Texas 2023 - 88th Regular

Texas House Bill HB1128 Compare Versions

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1	1	By: Martinez Fischer H.B. No. 1128
2	2
3	3
4	4	A BILL TO BE ENTITLED
5	5	AN ACT
6	6	relating to availability of and benefits provided under health
7	7	benefit plan coverage.
8	8	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
9	9	ARTICLE 1. HEALTH BENEFIT COVERAGE AVAILABILITY
10	10	SECTION 1.01. Subtitle G, Title 8, Insurance Code, is
11	11	amended by adding Chapter 1511 to read as follows:
12	12	CHAPTER 1511. HEALTH BENEFIT COVERAGE AVAILABILITY
13	13	SUBCHAPTER A. GENERAL PROVISIONS
14	14	Sec. 1511.001. APPLICABILITY OF CHAPTER. (a) Except as
15	15	otherwise provided by this chapter, this chapter applies only to a
16	16	health benefit plan that provides benefits for medical or surgical
17	17	expenses incurred as a result of a health condition, accident, or
18	18	sickness, including an individual, group, blanket, or franchise
19	19	insurance policy or insurance agreement, a group hospital service
20	20	contract, or an individual or group evidence of coverage or similar
21	21	coverage document that is issued by:
22	22	(1) an insurance company;
23	23	(2) a group hospital service corporation operating
24	24	under Chapter 842;
25	25	(3) a health maintenance organization operating under
26	26	Chapter 843;
27	27	(4) an approved nonprofit health corporation that
28	28	holds a certificate of authority under Chapter 844;
29	29	(5) a multiple employer welfare arrangement that holds
30	30	a certificate of authority under Chapter 846;
31	31	(6) a stipulated premium company operating under
32	32	Chapter 884;
33	33	(7) a fraternal benefit society operating under
34	34	Chapter 885;
35	35	(8) a Lloyd's plan operating under Chapter 941; or
36	36	(9) an exchange operating under Chapter 942.
37	37	(b) Notwithstanding any other law, this chapter applies to:
38	38	(1) a small employer health benefit plan subject to
39	39	Chapter 1501, including coverage provided through a health group
40	40	cooperative under Subchapter B of that chapter; and
41	41	(2) a standard health benefit plan issued under
42	42	Chapter 1507.
43	43	(c) This chapter applies to coverage under a group health
44	44	benefit plan provided to a resident of this state regardless of
45	45	whether the group policy, agreement, or contract is delivered,
46	46	issued for delivery, or renewed in this state.
47	47	Sec. 1511.002. EXCEPTIONS. (a) This chapter does not apply
48	48	to:
49	49	(1) a plan that provides coverage:
50	50	(A) for wages or payments in lieu of wages for a
51	51	period during which an employee is absent from work because of
52	52	sickness or injury;
53	53	(B) as a supplement to a liability insurance
54	54	policy;
55	55	(C) for credit insurance;
56	56	(D) only for dental or vision care;
57	57	(E) only for a specified disease or for another
58	58	limited benefit; or
59	59	(F) only for accidental death or dismemberment;
60	60	(2) a Medicare supplemental policy as defined by
61	61	Section 1882(g)(1), Social Security Act (42 U.S.C. Section
62	62	1395ss(g)(1));
63	63	(3) a workers' compensation insurance policy;
64	64	(4) medical payment insurance coverage provided under
65	65	a motor vehicle insurance policy; or
66	66	(5) a long-term care policy, including a nursing home
67	67	fixed indemnity policy, unless the commissioner determines that the
68	68	policy provides benefit coverage so comprehensive that the policy
69	69	is a health benefit plan as described by Section 1511.001.
70	70	(b) This chapter does not apply to an individual health
71	71	benefit plan issued on or before March 23, 2010, that has not had
72	72	any significant changes since that date that reduce benefits or
73	73	increase costs to the individual.
74	74	Sec. 1511.003. CONFLICT WITH OTHER LAW. If there is a
75	75	conflict between this chapter and other law, this chapter prevails.
