Bill Text: TX SB145 | 2019-2020 | 86th Legislature | Introduced


Bill Title: Relating to health benefit plan coverage in this state.

Spectrum: Partisan Bill (Democrat 1-0)

Status: (Introduced - Dead) 2019-02-01 - Referred to Business & Commerce [SB145 Detail]

Download: Texas-2019-SB145-Introduced.html
  86R1744 MEW-F
 
  By: Rodríguez S.B. No. 145
 
 
 
A BILL TO BE ENTITLED
 
AN ACT
  relating to health benefit plan coverage in this state.
         BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
  ARTICLE 1. HEALTH BENEFIT AFFORDABILITY AND ACCESSIBILITY
         SECTION 1.01.  Subtitle A, Title 8, Insurance Code, is
  amended by adding Chapter 1219 to read as follows:
  CHAPTER 1219.  HEALTH BENEFIT AFFORDABILITY AND ACCESSIBILITY
  SUBCHAPTER A.  GENERAL PROVISIONS
         Sec. 1219.001.  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. 1219.002.  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 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)  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 1219.001.
         (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. 1219.003.  CONFLICT WITH OTHER LAW. If this chapter
  conflicts with another law relating to lifetime or annual benefit
  limits or the imposition of a premium, deductible, copayment,
  coinsurance, or other cost-sharing provision, this chapter
  controls.
  SUBCHAPTER B.  CERTAIN COST-SHARING AND COVERAGE AMOUNT LIMITS
  PROHIBITED
         Sec. 1219.051.  CERTAIN COST-SHARING PROVISIONS FOR
  PREVENTIVE SERVICES PROHIBITED.  A health benefit plan issuer may
  not impose a deductible, copayment, coinsurance, or other
  cost-sharing provision applicable to benefits for:
               (1)  a preventive item or service that has in effect a
  rating of "A" or "B" in the most recent recommendations of the
  United States Preventive Services Task Force;
               (2)  an immunization recommended for routine use in the
  most recent immunization schedules published by the United States
  Centers for Disease Control and Prevention of the United States
  Public Health Service; or
               (3)  preventive care and screenings supported by the
  most recent comprehensive guidelines adopted by the United States
  Health Resources and Services Administration.
         Sec. 1219.052.  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. 1219.053.  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. 1219.054.  DISCRIMINATION BASED ON GENDER PROHIBITED.
  A health benefit plan issuer may not charge an individual a higher
  premium rate based on the individual's gender.
  SUBCHAPTER C.  COVERAGE OF PREEXISTING CONDITIONS
         Sec. 1219.101.  DEFINITION. In this subchapter,
  "preexisting condition" means a condition present before the
  effective date of an individual's coverage under a health benefit
  plan.
         Sec. 1219.102.  PREEXISTING CONDITION RESTRICTIONS
  PROHIBITED. Notwithstanding any other law, a health benefit plan
  issuer may not:
               (1)  deny an individual's application for coverage or
  refuse to enroll an individual in a health benefit plan due to a
  preexisting condition;
               (2)  limit or exclude coverage under the health benefit
  plan for the treatment of a preexisting condition otherwise covered
  under the plan; or
               (3)  charge the individual more for coverage than the
  health benefit plan issuer charges an individual who does not have a
  preexisting condition.
  SUBCHAPTER D.  EXTERNAL REVIEW PROCEDURE
         Sec. 1219.151.  EXTERNAL REVIEW MODEL ACT RULES.  (a)  The
  department shall adopt rules as necessary to conform Texas law with
  the requirements of the NAIC Uniform Health Carrier External Review
  Model Act (April 2010).
         (b)  To the extent that the rules adopted under this section
  conflict with Chapter 843 or Title 14, the rules control.
         ARTICLE 2.  HEALTH BENEFIT PLAN COVERAGE FOR MENTAL HEALTH
  CONDITIONS AND SUBSTANCE USE DISORDERS
         SECTION 2.01.  Section 1355.252, Insurance Code, is amended
  by adding Subsections (d) and (e) to read as follows:
         (d)  Notwithstanding any other law, 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.
         (e)  This subchapter 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.
         SECTION 2.02.  Section 1355.253, Insurance Code, is amended
  by amending Subsection (b) and adding Subsection (c) to read as
