By: Martinez Fischer H.B. No. 1128
A BILL TO BE ENTITLED
AN ACT
relating to availability of and benefits provided under health
benefit plan coverage.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
ARTICLE 1. HEALTH BENEFIT COVERAGE AVAILABILITY
SECTION 1.01. Subtitle G, Title 8, Insurance Code, is
amended by adding Chapter 1511 to read as follows:
CHAPTER 1511. HEALTH BENEFIT COVERAGE AVAILABILITY
SUBCHAPTER A. GENERAL PROVISIONS
Sec. 1511.001. APPLICABILITY OF CHAPTER. (a) Except as
otherwise provided by this chapter, this chapter applies only to a
health benefit plan that provides benefits for medical or surgical
expenses incurred as a result of a health condition, accident, or
sickness, including an individual, group, blanket, or franchise
insurance policy or insurance agreement, a group hospital service
contract, or an individual or group evidence of coverage or similar
coverage document that is issued by:
(1) an insurance company;
(2) a group hospital service corporation operating
under Chapter 842;
(3) a health maintenance organization operating under
Chapter 843;
(4) an approved nonprofit health corporation that
holds a certificate of authority under Chapter 844;
(5) a multiple employer welfare arrangement that holds
a certificate of authority under Chapter 846;
(6) a stipulated premium company operating under
Chapter 884;
(7) a fraternal benefit society operating under
Chapter 885;
(8) a Lloyd's plan operating under Chapter 941; or
(9) an exchange operating under Chapter 942.
(b) Notwithstanding any other law, this chapter applies to:
(1) a small employer health benefit plan subject to
Chapter 1501, including coverage provided through a health group
cooperative under Subchapter B of that chapter; and
(2) a standard health benefit plan issued under
Chapter 1507.
(c) This chapter applies to coverage under a group health
benefit plan provided to a resident of this state regardless of
whether the group policy, agreement, or contract is delivered,
issued for delivery, or renewed in this state.
Sec. 1511.002. EXCEPTIONS. (a) This chapter does not apply
to:
(1) a plan that provides coverage:
(A) for wages or payments in lieu of wages for a
period during which an employee is absent from work because of
sickness or injury;
(B) as a supplement to a liability insurance
policy;
(C) for credit insurance;
(D) only for dental or vision care;
(E) only for a specified disease or for another
limited benefit; or
(F) only for accidental death or dismemberment;
(2) a Medicare supplemental policy as defined by
Section 1882(g)(1), Social Security Act (42 U.S.C. Section
1395ss(g)(1));
(3) a workers' compensation insurance policy;
(4) medical payment insurance coverage provided under
a motor vehicle insurance policy; or
(5) a long-term care policy, including a nursing home
fixed indemnity policy, unless the commissioner determines that the
policy provides benefit coverage so comprehensive that the policy
is a health benefit plan as described by Section 1511.001.
(b) This chapter does not apply to an individual health
benefit plan issued on or before March 23, 2010, that has not had
any significant changes since that date that reduce benefits or
increase costs to the individual.
Sec. 1511.003. CONFLICT WITH OTHER LAW. If there is a
conflict between this chapter and other law, this chapter prevails.
Sec. 1511.004. RULES. (a) Subject to Subsection (b), the
commissioner may adopt rules as necessary to implement this
chapter.
(b) Rules adopted by the commissioner to implement this
chapter must be consistent with the Patient Protection and
Affordable Care Act (Pub. L. No. 111-148), as that Act existed on
January 1, 2017.
SUBCHAPTER B. GUARANTEED ISSUE AND RENEWABILITY
Sec. 1511.051. GUARANTEED ISSUE. A health benefit plan
issuer shall issue a group or individual health benefit plan chosen
by a group plan sponsor or individual to each group plan sponsor or
individual that elects to be covered under the plan and agrees to
satisfy the requirements of the plan.
