88R1400 MEW-D
By: Johnson S.B. No. 344
A BILL TO BE ENTITLED
AN ACT
relating to the creation of the Texas Health Insurance Exchange and
premium assistance and cost-sharing reduction programs;
authorizing a fee.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Subtitle G, Title 8, Insurance Code, is amended
by adding Chapter 1511 to read as follows:
CHAPTER 1511. TEXAS HEALTH INSURANCE EXCHANGE AND PREMIUM
ASSISTANCE AND COST-SHARING REDUCTION PROGRAMS
SUBCHAPTER A. GENERAL PROVISIONS
Sec. 1511.001. DEFINITIONS. In this chapter:
(1) "Advance premium tax credit" means the premium
assistance amount determined in accordance with the Patient
Protection and Affordable Care Act (Pub. L. No. 111-148), as
amended by the Health Care and Education Reconciliation Act of 2010
(Pub. L. No. 111-152), or regulations or guidance promulgated under
that law.
(2) "Board" means the board of directors of the Texas
Health Insurance Exchange Authority.
(3) "Enrollee" means an individual who is enrolled in
a qualified health plan.
(4) "Exchange" means the Texas Health Insurance
Exchange established under this chapter.
(5) "Exchange assister" means an individual or
organization, including a navigator, who provides public education
or assists consumers on behalf of the exchange. The term does not
include a licensed insurance agent.
(6) "Exchange authority" means the Texas Health
Insurance Exchange Authority established under this chapter.
(7) "Exchange fund" means the exchange revolving fund
established under Section 1511.251.
(8) "Executive commissioner" means the executive
commissioner of the Health and Human Services Commission.
(9) "Income," with respect to an individual, means the
modified adjusted gross income attributed to the individual for
purposes of determining the individual's eligibility for advance
premium tax credits.
(10) "Navigator" means an individual or entity
performing the activities and duties of a navigator as described by
42 U.S.C. Section 18031 or any regulation enacted under that
section.
(11) "Premium assistance and cost-sharing reduction
fund" means the premium assistance and cost-sharing reduction
revolving fund established under Section 1511.306.
(12) "Premium assistance or cost-sharing reduction
program" means a premium assistance or cost-sharing reduction
program established under Subchapter G.
(13) "Qualified health plan" has the meaning assigned
by Section 1301(a), Patient Protection and Affordable Care Act (42
U.S.C. Section 18021).
Sec. 1511.002. DEFINITION OF HEALTH BENEFIT PLAN. (a) In
this chapter, "health benefit plan" means an insurance policy,
insurance agreement, evidence of coverage, or other similar
coverage document that provides coverage for medical or surgical
expenses incurred as a result of a health condition, accident, or
sickness 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; or
(8) an exchange operating under Chapter 942.
(b) In this chapter, "health benefit plan" does not include:
(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 vision care;
(E) only for hospital expenses; or
(F) only for indemnity for hospital confinement;
(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) 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. RULEMAKING AUTHORITY. The commissioner and
the board may adopt rules necessary and proper to implement this
chapter. Rules adopted under this section may not conflict with or
prevent the application of regulations promulgated by the United
States secretary of health and human services under the Patient
Protection and Affordable Care Act (Pub. L. No. 111-148).
Sec. 1511.004. AGENCY COOPERATION. (a) The exchange
authority, the department, and the Health and Human Services
Commission shall cooperate fully in performing their respective
duties under this code or another law of this state relating to the
operation of the exchange.
