of a coverage period,
483	483	the commission shall, before the beginning of that period, fund
484	484	each account with the following amounts:
485	485	(1) for a participant enrolled in the basic plan, the
486	486	annual universal deductible amount; and
487	487	(2) for a participant enrolled in the plus plan, the
488	488	difference between the annual universal deductible amount and the
489	489	participant's required annual contribution as determined by the
490	490	schedule established under Subsection (c).
491	491	(c) The executive commissioner by rule shall establish a
492	492	graduated annual MyHealth account contribution schedule for
493	493	participants enrolled in the plus plan that:
494	494	(1) is based on a participant's annual household
495	495	income, with participants whose annual household incomes are less
496	496	than the federal poverty level paying progressively less and
497	497	participants whose annual household incomes are equal to or greater
498	498	than the federal poverty level paying progressively more; and
499	499	(2) may not require a participant to contribute more
500	500	than a total of five percent of the participant's annual household
501	501	income to the participant's MyHealth account.
502	502	(d) A participant's employer may contribute on behalf of the
503	503	participant any amount of the participant's annual MyHealth account
504	504	contribution. A nonprofit organization may contribute on behalf of
505	505	a participant any amount of the participant's annual MyHealth
506	506	account contribution.
507	507	(e) Subject to the contribution cap described by Subsection
508	508	(c)(2) and not before the expiration of the participant's first
509	509	coverage period, the commission shall require a participant who
510	510	uses one or more tobacco products to contribute to the
511	511	participant's MyHealth account an annual MyHealth account
512	512	contribution amount that is one percent more than the participant
513	513	would otherwise be required to contribute under the schedule
514	514	established under Subsection (c).
515	515	(f) An annual MyHealth account contribution must be paid by
516	516	or on behalf of a participant monthly in installments that are at
517	517	least equal to one-twelfth of the total required contribution. The
518	518	coverage period for a participant whose annual household income
519	519	exceeds 100 percent of the federal poverty level may not begin until
520	520	the first day of the first month following the month in which the
521	521	first monthly installment is received.
522	522	Sec. 537A.0253. USE OF MYHEALTH ACCOUNT MONEY. A
523	523	participant may use money in the participant's MyHealth account to
524	524	pay copayments and deductible costs required under the
525	525	participant's program health benefit plan. The commission shall
526	526	issue to each participant an electronic payment card that allows
527	527	the participant to use the card to pay the program health benefit
528	528	plan costs.
529	529	Sec. 537A.0254. PROGRAM HEALTH BENEFIT PLAN PROVIDER
530	530	REWARDS PROGRAM FOR ENGAGEMENT IN CERTAIN HEALTHY BEHAVIORS;
531	531	SMOKING CESSATION INITIATIVE. (a) A program health benefit plan
532	532	provider shall establish a rewards program through which a
533	533	participant receiving health care through a program health benefit
534	534	plan offered by the program health benefit plan provider may earn
535	535	money to be contributed to the participant's MyHealth account.
536	536	(b) Under a rewards program, a program health benefit plan
537	537	provider shall contribute money to a participant's MyHealth account
538	538	if the participant engages in certain healthy behaviors. The
539	539	executive commissioner by rule shall determine:
540	540	(1) the behaviors in which a participant must engage
541	541	to receive a contribution, which must include behaviors related to:
542	542	(A) completion of a health risk assessment;
543	543	(B) smoking cessation; and
544	544	(C) as applicable, chronic disease management;
545	545	and
546	546	(2) the amount of money a program health benefit plan
547	547	provider shall contribute for each behavior described by
548	548	Subdivision (1).
549	549	(c) Subsection (b) does not prevent a program health benefit
550	550	plan provider from contributing money to a participant's MyHealth
551	551	account if the participant engages in a behavior not specified by
552	552	that subsection or a rule adopted in accordance with that
553	553	subsection. If a program health benefit plan provider chooses to
554	554	contribute money under this subsection, the program health benefit
555	555	plan provider shall determine the amount of money to be contributed
556	556	for the behavior.
557	557	(d) A participant may use contributions a program health
558	558	benefit plan provider makes under a rewards program to offset a
559	559	maximum of 50 percent of the participant's required annual MyHealth
560	560	account contribution established under Section 537A.0252.
561	561	(e) Contributions a program health benefit plan provider
562	562	makes under a rewards program that result in a participant's
563	563	MyHealth account balance exceeding the participant's required
564	564	annual MyHealth account contribution may be rolled over into the
565	565	next coverage period in accordance with Section 537A.0256.
566	566	(f) During the first coverage period of a participant who
567	567	uses one or more tobacco products, a program health benefit plan
568	568	provider shall actively attempt to engage the participant in and
569	569	provide educational materials to the participant on:
570	570	(1) smoking cessation activities for which the
571	571	participant may receive a monetary contribution under this section;
572	572	and
573	573	(2) other smoking cessation programs or resources
574	574	available to the participant.
575	575	Sec. 537A.0255. MONTHLY STATEMENTS. The commission shall
576	576	distribute to each participant with a MyHealth account a monthly
577	577	statement that includes information on:
578	578	(1) the participant's MyHealth account activity during
579	579	the preceding month, including information on the cost of health
580	580	care services delivered to the participant during that month;
581	581	(2) the balance of money available in the MyHealth
582	582	account at the time the statement is issued; and
583	583	(3) the amount of any contributions due from the
584	584	participant.
585	585	Sec. 537A.0256. MYHEALTH ACCOUNT ROLL OVER. (a) The
586	586	executive commissioner by rule shall establish a process in
587	587	accordance with this section to roll over money in a participant's
588	588	MyHealth account to the succeeding coverage period. The commission
589	589	shall calculate the amount to be rolled over at the time the
590	590	participant's program eligibility is redetermined.
591	591	(b) For a participant enrolled in the basic plan, the
592	592	commission shall calculate the amount to be rolled over to a
593	593	subsequent coverage period MyHealth account from the participant's
594	594	current coverage period MyHealth account based on:
595	595	(1) the amount of money remaining in the participant's
596	596	MyHealth account from the current coverage period; and
597	597	(2) whether the participant received recommended
598	598	preventative care services during the current coverage period.
599	599	(c) For a participant enrolled in the plus plan who, as
600	600	determined by the commission, timely makes MyHealth account
601	601	contributions in accordance with this subchapter, the commission
602	602	shall calculate the amount to be rolled over to a subsequent
603	603	coverage period MyHealth account from the participant's current
604	604	coverage period MyHealth account based on:
605	605	(1) the amount of money remaining in the participant's
606	606	MyHealth account from the current coverage period;
607	607	(2) the total amount of money the participant
608	608	contributed to the participant's MyHealth account during the
609	609	current coverage period; and
610	610	(3) whether the participant received recommended
611	611	preventative care services during the current coverage period.
612	612	(d) Except as provided by Subsection (e), a participant may
613	613	use money rolled over into the participant's MyHealth account for
614	614	the succeeding coverage period to offset required annual MyHealth
615	615	account contributions, as applicable, during that coverage period.
616	616	(e) A participant enrolled in the basic plan who rolls over
617	617	money into the participant's MyHealth account for the succeeding
618	618	coverage period and who chooses to enroll in the plus plan for that
619	619	coverage period may use the money rolled over to offset a maximum of
620	620	50 percent of the required annual MyHealth account contributions
621	621	for that coverage period.
622	622	Sec. 537A.0257. REFUND. If at the end of a participant's
623	623	coverage period the participant chooses to cease participating in a
624	624	program health benefit plan or is no longer eligible to participate
625	625	in a program health benefit plan, or if a participant is terminated
626	626	from the program health benefit plan under Section 537A.0258 for
627	627	failure to pay required contributions, the commission shall refund
628	628	to the participant any money the participant contributed that
629	629	remains in the participant's MyHealth account at the end of the
630	630	coverage period or on the termination date.
631	631	Sec. 537A.0258. PENALTIES FOR FAILURE TO MAKE MYHEALTH
632	632	ACCOUNT CONTRIBUTIONS. (a) For a participant whose annual
633	633	household income exceeds 100 percent of the federal poverty level
634	634	and who fails to make a contribution in accordance with Section
635	635	537A.0252, the commission shall provide a 60-day grace period
636	636	during which the participant may make the contribution without
637	637	penalty. If the participant fails to make the contribution during
638	638	the grace period, the participant will be disenrolled from the
639	639	program health benefit plan in which the participant is enrolled
640	640	and may not reenroll in a program health benefit plan until:
641	641	(1) the 181st day after the date the participant is
642	642	disenrolled; and
643	643	(2) the participant pays any debt accrued due to the
644	644	participant's failure to make the contribution.
645	645	(b) For a participant enrolled in the plus plan whose annual
646	646	household income is equal to or less than 100 percent of the federal
647	647	poverty level and who fails to make a contribution in accordance
648	648	with Section 537A.0252, the commission shall disenroll the
649	649	participant from the plus plan and enroll the participant in the
650	650	basic plan. A participant enrolled in the basic plan under this
651	651	subsection may not change enrollment to the plus plan until the
652	652	participant's program eligibility is redetermined.
653	653	SUBCHAPTER G. EMPLOYMENT INITIATIVE
654	654	Sec. 537A.0301. GATEWAY TO WORK PROGRAM. (a) The
655	655	commission shall develop and implement a gateway to work program
656	656	to:
657	657	(1) integrate existing job training and job search
658	658	programs available in this state through the Texas Workforce
659	659	Commission or other appropriate state agencies with the Live Well
660	660	Texas program; and
661	661	(2) provide each participant with general information
662	662	on the job training and job search programs.
663	663	(b) Under the gateway to work program, the commission shall
664	664	refer each participant who is unemployed or working less than 20
665	665	hours a week to available job search and job training programs.
666	666	SUBCHAPTER H. HEALTH CARE FINANCIAL ASSISTANCE FOR CERTAIN
667	667	PARTICIPANTS
668	668	Sec. 537A.0351. HEALTH CARE FINANCIAL ASSISTANCE FOR
669	669	CONTINUITY OF CARE. (a) The commission shall ensure continuity of
670	670	care by providing health care financial assistance in accordance
671	671	with and in the manner described by this subchapter for a
672	672	participant who:
673	673	(1) is disenrolled from a program health benefit plan
674	674	in accordance with Section 537A.0155 because the participant's
675	675	annual household income exceeds the income eligibility
676	676	requirements for enrollment in a program health benefit plan; and
677	677	(2) seeks and obtains private health benefit coverage
678	678	within 12 months following the date of disenrollment.
679	679	(b) To receive health care financial assistance under this
680	680	subchapter, a participant must provide to the commission, in the
681	681	form and manner required by the commission, documentation showing
682	682	the participant has obtained or is actively seeking private health
683	683	benefit coverage.
684	684	(c) The commission may not impose an upper income
685	685	eligibility limit on a participant to receive health care financial
686	686	assistance under this subchapter.
687	687	Sec. 537A.0352. DURATION AND AMOUNT OF HEALTH CARE
688	688	FINANCIAL ASSISTANCE. (a) A participant described by Section
689	689	537A.0351 may receive health care financial assistance under this
690	690	subchapter until the first anniversary of the date the participant
691	691	was disenrolled from a program health benefit plan.
692	692	(b) Health care financial assistance made available to a
693	693	participant under this subchapter:
694	694	(1) may not exceed the amount described by Section
695	695	537A.0353; and
696	696	(2) is limited to payment for eligible services
697	697	described by Section 537A.0354.
698	698	Sec. 537A.0353. BRIDGE ACCOUNT; FUNDING. (a) The
699	699	commission shall establish a bridge account for each participant
700	700	eligible to receive health care financial assistance under Section
701	701	537A.0351. The account is funded with money the commission
702	702	contributes in accordance with this section.
703	703	(b) The commission shall enable each participant for whom a
704	704	bridge account is established to access and manage money in and
705	705	information regarding the participant's account through an
706	706	electronic system. The commission may contract with the same
707	707	entity described by Section 537A.0251(b) or another entity with
708	708	appropriate experience and expertise to establish, implement, or
709	709	administer the electronic system.
710	710	(c) The commission shall fund each bridge account in an
711	711	amount equal to $1,000 using money the commission retains or
712	712	recoups during the roll over process described by Section 537A.0256
713	713	or following the issuance of a refund as described by Section
714	714	537A.0257.
715	715	(d) The commission may not require a participant to
716	716	contribute money to the participant's bridge account.