Sec. 1511.052. RENEWABILITY AND CONTINUATION OF HEALTH
BENEFIT PLANS. (a) Except as provided by Subsection (b), a health
benefit plan issuer shall renew or continue a group or individual
health benefit plan at the option of the group plan sponsor or
individual, as applicable.
(b) A health benefit plan issuer may decline to renew or
continue a group or individual health benefit plan:
(1) for failure to pay a premium or contribution in
accordance with the terms of the plan;
(2) for fraud or intentional misrepresentation;
(3) because the issuer is ceasing to offer coverage in
the relevant market in accordance with rules adopted by the
commissioner;
(4) with respect to an individual plan, because an
individual no longer resides, lives, or works in an area in which
the issuer is authorized to provide coverage, but only if all plans
are not renewed or not continued under this subdivision uniformly
without regard to any health status related factor of covered
individuals; or
(5) in accordance with federal law, including
regulations.
Sec. 1511.053. OPEN AND SPECIAL ENROLLMENT PERIODS. (a) A
health benefit plan issuer issuing an individual health benefit
plan may restrict enrollment in coverage to an annual open
enrollment period and special enrollment periods.
(b) An individual or an individual's dependent qualified to
enroll in an individual health benefit plan may enroll anytime
during the open enrollment period or during a special enrollment
period designated by the commissioner.
(c) A health benefit plan issuer issuing a group health
benefit plan may not limit enrollment to an open or special
enrollment period.
(d) The commissioner shall adopt rules as necessary to
administer this section, including rules designating enrollment
periods.
SUBCHAPTER C. PREEXISTING CONDITIONS AND HEALTH STATUS
Sec. 1511.101. DEFINITIONS. In this subchapter:
(1) "Dependent" has the meaning assigned by Section
1501.002.
(2) "Health status related factor" has the meaning
assigned by Section 1501.002.
(3) "Preexisting condition" means a condition present
before the effective date of an individual's coverage under a
health benefit plan.
Sec. 1511.102. APPLICABILITY OF SUBCHAPTER.
Notwithstanding any other law, in addition to a health benefit plan
to which this chapter applies under Subchapter A, this subchapter
applies to:
(1) a basic coverage plan under Chapter 1551;
(2) a basic plan under Chapter 1575;
(3) a primary care coverage plan under Chapter 1579;
(4) a plan providing basic coverage under Chapter
1601;
(5) health benefits provided by or through a church
benefits board under Subchapter I, Chapter 22, Business
Organizations Code;
(6) group health coverage made available by a school
district in accordance with Section 22.004, Education Code;
(7) the state Medicaid program, including the Medicaid
managed care program operated under Chapter 533, Government Code;
(8) the child health plan program under Chapter 62,
Health and Safety Code;
(9) a regional or local health care program operated
under Section 75.104, Health and Safety Code;
(10) a self-funded health benefit plan sponsored by a
professional employer organization under Chapter 91, Labor Code;
(11) county employee group health benefits provided
under Chapter 157, Local Government Code; and
(12) health and accident coverage provided by a risk
pool created under Chapter 172, Local Government Code.
Sec. 1511.103. PREEXISTING CONDITION AND HEALTH STATUS
RESTRICTIONS PROHIBITED. Notwithstanding any other law, a health
benefit plan issuer may not:
(1) deny coverage to or refuse to enroll a group, an
individual, or an individual's dependent in a health benefit plan
on the basis of a preexisting condition or health status related
factor;
(2) limit or exclude, or require a waiting period for,
coverage under the health benefit plan for treatment of a
preexisting condition otherwise covered under the plan; or
(3) charge a group, individual, or dependent more for
coverage than the health benefit plan issuer charges a group,
individual, or dependent who does not have a preexisting condition
or health status related factor.
SUBCHAPTER D. PROHIBITED DISCRIMINATION
Sec. 1511.151. DISCRIMINATORY BENEFIT DESIGN PROHIBITED.
(a) A health benefit plan issuer may not, through the plan's
benefit design, discriminate against an enrollee on the basis of
race, color, national origin, age, sex, expected length of life,
present or predicted disability, degree of medical dependency,
quality of life, or other health condition.