(b) The exchange authority and the Health and Human Services
Commission shall cooperate fully to:
(1) ensure that the development of eligibility and
enrollment systems for the exchange and related premium tax credits
are fully integrated with the planning and development of the
Health and Human Services Commission's eligibility systems
modernization efforts;
(2) ensure full and seamless interoperability and
minimize duplication of cost and effort;
(3) develop and administer transition procedures
that:
(A) address the needs of individuals and families
who experience a change in income that results in a change in the
source of coverage, with a particular emphasis on children and
adults with special health care needs and chronic illnesses,
conditions, and disabilities, as well as all individuals who are
also enrolled in Medicare; and
(B) to the extent practicable under the Patient
Protection and Affordable Care Act (Pub. L. No. 111-148), provide
for the coordination of payments to Medicaid managed care
organizations and qualified health plans that experience changes in
enrollment resulting from changes in eligibility for Medicaid
during an enrollment period;
(4) ensure consistent methods and standards,
including formulas and verification methods, for prompt
calculation of income based on individuals' modified adjusted gross
incomes in order to guard against lapses in coverage and
inconsistent eligibility determinations and procedures;
(5) ensure maximum access to federal data sources for
the purpose of verifying income eligibility for Medicaid, the state
child health plan program, premium tax credits, and cost-sharing
reductions;
(6) ensure the prompt processing of applications and
enrollment in the correct state subsidy program, regardless of
whether the program is Medicaid, the state child health plan
program, premium tax credits, or cost-sharing reductions;
(7) ensure procedures for transitioning individuals
between Medicaid and tax-credit-based subsidies that protect
individuals against delays in eligibility and plan enrollment; and
(8) ensure rapid resolution of inconsistent
information affecting eligibility and dissemination of clear and
understandable information to applicants regarding the resolution
process and any interim assistance that may be available while
resolution is pending.
Sec. 1511.005. CONFIDENTIALITY OF RECORDS. (a) Except as
otherwise provided by this chapter, documents, materials, or other
information, including a disclosure, in the possession or control
of the department or the exchange authority that is obtained by,
created by, or disclosed to the commissioner or any other person
under this chapter is confidential and privileged and is:
(1) not subject to disclosure under Chapter 552,
Government Code;
(2) not subject to subpoena; and
(3) not subject to discovery or admissible in evidence
in any private civil action.
(b) Except as otherwise provided by this chapter,
documents, materials, or other information, including a
disclosure, in the possession or control of the department or the
exchange authority that is obtained by, created by, or disclosed to
the commissioner or any other person under this chapter is
recognized by this state as being proprietary and to contain trade
secrets.
Sec. 1511.006. PERSONAL HEALTH AND FINANCIAL INFORMATION
CONFIDENTIAL. The department and the exchange authority shall
protect all personally identifiable health and financial
information in accordance with all applicable federal and state
laws, including the Patient Protection and Affordable Care Act
(Pub. L. No. 111-148), the Health Insurance Portability and
Accountability Act of 1996 (Pub. L. No. 104-191), and the Health
Information Technology for Economic and Clinical Health Act (Pub.
L. No. 111-5), enacted under the American Recovery and Reinvestment
Act of 2009 (Pub. L. No. 111-5), and any regulations promulgated
under those laws.
Sec. 1511.007. INFORMATION SHARING AND CONFIDENTIALITY.
(a) The department or the exchange authority may enter into
information-sharing agreements with each other to carry out the
department's or exchange authority's responsibilities under this
chapter or with:
(1) a federal or state agency; or
(2) a health benefit plan issuer.
(b) An agreement entered into under this section must
include adequate protection with respect to the confidentiality of
any information shared and comply with all applicable state and
federal law.
Sec. 1511.008. IMMUNITY. The following persons are not
liable, and a cause of action does not arise against any of the
following persons, for a good faith act or omission in exercising
powers and performing duties under this chapter:
(1) the board, the department, or the exchange
authority;
(2) a board member or member of the advisory committee
established in Section 1511.152; or
(3) an officer or employee of an entity listed in
Subdivision (1).
Sec. 1511.009. COMPLIANCE WITH FEDERAL LAW. The exchange
authority shall comply with all applicable federal law and
regulations, including all federal reporting requirements.
Sec. 1511.010. NO ENTITLEMENT. Nothing in this chapter
constitutes an entitlement or a claim on any money of the state.
Sec. 1511.011. TERMINATION OF EXCHANGE OR PROGRAM. If any
provision of the Patient Protection and Affordable Care Act (Pub.
L. No. 111-148), as amended by the Health Care and Education
Reconciliation Act of 2010 (Pub. L. No. 111-152), integral to the
operation of the exchange authority or a premium assistance or
cost-sharing reduction program established under this chapter is
repealed, defunded, or invalidated, the commissioner shall notify
the exchange authority to initiate steps to cease operations of the
exchange or premium assistance or cost-sharing reduction program
and to cease those operations not later than 15 months after
notification is received under this section.