717	717	(e) The commission shall retain or recoup any unexpended
718	718	money in a participant's bridge account at the end of the period for
719	719	which the participant is eligible to receive health care financial
720	720	assistance under this subchapter for the purpose of funding another
721	721	participant's MyHealth account under Subchapter F or bridge account
722	722	under this subchapter.
723	723	Sec. 537A.0354. USE OF BRIDGE ACCOUNT MONEY. (a) The
724	724	commission shall issue to each participant for whom a bridge
725	725	account is established an electronic payment card that allows the
726	726	participant to use the card to pay costs for eligible services
727	727	described by Subsection (b).
728	728	(b) A participant may use money in the participant's bridge
729	729	account to pay:
730	730	(1) premium costs incurred during the private health
731	731	benefit coverage enrollment process and coverage period; and
732	732	(2) copayments, deductible costs, and coinsurance
733	733	associated with the private health benefit coverage obtained by the
734	734	participant for health care services that would otherwise be
735	735	reimbursable under Medicaid.
736	736	(c) Costs described by Subsection (b)(2) associated with
737	737	eligible services delivered to a participant may be paid by:
738	738	(1) a participant using the electronic payment card
739	739	issued under Subsection (a); or
740	740	(2) a health care provider directly charging and
741	741	receiving payment from the participant's bridge account.
742	742	Sec. 537A.0355. ENROLLMENT COUNSELING. The commission
743	743	shall provide enrollment counseling to an individual who is seeking
744	744	private health benefit coverage and who is otherwise eligible to
745	745	receive health care financial assistance under this subchapter.
746	746	(b) As soon as practicable after the effective date of this
747	747	Act, the executive commissioner of the Health and Human Services
748	748	Commission shall apply for and actively pursue from the appropriate
749	749	federal agency the waiver as required by Section 537A.0051,
750	750	Government Code, as added by this section. The commission may delay
751	751	implementing this section until the waiver applied for under
752	752	Section 537.0051 is granted, subject to Subsection (c) of this
753	753	section.
754	754	(c) To maximize budget savings, not later than the 90th day
755	755	after the effective date of this Act, the executive commissioner of
756	756	the Health and Human Services Commission shall seek from the
757	757	appropriate federal agency an amendment to the state Medicaid plan
758	758	to implement the provisions of this section that the commission
759	759	would otherwise be authorized to implement under the state Medicaid
760	760	plan without the waiver described by Subsection (b) of this
761	761	section. The commission shall implement the provisions described by
762	762	this subsection as soon as practicable after the state Medicaid
763	763	plan amendment is approved.
764	764	SECTION 1.02. (a) Subtitle E, Title 8, Insurance Code, is
765	765	amended by adding Chapter 1380 to read as follows:
766	766	CHAPTER 1380. COVERAGE OF ESSENTIAL HEALTH BENEFITS
767	767	Sec. 1380.001. APPLICABILITY OF CHAPTER. (a) This chapter
768	768	applies only to a health benefit plan that provides benefits for
769	769	medical or surgical expenses incurred as a result of a health
770	770	condition, accident, or sickness, including an individual, group,
771	771	blanket, or franchise insurance policy or insurance agreement, a
772	772	group hospital service contract, or an individual or group evidence
773	773	of coverage or similar coverage document that is issued by:
774	774	(1) an insurance company;
775	775	(2) a group hospital service corporation operating
776	776	under Chapter 842;
777	777	(3) a health maintenance organization operating under
778	778	Chapter 843;
779	779	(4) an approved nonprofit health corporation that
780	780	holds a certificate of authority under Chapter 844;
781	781	(5) a multiple employer welfare arrangement that holds
782	782	a certificate of authority under Chapter 846;
783	783	(6) a stipulated premium company operating under
784	784	Chapter 884;
785	785	(7) a fraternal benefit society operating under
786	786	Chapter 885;
787	787	(8) a Lloyd's plan operating under Chapter 941; or
788	788	(9) an exchange operating under Chapter 942.
789	789	(b) Notwithstanding any other law, this chapter applies to:
790	790	(1) a small employer health benefit plan subject to
791	791	Chapter 1501, including coverage provided through a health group
792	792	cooperative under Subchapter B of that chapter;
793	793	(2) a standard health benefit plan issued under
794	794	Chapter 1507;
795	795	(3) a basic coverage plan under Chapter 1551;
796	796	(4) a basic plan under Chapter 1575;
797	797	(5) a primary care coverage plan under Chapter 1579;
798	798	(6) a plan providing basic coverage under Chapter
799	799	1601;
800	800	(7) health benefits provided by or through a church
801	801	benefits board under Subchapter I, Chapter 22, Business
802	802	Organizations Code;
803	803	(8) group health coverage made available by a school
804	804	district in accordance with Section 22.004, Education Code;
805	805	(9) the state Medicaid program, including the Medicaid
806	806	managed care program operated under Chapter 533, Government Code;
807	807	(10) the child health plan program under Chapter 62,
808	808	Health and Safety Code;
809	809	(11) a regional or local health care program operated
810	810	under Section 75.104, Health and Safety Code;
811	811	(12) a self-funded health benefit plan sponsored by a
812	812	professional employer organization under Chapter 91, Labor Code;
813	813	(13) county employee group health benefits provided
814	814	under Chapter 157, Local Government Code; and
815	815	(14) health and accident coverage provided by a risk
816	816	pool created under Chapter 172, Local Government Code.
817	817	(c) This chapter applies to coverage under a group health
818	818	benefit plan provided to a resident of this state regardless of
819	819	whether the group policy, agreement, or contract is delivered,
820	820	issued for delivery, or renewed in this state.
821	821	Sec. 1380.002. EXCEPTION. This chapter does not apply to an
822	822	individual health benefit plan issued on or before March 23, 2010,
823	823	that has not had any significant changes since that date that reduce
824	824	benefits or increase costs to the individual.
825	825	Sec. 1380.003. REQUIRED COVERAGE FOR ESSENTIAL HEALTH
826	826	BENEFITS. (a) In this section:
827	827	(1) "Individual health benefit plan" means:
828	828	(A) an individual accident and health insurance
829	829	policy to which Chapter 1201 applies; or
830	830	(B) individual health maintenance organization
831	831	coverage.
832	832	(2) "Small employer health benefit plan" has the
833	833	meaning assigned by Section 1501.002.
834	834	(b) An individual or small employer health benefit plan must
835	835	provide coverage for the essential health benefits listed in 42
836	836	U.S.C. Section 18022(b)(1), as that section existed on January 1,
837	837	2017, and other benefits identified by the United States secretary
838	838	of health and human services as essential health benefits as of that
839	839	date.
840	840	Sec. 1380.004. CERTAIN ANNUAL AND LIFETIME LIMITS
841	841	PROHIBITED. A health benefit plan issuer may not establish an
842	842	annual or lifetime benefit amount for an enrollee in relation to
843	843	essential health benefits listed in 42 U.S.C. Section 18022(b)(1),
844	844	as that section existed on January 1, 2017, and other benefits
845	845	identified by the United States secretary of health and human
846	846	services as essential health benefits as of that date.
847	847	Sec. 1380.005. LIMITATIONS ON COST-SHARING. A health
848	848	benefit plan issuer may not impose cost-sharing requirements that
849	849	exceed the limits established in 42 U.S.C. Section 18022(c)(1) in
850	850	relation to essential health benefits listed in 42 U.S.C. Section
851	851	18022(b)(1), as those sections existed on January 1, 2017, and
852	852	other benefits identified by the United States secretary of health
853	853	and human services as essential health benefits as of that date.
854	854	Sec. 1380.006. RULES. (a) Subject to Subsection (b), the
855	855	commissioner may adopt rules as necessary to implement this
856	856	chapter.
857	857	(b) Rules adopted by the commissioner to implement this
858	858	chapter must be consistent with the Patient Protection and
859	859	Affordable Care Act (Pub. L. No. 111-148), as that Act existed on
860	860	January 1, 2017.
861	861	(b) Subtitle G, Title 8, Insurance Code, is amended by
862	862	adding Chapter 1512 to read as follows:
863	863	CHAPTER 1512. HEALTH BENEFIT COVERAGE AVAILABILITY
864	864	SUBCHAPTER A. GENERAL PROVISIONS
865	865	Sec. 1512.001. APPLICABILITY OF CHAPTER. (a) Except as
866	866	otherwise provided by this chapter, this chapter applies only to a
867	867	health benefit plan that provides benefits for medical or surgical
868	868	expenses incurred as a result of a health condition, accident, or
869	869	sickness, including an individual, group, blanket, or franchise
870	870	insurance policy or insurance agreement, a group hospital service
871	871	contract, or an individual or group evidence of coverage or similar
872	872	coverage document that is issued by:
873	873	(1) an insurance company;
874	874	(2) a group hospital service corporation operating
875	875	under Chapter 842;
876	876	(3) a health maintenance organization operating under
877	877	Chapter 843;
878	878	(4) an approved nonprofit health corporation that
879	879	holds a certificate of authority under Chapter 844;
880	880	(5) a multiple employer welfare arrangement that holds
881	881	a certificate of authority under Chapter 846;
882	882	(6) a stipulated premium company operating under
883	883	Chapter 884;
884	884	(7) a fraternal benefit society operating under
885	885	Chapter 885;
886	886	(8) a Lloyd's plan operating under Chapter 941; or
887	887	(9) an exchange operating under Chapter 942.
888	888	(b) Notwithstanding any other law, this chapter applies to:
889	889	(1) a small employer health benefit plan subject to
890	890	Chapter 1501, including coverage provided through a health group
891	891	cooperative under Subchapter B of that chapter; and
892	892	(2) a standard health benefit plan issued under
893	893	Chapter 1507.
894	894	(c) This chapter applies to coverage under a group health
895	895	benefit plan provided to a resident of this state regardless of
896	896	whether the group policy, agreement, or contract is delivered,
897	897	issued for delivery, or renewed in this state.
898	898	Sec. 1512.002. EXCEPTIONS. (a) This chapter does not apply
899	899	to:
900	900	(1) a plan that provides coverage:
901	901	(A) for wages or payments in lieu of wages for a
902	902	period during which an employee is absent from work because of
903	903	sickness or injury;
904	904	(B) as a supplement to a liability insurance
905	905	policy;
906	906	(C) for credit insurance;
907	907	(D) only for dental or vision care;
908	908	(E) only for a specified disease or for another
909	909	limited benefit; or
910	910	(F) only for accidental death or dismemberment;
911	911	(2) a Medicare supplemental policy as defined by
912	912	Section 1882(g)(1), Social Security Act (42 U.S.C. Section
913	913	1395ss(g)(1));
914	914	(3) a workers' compensation insurance policy;
915	915	(4) medical payment insurance coverage provided under
916	916	a motor vehicle insurance policy; or
917	917	(5) a long-term care policy, including a nursing home
918	918	fixed indemnity policy, unless the commissioner determines that the
919	919	policy provides benefit coverage so comprehensive that the policy
920	920	is a health benefit plan as described by Section 1512.001.
921	921	(b) This chapter does not apply to an individual health
922	922	benefit plan issued on or before March 23, 2010, that has not had
923	923	any significant changes since that date that reduce benefits or
924	924	increase costs to the individual.
925	925	Sec. 1512.003. CONFLICT WITH OTHER LAW. If there is a
926	926	conflict between this chapter and other law, this chapter prevails.
927	927	Sec. 1512.004. RULES. (a) Subject to Subsection (b), the
928	928	commissioner may adopt rules as necessary to implement this
929	929	chapter.
930	930	(b) Rules adopted by the commissioner to implement this
931	931	chapter must be consistent with the Patient Protection and
932	932	Affordable Care Act (Pub. L. No. 111-148), as that Act existed on
933	933	January 1, 2017.
934	934	SUBCHAPTER B. GUARANTEED ISSUE AND RENEWABILITY
935	935	Sec. 1512.051. GUARANTEED ISSUE. A health benefit plan
936	936	issuer shall issue a group or individual health benefit plan chosen
937	937	by a group plan sponsor or individual to each group plan sponsor or
938	938	individual that elects to be covered under the plan and agrees to
939	939	satisfy the requirements of the plan.
940	940	Sec. 1512.052. RENEWABILITY AND CONTINUATION OF HEALTH
941	941	BENEFIT PLANS. (a) Except as provided by Subsection (b), a health
942	942	benefit plan issuer shall renew or continue a group or individual
943	943	health benefit plan at the option of the group plan sponsor or
944	944	individual, as applicable.
