88R21068 CJD-F
By: Buckley, et al. H.B. No. 1322
Substitute the following for H.B. No. 1322:
By: Oliverson C.S.H.B. No. 1322
A BILL TO BE ENTITLED
AN ACT
relating to coordination of vision and eye care benefits under
certain health benefit plans and vision benefit plans.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Chapter 1203, Insurance Code, is amended by
adding Subchapter C to read as follows:
SUBCHAPTER C. VISION AND EYE CARE BENEFITS
Sec. 1203.101. DEFINITIONS. In this subchapter:
(1) "Eye care expenses" means expenses related to
vision or medical eye care services, procedures, or products.
(2) "Health benefit plan" means a policy, agreement,
contract, or evidence of coverage that provides comprehensive
medical coverage.
(3) "Vision benefit plan" means a limited-scope
policy, agreement, contract, or evidence of coverage that provides
coverage for eye care expenses but does not provide comprehensive
medical coverage.
Sec. 1203.102. APPLICABILITY OF SUBCHAPTER. This
subchapter applies only to a health benefit plan or vision benefit
plan that provides or arranges for benefits for vision or medical
eye care services, procedures, or products, including an
individual, group, blanket, or franchise insurance policy or
insurance agreement, a group hospital service contract, an evidence
of coverage, or a vision benefit plan offered 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) a stipulated premium company operating under
Chapter 884;
(5) a fraternal benefit society operating under
Chapter 885;
(6) a Lloyd's plan operating under Chapter 941;
(7) an exchange operating under Chapter 942; or
(8) a person or entity that provides a vision benefit
plan.
Sec. 1203.103. EXCEPTION. This subchapter does not apply
to a supplemental insurance policy that only pays benefits directly
to the policyholder.
Sec. 1203.104. COORDINATION OF BENEFITS BETWEEN PRIMARY AND
SECONDARY PLAN ISSUERS. (a) This section applies if:
(1) an enrollee is covered by at least two different
health benefit plans or vision benefit plans; and
(2) each plan provides the enrollee coverage for the
same vision or medical eye care services, procedures, or products.
(b) The issuer of the primary health benefit plan or vision
benefit plan, as determined under a coordination of benefits
provision applicable to the plan, is responsible for eye care
expenses covered under the plan up to the full amount of any plan
coverage limit applicable to the covered eye care expenses.
(c) Before the plan coverage limit described by Subsection
(b) is reached, the issuer of a secondary health benefit plan or
vision benefit plan, as determined under a coordination of benefits
provision applicable to the plan, is responsible only for eye care
expenses covered under the plan that are not covered under the
health benefit plan or vision benefit plan issued by the primary
plan issuer.
(d) After the plan coverage limit described by Subsection
(b) has been reached, the secondary plan issuer, in addition to the
responsibilities described by Subsection (c), is responsible for
any eye care expenses covered by both plans that exceed the plan
coverage limit described by Subsection (b) up to the coverage limit
of the secondary plan.
(e) When an enrollee is covered by more than one health
benefit plan or vision benefit plan that provides benefits for eye
care expenses, the enrollee may use each plan on the same date of
service up to the coverage limit of each plan.
(f) A vision benefit plan issuer shall coordinate benefits
with a health benefit plan issuer if both provide benefits for eye
care expenses.
(g) A vision benefit plan issuer may not require a claim
denial before adjudicating a claim up to the coverage limit of the
plan.
(h) Nothing in this section prevents a secondary plan issuer
from requiring proof that a related claim has been submitted to a
primary plan issuer for purposes of determining the remaining
balance up to the secondary plan's coverage limits.
(i) If a secondary plan issuer requires proof that a related
claim has been submitted to a primary plan issuer as described by
Subsection (h), the mechanism of providing proof must be through an
online submission.
Sec. 1203.105. CERTAIN COORDINATION OF BENEFITS PROVISIONS
PROHIBITED. (a) A health benefit plan or vision benefit plan
subject to this subchapter may not be delivered, issued for
delivery, or renewed in this state if:
(1) a provision of the plan excludes or reduces the
payment of benefits for eye care expenses to or on behalf of an
enrollee;
(2) the reason for the exclusion or reduction is that
eye care benefits are payable or have been paid to or on behalf of
the enrollee under another plan; and
(3) the exclusion or reduction would apply before the
full amount of the eye care expenses incurred by the enrollee and
covered by both plans have been paid or reimbursed or the full
amount of the applicable coverage limit of the plan containing the
exclusion or reduction is reached.
(b) Nothing in this section requires a secondary plan issuer
to pay an amount that, when added to a payment amount made by a
primary plan issuer, would exceed the usual and customary billed
charges of the health care provider.
Sec. 1203.106. CERTAIN COORDINATION OF BENEFITS PROVISIONS
VOID. A provision of a health benefit plan or vision benefit plan
that violates this subchapter is void.
Sec. 1203.107. RULES. The commissioner may adopt rules
necessary to implement this subchapter.
SECTION 2. The change in law made by this Act applies only
to a health benefit plan or vision benefit plan that is delivered,
issued for delivery, or renewed on or after January 1, 2024. A plan
delivered, issued for delivery, or renewed before January 1, 2024,
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 3. This Act takes effect September 1, 2023.