SUBCHAPTER B. EXCHANGE ESTABLISHMENT AND PURPOSE
Sec. 1511.051. EXCHANGE AUTHORITY ESTABLISHED. (a) This
chapter establishes the Texas Health Insurance Exchange Authority
to implement the Texas Health Insurance Exchange as an American
Health Benefit Exchange authorized by Section 1311, Patient
Protection and Affordable Care Act (42 U.S.C. Section 18031).
(b) The exchange authority is a public nonprofit
corporation and, except as otherwise provided in this chapter, has
all the powers and duties incident to a nonprofit corporation under
the Business Organizations Code.
(c) The exchange authority is subject to state law governing
nonprofit corporations, except that:
(1) the corporation may not be placed in receivership;
and
(2) the corporation is not required to make reports to
the secretary of state under Section 22.357, Business Organizations
Code.
(d) Except as otherwise provided by law, all expenses of the
corporation shall be paid from income of the corporation.
(e) Except as otherwise provided by this chapter, the
exchange authority is subject to Chapter 551, Government Code.
Sec. 1511.052. PURPOSE. The purpose of the exchange
authority is to create, manage, and maintain the exchange in order
to:
(1) benefit the state health insurance market and
individuals enrolling in health benefit plans;
(2) facilitate or assist in facilitating the
purchasing of qualified health plans on the exchange by qualified
enrollees in the individual market or the individual and small
group markets; and
(3) reduce or eliminate barriers to enrollment in
qualified health plans offered on the exchange by:
(A) simplifying the process to resolve data
matching issues;
(B) reducing circumstances under which
documentation must be submitted;
(C) simplifying the process for consumers to
submit documentation;
(D) streamlining special enrollment periods; and
(E) making the Internet website for the exchange
user-friendly and mobile-friendly.
SUBCHAPTER C. GOVERNANCE OF EXCHANGE
Sec. 1511.101. GOVERNANCE OF EXCHANGE AUTHORITY; BOARD
MEMBERSHIP. The exchange authority is governed by a board of nine
directors, with the advice and consent of the senate, as follows:
(1) seven members appointed by the governor:
(A) four of whom are health benefit plan issuers
that offer health benefit plans through the exchange;
(B) two of whom are individuals with experience
in health care public education and consumer assistance activities
who do not have a conflict of interest as provided by Section
1511.106; and
(C) one of whom is a consumer advocate;
(2) the commissioner, or the commissioner's designee,
as an ex officio voting member; and
(3) the executive commissioner, or the executive
commissioner's designee, as an ex officio voting member.
Sec. 1511.102. PRESIDING OFFICER. The commissioner, or the
commissioner's designee, shall serve as the presiding officer.
Sec. 1511.103. TERMS; VACANCY. (a) Appointed members of
the board serve six-year staggered terms, with two or three of the
members' terms expiring February 1 of each odd-numbered year.
(b) The governor shall fill a vacancy on the board by
appointing, for the unexpired term, an individual who has the
appropriate qualifications to fill that position.
Sec. 1511.104. MEETINGS; QUORUM. (a) The board shall meet
at the call of the presiding officer or as provided in the bylaws of
the board, but not less frequently than quarterly.
(b) A majority of the appointed members of the board
constitutes a quorum. If a quorum is present, the board by majority
vote may act on any matter within the board's jurisdiction.
(c) Meetings of the board are subject to Chapter 551,
Government Code.
Sec. 1511.105. BOARD MEMBER COMPENSATION. (a) A board
member may not receive compensation but is entitled to
reimbursement of the travel expenses incurred by the board member
while conducting board business, subject to the availability of
money.
(b) Reimbursement under Subsection (a) shall be paid from
the exchange fund.
Sec. 1511.106. CONFLICTS OF INTEREST; RELEVANT EXPERIENCE.
The board shall ensure compliance with the standards described by
42 U.S.C. Section 18041 and all applicable federal regulations
promulgated under the Patient Protection and Affordable Care Act
(Pub. L. No. 111-148) regarding conflicts of interest and relevant
experience.
SUBCHAPTER D. POWERS AND DUTIES OF EXCHANGE
Sec. 1511.151. EMPLOYEES; COMMITTEES. (a) The board may
employ an executive director and any other agents and employees
that the board considers necessary to assist the exchange authority
in carrying out its responsibilities and functions.
(b) The executive director shall organize, administer, and
manage the operations of the exchange authority. The executive
director may hire other employees as necessary to carry out the
responsibilities of the exchange authority.