945	945	(b) A health benefit plan issuer may decline to renew or
946	946	continue a group or individual health benefit plan:
947	947	(1) for failure to pay a premium or contribution in
948	948	accordance with the terms of the plan;
949	949	(2) for fraud or intentional misrepresentation;
950	950	(3) because the issuer is ceasing to offer coverage in
951	951	the relevant market in accordance with rules adopted by the
952	952	commissioner;
953	953	(4) with respect to an individual plan, because an
954	954	individual no longer resides, lives, or works in an area in which
955	955	the issuer is authorized to provide coverage, but only if all plans
956	956	are not renewed or not continued under this subdivision uniformly
957	957	without regard to any health status related factor of covered
958	958	individuals; or
959	959	(5) in accordance with federal law, including
960	960	regulations.
961	961	Sec. 1512.053. OPEN AND SPECIAL ENROLLMENT PERIODS. (a) A
962	962	health benefit plan issuer issuing an individual health benefit
963	963	plan may restrict enrollment in coverage to an annual open
964	964	enrollment period and special enrollment periods.
965	965	(b) An individual or an individual's dependent qualified to
966	966	enroll in an individual health benefit plan may enroll anytime
967	967	during the open enrollment period or during a special enrollment
968	968	period designated by the commissioner.
969	969	(c) A health benefit plan issuer issuing a group health
970	970	benefit plan may not limit enrollment to an open or special
971	971	enrollment period.
972	972	(d) The commissioner shall adopt rules as necessary to
973	973	administer this section, including rules designating enrollment
974	974	periods.
975	975	SUBCHAPTER C. PREEXISTING CONDITIONS AND HEALTH STATUS
976	976	Sec. 1512.101. DEFINITIONS. In this subchapter:
977	977	(1) "Dependent" has the meaning assigned by Section
978	978	1501.002.
979	979	(2) "Health status related factor" has the meaning
980	980	assigned by Section 1501.002.
981	981	(3) "Preexisting condition" means a condition present
982	982	before the effective date of an individual's coverage under a
983	983	health benefit plan.
984	984	Sec. 1512.102. APPLICABILITY OF SUBCHAPTER.
985	985	Notwithstanding any other law, in addition to a health benefit plan
986	986	to which this chapter applies under Subchapter A, this subchapter
987	987	applies to:
988	988	(1) a basic coverage plan under Chapter 1551;
989	989	(2) a basic plan under Chapter 1575;
990	990	(3) a primary care coverage plan under Chapter 1579;
991	991	(4) a plan providing basic coverage under Chapter
992	992	1601;
993	993	(5) health benefits provided by or through a church
994	994	benefits board under Subchapter I, Chapter 22, Business
995	995	Organizations Code;
996	996	(6) group health coverage made available by a school
997	997	district in accordance with Section 22.004, Education Code;
998	998	(7) the state Medicaid program, including the Medicaid
999	999	managed care program operated under Chapter 533, Government Code;
1000	1000	(8) the child health plan program under Chapter 62,
1001	1001	Health and Safety Code;
1002	1002	(9) a regional or local health care program operated
1003	1003	under Section 75.104, Health and Safety Code;
1004	1004	(10) a self-funded health benefit plan sponsored by a
1005	1005	professional employer organization under Chapter 91, Labor Code;
1006	1006	(11) county employee group health benefits provided
1007	1007	under Chapter 157, Local Government Code; and
1008	1008	(12) health and accident coverage provided by a risk
1009	1009	pool created under Chapter 172, Local Government Code.
1010	1010	Sec. 1512.103. PREEXISTING CONDITION AND HEALTH STATUS
1011	1011	RESTRICTIONS PROHIBITED. Notwithstanding any other law, a health
1012	1012	benefit plan issuer may not:
1013	1013	(1) deny coverage to or refuse to enroll a group, an
1014	1014	individual, or an individual's dependent in a health benefit plan
1015	1015	on the basis of a preexisting condition or health status related
1016	1016	factor;
1017	1017	(2) limit or exclude, or require a waiting period for,
1018	1018	coverage under the health benefit plan for treatment of a
1019	1019	preexisting condition otherwise covered under the plan; or
1020	1020	(3) charge a group, individual, or dependent more for
1021	1021	coverage than the health benefit plan issuer charges a group,
1022	1022	individual, or dependent who does not have a preexisting condition
1023	1023	or health status related factor.
1024	1024	SUBCHAPTER D. PROHIBITED DISCRIMINATION
1025	1025	Sec. 1512.151. DISCRIMINATORY BENEFIT DESIGN PROHIBITED.
1026	1026	(a) A health benefit plan issuer may not, through the plan's
1027	1027	benefit design, discriminate against an enrollee on the basis of
1028	1028	race, color, national origin, age, sex, expected length of life,
1029	1029	present or predicted disability, degree of medical dependency,
1030	1030	quality of life, or other health condition.
1031	1031	(b) A health benefit plan issuer may not use a health
1032	1032	benefit design that will have the effect of discouraging the
1033	1033	enrollment of individuals with significant health needs in the
1034	1034	health benefit plan.
1035	1035	(c) This section may not be construed to prevent a health
1036	1036	benefit plan issuer from appropriately utilizing reasonable
1037	1037	medical management techniques.
1038	1038	Sec. 1512.152. DISCRIMINATORY MARKETING PROHIBITED. A
1039	1039	health benefit plan issuer may not use a marketing practice that
1040	1040	will have the effect of discouraging the enrollment of individuals
1041	1041	with significant health needs in the health benefit plan or that
1042	1042	discriminates on the basis of race, color, national origin, age,
1043	1043	sex, expected length of life, present or predicted disability,
1044	1044	degree of medical dependency, quality of life, or other health
1045	1045	condition.
1046	1046	(c) Section 841.002, Insurance Code, is amended to read as
1047	1047	follows:
1048	1048	Sec. 841.002. APPLICABILITY OF CHAPTER AND OTHER
1049	1049	LAW. Except as otherwise expressly provided by this code, each
1050	1050	insurance company incorporated or engaging in business in this
1051	1051	state as a life insurance company, an accident insurance company, a
1052	1052	life and accident insurance company, a health and accident
1053	1053	insurance company, or a life, health, and accident insurance
1054	1054	company is subject to:
1055	1055	(1) this chapter;
1056	1056	(2) Chapter 3;
1057	1057	(3) Chapters 425 and 493;
1058	1058	(4) Title 7;
1059	1059	(5) Sections [1202.051,] 1204.151, 1204.153, and
1060	1060	1204.154;
1061	1061	(6) Subchapter A, Chapter 1202, Subchapters A and F,
1062	1062	Chapter 1204, Subchapter A, Chapter 1273, Subchapters A, B, and D,
1063	1063	Chapter 1355, and Subchapter A, Chapter 1366;
1064	1064	(7) Subchapter A, Chapter 1507;
1065	1065	(8) Chapters 1203, 1210, 1251-1254, 1301, 1351, 1354,
1066	1066	1359, 1364, 1368, 1505, 1651, 1652, and 1701; and
1067	1067	(9) Chapter 177, Local Government Code.
1068	1068	(d) Section 1201.005, Insurance Code, is amended to read as
1069	1069	follows:
1070	1070	Sec. 1201.005. REFERENCES TO CHAPTER. In this chapter, a
1071	1071	reference to this chapter includes a reference to:
1072	1072	(1) [Section 1202.052;
1073	1073	[(2)] Section 1271.005(a), to the extent that the
1074	1074	subsection relates to the applicability of Section 1201.105, and
1075	1075	Sections 1271.005(d) and (e);
1076	1076	(2) [(3)] Chapter 1351;
1077	1077	(3) [(4)] Subchapters C and E, Chapter 1355;
1078	1078	(4) [(5)] Chapter 1356;
1079	1079	(5) [(6)] Chapter 1365;
1080	1080	(6) [(7)] Subchapter A, Chapter 1367;
1081	1081	(7) Subchapter B, Chapter 1512; and
1082	1082	(8) Subchapters A, B, and G, Chapter 1451.
1083	1083	(e) Section 1507.003(b), Insurance Code, is amended to read
1084	1084	as follows:
1085	1085	(b) For purposes of this subchapter, "state-mandated health
1086	1086	benefits" does not include benefits that are mandated by federal
1087	1087	law or standard provisions or rights required under this code or
1088	1088	other laws of this state to be provided in an individual, blanket,
1089	1089	or group policy for accident and health insurance that are
1090	1090	unrelated to a specific health illness, injury, or condition of an
1091	1091	insured, including provisions related to:
1092	1092	(1) continuation of coverage under:
1093	1093	(A) Subchapters F and G, Chapter 1251;
1094	1094	(B) Section 1201.059; and
1095	1095	(C) Subchapter B, Chapter 1253;
1096	1096	(2) termination of coverage under Sections [1202.051
1097	1097	and] 1501.108 and 1512.052;
1098	1098	(3) preexisting conditions under Subchapter D,
1099	1099	Chapter 1201, and Sections 1501.102-1501.105;
1100	1100	(4) coverage of children, including newborn or adopted
1101	1101	children, under:
1102	1102	(A) Subchapter D, Chapter 1251;
1103	1103	(B) Sections 1201.053, 1201.061,
1104	1104	1201.063-1201.065, and Subchapter A, Chapter 1367;
1105	1105	(C) Chapter 1504;
1106	1106	(D) Chapter 1503;
1107	1107	(E) Section 1501.157;
1108	1108	(F) Section 1501.158; and
1109	1109	(G) Sections 1501.607-1501.609;
1110	1110	(5) services of practitioners under:
1111	1111	(A) Subchapters A, B, and C, Chapter 1451; or
1112	1112	(B) Section 1301.052;
1113	1113	(6) supplies and services associated with the
1114	1114	treatment of diabetes under Subchapter B, Chapter 1358;
1115	1115	(7) coverage for serious mental illness under
1116	1116	Subchapter A, Chapter 1355;
1117	1117	(8) coverage for childhood immunizations and hearing
1118	1118	screening as required by Subchapters B and C, Chapter 1367, other
1119	1119	than Section 1367.053(c) and Chapter 1353;
1120	1120	(9) coverage for reconstructive surgery for certain
1121	1121	craniofacial abnormalities of children as required by Subchapter D,
1122	1122	Chapter 1367;
1123	1123	(10) coverage for the dietary treatment of
1124	1124	phenylketonuria as required by Chapter 1359;
1125	1125	(11) coverage for referral to a non-network physician
1126	1126	or provider when medically necessary covered services are not
1127	1127	available through network physicians or providers, as required by
1128	1128	Section 1271.055; and
1129	1129	(12) coverage for cancer screenings under:
1130	1130	(A) Chapter 1356;
1131	1131	(B) Chapter 1362;
1132	1132	(C) Chapter 1363; and
1133	1133	(D) Chapter 1370.
1134	1134	(f) Section 1507.053(b), Insurance Code, is amended to read
1135	1135	as follows:
1136	1136	(b) For purposes of this subchapter, "state-mandated health
1137	1137	benefits" does not include coverage that is mandated by federal law
1138	1138	or standard provisions or rights required under this code or other
1139	1139	laws of this state to be provided in an evidence of coverage that
1140	1140	are unrelated to a specific health illness, injury, or condition of
1141	1141	an enrollee, including provisions related to:
1142	1142	(1) continuation of coverage under Subchapter G,
1143	1143	Chapter 1251;
1144	1144	(2) termination of coverage under Sections [1202.051
1145	1145	and] 1501.108 and 1512.052;
1146	1146	(3) preexisting conditions under Subchapter D,
1147	1147	Chapter 1201, and Sections 1501.102-1501.105;
1148	1148	(4) coverage of children, including newborn or adopted
1149	1149	children, under:
1150	1150	(A) Chapter 1504;
1151	1151	(B) Chapter 1503;
1152	1152	(C) Section 1501.157;
1153	1153	(D) Section 1501.158; and
1154	1154	(E) Sections 1501.607-1501.609;
1155	1155	(5) services of providers under Section 843.304;
1156	1156	(6) coverage for serious mental health illness under
1157	1157	Subchapter A, Chapter 1355; and
1158	1158	(7) coverage for cancer screenings under:
1159	1159	(A) Chapter 1356;
1160	1160	(B) Chapter 1362;
1161	1161	(C) Chapter 1363; and
1162	1162	(D) Chapter 1370.