76	76	Sec. 1511.004. RULES. (a) Subject to Subsection (b), the
77	77	commissioner may adopt rules as necessary to implement this
78	78	chapter.
79	79	(b) Rules adopted by the commissioner to implement this
80	80	chapter must be consistent with the Patient Protection and
81	81	Affordable Care Act (Pub. L. No. 111-148), as that Act existed on
82	82	January 1, 2017.
83	83	SUBCHAPTER B. GUARANTEED ISSUE AND RENEWABILITY
84	84	Sec. 1511.051. GUARANTEED ISSUE. A health benefit plan
85	85	issuer shall issue a group or individual health benefit plan chosen
86	86	by a group plan sponsor or individual to each group plan sponsor or
87	87	individual that elects to be covered under the plan and agrees to
88	88	satisfy the requirements of the plan.
89	89	Sec. 1511.052. RENEWABILITY AND CONTINUATION OF HEALTH
90	90	BENEFIT PLANS. (a) Except as provided by Subsection (b), a health
91	91	benefit plan issuer shall renew or continue a group or individual
92	92	health benefit plan at the option of the group plan sponsor or
93	93	individual, as applicable.
94	94	(b) A health benefit plan issuer may decline to renew or
95	95	continue a group or individual health benefit plan:
96	96	(1) for failure to pay a premium or contribution in
97	97	accordance with the terms of the plan;
98	98	(2) for fraud or intentional misrepresentation;
99	99	(3) because the issuer is ceasing to offer coverage in
100	100	the relevant market in accordance with rules adopted by the
101	101	commissioner;
102	102	(4) with respect to an individual plan, because an
103	103	individual no longer resides, lives, or works in an area in which
104	104	the issuer is authorized to provide coverage, but only if all plans
105	105	are not renewed or not continued under this subdivision uniformly
106	106	without regard to any health status related factor of covered
107	107	individuals; or
108	108	(5) in accordance with federal law, including
109	109	regulations.
110	110	Sec. 1511.053. OPEN AND SPECIAL ENROLLMENT PERIODS. (a) A
111	111	health benefit plan issuer issuing an individual health benefit
112	112	plan may restrict enrollment in coverage to an annual open
113	113	enrollment period and special enrollment periods.
114	114	(b) An individual or an individual's dependent qualified to
115	115	enroll in an individual health benefit plan may enroll anytime
116	116	during the open enrollment period or during a special enrollment
117	117	period designated by the commissioner.
118	118	(c) A health benefit plan issuer issuing a group health
119	119	benefit plan may not limit enrollment to an open or special
120	120	enrollment period.
121	121	(d) The commissioner shall adopt rules as necessary to
122	122	administer this section, including rules designating enrollment
123	123	periods.
124	124	SUBCHAPTER C. PREEXISTING CONDITIONS AND HEALTH STATUS
125	125	Sec. 1511.101. DEFINITIONS. In this subchapter:
126	126	(1) "Dependent" has the meaning assigned by Section
127	127	1501.002.
128	128	(2) "Health status related factor" has the meaning
129	129	assigned by Section 1501.002.
130	130	(3) "Preexisting condition" means a condition present
131	131	before the effective date of an individual's coverage under a
132	132	health benefit plan.
133	133	Sec. 1511.102. APPLICABILITY OF SUBCHAPTER.
134	134	Notwithstanding any other law, in addition to a health benefit plan
135	135	to which this chapter applies under Subchapter A, this subchapter
136	136	applies to:
137	137	(1) a basic coverage plan under Chapter 1551;
138	138	(2) a basic plan under Chapter 1575;
139	139	(3) a primary care coverage plan under Chapter 1579;
140	140	(4) a plan providing basic coverage under Chapter
141	141	1601;
142	142	(5) health benefits provided by or through a church
143	143	benefits board under Subchapter I, Chapter 22, Business
144	144	Organizations Code;
145	145	(6) group health coverage made available by a school
146	146	district in accordance with Section 22.004, Education Code;
147	147	(7) the state Medicaid program, including the Medicaid
148	148	managed care program operated under Chapter 533, Government Code;
149	149	(8) the child health plan program under Chapter 62,
150	150	Health and Safety Code;
151	151	(9) a regional or local health care program operated
152	152	under Section 75.104, Health and Safety Code;
153	153	(10) a self-funded health benefit plan sponsored by a
154	154	professional employer organization under Chapter 91, Labor Code;
155	155	(11) county employee group health benefits provided
156	156	under Chapter 157, Local Government Code; and
157	157	(12) health and accident coverage provided by a risk
158	158	pool created under Chapter 172, Local Government Code.