(c) The executive director shall attend all meetings of the
board, but is not a member of the board, and may not vote or be
counted for purposes of establishing a quorum.
(d) The exchange authority may appoint appropriate legal,
actuarial, and other committees necessary to provide technical
assistance in operating the exchange and performing any of the
functions of the exchange or exchange authority.
Sec. 1511.152. ADVISORY COMMITTEE. (a) An advisory
committee is established to advise the board on:
(1) initial operational decisions;
(2) ongoing financing decisions; and
(3) any other decisions considered appropriate by the
board.
(b) The advisory committee is composed of eight members
appointed or selected as follows:
(1) four consumer representatives, including:
(A) two persons appointed by the governor, one of
whom must be an exchange assister;
(B) one person appointed by the speaker of the
house of representatives; and
(C) one person appointed by the lieutenant
governor;
(2) one representative selected by the Texas Hospital
Association;
(3) one representative selected by the Texas Medical
Association;
(4) one representative selected by the Texas Chamber
of Commerce Executives from a small employer, as that term is
defined by Section 1501.002; and
(5) one representative selected by the Texas
Association of Health Underwriters.
(c) Advisory committee members serve staggered four-year
terms, with two of the members' terms expiring February 1 of each
odd-numbered year. A member may be reappointed for a second term.
If a vacancy occurs on the committee, the appropriate appointing
authority shall appoint a successor, in the same manner as the
original appointment, to serve for the remainder of the unexpired
term.
(d) A majority of the members of the advisory committee
constitutes a quorum. If a quorum is present, the advisory
committee by majority vote may act on any matter within the
committee's jurisdiction.
(e) The advisory committee shall meet at least twice per
year, with each meeting being held before a meeting of the board.
Additional meetings may be held on reasonable notice of the time and
location of the meeting selected by the board. The advisory
committee shall meet at the call of the presiding officer or on
written request of three members of the committee. A meeting of the
committee is subject to Chapter 551, Government Code.
(f) The executive director of the exchange authority, or the
executive director's designee, shall attend each meeting of the
advisory committee.
(g) The members of the advisory committee shall determine
the dates of each meeting by majority vote or by the call of the
presiding officer on seven days' notice to all members.
(h) The advisory committee must post a notice, including the
date, time, and place, of a committee meeting on the exchange
authority's Internet website not less than five days before each
meeting. The notice must state that the meeting is open to the
public. All actions taken by the committee must be taken in open
session and on a majority vote of the members present.
(i) A member of the advisory committee may not receive
compensation but is entitled to reimbursement of the travel
expenses incurred by the member while conducting committee
business, subject to the availability of money. Reimbursement
under this subsection shall be paid from the exchange fund.
Sec. 1511.153. ADMINISTRATIVE POWERS AND DUTIES OF EXCHANGE
AUTHORITY. (a) The exchange authority shall exercise all powers
and duties necessary and appropriate to carry out the authority's
purpose, including:
(1) adopting bylaws;
(2) employing staff;
(3) making, executing, and delivering contracts;
(4) applying for, soliciting, and receiving money from
any source consistent with the purposes of this chapter;
(5) establishing priorities for and allocating and
distributing money received by the exchange authority;
(6) submitting the exchange authority's budget
annually and the exchange authority's budget request, including
amounts to be appropriated out of the exchange fund or premium
assistance and cost-sharing reduction fund as necessary to
administer the provisions of this chapter and the transfer of money
to the premium assistance and cost-sharing reduction fund,
biennially to the governor and the chairs of the standing
committees of the senate and house of representatives with primary
jurisdiction over appropriations;
(7) establishing travel reimbursement policies for
the exchange authority, the board, and the advisory committee;
(8) coordinating with the appropriate federal and
state agencies to seek waivers from statutory or regulatory
requirements as necessary to carry out the purposes of this
chapter;
(9) entering into other arrangements, including
interagency agreements with federal agencies and state agencies, as
necessary;
(10) giving reasonable public notice of any policies
and procedures the exchange authority may implement to operate the
exchange authority;
(11) ensuring that there is a sufficient number of
navigators and exchange assisters by awarding grants to navigators
and exchange assisters at a yearly average number that exceeds the
yearly average number of grants awarded in this state from 2013
through 2016;
(12) providing centralized training, support, and
technical assistance for navigators and exchange assisters;
(13) spending money on marketing and advertisements
for the exchange in an amount that exceeds the amount of money spent
in this state annually on marketing and advertisements in relation
to the federally facilitated marketplace from 2013 to 2016;
(14) coordinating innovative marketing and outreach
campaigns, including by working with and supporting local
enrollment coalitions, agents, and stakeholders;
(15) ensuring a sufficient amount of money is spent on
customer support services, including call centers, web support, and
navigator and agent support, to provide high-quality services,
including by:
(A) creating a special team with knowledge and
authority to resolve difficult eligibility and enrollment
challenges;
(B) ensuring call center staff are able to access
and share information specific to a consumer's application;
(C) investing in services and systems to improve
information for consumers with limited English proficiency;
(D) making the exchange Internet website and
application process mobile-friendly; and
(E) ensuring consumers can easily submit
documentation, when needed; and
(16) performing any other operational activities
necessary or appropriate under this chapter.