1163	1163	(g) Section 1501.602(a), Insurance Code, is amended to read
1164	1164	as follows:
1165	1165	(a) A large employer health benefit plan issuer[:
1166	1166	[(1) may refuse to provide coverage to a large
1167	1167	employer in accordance with the issuer's underwriting standards and
1168	1168	criteria;
1169	1169	[(2) shall accept or reject the entire group of
1170	1170	individuals who meet the participation criteria and choose
1171	1171	coverage; and
1172	1172	[(3)] may exclude only those employees or dependents
1173	1173	who decline coverage.
1174	1174	(h) Subchapter B, Chapter 1202, Insurance Code, is
1175	1175	repealed.
1176	1176	(i) The change in law made by this section applies only to a
1177	1177	health benefit plan that is delivered, issued for delivery, or
1178	1178	renewed on or after January 1, 2022. A health benefit plan that is
1179	1179	delivered, issued for delivery, or renewed before January 1, 2022,
1180	1180	is governed by the law as it existed immediately before the
1181	1181	effective date of this Act, and that law is continued in effect for
1182	1182	that purpose.
1183	1183	ARTICLE 2. TEXAS HEALTH INSURANCE EXCHANGE AUTHORITY AND
1184	1184	REINSURANCE PROGRAM
1185	1185	SECTION 2.01. (a) This section establishes the Texas
1186	1186	Health Insurance Exchange Authority governed by a board of
1187	1187	directors to implement the Texas Health Insurance Exchange as an
1188	1188	American Health Benefit Exchange authorized by Section 1311,
1189	1189	Patient Protection and Affordable Care Act (42 U.S.C. Section
1190	1190	18031).
1191	1191	(b) The purpose of the Texas Health Insurance Exchange
1192	1192	Authority created under this section is to create, manage, and
1193	1193	maintain the exchange in order to:
1194	1194	(1) benefit the state health insurance market and
1195	1195	individuals enrolling in health benefit plans; and
1196	1196	(2) facilitate or assist in facilitating the
1197	1197	purchasing of qualified plans on the exchange by qualified
1198	1198	enrollees in the individual market or the individual and small
1199	1199	group markets.
1200	1200	(c) In carrying out the purposes of this section, the Texas
1201	1201	Health Exchange Authority shall:
1202	1202	(1) educate consumers, including through outreach, a
1203	1203	navigator program, and postenrollment support;
1204	1204	(2) assist individuals in accessing income-based
1205	1205	assistance for which the individual may be eligible, including
1206	1206	premium tax credits, cost-sharing reductions, and government
1207	1207	programs;
1208	1208	(3) negotiate premium rates with health benefit plan
1209	1209	issuers on the exchange;
1210	1210	(4) contract selectively with health benefit plan
1211	1211	issuers to drive value and promote improvement in the delivery
1212	1212	system;
1213	1213	(5) standardize health benefit plan designs and
1214	1214	cost-sharing;
1215	1215	(6) leverage quality improvement and delivery system
1216	1216	reforms by encouraging participating health benefit plans to
1217	1217	implement strategies to promote the delivery of better coordinated,
1218	1218	more efficient health care services;
1219	1219	(7) consider the need for consumer choice in rural,
1220	1220	urban, and suburban areas of the state;
1221	1221	(8) assess and collect fees from health benefit plan
1222	1222	issuers on the Texas Health Insurance Exchange to support the
1223	1223	operation of the exchange and the reinsurance program; and
1224	1224	(9) distribute receipted fees, including to benefit
1225	1225	the reinsurance program.
1226	1226	(d) As soon as practicable after the effective date of this
1227	1227	Act, the board of directors of the Texas Health Insurance Exchange
1228	1228	Authority shall adopt rules and procedures necessary to implement
1229	1229	this section.
1230	1230	SECTION 2.02. (a) The Texas Department of Insurance may
1231	1231	apply to the United States secretary of health and human services to
1232	1232	obtain a waiver under 42 U.S.C. Section 18052 to:
1233	1233	(1) waive any applicable provisions of the Patient
1234	1234	Protection and Affordable Care Act (Pub. L. No. 111-148) with
1235	1235	respect to health benefit plan coverage in this state;
1236	1236	(2) establish a reinsurance program in accordance with
1237	1237	an approved waiver; and
1238	1238	(3) maximize federal funding for the reinsurance
1239	1239	program for plan years beginning on or after the effective date of
1240	1240	the implementation of the program.
1241	1241	(b) On approval by the United States secretary of health and
1242	1242	human services of the Texas Department of Insurance's application
1243	1243	waiver under Subsection (a) of this section, the department shall
1244	1244	establish and implement a reinsurance program for the purposes of:
1245	1245	(1) stabilizing rates and premiums for health benefit
1246	1246	plans in the individual market; and
1247	1247	(2) providing greater financial certainty to
1248	1248	consumers of health benefit plans in this state.
1249	1249	ARTICLE 3. HEALTH BENEFIT PLAN RATES
1250	1250	SECTION 3.01. Title 8, Insurance Code, is amended by adding
1251	1251	Subtitle N to read as follows:
1252	1252	SUBTITLE N. RATES
1253	1253	CHAPTER 1698. RATES FOR CERTAIN COVERAGE
1254	1254	SUBCHAPTER A. GENERAL PROVISIONS
1255	1255	Sec. 1698.001. APPLICABILITY OF CHAPTER. This chapter
1256	1256	applies only to rates for the following health benefit plans:
1257	1257	(1) an individual major medical expense insurance
1258	1258	policy to which Chapter 1201 applies;
1259	1259	(2) individual health maintenance organization
1260	1260	coverage;
1261	1261	(3) a group accident and health insurance policy
1262	1262	issued to an association under Section 1251.052;
1263	1263	(4) a blanket accident and health insurance policy
1264	1264	issued to an association under Section 1251.358;
1265	1265	(5) group health maintenance organization coverage
1266	1266	issued to an association described by Section 1251.052 or 1251.358;
1267	1267	or
1268	1268	(6) a small employer health benefit plan provided
1269	1269	under Chapter 1501.
1270	1270	Sec. 1698.002. APPLICABILITY OF OTHER LAWS GOVERNING RATES.
1271	1271	The requirements of this chapter are in addition to any other
1272	1272	provision of this code governing health benefit plan rates. Except
1273	1273	as otherwise provided by this chapter, in the case of a conflict
1274	1274	between this chapter and another provision of this code, this
1275	1275	chapter controls.
1276	1276	SUBCHAPTER B. RATE STANDARDS
1277	1277	Sec. 1698.051. EXCESSIVE, INADEQUATE, AND UNFAIRLY
1278	1278	DISCRIMINATORY RATES. (a) A rate is excessive, inadequate, or
1279	1279	unfairly discriminatory for purposes of this chapter as provided by
1280	1280	this section.
1281	1281	(b) A rate is excessive if the rate is likely to produce a
1282	1282	long-term profit that is unreasonably high in relation to the
1283	1283	health benefit plan coverage provided.
1284	1284	(c) A rate is inadequate if:
1285	1285	(1) the rate is insufficient to sustain projected
1286	1286	losses and expenses to which the rate applies; and
1287	1287	(2) continued use of the rate:
1288	1288	(A) endangers the solvency of a health benefit
1289	1289	plan issuer using the rate; or
1290	1290	(B) has the effect of substantially lessening
1291	1291	competition or creating a monopoly in a market.
1292	1292	(d) A rate is unfairly discriminatory if the rate:
1293	1293	(1) is not based on sound actuarial principles;
1294	1294	(2) does not bear a reasonable relationship to the
1295	1295	expected loss and expense experience among risks or is based on
1296	1296	unreasonable administrative expenses; or
1297	1297	(3) is based wholly or partly on the race, creed,
1298	1298	color, ethnicity, or national origin of an individual or group
1299	1299	sponsoring coverage under or covered by the health benefit plan.
1300	1300	SUBCHAPTER C. DISAPPROVAL OF RATES
1301	1301	Sec. 1698.101. REVIEW OF PREMIUM RATES. (a) In this
1302	1302	section:
1303	1303	(1) "Individual health benefit plan" means:
1304	1304	(A) an individual accident and health insurance
1305	1305	policy to which Chapter 1201 applies; or
1306	1306	(B) individual health maintenance organization
1307	1307	coverage.
1308	1308	(2) "Small employer health benefit plan" has the
1309	1309	meaning assigned by Section 1501.002.
1310	1310	(b) The commissioner by rule shall establish a process under
1311	1311	which the commissioner:
1312	1312	(1) reviews health benefit plan rates and rate changes
1313	1313	for compliance with this chapter and other applicable law; and
1314	1314	(2) disapproves rates that do not comply with this
1315	1315	chapter not later than the 60th day after the date the department
1316	1316	receives a complete filing.
1317	1317	(c) The rules must:
1318	1318	(1) require an individual or small employer health
1319	1319	benefit plan issuer to:
1320	1320	(A) submit to the commissioner a justification
1321	1321	for a rate increase that results in an increase equal to or greater
1322	1322	than 10 percent; and
1323	1323	(B) post information regarding the rate increase
1324	1324	on the health benefit plan issuer's Internet website;
1325	1325	(2) require the commissioner to make available to the
1326	1326	public information on rate increases and justifications submitted
1327	1327	by health benefit plan issuers under Subdivision (1);
1328	1328	(3) provide a mechanism for receiving public comment
1329	1329	on proposed rate increases; and
1330	1330	(4) provide for the results of rate reviews to be
1331	1331	reported to the Centers for Medicare and Medicaid Services.
1332	1332	Sec. 1698.102. DISAPPROVAL OF RATE CHANGE AUTHORIZED. (a)
1333	1333	In this section, "qualified health plan" has the meaning assigned
1334	1334	by Section 1301(a), Patient Protection and Affordable Care Act (42
1335	1335	U.S.C. Section 18021).
1336	1336	(b) The commissioner may disapprove a rate or rate change
1337	1337	filed with the department by a health benefit plan issuer not later
1338	1338	than the 60th day after the date the department receives a complete
1339	1339	filing if:
1340	1340	(1) the commissioner determines that the proposed rate
1341	1341	is excessive, inadequate, or unfairly discriminatory; or
1342	1342	(2) the required rate filing is incomplete.
1343	1343	(c) In making a determination under this section, the
1344	1344	commissioner shall consider the following factors:
1345	1345	(1) the reasonableness and soundness of the actuarial
1346	1346	assumptions, calculations, projections, and other factors used by
1347	1347	the plan issuer to arrive at the proposed rate or rate change;
1348	1348	(2) the historical trends for medical claims
1349	1349	experienced by the plan issuer;
1350	1350	(3) the reasonableness of the plan issuer's historical
1351	1351	and projected administrative expenses;
1352	1352	(4) the plan issuer's compliance with medical loss
1353	1353	ratio standards applicable under state or federal law;
1354	1354	(5) whether the rate applies to an open or closed block
1355	1355	of business;
1356	1356	(6) whether the plan issuer has complied with all
1357	1357	requirements for pooling risk and participating in risk adjustment
1358	1358	programs in effect under state or federal law;
1359	1359	(7) the financial condition of the plan issuer for at
1360	1360	least the previous five years, or for the plan issuer's time in
1361	1361	existence, if less than five years, including profitability,
1362	1362	surplus, reserves, investment income, reinsurance, dividends, and
1363	1363	transfers of funds to affiliates or parent companies;
1364	1364	(8) for a rate change, the financial performance for
1365	1365	at least the previous five years of the block of business subject to
1366	1366	the proposed rate change, or for the block's time in existence, if
1367	1367	less than five years, including past and projected profits,
1368	1368	surplus, reserves, investment income, and reinsurance applicable
1369	1369	to the block;
1370	1370	(9) the covered benefits or health benefit plan design
1371	1371	or, for a rate change, any changes to the benefits or design;
1372	1372	(10) the allowable variations for case
1373	1373	characteristics, risk classifications, and participation in
1374	1374	programs promoting wellness;
1375	1375	(11) whether the proposed rate is necessary to
1376	1376	maintain the plan issuer's solvency or maintain rate stability and
1377	1377	prevent excessive rate increases in the future; and
1378	1378	(12) any other factor listed in 45 C.F.R. Section
1379	1379	154.301(a)(4) to the extent applicable.