159	159	Sec. 1511.103. PREEXISTING CONDITION AND HEALTH STATUS
160	160	RESTRICTIONS PROHIBITED. Notwithstanding any other law, a health
161	161	benefit plan issuer may not:
162	162	(1) deny coverage to or refuse to enroll a group, an
163	163	individual, or an individual's dependent in a health benefit plan
164	164	on the basis of a preexisting condition or health status related
165	165	factor;
166	166	(2) limit or exclude, or require a waiting period for,
167	167	coverage under the health benefit plan for treatment of a
168	168	preexisting condition otherwise covered under the plan; or
169	169	(3) charge a group, individual, or dependent more for
170	170	coverage than the health benefit plan issuer charges a group,
171	171	individual, or dependent who does not have a preexisting condition
172	172	or health status related factor.
173	173	SUBCHAPTER D. PROHIBITED DISCRIMINATION
174	174	Sec. 1511.151. DISCRIMINATORY BENEFIT DESIGN PROHIBITED.
175	175	(a) A health benefit plan issuer may not, through the plan's
176	176	benefit design, discriminate against an enrollee on the basis of
177	177	race, color, national origin, age, sex, expected length of life,
178	178	present or predicted disability, degree of medical dependency,
179	179	quality of life, or other health condition.
180	180	(b) A health benefit plan issuer may not use a health
181	181	benefit design that will have the effect of discouraging the
182	182	enrollment of individuals with significant health needs in the
183	183	health benefit plan.
184	184	(c) This section may not be construed to prevent a health
185	185	benefit plan issuer from appropriately utilizing reasonable
186	186	medical management techniques.
187	187	Sec. 1511.152. DISCRIMINATORY MARKETING PROHIBITED. A
188	188	health benefit plan issuer may not use a marketing practice that
189	189	will have the effect of discouraging the enrollment of individuals
190	190	with significant health needs in the health benefit plan or that
191	191	discriminates on the basis of race, color, national origin, age,
192	192	sex, expected length of life, present or predicted disability,
193	193	degree of medical dependency, quality of life, or other health
194	194	condition.
195	195	ARTICLE 2. COVERAGE OF ESSENTIAL HEALTH BENEFITS
196	196	SECTION 2.01. Subtitle E, Title 8, Insurance Code, is
197	197	amended by adding Chapter 1380 to read as follows:
198	198	CHAPTER 1380. COVERAGE OF ESSENTIAL HEALTH BENEFITS
199	199	Sec. 1380.001. APPLICABILITY OF CHAPTER. (a) This chapter
200	200	applies only to a health benefit plan that provides benefits for
201	201	medical or surgical expenses incurred as a result of a health
202	202	condition, accident, or sickness, including an individual, group,
203	203	blanket, or franchise insurance policy or insurance agreement, a
204	204	group hospital service contract, or an individual or group evidence
205	205	of coverage or similar coverage document that is issued by:
206	206	(1) an insurance company;
207	207	(2) a group hospital service corporation operating
208	208	under Chapter 842;
209	209	(3) a health maintenance organization operating under
210	210	Chapter 843;
211	211	(4) an approved nonprofit health corporation that
212	212	holds a certificate of authority under Chapter 844;
213	213	(5) a multiple employer welfare arrangement that holds
214	214	a certificate of authority under Chapter 846;
215	215	(6) a stipulated premium company operating under
216	216	Chapter 884;
217	217	(7) a fraternal benefit society operating under
218	218	Chapter 885;
219	219	(8) a Lloyd's plan operating under Chapter 941; or
220	220	(9) an exchange operating under Chapter 942.