  follows:
         (b)  To the extent that this section would otherwise require
  this state to make a payment under 42 U.S.C. Section
  18031(d)(3)(B)(ii), a qualified health plan, as defined by 45
  C.F.R. Section 155.20, is not required to provide a benefit under
  this subchapter that exceeds the specified essential health
  benefits required under 42 U.S.C. Section 18022(b), as that section
  existed on January 1, 2017.
         (c)  This subchapter 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.
  ARTICLE 3.  COVERAGE OF ESSENTIAL HEALTH BENEFITS
         SECTION 3.01.  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 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.
  ARTICLE 4. HEALTH BENEFIT PLAN COVERAGE FOR CERTAIN YOUNG ADULTS
         SECTION 4.01.  Subchapter A, Chapter 533, Government Code,
  is amended by adding Section 533.0057 to read as follows:
         Sec. 533.0057.  ELIGIBILITY AGE FOR STAR HEALTH COVERAGE. A
  child enrolled in the STAR Health Medicaid managed care program is
  eligible to receive health care services under the program until
  the child is 26 years of age.
         SECTION 4.02.  Section 846.260, Insurance Code, is amended
  to read as follows:
         Sec. 846.260.  LIMITING AGE APPLICABLE TO UNMARRIED CHILD.
  If children are eligible for coverage under the terms of a multiple
  employer welfare arrangement's plan document, any limiting age
  applicable to an unmarried child of an enrollee is 26 [25] years of
  age.
         SECTION 4.03.  Section 1201.053(b), Insurance Code, is
  amended to read as follows:
         (b)  On the application of an adult member of a family, an
  individual accident and health insurance policy may, at the time of
  original issuance or by subsequent amendment, insure two or more
  eligible members of the adult's family, including a spouse,
  unmarried children younger than 26 [25] years of age, including a
  grandchild of the adult as described by Section 1201.062(a)(1), a
  child the adult is required to insure under a medical support order
  or dental support order, if the policy provides dental coverage,
  issued under Chapter 154, Family Code, or enforceable by a court in
  this state, and any other individual dependent on the adult.
         SECTION 4.04.  Section 1201.062(a), Insurance Code, is
  amended to read as follows:
         (a)  An individual or group accident and health insurance
  policy that is delivered, issued for delivery, or renewed in this
  state, including a policy issued by a corporation operating under
  Chapter 842, or a self-funded or self-insured welfare or benefit
  plan or program, to the extent that regulation of the plan or
  program is not preempted by federal law, that provides coverage for
  a child of an insured or group member, on payment of a premium, must
  provide coverage for:
               (1)  each grandchild of the insured or group member if
  the grandchild is:
                     (A)  unmarried;
                     (B)  younger than 26 [25] years of age; and
                     (C)  a dependent of the insured or group member
  for federal income tax purposes at the time application for
  coverage of the grandchild is made; and
               (2)  each child for whom the insured or group member
  must provide medical support or dental support, if the policy
  provides dental coverage, under an order issued under Chapter 154,
  Family Code, or enforceable by a court in this state.
         SECTION 4.05.  Section 1201.065(a), Insurance Code, is
  amended to read as follows:
         (a)  An individual or group accident and health insurance
  policy may contain criteria relating to a maximum age or enrollment
  in school to establish continued eligibility for coverage of a
  child 26 [25] years of age or older.
         SECTION 4.06.  Section 1251.151(a), Insurance Code, is
  amended to read as follows:
         (a)  A group policy or contract of insurance for hospital,
  surgical, or medical expenses incurred as a result of accident or
  sickness, including a group contract issued by a group hospital
  service corporation, that provides coverage under the policy or
  contract for a child of an insured must, on payment of a premium,
  provide coverage for any grandchild of the insured if the
  grandchild is:
               (1)  unmarried;
               (2)  younger than 26 [25] years of age; and