(b) The board must consider the advice of the advisory
committee established under Section 1511.152.
Sec. 1511.154. FUNCTIONS OF EXCHANGE AUTHORITY. (a) In
carrying out the purposes of this chapter, the exchange authority
shall:
(1) educate consumers, including through outreach, a
navigator program, and post-enrollment support;
(2) assist individuals in accessing income-based
assistance for which the individual may be eligible, including
premium assistance, premium tax credits, cost-sharing reductions,
and government programs;
(3) consider the need for consumer choice in rural,
urban, and suburban areas of the state;
(4) negotiate premium rates with health benefit plan
issuers on the exchange;
(5) contract selectively with health benefit plan
issuers to drive value and promote improvement in the delivery
system;
(6) standardize health benefit plan designs and
cost-sharing;
(7) leverage quality improvement and delivery system
reforms by encouraging participating health benefit plan issuers to
implement strategies to promote the delivery of better coordinated,
more efficient health care services;
(8) align with other large purchasers of health
benefit plans, including the state Medicaid program, the child
health plan program under Chapter 62, Health and Safety Code, the
Teacher Retirement System of Texas, and the Employees Retirement
System of Texas, to send consistent purchasing signals to health
benefit plan issuers and providers;
(9) recruit new health benefit plan issuers to areas
with less competition;
(10) leverage consumer decision-making through better
information and web-based decision-making tools;
(11) subject to Subsection (b), assess and collect
fees from health benefit plan issuers on the exchange to support the
operation of the exchange and premium assistance and cost-sharing
reduction programs; and
(12) distribute collected fees, including to benefit
premium assistance and cost-sharing reduction programs.
(b) The exchange authority may not assess or collect any
costs or fees under Subsection (a)(11) other than an exchange user
fee on total monthly premiums for health benefit plans on the
exchange. The fee may not exceed three percent unless approved by
unanimous consent of the board, and in no circumstance may the fee
exceed 3.5 percent. The exchange authority shall set aside a
percentage of the exchange user fee to increase subsidies for
health benefit plans.
Sec. 1511.155. DUTIES OF HEALTH BENEFIT PLAN ISSUERS. A
health benefit plan issuer that offers a qualified health plan on
the exchange shall:
(1) accept payment for enrollee premiums or
cost-sharing assistance provided under a premium assistance or
cost-sharing reduction program;
(2) clearly communicate premium assistance amounts to
enrollees as part of the invoicing and payment process; and
(3) accept and process enrollment and payment
information transferred by the exchange in a timely manner.
Sec. 1511.156. FEDERAL WAIVERS. (a) The exchange
authority, in close consultation with the commissioner and the
Health and Human Services Commission, shall explore all
opportunities to apply to the United States secretary of health and
human services for a waiver or other available federal
flexibilities under 42 U.S.C. Section 18052 to:
(1) receive federal money for the implementation of a
premium assistance or cost-sharing reduction program established
under Subchapter G;
(2) increase access to qualified health plans; and
(3) implement or expand other exchange programs that
increase affordability of or access to health insurance coverage in
this state.
(b) If the exchange authority identifies an opportunity to
apply for a waiver under Subsection (a), the exchange authority, in
collaboration with the commissioner and the Health and Human
Services Commission, may develop a waiver application to be
submitted by the Health and Human Services Commission. The Health
and Human Services Commission shall promptly notify the chairs of
the standing committees of the senate and house of representatives
with primary jurisdiction over appropriations and insurance of any
submitted waiver application.