221	221	(b) Notwithstanding any other law, this chapter applies to:
222	222	(1) a small employer health benefit plan subject to
223	223	Chapter 1501, including coverage provided through a health group
224	224	cooperative under Subchapter B of that chapter;
225	225	(2) a standard health benefit plan issued under
226	226	Chapter 1507;
227	227	(3) a basic coverage plan under Chapter 1551;
228	228	(4) a basic plan under Chapter 1575;
229	229	(5) a primary care coverage plan under Chapter 1579;
230	230	(6) a plan providing basic coverage under Chapter
231	231	1601;
232	232	(7) health benefits provided by or through a church
233	233	benefits board under Subchapter I, Chapter 22, Business
234	234	Organizations Code;
235	235	(8) group health coverage made available by a school
236	236	district in accordance with Section 22.004, Education Code;
237	237	(9) the state Medicaid program, including the Medicaid
238	238	managed care program operated under Chapter 533, Government Code;
239	239	(10) the child health plan program under Chapter 62,
240	240	Health and Safety Code;
241	241	(11) a regional or local health care program operated
242	242	under Section 75.104, Health and Safety Code;
243	243	(12) a self-funded health benefit plan sponsored by a
244	244	professional employer organization under Chapter 91, Labor Code;
245	245	(13) county employee group health benefits provided
246	246	under Chapter 157, Local Government Code; and
247	247	(14) health and accident coverage provided by a risk
248	248	pool created under Chapter 172, Local Government Code.
249	249	(c) This chapter applies to coverage under a group health
250	250	benefit plan provided to a resident of this state regardless of
251	251	whether the group policy, agreement, or contract is delivered,
252	252	issued for delivery, or renewed in this state.
253	253	Sec. 1380.002. EXCEPTION. This chapter does not apply to an
254	254	individual health benefit plan issued on or before March 23, 2010,
255	255	that has not had any significant changes since that date that reduce
256	256	benefits or increase costs to the individual.
257	257	Sec. 1380.003. REQUIRED COVERAGE FOR ESSENTIAL HEALTH
258	258	BENEFITS. (a) In this section:
259	259	(1) "Individual health benefit plan" means:
260	260	(A) an individual accident and health insurance
261	261	policy to which Chapter 1201 applies; or
262	262	(B) individual health maintenance organization
263	263	coverage.
264	264	(2) "Small employer health benefit plan" has the
265	265	meaning assigned by Section 1501.002.
266	266	(b) An individual or small employer health benefit plan must
267	267	provide coverage for the essential health benefits listed in 42
268	268	U.S.C. Section 18022(b)(1), as that section existed on January 1,
269	269	2017, and other benefits identified by the United States secretary
270	270	of health and human services as essential health benefits as of that
271	271	date.
272	272	Sec. 1380.004. CERTAIN ANNUAL AND LIFETIME LIMITS
273	273	PROHIBITED. A health benefit plan issuer may not establish an
274	274	annual or lifetime benefit amount for an enrollee in relation to
275	275	essential health benefits listed in 42 U.S.C. Section 18022(b)(1),
276	276	as that section existed on January 1, 2017, and other benefits
277	277	identified by the United States secretary of health and human
278	278	services as essential health benefits as of that date.
279	279	Sec. 1380.005. LIMITATIONS ON COST-SHARING. A health
280	280	benefit plan issuer may not impose cost-sharing requirements that
281	281	exceed the limits established in 42 U.S.C. Section 18022(c)(1) in
282	282	relation to essential health benefits listed in 42 U.S.C. Section
283	283	18022(b)(1), as those sections existed on January 1, 2017, and
284	284	other benefits identified by the United States secretary of health
285	285	and human services as essential health benefits as of that date.
286	286	Sec. 1380.006. RULES. (a) Subject to Subsection (b), the
287	287	commissioner may adopt rules as necessary to implement this
288	288	chapter.