1380	1380	(d) In making a determination under this section regarding a
1381	1381	proposed rate for a qualified health plan, the commissioner shall
1382	1382	consider, in addition to the factors under Subsection (c), the
1383	1383	following factors:
1384	1384	(1) the purchasing power of consumers who are eligible
1385	1385	for a premium subsidy under the Patient Protection and Affordable
1386	1386	Care Act (Pub. L. No. 111-148);
1387	1387	(2) if the plan is in the silver level, as described by
1388	1388	42 U.S.C. Section 18022(d), whether the rate is appropriate for the
1389	1389	plan in relation to the rates charged for qualified health plans
1390	1390	offering different levels of coverage, taking into account lack of
1391	1391	funding for cost-sharing reductions and the covered benefits for
1392	1392	each level of coverage; and
1393	1393	(3) whether the plan issuer utilized the induced
1394	1394	demand factors developed by the Centers for Medicare and Medicaid
1395	1395	Services for the risk adjustment program established under 42
1396	1396	U.S.C. Section 18063 for the level of coverage offered by the plan,
1397	1397	and, if the plan did not utilize those factors, whether the plan
1398	1398	issuer provided objective evidence showing why those factors are
1399	1399	inappropriate for the rate.
1400	1400	(e) In making a determination under this section, the
1401	1401	commissioner may consider the following factors:
1402	1402	(1) if the commissioner determines appropriate for
1403	1403	comparison purposes, medical claims trends reported by plan issuers
1404	1404	in this state or in a region of this country or the country as a
1405	1405	whole; and
1406	1406	(2) inflation indexes.
1407	1407	Sec. 1698.103. DISPUTE RESOLUTION. The commissioner by
1408	1408	rule shall establish a method for a health benefit plan issuer to
1409	1409	dispute the disapproval of a rate under this subchapter, which may
1410	1410	include an informal method for the plan issuer and the commissioner
1411	1411	to reach an agreement about an appropriate rate.
1412	1412	Sec. 1698.104. USE OF DISAPPROVED RATE PENDING DISPUTE
1413	1413	RESOLUTION. (a) If the commissioner disapproves a rate under this
1414	1414	subchapter and the plan issuer objects to the disapproval, the plan
1415	1415	issuer may use the disapproved rate pending the completion of:
1416	1416	(1) the dispute resolution process established under
1417	1417	this subchapter; and
1418	1418	(2) any other appeal of the disapproval authorized by
1419	1419	law and pursued by the plan issuer.
1420	1420	(b) The commissioner shall adopt rules establishing the
1421	1421	conditions under which any excess premiums will be refunded or
1422	1422	credited to the persons who paid the premiums if the plan issuer
1423	1423	uses a disapproved rate while an appeal is pending and the rate
1424	1424	dispute is not resolved in the plan issuer's favor.
1425	1425	Sec. 1698.105. FEDERAL FUNDING. The commissioner shall
1426	1426	seek all available federal funding to cover the cost to the
1427	1427	department of reviewing rates and resolving rate disputes under
1428	1428	this subchapter.
1429	1429	SECTION 3.02. Subtitle N, Title 8, Insurance Code, as added
1430	1430	by this article, applies only to rates for health benefit plan
1431	1431	coverage delivered, issued for delivery, or renewed on or after
1432	1432	January 1, 2022. Rates for health benefit plan coverage delivered,
1433	1433	issued for delivery, or renewed before January 1, 2022, are
1434	1434	governed by the law in effect immediately before the effective date
1435	1435	of this Act, and that law is continued in effect for that purpose.
1436	1436	ARTICLE 4. HEALTH INSURANCE RISK POOL
1437	1437	SECTION 4.01. Subtitle G, Title 8, Insurance Code, is
1438	1438	amended by adding Chapter 1511 to read as follows:
1439	1439	CHAPTER 1511. HEALTH INSURANCE RISK POOL
1440	1440	SUBCHAPTER A. GENERAL PROVISIONS
1441	1441	Sec. 1511.0001. DEFINITIONS. In this chapter:
1442	1442	(1) "Board" means the board of directors appointed
1443	1443	under this chapter.
1444	1444	(2) "Pool" means a health insurance risk pool
1445	1445	established under this chapter and administered by the board.
1446	1446	Sec. 1511.0002. WAIVER. The commissioner shall:
1447	1447	(1) apply to the United States secretary of health and
1448	1448	human services under 42 U.S.C. Section 18052 for a waiver of Section
1449	1449	1312(c)(1) of the Patient Protection and Affordable Care Act (Pub.
1450	1450	L. No. 111-148) and any applicable regulations or guidance
1451	1451	beginning with the 2022 plan year;
1452	1452	(2) take any action the commissioner considers
1453	1453	appropriate to make an application under Subdivision (1); and
1454	1454	(3) implement a state plan that meets the requirements
1455	1455	of a waiver granted in response to an application under Subdivision
1456	1456	(1) if the plan is:
1457	1457	(A) consistent with state and federal law; and
1458	1458	(B) approved by the United States secretary of
1459	1459	health and human services.
1460	1460	Sec. 1511.0003. EXEMPTION FROM STATE TAXES AND FEES.
1461	1461	Notwithstanding any other law, a program created under this chapter
1462	1462	is not subject to any state tax, regulatory fee, or surcharge,
1463	1463	including a premium or maintenance tax or fee.
1464	1464	Sec. 1511.0004. NOTICE AND COMMENT. Following the grant of
1465	1465	a waiver under Section 1511.0002 and before the commissioner
1466	1466	implements a state plan under that section, the commissioner shall
1467	1467	hold a public hearing to solicit stakeholder comments regarding the
1468	1468	establishment of a health insurance risk pool under this chapter.
1469	1469	SUBCHAPTER B. ESTABLISHMENT AND PURPOSE
1470	1470	Sec. 1511.0051. ESTABLISHMENT OF HEALTH INSURANCE RISK
1471	1471	POOL. To the extent that federal money is available and only if the
1472	1472	United States secretary of health and human services grants the
1473	1473	waiver application submitted under Section 1511.0002, the
1474	1474	commissioner shall:
1475	1475	(1) apply for the federal money;
1476	1476	(2) use the federal money to establish a pool for the
1477	1477	purpose of this chapter; and
1478	1478	(3) authorize the board to use the federal money to
1479	1479	administer a pool for the purpose of this chapter.
1480	1480	Sec. 1511.0052. PURPOSE OF POOL. The purpose of the pool is
1481	1481	to provide a reinsurance mechanism to:
1482	1482	(1) meaningfully reduce health benefit plan premiums
1483	1483	in the individual market by mitigating the impact of high-risk
1484	1484	individuals on rates;
1485	1485	(2) maximize available federal money to assist
1486	1486	residents of this state to obtain guaranteed issue health benefit
1487	1487	coverage without increasing the federal deficit; and
1488	1488	(3) increase enrollment in guaranteed issue,
1489	1489	individual market health benefit plans that provide benefits and
1490	1490	coverage and cost-sharing protections against out-of-pocket costs
1491	1491	comparable to and as comprehensive as health benefit plans that
1492	1492	would be available without the pool.
1493	1493	SUBCHAPTER C. ADMINISTRATION
1494	1494	Sec. 1511.0101. BOARD OF DIRECTORS. (a) The pool is
1495	1495	governed by a board of directors.
1496	1496	(b) The board consists of nine members appointed by the
1497	1497	commissioner as follows:
1498	1498	(1) at least two, but not more than four, members must
1499	1499	be individuals who are affiliated with a health benefit plan issuer
1500	1500	authorized to write health benefit plans in this state;
1501	1501	(2) at least two members must be:
1502	1502	(A) individuals or the parents of individuals who
1503	1503	are covered by the pool or are reasonably expected to qualify for
1504	1504	coverage by the pool; or
1505	1505	(B) individuals who work as advocates for
1506	1506	individuals described by Paragraph (A); and
1507	1507	(3) the other members may be selected from individuals
1508	1508	such as:
1509	1509	(A) a physician licensed to practice in this
1510	1510	state by the Texas State Board of Medical Examiners;
1511	1511	(B) a hospital administrator;
1512	1512	(C) an advanced nurse practitioner; or
1513	1513	(D) a representative of the public who is not:
1514	1514	(i) employed by or affiliated with an
1515	1515	insurance company or insurance plan, group hospital service
1516	1516	corporation, or health maintenance organization;
1517	1517	(ii) related within the first degree of
1518	1518	consanguinity or affinity to an individual described by
1519	1519	Subparagraph (i); or
1520	1520	(iii) licensed as, employed by, or
1521	1521	affiliated with a physician, hospital, or other health care
1522	1522	provider.
1523	1523	(c) For purposes of Subsection (b), an individual who is
1524	1524	required to register under Chapter 305, Government Code, because of
1525	1525	the individual's activities with respect to health benefit
1526	1526	plan-related matters is affiliated with a health benefit plan
1527	1527	issuer.
1528	1528	(d) An individual is not disqualified under Subsection
1529	1529	(b)(3)(D)(i) from representing the public if the individual's only
1530	1530	affiliation with an insurance company or insurance plan, group
1531	1531	hospital service corporation, or health maintenance organization
1532	1532	is as an insured or as an individual who has coverage through a plan
1533	1533	provided by the corporation or organization.
1534	1534	Sec. 1511.0102. TERMS; VACANCY. (a) Board members serve
1535	1535	staggered six-year terms.
1536	1536	(b) The commissioner shall fill a vacancy on the board by
1537	1537	appointing, for the unexpired term, an individual who has the
1538	1538	appropriate qualifications to fill that position.
1539	1539	Sec. 1511.0103. PRESIDING OFFICER. The commissioner shall
1540	1540	designate one board member to serve as presiding officer at the
1541	1541	pleasure of the commissioner.
1542	1542	Sec. 1511.0104. PER DIEM; REIMBURSEMENT. A board member is
1543	1543	not entitled to compensation for service on the board but is
1544	1544	entitled to:
1545	1545	(1) a per diem in the amount provided by the General
1546	1546	Appropriations Act for state officials for each day the member
1547	1547	performs duties as a board member; and
1548	1548	(2) reimbursement of expenses incurred while
1549	1549	performing duties as a board member in the amount provided by the
1550	1550	General Appropriations Act for state officials.
1551	1551	Sec. 1511.0105. MEMBER'S IMMUNITY. (a) A board member is
1552	1552	not liable for an act or omission made in good faith in the
1553	1553	performance of powers and duties under this chapter.
1554	1554	(b) A cause of action does not arise against a board member
1555	1555	for an act or omission described by Subsection (a).
1556	1556	Sec. 1511.0106. ADDITIONAL POWERS AND DUTIES. The
1557	1557	commissioner by rule may establish powers and duties of the board in
1558	1558	addition to those provided by this chapter.
1559	1559	Sec. 1511.0107. PLAN OF OPERATION. (a) Operation and
1560	1560	management of the pool are governed by a plan of operation adopted
1561	1561	by the board and approved by the commissioner. The plan of
1562	1562	operation includes the articles, bylaws, and operating rules of the
1563	1563	pool.
1564	1564	(b) The plan of operation must ensure the fair, reasonable,
1565	1565	and equitable administration of the pool.
1566	1566	(c) The board shall amend the plan of operation as necessary
1567	1567	to carry out this chapter. An amendment to the plan of operation
1568	1568	must be approved by the commissioner before the board may adopt the
1569	1569	amendment.
1570	1570	SUBCHAPTER D. POWERS AND DUTIES
1571	1571	Sec. 1511.0151. METHODS TO REDUCE PREMIUM IN INDIVIDUAL
1572	1572	MARKET. Subject to any requirements to obtain federal money for the
1573	1573	pool, the board may use pool money to achieve lower enrollee premium
1574	1574	rates by establishing a reinsurance mechanism for health benefit
1575	1575	plan issuers writing comprehensive, guaranteed issue coverage in
1576	1576	the individual market.
1577	1577	Sec. 1511.0152. INCREASED ACCESS TO GUARANTEED ISSUE
1578	1578	COVERAGE. The board shall use pool money to increase enrollment in
1579	1579	guaranteed issue coverage in the individual market in a manner that
1580	1580	ensures that the benefits and cost-sharing protections available in
1581	1581	the individual market are maintained in the same manner the
1582	1582	benefits and protections would be maintained without the waiver
1583	1583	described by Section 1511.0002.