(b) A health benefit plan issuer may not use a health
benefit design that will have the effect of discouraging the
enrollment of individuals with significant health needs in the
health benefit plan.
(c) This section may not be construed to prevent a health
benefit plan issuer from appropriately utilizing reasonable
medical management techniques.
Sec. 1511.152. DISCRIMINATORY MARKETING PROHIBITED. A
health benefit plan issuer may not use a marketing practice that
will have the effect of discouraging the enrollment of individuals
with significant health needs in the health benefit plan or that
discriminates on the basis of race, color, national origin, age,
sex, expected length of life, present or predicted disability,
degree of medical dependency, quality of life, or other health
condition.
ARTICLE 2. COVERAGE OF ESSENTIAL HEALTH BENEFITS
SECTION 2.01. Subtitle E, Title 8, Insurance Code, is
amended by adding Chapter 1380 to read as follows:
CHAPTER 1380. COVERAGE OF ESSENTIAL HEALTH BENEFITS
Sec. 1380.001. APPLICABILITY OF CHAPTER. (a) This chapter
applies only to a health benefit plan that provides benefits for
medical or surgical expenses incurred as a result of a health
condition, accident, or sickness, including an individual, group,
blanket, or franchise insurance policy or insurance agreement, a
group hospital service contract, or an individual or group evidence
of coverage or similar coverage document that is issued by:
(1) an insurance company;
(2) a group hospital service corporation operating
under Chapter 842;
(3) a health maintenance organization operating under
Chapter 843;
(4) an approved nonprofit health corporation that
holds a certificate of authority under Chapter 844;
(5) a multiple employer welfare arrangement that holds
a certificate of authority under Chapter 846;
(6) a stipulated premium company operating under
Chapter 884;
(7) a fraternal benefit society operating under
Chapter 885;
(8) a Lloyd's plan operating under Chapter 941; or
(9) an exchange operating under Chapter 942.
(b) Notwithstanding any other law, this chapter applies to:
(1) a small employer health benefit plan subject to
Chapter 1501, including coverage provided through a health group
cooperative under Subchapter B of that chapter;
(2) a standard health benefit plan issued under
Chapter 1507;
(3) a basic coverage plan under Chapter 1551;
(4) a basic plan under Chapter 1575;
(5) a primary care coverage plan under Chapter 1579;
(6) a plan providing basic coverage under Chapter
1601;
(7) health benefits provided by or through a church
benefits board under Subchapter I, Chapter 22, Business
Organizations Code;
(8) group health coverage made available by a school
district in accordance with Section 22.004, Education Code;
(9) the state Medicaid program, including the Medicaid
managed care program operated under Chapter 533, Government Code;
(10) the child health plan program under Chapter 62,
Health and Safety Code;
(11) a regional or local health care program operated
under Section 75.104, Health and Safety Code;
(12) a self-funded health benefit plan sponsored by a
professional employer organization under Chapter 91, Labor Code;
(13) county employee group health benefits provided
under Chapter 157, Local Government Code; and
(14) health and accident coverage provided by a risk
pool created under Chapter 172, Local Government Code.
(c) This chapter applies to coverage under a group health
benefit plan provided to a resident of this state regardless of
whether the group policy, agreement, or contract is delivered,
issued for delivery, or renewed in this state.
Sec. 1380.002. EXCEPTION. This chapter does not apply to an
individual health benefit plan issued on or before March 23, 2010,
that has not had any significant changes since that date that reduce
benefits or increase costs to the individual.
Sec. 1380.003. REQUIRED COVERAGE FOR ESSENTIAL HEALTH
BENEFITS. (a) In this section:
(1) "Individual health benefit plan" means:
(A) an individual accident and health insurance
policy to which Chapter 1201 applies; or
(B) individual health maintenance organization
coverage.
(2) "Small employer health benefit plan" has the
meaning assigned by Section 1501.002.