289	289	(b) Rules adopted by the commissioner to implement this
290	290	chapter must be consistent with the Patient Protection and
291	291	Affordable Care Act (Pub. L. No. 111-148), as that Act existed on
292	292	January 1, 2017.
293	293	ARTICLE 3. CONFORMING AMENDMENTS; REPEALER
294	294	SECTION 3.01. Section 841.002, Insurance Code, is amended
295	295	to read as follows:
296	296	Sec. 841.002. APPLICABILITY OF CHAPTER AND OTHER LAW.
297	297	Except as otherwise expressly provided by this code, each insurance
298	298	company incorporated or engaging in business in this state as a life
299	299	insurance company, an accident insurance company, a life and
300	300	accident insurance company, a health and accident insurance
301	301	company, or a life, health, and accident insurance company is
302	302	subject to:
303	303	(1) this chapter;
304	304	(2) Chapter 3;
305	305	(3) Chapters 425 and 493;
306	306	(4) Title 7;
307	307	(5) Sections [1202.051,] 1204.151, 1204.153, and
308	308	1204.154;
309	309	(6) Subchapter A, Chapter 1202, Subchapters A and F,
310	310	Chapter 1204, Subchapter A, Chapter 1273, Subchapters A, B, and D,
311	311	Chapter 1355, and Subchapter A, Chapter 1366;
312	312	(7) Subchapter A, Chapter 1507;
313	313	(8) Chapters 1203, 1210, 1251-1254, 1301, 1351, 1354,
314	314	1359, 1364, 1368, 1505, 1651, 1652, and 1701; and
315	315	(9) Chapter 177, Local Government Code.
316	316	SECTION 3.02. Section 1201.005, Insurance Code, is amended
317	317	to read as follows:
318	318	Sec. 1201.005. REFERENCES TO CHAPTER. In this chapter, a
319	319	reference to this chapter includes a reference to:
320	320	(1) [Section 1202.052;
321	321	[(2)] Section 1271.005(a), to the extent that the
322	322	subsection relates to the applicability of Section 1201.105, and
323	323	Sections 1271.005(d) and (e);
324	324	(2) [(3)] Chapter 1351;
325	325	(3) [(4)] Subchapters C and E, Chapter 1355;
326	326	(4) [(5)] Chapter 1356;
327	327	(5) [(6)] Chapter 1365;
328	328	(6) [(7)] Subchapter A, Chapter 1367;
329	329	(7) Subchapter B, Chapter 1511; and
330	330	(8) Subchapters A, B, and G, Chapter 1451.
331	331	SECTION 3.03. Section 1507.003(b), Insurance Code, is
332	332	amended to read as follows:
333	333	(b) For purposes of this subchapter, "state-mandated health
334	334	benefits" does not include benefits that are mandated by federal
335	335	law or standard provisions or rights required under this code or
336	336	other laws of this state to be provided in an individual, blanket,
337	337	or group policy for accident and health insurance that are
338	338	unrelated to a specific health illness, injury, or condition of an
339	339	insured, including provisions related to:
340	340	(1) continuation of coverage under:
341	341	(A) Subchapters F and G, Chapter 1251;
342	342	(B) Section 1201.059; and
343	343	(C) Subchapter B, Chapter 1253;
344	344	(2) termination of coverage under Sections [1202.051
345	345	and] 1501.108 and 1511.052;
346	346	(3) preexisting conditions under Subchapter D,
347	347	Chapter 1201, and Sections 1501.102-1501.105;
348	348	(4) coverage of children, including newborn or adopted
349	349	children, under:
350	350	(A) Subchapter D, Chapter 1251;
351	351	(B) Sections 1201.053, 1201.061,
352	352	1201.063-1201.065, and Subchapter A, Chapter 1367;
353	353	(C) Chapter 1504;
354	354	(D) Chapter 1503;
355	355	(E) Section 1501.157;
356	356	(F) Section 1501.158; and
357	357	(G) Sections 1501.607-1501.609;
358	358	(5) services of practitioners under:
359	359	(A) Subchapters A, B, and C, Chapter 1451; or
360	360	(B) Section 1301.052;
361	361	(6) supplies and services associated with the
362	362	treatment of diabetes under Subchapter B, Chapter 1358;
363	363	(7) coverage for serious mental illness under
364	364	Subchapter A, Chapter 1355;
365	365	(8) coverage for childhood immunizations and hearing
366	366	screening as required by Subchapters B and C, Chapter 1367, other
367	367	than Section 1367.053(c) and Chapter 1353;
368	368	(9) coverage for reconstructive surgery for certain
369	369	craniofacial abnormalities of children as required by Subchapter D,
370	370	Chapter 1367;
371	371	(10) coverage for the dietary treatment of
372	372	phenylketonuria as required by Chapter 1359;
373	373	(11) coverage for referral to a non-network physician
374	374	or provider when medically necessary covered services are not
375	375	available through network physicians or providers, as required by
376	376	Section 1271.055; and
377	377	(12) coverage for cancer screenings under:
378	378	(A) Chapter 1356;
379	379	(B) Chapter 1362;
380	380	(C) Chapter 1363; and
381	381	(D) Chapter 1370.