1584	1584	Sec. 1511.0153. CONTRACTS AND AGREEMENTS. The board may
1585	1585	enter into a contract or agreement that the board determines is
1586	1586	appropriate to carry out this chapter, including a contract or
1587	1587	agreement with:
1588	1588	(1) a similar pool in another state for the joint
1589	1589	performance of common administrative functions;
1590	1590	(2) another organization for the performance of
1591	1591	administrative functions; or
1592	1592	(3) a federal agency.
1593	1593	Sec. 1511.0154. RULES. The commissioner and board may
1594	1594	adopt rules necessary to implement this chapter, including rules to
1595	1595	administer the pool and distribute pool money.
1596	1596	Sec. 1511.0155. PROCEDURES, CRITERIA, AND FORMS. The board
1597	1597	by rule shall provide the procedures, criteria, and forms necessary
1598	1598	to implement, collect, and deposit assessments under Subchapter E.
1599	1599	Sec. 1511.0156. PUBLIC EDUCATION AND OUTREACH. (a) The
1600	1600	board may develop and implement public education, outreach, and
1601	1601	facilitated enrollment strategies under this chapter.
1602	1602	(b) The board may contract with marketing organizations to
1603	1603	perform or provide assistance with the strategies described by
1604	1604	Subsection (a).
1605	1605	Sec. 1511.0157. AUTHORITY TO ACT AS REINSURER. In addition
1606	1606	to the powers granted to the board under this chapter, the board may
1607	1607	exercise any authority that may be exercised under the law of this
1608	1608	state by a reinsurer.
1609	1609	SUBCHAPTER E. FUNDING
1610	1610	Sec. 1511.0201. FUNDING. The commissioner may use money
1611	1611	appropriated to the department to:
1612	1612	(1) apply for federal money and grants; and
1613	1613	(2) implement this chapter.
1614	1614	Sec. 1511.0202. ASSESSMENTS. (a) The board may assess
1615	1615	health benefit plan issuers, including making advance interim
1616	1616	assessments, as reasonable and necessary for the pool's
1617	1617	organizational and interim operating expenses.
1618	1618	(b) The board shall credit an interim assessment as an
1619	1619	offset against any regular assessment that is due after the end of
1620	1620	the fiscal year.
1621	1621	(c) The regular assessment is the amount calculated under
1622	1622	Section 1511.0204.
1623	1623	(d) The board shall deposit money from the interim and
1624	1624	regular assessments described by this section in an account
1625	1625	established outside the treasury and administered by the board.
1626	1626	Money in the account may be spent without an appropriation and may
1627	1627	be used only for purposes authorized by this chapter.
1628	1628	Sec. 1511.0203. DETERMINATION OF POOL FUNDING
1629	1629	REQUIREMENTS. After the end of each fiscal year, the board shall
1630	1630	determine for the next calendar year the amount of money required by
1631	1631	the pool to reduce enrollee premiums in accordance with this
1632	1632	chapter after applying the federal money obtained under this
1633	1633	chapter.
1634	1634	Sec. 1511.0204. ASSESSMENTS TO COVER POOL FUNDING
1635	1635	REQUIREMENTS. (a) The board shall recover an amount equal to the
1636	1636	funding required as determined under Section 1511.0203 by assessing
1637	1637	each health benefit plan issuer an amount determined annually by
1638	1638	the board based on information in annual statements, the health
1639	1639	benefit plan issuer's annual report to the board under Sections
1640	1640	1511.0251 and 1511.0252, and any other reports required by and
1641	1641	filed with the board.
1642	1642	(b) The board shall use the total number of enrolled
1643	1643	individuals reported by all health benefit plan issuers under
1644	1644	Section 1511.0252 as of the preceding December 31 to compute the
1645	1645	amount of a health benefit plan issuer's assessment, if any, in
1646	1646	accordance with this subsection. The board shall allocate the
1647	1647	total amount to be assessed based on the total number of enrolled
1648	1648	individuals covered by excess loss, stop-loss, or reinsurance
1649	1649	policies and on the total number of other enrolled individuals as
1650	1650	determined under Section 1511.0252. To compute the amount of a
1651	1651	health benefit plan issuer's assessment:
1652	1652	(1) for the issuer's enrolled individuals covered by
1653	1653	an excess loss, stop-loss, or reinsurance policy, the board shall:
1654	1654	(A) divide the allocated amount to be assessed by
1655	1655	the total number of enrolled individuals covered by excess loss,
1656	1656	stop-loss, or reinsurance policies, as determined under Section
1657	1657	1511.0252, to determine the per capita amount; and
1658	1658	(B) multiply the number of a health benefit plan
1659	1659	issuer's enrolled individuals covered by an excess loss, stop-loss,
1660	1660	or reinsurance policy, as determined under Section 1511.0252, by
1661	1661	the per capita amount to determine the amount assessed to that
1662	1662	health benefit plan issuer; and
1663	1663	(2) for the issuer's enrolled individuals not covered
1664	1664	by excess loss, stop-loss, or reinsurance policies, the board,
1665	1665	using the gross health benefit plan premiums reported for the
1666	1666	preceding calendar year by health benefit plan issuers under
1667	1667	Section 1511.0253, shall:
1668	1668	(A) divide the gross premium collected by a
1669	1669	health benefit plan issuer by the gross premium collected by all
1670	1670	health benefit plan issuers; and
1671	1671	(B) multiply the allocated amount to be assessed
1672	1672	by the fraction computed under Paragraph (A) to determine the
1673	1673	amount assessed to that health benefit plan issuer.
1674	1674	(c) A small employer health benefit plan described by
1675	1675	Chapter 1501 is not subject to an assessment under this section.
1676	1676	Sec. 1511.0205. ASSESSMENT DUE DATE; INTEREST. (a) An
1677	1677	assessment is due on the date specified by the board that is not
1678	1678	earlier than the 30th day after the date written notice of the
1679	1679	assessment is transmitted to the health benefit plan issuer.
1680	1680	(b) Interest accrues on the unpaid amount of an assessment
1681	1681	at a rate equal to the prime lending rate, as published in the most
1682	1682	recent issue of the Wall Street Journal and determined as of the
1683	1683	first day of each month during which the assessment is delinquent,
1684	1684	plus three percent.
1685	1685	Sec. 1511.0206. ABATEMENT OR DEFERMENT OF ASSESSMENT. (a)
1686	1686	A health benefit plan issuer may petition the board for an abatement
1687	1687	or deferment of all or part of an assessment imposed by the board.
1688	1688	The board may abate or defer all or part of the assessment if the
1689	1689	board determines that payment of the assessment would endanger the
1690	1690	ability of the health benefit plan issuer to fulfill its
1691	1691	contractual obligations.
1692	1692	(b) If all or part of an assessment against a health benefit
1693	1693	plan issuer is abated or deferred, the amount of the abatement or
1694	1694	deferment shall be assessed against the other health benefit plan
1695	1695	issuers in a manner consistent with the method for computing
1696	1696	assessments under this chapter.
1697	1697	(c) A health benefit plan issuer receiving an abatement or
1698	1698	deferment under this section remains liable to the pool for the
1699	1699	deficiency.
1700	1700	Sec. 1511.0207. USE OF EXCESS FROM ASSESSMENTS. If the
1701	1701	total amount of the assessments exceeds the pool's actual losses
1702	1702	and administrative expenses, the board shall credit each health
1703	1703	benefit plan issuer with the excess in an amount proportionate to
1704	1704	the amount the health benefit plan issuer paid in assessments. The
1705	1705	credit may be paid to the health benefit plan issuer or applied to
1706	1706	future assessments under this chapter.
1707	1707	Sec. 1511.0208. COLLECTION OF ASSESSMENTS. The pool may
1708	1708	recover or collect assessments made under this subchapter.
1709	1709	SUBCHAPTER F. REPORTING
1710	1710	Sec. 1511.0251. ANNUAL ISSUER REPORT TO BOARD: REQUESTED
1711	1711	INFORMATION. Each health benefit plan issuer shall report to the
1712	1712	board the information requested by the board, as of December 31 of
1713	1713	the preceding year.
1714	1714	Sec. 1511.0252. ANNUAL ISSUER REPORT TO BOARD: ENROLLED
1715	1715	INDIVIDUALS. (a) Each health benefit plan issuer shall report to
1716	1716	the board the number of residents of this state enrolled, as of
1717	1717	December 31 of the preceding year, in the issuer's health benefit
1718	1718	plans providing coverage for residents in this state, as:
1719	1719	(1) an employee under a group health benefit plan; or
1720	1720	(2) an individual policyholder or subscriber.
1721	1721	(b) In determining the number of individuals to report under
1722	1722	Subsection (a)(1), the health benefit plan issuer shall include
1723	1723	each employee for whom a premium is paid and coverage is provided
1724	1724	under an excess loss, stop-loss, or reinsurance policy issued by
1725	1725	the issuer to an employer or group health benefit plan providing
1726	1726	coverage for employees in this state. A health benefit plan issuer
1727	1727	providing excess loss insurance, stop-loss insurance, or
1728	1728	reinsurance, as described by this subsection, for a primary health
1729	1729	benefit plan issuer may not report individuals reported by the
1730	1730	primary health benefit plan issuer.
1731	1731	(c) Ten employees covered by a health benefit plan issuer
1732	1732	under a policy of excess loss insurance, stop-loss insurance, or
1733	1733	reinsurance count as one employee for purposes of determining that
1734	1734	health benefit plan issuer's assessment.
1735	1735	(d) In determining the number of individuals to report under
1736	1736	this section, the health benefit plan issuer shall exclude:
1737	1737	(1) the dependents of the employee or an individual
1738	1738	policyholder or subscriber; and
1739	1739	(2) individuals who are covered by the health benefit
1740	1740	plan issuer under a Medicare supplement benefit plan subject to
1741	1741	Chapter 1652.
1742	1742	(e) In determining the number of enrolled individuals to
1743	1743	report under this section, the health benefit plan issuer shall
1744	1744	exclude individuals who are retired employees 65 years of age or
1745	1745	older.
1746	1746	Sec. 1511.0253. ANNUAL ISSUER REPORT TO BOARD: GROSS
1747	1747	PREMIUMS. (a) Each health benefit plan issuer shall report to the
1748	1748	board the gross premiums collected for the preceding calendar year
1749	1749	for health benefit plans.
1750	1750	(b) For purposes of this section, gross health benefit plan
1751	1751	premiums do not include premiums collected for:
1752	1752	(1) coverage under a Medicare supplement benefit plan
1753	1753	subject to Chapter 1652;
1754	1754	(2) coverage under a small employer health benefit
1755	1755	plan subject to Chapter 1501;
1756	1756	(3) coverage:
1757	1757	(A) for wages or payments in lieu of wages for a
1758	1758	period during which an employee is absent from work because of
1759	1759	accident or disability;
1760	1760	(B) as a supplement to a liability insurance
1761	1761	policy;
1762	1762	(C) for credit insurance;
1763	1763	(D) only for dental or vision care; or
1764	1764	(E) only for a specified disease or illness;
1765	1765	(4) a workers' compensation insurance policy;
1766	1766	(5) medical payment insurance coverage provided under
1767	1767	a motor vehicle insurance policy;
1768	1768	(6) a long-term care policy, including a nursing home
1769	1769	fixed indemnity policy, unless the commissioner determines that the
1770	1770	policy provides comprehensive health benefit plan coverage;
1771	1771	(7) liability insurance coverage, including general
1772	1772	liability insurance and automobile liability insurance;
1773	1773	(8) coverage for on-site medical clinics;
1774	1774	(9) insurance coverage under which benefits are
1775	1775	payable with or without regard to fault and that is statutorily
1776	1776	required to be contained in a liability insurance policy or
1777	1777	equivalent self-insurance; or
1778	1778	(10) other similar insurance coverage, as specified by
1779	1779	federal regulations issued under the Health Insurance Portability
1780	1780	and Accountability Act of 1996 (Pub. L. No. 104-191), under which
1781	1781	benefits for medical care are secondary or incidental to other
1782	1782	insurance benefits.
1783	1783	Sec. 1511.0254. ANNUAL BOARD REPORT OF POOL ACTIVITIES.
1784	1784	(a) Beginning June 1, 2022, not later than June 1 of each year, the
1785	1785	board shall submit a report to the governor, lieutenant governor,
1786	1786	and speaker of the house of representatives.