(b) An individual or small employer health benefit plan must
provide coverage for the essential health benefits listed in 42
U.S.C. Section 18022(b)(1), as that section existed on January 1,
2017, and other benefits identified by the United States secretary
of health and human services as essential health benefits as of that
date.
Sec. 1380.004. CERTAIN ANNUAL AND LIFETIME LIMITS
PROHIBITED. A health benefit plan issuer may not establish an
annual or lifetime benefit amount for an enrollee in relation to
essential health benefits listed in 42 U.S.C. Section 18022(b)(1),
as that section existed on January 1, 2017, and other benefits
identified by the United States secretary of health and human
services as essential health benefits as of that date.
Sec. 1380.005. LIMITATIONS ON COST-SHARING. A health
benefit plan issuer may not impose cost-sharing requirements that
exceed the limits established in 42 U.S.C. Section 18022(c)(1) in
relation to essential health benefits listed in 42 U.S.C. Section
18022(b)(1), as those sections existed on January 1, 2017, and
other benefits identified by the United States secretary of health
and human services as essential health benefits as of that date.
Sec. 1380.006. RULES. (a) Subject to Subsection (b), the
commissioner may adopt rules as necessary to implement this
chapter.
(b) Rules adopted by the commissioner to implement this
chapter must be consistent with the Patient Protection and
Affordable Care Act (Pub. L. No. 111-148), as that Act existed on
January 1, 2017.
ARTICLE 3. CONFORMING AMENDMENTS; REPEALER
SECTION 3.01. Section 841.002, Insurance Code, is amended
to read as follows:
Sec. 841.002. APPLICABILITY OF CHAPTER AND OTHER LAW.
Except as otherwise expressly provided by this code, each insurance
company incorporated or engaging in business in this state as a life
insurance company, an accident insurance company, a life and
accident insurance company, a health and accident insurance
company, or a life, health, and accident insurance company is
subject to:
(1) this chapter;
(2) Chapter 3;
(3) Chapters 425 and 493;
(4) Title 7;
(5) Sections [1202.051,] 1204.151, 1204.153, and
1204.154;
(6) Subchapter A, Chapter 1202, Subchapters A and F,
Chapter 1204, Subchapter A, Chapter 1273, Subchapters A, B, and D,
Chapter 1355, and Subchapter A, Chapter 1366;
(7) Subchapter A, Chapter 1507;
(8) Chapters 1203, 1210, 1251-1254, 1301, 1351, 1354,
1359, 1364, 1368, 1505, 1651, 1652, and 1701; and
(9) Chapter 177, Local Government Code.
SECTION 3.02. Section 1201.005, Insurance Code, is amended
to read as follows:
Sec. 1201.005. REFERENCES TO CHAPTER. In this chapter, a
reference to this chapter includes a reference to:
(1) [Section 1202.052;
[(2)] Section 1271.005(a), to the extent that the
subsection relates to the applicability of Section 1201.105, and
Sections 1271.005(d) and (e);
(2) [(3)] Chapter 1351;
(3) [(4)] Subchapters C and E, Chapter 1355;
(4) [(5)] Chapter 1356;
(5) [(6)] Chapter 1365;
(6) [(7)] Subchapter A, Chapter 1367;
(7) Subchapter B, Chapter 1511; and
(8) Subchapters A, B, and G, Chapter 1451.