382	382	SECTION 3.04. Section 1507.053(b), Insurance Code, is
383	383	amended to read as follows:
384	384	(b) For purposes of this subchapter, "state-mandated health
385	385	benefits" does not include coverage that is mandated by federal law
386	386	or standard provisions or rights required under this code or other
387	387	laws of this state to be provided in an evidence of coverage that
388	388	are unrelated to a specific health illness, injury, or condition of
389	389	an enrollee, including provisions related to:
390	390	(1) continuation of coverage under Subchapter G,
391	391	Chapter 1251;
392	392	(2) termination of coverage under Sections [1202.051
393	393	and] 1501.108 and 1511.052;
394	394	(3) preexisting conditions under Subchapter D,
395	395	Chapter 1201, and Sections 1501.102-1501.105;
396	396	(4) coverage of children, including newborn or adopted
397	397	children, under:
398	398	(A) Chapter 1504;
399	399	(B) Chapter 1503;
400	400	(C) Section 1501.157;
401	401	(D) Section 1501.158; and
402	402	(E) Sections 1501.607-1501.609;
403	403	(5) services of providers under Section 843.304;
404	404	(6) coverage for serious mental health illness under
405	405	Subchapter A, Chapter 1355; and
406	406	(7) coverage for cancer screenings under:
407	407	(A) Chapter 1356;
408	408	(B) Chapter 1362;
409	409	(C) Chapter 1363; and
410	410	(D) Chapter 1370.
411	411	SECTION 3.05. Section 1501.602(a), Insurance Code, is
412	412	amended to read as follows:
413	413	(a) A large employer health benefit plan issuer[:
414	414	[(1) may refuse to provide coverage to a large
415	415	employer in accordance with the issuer's underwriting standards and
416	416	criteria;
417	417	[(2) shall accept or reject the entire group of
418	418	individuals who meet the participation criteria and choose
419	419	coverage; and
420	420	[(3)] may exclude only those employees or dependents
421	421	who decline coverage.
422	422	SECTION 3.06. Subchapter B, Chapter 1202, Insurance Code,
423	423	is repealed.
424	424	ARTICLE 4. IMPLEMENTATION; TRANSITION; EFFECTIVE DATE
425	425	SECTION 4.01. If before implementing any provision of this
426	426	Act a state agency determines that a waiver or authorization from a
427	427	federal agency is necessary for implementation of that provision,
428	428	the agency affected by the provision shall request the waiver or
429	429	authorization and may delay implementing that provision until the
430	430	waiver or authorization is granted.
431	431	SECTION 4.02. The change in law made by this Act applies
432	432	only to a health benefit plan that is delivered, issued for
433	433	delivery, or renewed on or after January 1, 2022. A health benefit
434	434	plan that is delivered, issued for delivery, or renewed before
435	435	January 1, 2022, is governed by the law as it existed immediately
436	436	before the effective date of this Act, and that law is continued in
437	437	effect for that purpose.
438	438	SECTION 4.03. This Act takes effect September 1, 2023.