1787	1787	(b) The report submitted under Subsection (a) must include:
1788	1788	(1) a summary of the activities conducted under this
1789	1789	chapter in the calendar year preceding the year in which the report
1790	1790	is submitted;
1791	1791	(2) the average amount by which health benefit plan
1792	1792	premiums were reduced in this state and in each rating region;
1793	1793	(3) the average change in each rating region in the
1794	1794	amount of health benefit plan premiums paid by individuals who
1795	1795	receive a premium subsidy under the Patient Protection and
1796	1796	Affordable Care Act (Pub. L. No. 111-148); and
1797	1797	(4) an estimate of the change in each rating region in
1798	1798	enrollment in health benefit plans due to the reduction in
1799	1799	premiums.
1800	1800	SEC. 4.02. Notwithstanding Section 1511.0002(1), Insurance
1801	1801	Code, as added by this article, the commissioner of insurance may
1802	1802	not apply for the waiver as required by that subdivision until the
1803	1803	commissioner determines that the commissioner has completed a
1804	1804	review under Chapter 1698, Insurance Code, as added by this Act, of
1805	1805	all health benefit plan rates in effect for compliance with that
1806	1806	chapter and other applicable law.
1807	1807	ARTICLE 5. ADMINISTRATION OF, ELIGIBILITY FOR, AND BENEFITS
1808	1808	PROVIDED UNDER MEDICAID
1809	1809	SECTION 5.01. Section 533.001, Government Code, is amended
1810	1810	by adding Subdivision (6-a) to read as follows:
1811	1811	(6-a) "Social determinants of health" means the
1812	1812	environmental conditions in which a person is born, lives, learns,
1813	1813	works, plays, worships, and ages that affect a range of health,
1814	1814	functional, and quality of life outcomes and risks.
1815	1815	SECTION 5.02. (a) Section 533.003(a), Government Code, is
1816	1816	amended to read as follows:
1817	1817	(a) In awarding contracts to managed care organizations,
1818	1818	the commission shall:
1819	1819	(1) give preference to organizations that have
1820	1820	significant participation in the organization's provider network
1821	1821	from each health care provider in the region who has traditionally
1822	1822	provided care to Medicaid and charity care patients;
1823	1823	(2) give extra consideration to organizations that
1824	1824	agree to assure continuity of care for at least three months beyond
1825	1825	the period of Medicaid eligibility for recipients;
1826	1826	(3) consider the need to use different managed care
1827	1827	plans to meet the needs of different populations;
1828	1828	(4) consider the ability of organizations to process
1829	1829	Medicaid claims electronically; and
1830	1830	(5) give extra consideration to organizations that use
1831	1831	enriched data sets incorporating social determinants of health to
1832	1832	manage socially complex populations in a manner that achieves:
1833	1833	(A) cost savings through implementation of
1834	1834	appropriate interventions for those populations; and
1835	1835	(B) favorable health outcomes for those
1836	1836	populations by reducing preventable emergency room visits,
1837	1837	hospitalizations, and institutionalizations [in the initial
1838	1838	implementation of managed care in the South Texas service region,
1839	1839	give extra consideration to an organization that either:
1840	1840	[(A) is locally owned, managed, and operated, if
1841	1841	one exists; or
1842	1842	[(B) is in compliance with the requirements of
1843	1843	Section 533.004].
1844	1844	(b) Section 533.003(a), Government Code, as amended by this
1845	1845	section, applies to a contract entered into or renewed on or after
1846	1846	the effective date of this Act. A contract entered into or renewed
1847	1847	before that date is governed by the law in effect on the date the
1848	1848	contract was entered into or renewed, and that law is continued in
1849	1849	effect for that purpose.
1850	1850	SECTION 5.03. Subchapter A, Chapter 533, Government Code,
1851	1851	is amended by adding Sections 533.021 and 533.022 to read as
1852	1852	follows:
1853	1853	Sec. 533.021. PROMOTORAS AND COMMUNITY HEALTH WORKERS. (a)
1854	1854	In this section, "promotora" and "community health worker" have the
1855	1855	meaning assigned by Section 48.001, Health and Safety Code.
1856	1856	(b) The commission shall allow each Medicaid managed care
1857	1857	organization providing health care services under the STAR Medicaid
1858	1858	managed care program to categorize services provided by a promotora
1859	1859	or community health worker as a quality improvement cost, as
1860	1860	authorized by federal law, instead of as an administrative expense.
1861	1861	Sec. 533.022. ANNUAL REPORT ON USE OF SOCIAL DETERMINANTS
1862	1862	OF HEALTH. Each Medicaid managed care organization that uses
1863	1863	enriched data sets described by Section 533.003(a)(5) shall submit
1864	1864	to the commission an annual report that assesses any cost savings
1865	1865	and favorable health outcomes achieved by using those data sets.
1866	1866	SECTION 5.04. (a) Chapter 533, Government Code, is amended
1867	1867	by adding Subchapter F to read as follows:
1868	1868	SUBCHAPTER F. PILOT PROJECT TO ADDRESS CERTAIN SOCIAL DETERMINANTS
1869	1869	OF HEALTH
1870	1870	Sec. 533.101. DEFINITIONS. In this subchapter:
1871	1871	(1) "Pilot project" means the pilot project
1872	1872	established under Section 533.102.
1873	1873	(2) "Project participant" means an individual who
1874	1874	participates in the pilot project.
1875	1875	(3) "Social determinants of health" means the
1876	1876	environmental conditions in which an individual lives that affect
1877	1877	the individual's health and quality of life.
1878	1878	Sec. 533.102. PILOT PROJECT FOR PROVIDING ENHANCED CASE
1879	1879	MANAGEMENT AND OTHER SERVICES TO ADDRESS SOCIAL DETERMINANTS OF
1880	1880	HEALTH. (a) The executive commissioner shall seek a waiver under
1881	1881	Section 1115 of the federal Social Security Act (42 U.S.C. Section
1882	1882	1315) to the state Medicaid plan to develop and implement a
1883	1883	five-year pilot project to improve the health care outcomes of
1884	1884	Medicaid recipients and reduce associated health care costs by
1885	1885	providing enhanced case management and other coordinated,
1886	1886	evidence-based, nonmedical intervention services designed to
1887	1887	directly address recipient needs related to the following social
1888	1888	determinants of health:
1889	1889	(1) housing instability;
1890	1890	(2) food insecurity;
1891	1891	(3) transportation insecurity;
1892	1892	(4) interpersonal violence; and
1893	1893	(5) toxic stress.
1894	1894	(b) The commission shall develop and implement the pilot
1895	1895	project with the assistance and involvement of Medicaid managed
1896	1896	care organizations, public or private stakeholders, and other
1897	1897	persons the commission determines appropriate.
1898	1898	(c) A pilot project established under this section shall be
1899	1899	conducted in one or more regions of this state as selected by the
1900	1900	commission.
1901	1901	Sec. 533.103. BENEFITS: CASE MANAGEMENT AND INTERVENTION
1902	1902	SERVICES. (a) The pilot project must assign a case manager to each
1903	1903	project participant. The case manager will determine, authorize,
1904	1904	and coordinate individualized nonmedical intervention services for
1905	1905	participants that directly address and improve the participants'
1906	1906	quality of life respecting one or more of the social determinants of
1907	1907	health described by Section 533.102.
1908	1908	(b) The commission shall prescribe the nonmedical
1909	1909	intervention services that may be provided to project participants,
1910	1910	which may include:
1911	1911	(1) the following services to address housing
1912	1912	instability:
1913	1913	(A) tenancy support and sustaining services;
1914	1914	(B) housing quality and safety improvement
1915	1915	services;
1916	1916	(C) legal assistance with connecting
1917	1917	participants to community resources to address legal issues, other
1918	1918	than providing legal representation or paying for legal
1919	1919	representation;
1920	1920	(D) one-time financial assistance to secure
1921	1921	housing; and
1922	1922	(E) short-term post-hospitalization housing;
1923	1923	(2) the following services to address food insecurity:
1924	1924	(A) assistance applying for benefits under the
1925	1925	supplemental nutrition assistance program or the federal special
1926	1926	supplemental nutrition program for women, infants, and children
1927	1927	administered by 42 U.S.C. Section 1786;
1928	1928	(B) assistance accessing school-based meal
1929	1929	programs;
1930	1930	(C) assistance locating and accessing food banks
1931	1931	or community-based summer and after-school food programs;
1932	1932	(D) nutrition counseling; and
1933	1933	(E) financial assistance for targeted nutritious
1934	1934	food or meal delivery services for individuals with medically
1935	1935	related special dietary needs if funding cannot be obtained through
1936	1936	other sources;
1937	1937	(3) the following services to address transportation
1938	1938	insecurity:
1939	1939	(A) educational assistance to gain access to
1940	1940	public and private forms of transportation, including
1941	1941	ride-sharing; and
1942	1942	(B) financial assistance for public
1943	1943	transportation or, if public transportation is not available,
1944	1944	private transportation to support participants' ability to access
1945	1945	pilot project services; and
1946	1946	(4) the following services to address interpersonal
1947	1947	violence and toxic stress:
1948	1948	(A) assistance with locating and accessing
1949	1949	community-based social services and mental health agencies with
1950	1950	expertise in addressing interpersonal violence;
1951	1951	(B) assistance with locating and accessing
1952	1952	high-quality child-care and after-school programs;
1953	1953	(C) assistance with locating and accessing
1954	1954	community engagement activities;
1955	1955	(D) navigational services focused on identifying
1956	1956	and improving existing factors posing a risk to the safety and
1957	1957	health of victims transitioning from traumatic situations,
1958	1958	including:
1959	1959	(i) obtaining a new phone number or mailing
1960	1960	address;
1961	1961	(ii) securing immediate shelter and
1962	1962	long-term housing;
1963	1963	(iii) making school arrangements to
1964	1964	minimize disruption of school schedules; and
1965	1965	(iv) connecting participants to
1966	1966	medical-legal partnerships to address overlap between health care
1967	1967	and legal needs;
1968	1968	(E) legal assistance for interpersonal
1969	1969	violence-related issues, including assistance securing a
1970	1970	protection order, other than providing legal representation or
1971	1971	paying for legal representation;
1972	1972	(F) assistance accessing evidence-based
1973	1973	parenting support; and
1974	1974	(G) assistance accessing evidence-based
1975	1975	maternal, infant, and early home visiting services.
1976	1976	Sec. 533.104. PARTICIPANT ELIGIBILITY. An individual is
1977	1977	eligible to participate in the pilot project if the individual:
1978	1978	(1) is a Medicaid recipient and receives benefits
1979	1979	through a Medicaid managed care model or arrangement under this
1980	1980	chapter;
1981	1981	(2) resides in a region in which the pilot project is
1982	1982	implemented; and
1983	1983	(3) meets other eligibility criteria established by
1984	1984	the commission for project participation, including:
1985	1985	(A) having or being at a higher risk than the
1986	1986	general population of developing a chronic or serious health
1987	1987	condition; and
1988	1988	(B) experiencing at least one of the social
1989	1989	determinants of health described by Section 533.102.
1990	1990	Sec. 533.105. RULES. The executive commissioner may adopt
1991	1991	rules to implement this subchapter.
1992	1992	Sec. 533.106. REPORT. Not later than September 1 of each
1993	1993	even-numbered year, the commission shall submit to the legislature
1994	1994	a report on the pilot project. The report must include:
1995	1995	(1) an evaluation of the pilot project's success in
1996	1996	reducing or eliminating poor health outcomes and reducing
1997	1997	associated health care costs; and
1998	1998	(2) a recommendation on whether the pilot project
1999	1999	should be continued, expanded, or terminated.
2000	2000	Sec. 533.107. EXPIRATION. This subchapter expires
2001	2001	September 1, 2027.
2002	2002	(b) As soon as practicable after the effective date of this
2003	2003	Act, the executive commissioner of the Health and Human Services
2004	2004	Commission shall apply for and actively pursue a waiver under
2005	2005	Section 1115 of the federal Social Security Act (42 U.S.C. Section
2006	2006	1315) to the state Medicaid plan from the Centers for Medicare and
2007	2007	Medicaid Services or any other federal agency to implement
2008	2008	Subchapter F, Chapter 533, Government Code, as added by this
2009	2009	section. The commission may delay implementing Subchapter F,
2010	2010	Chapter 533, Government Code, as added by this section, until the
2011	2011	waiver applied for under this subsection is granted.
2012	2012	SECTION 5.05. Section 32.024, Human Resources Code, is
2013	2013	amended by adding Subsections (l-1) and (oo) to read as follows:
2014	2014	(l-1) The commission shall continue to provide medical
2015	2015	assistance to a woman who is eligible for medical assistance for
2016	2016	pregnant women for a period of not less than 12 months following the
2017	2017	last month of the woman's pregnancy.