SECTION 3.03. Section 1507.003(b), Insurance Code, is
amended to read as follows:
(b) For purposes of this subchapter, "state-mandated health
benefits" does not include benefits that are mandated by federal
law or standard provisions or rights required under this code or
other laws of this state to be provided in an individual, blanket,
or group policy for accident and health insurance that are
unrelated to a specific health illness, injury, or condition of an
insured, including provisions related to:
(1) continuation of coverage under:
(A) Subchapters F and G, Chapter 1251;
(B) Section 1201.059; and
(C) Subchapter B, Chapter 1253;
(2) termination of coverage under Sections [1202.051
and] 1501.108 and 1511.052;
(3) preexisting conditions under Subchapter D,
Chapter 1201, and Sections 1501.102-1501.105;
(4) coverage of children, including newborn or adopted
children, under:
(A) Subchapter D, Chapter 1251;
(B) Sections 1201.053, 1201.061,
1201.063-1201.065, and Subchapter A, Chapter 1367;
(C) Chapter 1504;
(D) Chapter 1503;
(E) Section 1501.157;
(F) Section 1501.158; and
(G) Sections 1501.607-1501.609;
(5) services of practitioners under:
(A) Subchapters A, B, and C, Chapter 1451; or
(B) Section 1301.052;
(6) supplies and services associated with the
treatment of diabetes under Subchapter B, Chapter 1358;
(7) coverage for serious mental illness under
Subchapter A, Chapter 1355;
(8) coverage for childhood immunizations and hearing
screening as required by Subchapters B and C, Chapter 1367, other
than Section 1367.053(c) and Chapter 1353;
(9) coverage for reconstructive surgery for certain
craniofacial abnormalities of children as required by Subchapter D,
Chapter 1367;
(10) coverage for the dietary treatment of
phenylketonuria as required by Chapter 1359;
(11) coverage for referral to a non-network physician
or provider when medically necessary covered services are not
available through network physicians or providers, as required by
Section 1271.055; and
(12) coverage for cancer screenings under:
(A) Chapter 1356;
(B) Chapter 1362;
(C) Chapter 1363; and
(D) Chapter 1370.
SECTION 3.04. Section 1507.053(b), Insurance Code, is
amended to read as follows:
(b) For purposes of this subchapter, "state-mandated health
benefits" does not include coverage that is mandated by federal law
or standard provisions or rights required under this code or other
laws of this state to be provided in an evidence of coverage that
are unrelated to a specific health illness, injury, or condition of
an enrollee, including provisions related to:
(1) continuation of coverage under Subchapter G,
Chapter 1251;
(2) termination of coverage under Sections [1202.051
and] 1501.108 and 1511.052;
(3) preexisting conditions under Subchapter D,
Chapter 1201, and Sections 1501.102-1501.105;
(4) coverage of children, including newborn or adopted
children, under:
(A) Chapter 1504;
(B) Chapter 1503;
(C) Section 1501.157;
(D) Section 1501.158; and
(E) Sections 1501.607-1501.609;
(5) services of providers under Section 843.304;
(6) coverage for serious mental health illness under
Subchapter A, Chapter 1355; and
(7) coverage for cancer screenings under:
(A) Chapter 1356;
(B) Chapter 1362;
(C) Chapter 1363; and
(D) Chapter 1370.
SECTION 3.05. Section 1501.602(a), Insurance Code, is
amended to read as follows:
(a) A large employer health benefit plan issuer[:
[(1) may refuse to provide coverage to a large
employer in accordance with the issuer's underwriting standards and
criteria;
[(2) shall accept or reject the entire group of
individuals who meet the participation criteria and choose
coverage; and
[(3)] may exclude only those employees or dependents
who decline coverage.
SECTION 3.06. Subchapter B, Chapter 1202, Insurance Code,
is repealed.
ARTICLE 4. IMPLEMENTATION; TRANSITION; EFFECTIVE DATE
SECTION 4.01. If before implementing any provision of this
Act a state agency determines that a waiver or authorization from a
federal agency is necessary for implementation of that provision,
the agency affected by the provision shall request the waiver or
authorization and may delay implementing that provision until the
waiver or authorization is granted.
SECTION 4.02. The change in law made by this Act applies
only to a health benefit plan that is delivered, issued for
delivery, or renewed on or after January 1, 2022. A health benefit
plan that is delivered, issued for delivery, or renewed before
January 1, 2022, is governed by the law as it existed immediately
before the effective date of this Act, and that law is continued in
effect for that purpose.
SECTION 4.03. This Act takes effect September 1, 2023.