               (3)  a dependent of the insured for federal income tax
  purposes at the time the application for coverage of the grandchild
  is made.
         SECTION 4.07.  Section 1251.152(a), Insurance Code, is
  amended to read as follows:
         (a)  For purposes of this section, "dependent" includes:
               (1)  a child of an employee or member who is:
                     (A)  unmarried; and
                     (B)  younger than 26 [25] years of age; and
               (2)  a grandchild of an employee or member who is:
                     (A)  unmarried;
                     (B)  younger than 26 [25] years of age; and
                     (C)  a dependent of the insured for federal income
  tax purposes at the time the application for coverage of the
  grandchild is made.
         SECTION 4.08.  Section 1271.006(a), Insurance Code, is
  amended to read as follows:
         (a)  If children are eligible for coverage under the terms of
  an evidence of coverage, any limiting age applicable to an
  unmarried child of an enrollee, including an unmarried grandchild
  of an enrollee, is 26 [25] years of age. The limiting age
  applicable to a child must be stated in the evidence of coverage.
         SECTION 4.09.  Section 1501.002(2), Insurance Code, is
  amended to read as follows:
               (2)  "Dependent" means:
                     (A)  a spouse;
                     (B)  a child younger than 26 [25] years of age,
  including a newborn child;
                     (C)  a child of any age who is:
                           (i)  medically certified as disabled; and
                           (ii)  dependent on the parent;
                     (D)  an individual who must be covered under:
                           (i)  Section 1251.154; or
                           (ii)  Section 1201.062; and
                     (E)  any other child eligible under an employer's
  health benefit plan, including a child described by Section
  1503.003.
         SECTION 4.10.  Section 1501.609(b), Insurance Code, is
  amended to read as follows:
         (b)  Any limiting age applicable under a large employer
  health benefit plan to an unmarried child of an enrollee is 26 [25]
  years of age.
         SECTION 4.11.  Sections 1503.003(a) and (b), Insurance Code,
  are amended to read as follows:
         (a)  A health benefit plan may not condition coverage for a
  child younger than 26 [25] years of age on the child's being
  enrolled at an educational institution.
         (b)  A health benefit plan that requires as a condition of
  coverage for a child 26 [25] years of age or older that the child be
  a full-time student at an educational institution must provide the
  coverage:
               (1)  for the entire academic term during which the
  child begins as a full-time student and remains enrolled,
  regardless of whether the number of hours of instruction for which
  the child is enrolled is reduced to a level that changes the child's
  academic status to less than that of a full-time student; and
               (2)  continuously until the 10th day of instruction of
  the subsequent academic term, on which date the health benefit plan
  may terminate coverage for the child if the child does not return to
  full-time student status before that date.
         SECTION 4.12.  Section 1601.004(a), Insurance Code, is
  amended to read as follows:
         (a)  In this chapter, "dependent," with respect to an
  individual eligible to participate in the uniform program under
  Section 1601.101 or 1601.102, means the individual's:
               (1)  spouse;
               (2)  unmarried child younger than 26 [25] years of age;
  and
               (3)  child of any age who lives with or has the child's
  care provided by the individual on a regular basis if the child has
  a mental disability or is [mentally retarded or] physically
  incapacitated to the extent that the child is dependent on the
  individual for care or support, as determined by the system.
  ARTICLE 5.  TRANSITION; EFFECTIVE DATE
         SECTION 5.01.  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, 2020. A health benefit
  plan that is delivered, issued for delivery, or renewed before
  January 1, 2020, 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 5.02.  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 5.03.  This Act takes effect September 1, 2019.
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