2018	2018	(oo) The commission shall provide medical assistance
2019	2019	reimbursement to a treating health care provider who participates
2020	2020	in Medicaid for the provision to a child or adult medical assistance
2021	2021	recipient of behavioral health services that are classified by a
2022	2022	Current Procedural Terminology code as collaborative care
2023	2023	management services.
2024	2024	SECTION 5.06. (a) Subchapter B, Chapter 32, Human
2025	2025	Resources Code, is amended by adding Section 32.02472 to read as
2026	2026	follows:
2027	2027	Sec. 32.02472. ELIGIBILITY OF CERTAIN PERSONS LAWFULLY
2028	2028	PRESENT IN THE UNITED STATES. (a) The commission shall provide
2029	2029	medical assistance in accordance with 8 U.S.C. Section 1612(b) to a
2030	2030	person who:
2031	2031	(1) is a qualified alien, as defined by 8 U.S.C.
2032	2032	Sections 1641(b) and (c);
2033	2033	(2) meets the eligibility requirements of the medical
2034	2034	assistance program;
2035	2035	(3) entered the United States on or after August 22,
2036	2036	1996; and
2037	2037	(4) has resided in the United States for a period of
2038	2038	five years after the date the person entered as a qualified alien.
2039	2039	(b) To the extent allowed by federal law, the commission
2040	2040	shall provide medical assistance for pregnant women to a person who
2041	2041	is pregnant and is lawfully present, or lawfully residing in the
2042	2042	United States as defined by the Centers for Medicare and Medicaid
2043	2043	Services, including a battered alien under 8 U.S.C. Section
2044	2044	1641(c), regardless of the date the person entered the United
2045	2045	States.
2046	2046	(b) Not later than October 1, 2021, the executive
2047	2047	commissioner of the Health and Human Services Commission shall seek
2048	2048	an amendment to the state Medicaid plan or a waiver or other
2049	2049	authorization from a federal agency as necessary to implement
2050	2050	Section 32.02472, Human Resources Code, as added by this section.
2051	2051	SECTION 5.07. Subchapter B, Chapter 32, Human Resources
2052	2052	Code, is amended by adding Section 32.02605 to read as follows:
2053	2053	Sec. 32.02605. PRESUMPTIVE ELIGIBILITY OF CERTAIN ELDERLY
2054	2054	INDIVIDUALS FOR HOME AND COMMUNITY-BASED SERVICES. (a) In this
2055	2055	section, "elderly" means an individual who is at least 65 years of
2056	2056	age.
2057	2057	(b) The executive commissioner shall by rule adopt a program
2058	2058	providing for:
2059	2059	(1) the determination and certification of
2060	2060	presumptive eligibility for medical assistance of an elderly
2061	2061	individual who requires a skilled level of nursing care; and
2062	2062	(2) the provision through the medical assistance
2063	2063	program to the individual of that care in a home or community-based
2064	2064	setting instead of in an institutional setting, provided the
2065	2065	individual applies for and meets the basic eligibility requirements
2066	2066	for medical assistance.
2067	2067	(c) The program established under this section must:
2068	2068	(1) provide medical assistance benefits under a
2069	2069	presumptive eligibility determination for a period of not more than
2070	2070	90 days;
2071	2071	(2) establish eligibility criteria and a process for
2072	2072	determining the entities authorized to make determinations of
2073	2073	presumptive eligibility under the program;
2074	2074	(3) provide a preliminary screening tool to entities
2075	2075	described by Subdivision (2) that will allow representatives of
2076	2076	those entities to:
2077	2077	(A) make a determination as to whether an
2078	2078	applicant is:
2079	2079	(i) functionally able to live at home or in
2080	2080	a community setting; and
2081	2081	(ii) likely to be financially eligible for
2082	2082	medical assistance;
2083	2083	(B) make the determination under Paragraph
2084	2084	(A)(ii) not later than the fourth day after the date a determination
2085	2085	is made under Paragraph (A)(i); and
2086	2086	(C) initiate the provision of medical assistance
2087	2087	benefits not later than the fifth day after the date an applicant is
2088	2088	determined eligible under Paragraph (A)(i); and
2089	2089	(4) require an applicant to sign a written agreement:
2090	2090	(A) attesting to the accuracy of financial and
2091	2091	other information the applicant provides and on which presumptive
2092	2092	eligibility is based; and
2093	2093	(B) acknowledging that:
2094	2094	(i) state-funded services are subject to
2095	2095	the period prescribed by Subdivision (1); and
2096	2096	(ii) the applicant is required to comply
2097	2097	with Subsection (d).
2098	2098	(d) An applicant who is determined presumptively eligible
2099	2099	for medical assistance under the program established by this
2100	2100	section must complete an application for medical assistance not
2101	2101	later than the 10th day after the date the applicant is screened for
2102	2102	functional eligibility under Subsection (c)(3)(A)(i).
2103	2103	(e) Not later than the 45th day after the date the
2104	2104	commission receives an application under Subsection (d), the
2105	2105	commission shall make a final determination of eligibility for
2106	2106	medical assistance.
2107	2107	(f) To the extent permitted by federal law, the commission
2108	2108	shall retroactively apply a final determination of eligibility for
2109	2109	medical assistance under Subsection (e) for a period that does not
2110	2110	precede the 90th day before the date the application was filed under
2111	2111	Subsection (d).
2112	2112	(g) The commission shall submit an annual report to the
2113	2113	standing committees of the senate and house of representatives
2114	2114	having jurisdiction over the medical assistance program that
2115	2115	details:
2116	2116	(1) the number of individuals determined
2117	2117	presumptively eligible for medical assistance under the program
2118	2118	established under this section;
2119	2119	(2) the savings to the state based on how much
2120	2120	institutional care would have cost for individuals determined
2121	2121	presumptively eligible for medical assistance under the program
2122	2122	established under this section who were later determined eligible
2123	2123	for medical assistance; and
2124	2124	(3) the number of individuals determined
2125	2125	presumptively eligible for medical assistance under the program
2126	2126	established under this section who were later determined not
2127	2127	eligible for medical assistance and the cost to the state to provide
2128	2128	those individuals with home or community-based services before the
2129	2129	final determination of eligibility for medical assistance.
2130	2130	(h) The report required under Subsection (g) may be combined
2131	2131	with any other report required by this chapter or other law.
2132	2132	SECTION 5.08. Section 32.0261, Human Resources Code, is
2133	2133	amended to read as follows:
2134	2134	Sec. 32.0261. CONTINUOUS ELIGIBILITY. The executive
2135	2135	commissioner shall adopt rules in accordance with 42 U.S.C. Section
2136	2136	1396a(e)(12), as amended, to provide for a period of continuous
2137	2137	eligibility for a child under 19 years of age who is determined to
2138	2138	be eligible for medical assistance under this chapter. The rules
2139	2139	shall provide that the child remains eligible for medical
2140	2140	assistance, without additional review by the commission and
2141	2141	regardless of changes in the child's resources or income, until the
2142	2142	earlier of:
2143	2143	(1) the first anniversary of [end of the six-month
2144	2144	period following] the date on which the child's eligibility was
2145	2145	determined; or
2146	2146	(2) the child's 19th birthday.
2147	2147	ARTICLE 6. HEALTH LITERACY
2148	2148	SECTION 6.01. Section 104.002, Health and Safety Code, is
2149	2149	amended by adding Subdivision (6) to read as follows:
2150	2150	(6) "Health literacy" means the degree to which an
2151	2151	individual has the capacity to obtain and understand basic health
2152	2152	information and services to make appropriate health decisions.
2153	2153	SECTION 6.02. Subchapter B, Chapter 104, Health and Safety
2154	2154	Code, is amended by adding Section 104.0157 to read as follows:
2155	2155	Sec. 104.0157. HEALTH LITERACY ADVISORY COMMITTEE. (a)
2156	2156	The statewide health coordinating council shall establish an
2157	2157	advisory committee on health literacy composed of representatives
2158	2158	of relevant interest groups, including the academic community,
2159	2159	consumer groups, health plans, pharmacies, and associations of
2160	2160	physicians, dentists, hospitals, and nurses.
2161	2161	(b) Members of the advisory committee shall elect one member
2162	2162	as presiding officer.
2163	2163	(c) The advisory committee shall develop a long-range plan
2164	2164	for improving health literacy in this state. The committee shall
2165	2165	update the plan at least once every two years.
2166	2166	(d) In developing the long-range plan, the advisory
2167	2167	committee shall study the economic impact low health literacy has
2168	2168	on state health programs and health insurance coverage for
2169	2169	residents of this state. The advisory committee shall:
2170	2170	(1) identify primary risk factors contributing to low
2171	2171	health literacy;
2172	2172	(2) examine methods for health care practitioners,
2173	2173	health care facilities, and others to address the health literacy
2174	2174	of patients and the public;
2175	2175	(3) examine the effectiveness of using quality
2176	2176	measures in state health programs to improve health literacy;
2177	2177	(4) identify strategies for expanding the use of plain
2178	2178	language instructions for patients; and
2179	2179	(5) examine the impact improved health literacy has on
2180	2180	enhancing patient safety, reducing preventable events, and
2181	2181	increasing medication adherence to attain greater
2182	2182	cost-effectiveness and better patient outcomes in the provision of
2183	2183	health care.
2184	2184	(e) Not later than December 1 of each even-numbered year,
2185	2185	the advisory committee shall submit the long-range plan developed
2186	2186	or updated under this section to the governor, the lieutenant
2187	2187	governor, the speaker of the house of representatives, and each
2188	2188	member of the legislature.
2189	2189	(f) An advisory committee member serves without
2190	2190	compensation but is entitled to reimbursement for the member's
2191	2191	travel expenses as provided by Chapter 660, Government Code, and
2192	2192	the General Appropriations Act.
2193	2193	(g) Sections 2110.002, 2110.003, and 2110.008, Government
2194	2194	Code, do not apply to the advisory committee.
2195	2195	(h) Meetings of the advisory committee under this section
2196	2196	are subject to Chapter 551, Government Code.
2197	2197	SECTION 6.03. Sections 104.022(e) and (f), Health and
2198	2198	Safety Code, are amended to read as follows:
2199	2199	(e) The state health plan shall be developed and used in
2200	2200	accordance with applicable state and federal law. The plan must
2201	2201	identify:
2202	2202	(1) major statewide health concerns, including the
2203	2203	prevalence of low health literacy among health care consumers;
2204	2204	(2) the availability and use of current health
2205	2205	resources of the state, including resources associated with
2206	2206	information technology and state-supported institutions of higher
2207	2207	education; and
2208	2208	(3) future health service, information technology,
2209	2209	and facility needs of the state.
2210	2210	(f) The state health plan must:
2211	2211	(1) propose strategies for the correction of major
2212	2212	deficiencies in the service delivery system;
2213	2213	(2) propose strategies for improving health literacy
2214	2214	to attain greater cost-effectiveness and better patient outcomes in
2215	2215	the provision of health care;
2216	2216	(3) [(2)] propose strategies for incorporating
2217	2217	information technology in the service delivery system;
2218	2218	(4) [(3)] propose strategies for involving
2219	2219	state-supported institutions of higher education in providing
2220	2220	health services and for coordinating those efforts with health and
2221	2221	human services agencies in order to close gaps in services; and
2222	2222	(5) [(4)] provide direction for the state's
2223	2223	legislative and executive decision-making processes to implement
2224	2224	the strategies proposed by the plan.
2225	2225	ARTICLE 7. FEDERAL AUTHORIZATION AND EFFECTIVE DATE
2226	2226	SEC. 7.01. (a) Except as provided by Subsection (b) of this
2227	2227	section, if before implementing any provision of this Act a state
2228	2228	agency determines that a waiver or authorization from a federal
2229	2229	agency is necessary for implementation of that provision, the
2230	2230	agency affected by the provision shall request the waiver or
2231	2231	authorization and may delay implementing that provision until the
2232	2232	waiver or authorization is granted.
2233	2233	(b) Subsection (a) of this section does not apply to the
2234	2234	extent another provision of this Act specifically authorizes or
2235	2235	requires a state agency to seek a waiver, state Medicaid plan
2236	2236	amendment, or other authorization from a federal agency.
2237	2237	SEC. 7.02. This Act takes effect September 1, 2021.