(c) To ensure a meaningful level of public input, a waiver
application submitted under Subsection (b) must meet all federal
public notice and comment requirements under 42 U.S.C. Section
18052(a)(4)(B), including public hearings.
Sec. 1511.157. ENFORCEMENT AND STATE SOVEREIGNTY. The
exchange authority shall ensure that the exchange complies with the
Patient Protection and Affordable Care Act (Pub. L. No. 111-148)
and its subsequent amendments and any federal regulations
promulgated under that act in a manner that maintains state
sovereignty over the health insurance market in this state.
Enforcement responsibilities shall be delegated to the appropriate
state agencies and must be sufficient to prevent a determination by
the United States secretary of health and human services that the
state has failed to substantially enforce any provision of the
Patient Protection and Affordable Care Act.
SUBCHAPTER E. EXAMINATION AND REPORTING REQUIREMENTS FOR EXCHANGE
AUTHORITY
Sec. 1511.201. ANNUAL AUDIT. (a) The exchange authority
shall have an examination and audit of the exchange authority
conducted annually by an independent certified public accounting
firm. The audit must:
(1) assess compliance with the requirements of this
chapter; and
(2) identify any material weaknesses or significant
deficiencies and identify and implement solutions to correct those
weaknesses or deficiencies.
(b) Not later than December 31 of each year, the exchange
authority shall:
(1) post on the exchange authority's Internet website:
(A) the audit for the preceding year; and
(B) a summary of the audit, including any
identified material weaknesses or significant deficiencies and the
authority's proposed solution for those weaknesses or
deficiencies; and
(2) provide to the secretary of the senate and the
chief clerk of the house of representatives and the department an
electronic link to the web page on which the audit information in
Subdivision (1) is posted.
(c) The exchange authority shall pay for the cost of the
annual examination and audit under Subsection (a) with money from
the exchange fund.
Sec. 1511.202. ANNUAL REPORTS. (a) The exchange authority
shall prepare an annual report regarding the activities of the
exchange authority for the preceding year.
(b) The exchange authority shall:
(1) electronically submit the report required under
this section to the governor, the lieutenant governor, the speaker
of the house of representatives, and the chairs of the standing
committees of the senate and house of representatives with primary
jurisdiction over appropriations and insurance;
(2) post the report on the exchange authority's
Internet website; and
(3) provide a copy of the electronic link to the posted
report under Subdivision (2) to the department.
SUBCHAPTER F. EXCHANGE FUND
Sec. 1511.251. EXCHANGE FUND. (a) The exchange fund is
established as a revolving fund in the state treasury outside the
general revenue fund.
(b) The exchange authority may deposit assessments, gifts
or donations, and any federal funding obtained by the exchange
authority in the exchange fund in accordance with procedures
established by the comptroller.
(c) The exchange fund shall be administered by the exchange
authority for the purposes of the exchange established under this
chapter, including the deposit of federal money available for the
exchange and all other money received under or distributed in
accordance with this subchapter.
(d) Interest or other income from the investment of the
exchange fund shall be deposited to the credit of the fund.
SUBCHAPTER G. PREMIUM ASSISTANCE AND COST-SHARING REDUCTION
PROGRAMS
Sec. 1511.301. ESTABLISHMENT OF PROGRAM. (a) The exchange
authority shall establish and administer a premium assistance or
cost-sharing reduction program.
(b) The exchange authority shall establish procedural
requirements for:
(1) eligibility for and continued participation in any
premium assistance or cost-sharing reduction program established
under this subchapter, including participant documentation
requirements that are necessary to administer the program; and
(2) facilitating payments to health benefit plan
issuers.
(c) Before establishing or altering premium assistance or
cost-sharing reduction amounts, eligibility criteria, or
procedural requirements under this subchapter, the exchange
authority must:
(1) publish a notice of the proposal on the exchange
authority's Internet website that includes:
(A) an explanation of the proposal;
(B) the date, time, and location of the public
hearing required under Subdivision (3); and
(C) instructions and reasonable timelines to
submit written comments on the proposal;
(2) provide an electronic notice of the proposal that
includes the information required under Subdivision (1) to any
person who requests notice;
(3) conduct at least one public hearing not earlier
than 20 days after the date on which the exchange authority
publishes notice under Subdivision (1);
(4) publish a notice of the finalized premium
assistance or cost-sharing reduction amounts, eligibility
criteria, or procedural requirements on the exchange authority's
Internet website that includes:
(A) a detailed description of the finalized
premium assistance or cost-sharing reduction amounts, eligibility
criteria, or procedural requirements; and
(B) a description and explanation of how the
finalized amounts, criteria, or requirements vary from the initial
proposal; and
(5) provide an electronic notice with the information
required under Subdivision (4) to any person who requests notice.
Sec. 1511.302. PREMIUM ASSISTANCE AND COST-SHARING
REDUCTION AMOUNTS. The exchange authority shall set premium
assistance and cost-sharing reduction amounts within parameters
that achieve the following goals:
(1) stay within the operating budget;
(2) lower net monthly premium payments for eligible
individuals to maximize enrollment and reduce the number of
uninsured individuals;
(3) reduce out-of-pocket costs, providing for less
exposure to medical debt; and
(4) maximize the impact of federal spending on advance
premium tax credits.
Sec. 1511.303. ELIGIBILITY FOR PROGRAM. An individual is
eligible for premium assistance or cost-sharing reductions under
this subchapter if the individual:
(1) is a resident of this state;
(2) is eligible to purchase coverage on the exchange
and to receive federal advance premium tax credits;
(3) has an income that is less than or equal to the
income threshold determined by the exchange authority;
(4) is enrolled in a qualified health plan in the
silver or gold level, as described by Section 1302(d), Patient
Protection and Affordable Care Act (42 U.S.C. Section 18022(d)),
that is offered in the enrollee's county of residence;
(5) applies for and accepts all federal advance
premium tax credits for which the individual is eligible before
receiving any state premium assistance;
(6) if the individual qualifies for a federal
cost-sharing reduction plan with an actuarial value of 87 percent
or higher, applies for and accepts all federal cost-sharing
reductions for which the individual is eligible before receiving
any state cost-sharing reductions;
(7) is ineligible for minimum essential coverage
through Medicare or a federal or state medical assistance program
administered by the Health and Human Services Commission; and
(8) meets any other eligibility criteria established
by the exchange authority.
Sec. 1511.304. DISQUALIFICATION FROM PROGRAM. The exchange
authority may disqualify an individual from receiving premium
assistance or cost-sharing reductions under this subchapter if the
individual:
(1) no longer meets the eligibility criteria described
by Section 1511.303;
(2) fails, without good cause, to comply with any
procedural or documentation requirements established by the
exchange authority under Section 1511.301;
(3) fails, without good cause, to notify the exchange
authority of a change of address in a timely manner;
(4) voluntarily withdraws from the program; or
(5) performs an act, practice, or omission that
constitutes fraud, and, as a result, a qualified health plan issuer
rescinds the individual's policy.
Sec. 1511.305. ELIGIBILITY APPEAL. The exchange authority
shall develop a process for an individual to appeal a premium
assistance or cost-sharing assistance eligibility determination.
Sec. 1511.306. PREMIUM ASSISTANCE AND COST-SHARING
REDUCTION FUND. (a) The premium assistance and cost-sharing
reduction fund is established as a revolving fund in the state
treasury outside the general revenue fund.
(b) The fund shall be administered by the exchange authority
for the purpose of premium assistance and cost-sharing reduction
programs established under this subchapter.
(c) The fund consists of:
(1) gifts, grants, and donations received by this
state for the purposes of the fund;
(2) legislative appropriations of money for the
purposes of this subchapter;
(3) federal money available to this state that may be
used for the purposes of this subchapter, including federal money
received through a federal waiver submitted under Section 1511.156;
and
(4) interest, dividends, and other income of the fund.
(d) Money from the fund may be used to:
(1) implement and operate premium assistance and
cost-sharing reduction programs established under this subchapter;
and
(2) make payments to health benefit plan issuers under
a premium assistance or cost-sharing reduction program established
under this subchapter.
SUBCHAPTER H. ENFORCEMENT
Sec. 1511.351. ENFORCEMENT REMEDIES. (a) On satisfactory
evidence of a violation of this chapter by a health benefit plan
issuer or other person, the commissioner may, at the commissioner's
discretion, impose any of the following enforcement remedies:
(1) suspension or revocation of the person's license
or certificate of authority;
(2) refusal to issue a new license or certificate of
authority to the person, for a period not to exceed one year; or
(3) a fine not to exceed $5,000 for each violation,
except that the fine may be up to $10,000 if the violation was
intentional.
(b) Fines imposed by the commissioner against an individual
health benefit plan issuer may not exceed an aggregate amount of
$500,000 during a single calendar year.
(c) Fines imposed against a person not described by
Subsection (b) may not exceed an aggregate amount of $100,000
during a single calendar year.
(d) The enforcement remedies under Subsection (a) are in
addition to any other remedies or penalties that may be imposed
under other law.
SUBCHAPTER I. TRANSITION PERIOD FOR ESTABLISHMENT OF EXCHANGE
Sec. 1511.401. BUDGET FOR EXCHANGE. (a) In developing the
exchange and premium assistance and cost-sharing reduction
programs, the exchange authority, in coordination with the
department, shall create a budget to fully implement the purposes
and functions of the exchange authority, the exchange, and premium
assistance and cost-sharing reduction programs under this chapter.
(b) The exchange authority shall conduct a fiscal analysis
to determine ways in which the exchange authority can achieve the
purposes of this chapter while spending less on exchange user fees
than was spent for the federally facilitated exchange. The
exchange authority must include in the fiscal analysis any funding
sources available for specific purposes or functions under this
chapter, including federal Medicaid matching funds.
(c) In creating a budget under Subsection (a), the exchange
authority shall set:
(1) subject to Section 1511.154(b), the exchange user
fee at an amount that covers the costs of operating the exchange and
premium assistance and cost-sharing reduction programs; and
(2) parameters for premium assistance and
cost-sharing reduction programs that achieve the goals described by
Section 1511.302.
Sec. 1511.402. ENROLLMENT INCREASE TARGETS. (a) For the
period of transition during which the exchange is being established
and for the following five years, the department shall establish
clearly stated numeric targets of increased enrollment in the
exchange, the state Medicaid program, and the child health plan
program under Chapter 62, Health and Safety Code.
(b) The department shall take immediate steps to increase
enrollment, including by lengthening open enrollment periods and
streamlining special enrollment periods.
Sec. 1511.403. INCREASED ENROLLMENT ADVISORY COMMITTEE.
(a) The department shall create an advisory committee to:
(1) study ways to increase enrollment in this state;
and
(2) help develop the five-year plan to reach the
numeric targets established under Section 1511.402.
(b) The department shall provide funding to the advisory
committee for the purpose of employing staff and contracting with a
person or entity to provide expertise, actuarial services, or other
services as needed.
(c) The advisory committee shall provide recommendations to
the department and the exchange authority regarding strategies for
increasing enrollment, including recommendations regarding the
establishment and administration of premium assistance and
cost-sharing reduction programs.
Sec. 1511.404. EXPIRATION OF SUBCHAPTER. This subchapter
expires September 1, 2029.
SECTION 2. (a) As soon as practicable after the effective
date of this Act, but not later than October 1, 2023, the governor
shall appoint the initial members of the board of directors of the
Texas Health Insurance Exchange Authority. The initial board
members shall draw lots to achieve staggered terms, with two of the
directors serving a term expiring February 1, 2025, two of the
directors serving a term expiring February 1, 2027, and three of the
directors serving a term expiring February 1, 2029.
(b) As soon as practicable after the effective date of this
Act, but not later than March 1, 2024, the board of directors of the
Texas Health Insurance Exchange Authority shall adopt rules and
procedures necessary to implement Chapter 1511, Insurance Code, as
added by this Act.
(c) Until the board of directors of the Texas Health
Insurance Exchange Authority adopts rules under Subsection (b) of
this section, the exchange authority shall operate the exchange in
accordance with:
(1) any applicable federal rules, regulations, or
guidance; or
(2) interim state guidelines consistent with Chapter
1511, Insurance Code, as added by this Act.
SECTION 3. This Act takes effect immediately if it receives
a vote of two-thirds of all the members elected to each house, as
provided by Section 39, Article III, Texas Constitution. If this
Act does not receive the vote necessary for immediate effect, this
Act takes effect September 1, 2023.