Bill Text: TX SB1782 | 2011-2012 | 82nd Legislature | Introduced
Bill Title: Relating to regulation of health benefit plan issuers in this state.
Spectrum: Partisan Bill (Democrat 1-0)
Status: (Introduced - Dead) 2011-03-23 - Referred to State Affairs [SB1782 Detail]
Download: Texas-2011-SB1782-Introduced.html
82R10135 TJS-F | ||
By: Ellis | S.B. No. 1782 |
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relating to regulation of health benefit plan issuers in this | ||
state. | ||
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: | ||
ARTICLE 1. CREATION OF THE TEXAS HEALTH INSURANCE EXCHANGE | ||
SECTION 1.01. Subtitle G, Title 8, Insurance Code, is | ||
amended by adding Chapter 1509 to read as follows: | ||
CHAPTER 1509. TEXAS HEALTH INSURANCE EXCHANGE | ||
SUBCHAPTER A. GENERAL PROVISIONS | ||
Sec. 1509.001. DEFINITIONS. In this chapter: | ||
(1) "Board" means the board of directors of the | ||
exchange. | ||
(2) "Catastrophic plan" has the meaning assigned by | ||
Section 1302(e), Patient Protection and Affordable Care Act (Pub. | ||
L. No. 111-148). | ||
(3) "Educated health care consumer" means an | ||
individual who is knowledgeable about the health care system and | ||
has background or experience in making informed decisions regarding | ||
health, medical, and scientific matters. | ||
(4) "Enrollee" means an individual who is enrolled in | ||
a qualified health plan. | ||
(5) "Exchange" means the Texas Health Insurance | ||
Exchange. | ||
(6) "Executive commissioner" means the executive | ||
commissioner of the Health and Human Services Commission. | ||
(7) "Qualified employer" means an employer that elects | ||
to make all of its full-time employees eligible for one or more | ||
qualified health plans offered through the exchange and, at the | ||
option of the employer, some or all of its part-time employees and: | ||
(A) has its principal place of business in this | ||
state and elects to provide coverage through the exchange to all of | ||
its eligible employees, wherever employed; or | ||
(B) elects to provide coverage through the | ||
exchange to all of its eligible employees who are principally | ||
employed in this state and who are eligible to participate in a | ||
qualified health plan. | ||
(8) "Qualified health plan" means a health benefit | ||
plan that has been certified by the board as meeting the criteria | ||
specified by Section 1311(c), Patient Protection and Affordable | ||
Care Act (Pub. L. No. 111-148). | ||
(9) "Qualified individual" means an individual, | ||
including a minor, who: | ||
(A) seeks to enroll in a qualified health plan | ||
offered to individuals through the exchange; | ||
(B) resides in this state; | ||
(C) at the time of enrollment, is not | ||
incarcerated, other than incarceration pending the disposition of | ||
charges; and | ||
(D) is, and is reasonably expected to be, for the | ||
entire period for which enrollment is sought, a citizen or national | ||
of the United States or an alien lawfully present in the United | ||
States. | ||
(10) "Secretary" means the secretary of the United | ||
States Department of Health and Human Services. | ||
(11) "SHOP Exchange" means a Small Business Health | ||
Options Program as defined by Section 1311(b)(1)(B), Patient | ||
Protection and Affordable Care Act (Pub. L. No. 111-148). | ||
Sec. 1509.002. 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 fraternal benefit society operating under | ||
Chapter 885; | ||
(4) a stipulated premium company operating under | ||
Chapter 884; | ||
(5) an exchange operating under Chapter 942; | ||
(6) a health maintenance organization operating under | ||
Chapter 843; | ||
(7) a multiple employer welfare arrangement that holds | ||
a certificate of authority under Chapter 846; or | ||
(8) an approved nonprofit health corporation that | ||
holds a certificate of authority under Chapter 844. | ||
(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); | ||
(3) a workers' compensation insurance policy; or | ||
(4) medical payment insurance coverage provided under | ||
a motor vehicle insurance policy. | ||
Sec. 1509.003. DEFINITION OF SMALL EMPLOYER. (a) For | ||
purposes of this chapter, "small employer" means a person who | ||
employed at least two, and an average of not more than 50 employees | ||
during the preceding calendar year. This subsection expires | ||
December 31, 2013. | ||
(b) All persons treated as a single employer under Section | ||
414(b), (c), (m), or (o), Internal Revenue Code of 1986, are single | ||
employers for purposes of this chapter. | ||
(c) An employer and any predecessor employer are a single | ||
employer for purposes of this chapter. | ||
(d) In determining the number of employees of an employer | ||
under this section, the number of employees: | ||
(1) includes part-time employees and employees who are | ||
not eligible for coverage through the employer; and | ||
(2) for an employer that did not have employees during | ||
the entire preceding calendar year, is the average number of | ||
employees that the employer is reasonably expected to employ on | ||
business days in the current calendar year. | ||
(e) A small employer that makes enrollment in qualified | ||
health benefit plans available to its employees through the | ||
exchange and ceases to be a small employer by reason of an increase | ||
in the number of its employees continues to be a small employer for | ||
purposes of this chapter as long as it continuously makes | ||
enrollment through the exchange available to its employees. | ||
Sec. 1509.004. RULEMAKING AUTHORITY. 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 secretary under the Patient | ||
Protection and Affordable Care Act (Pub. L. No. 111-148). | ||
Sec. 1509.005. AGENCY COOPERATION. (a) The exchange, 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 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 its 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; | ||
(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 and procedures to assure that individuals are | ||
meaningfully informed of: | ||
(A) the potential existence of overpayments of | ||
advance tax credits; | ||
(B) procedures for reconciling enrollee | ||
liability for repayment in the event that an advance tax credit is | ||
subsequently proved to be an overpayment; | ||
(C) procedures by which individuals can report a | ||
change in income that may affect the subsequent level of advance tax | ||
payment or the availability of a safe harbor; and | ||
(D) information regarding safe harbors against | ||
overpayment liability or recoupment that may exist under federal or | ||
state law; and | ||
(9) develop cross-market participation by: | ||
(A) encouraging the development of common | ||
provider networks, network performance standards for health | ||
benefit plans that participate in the exchange, Medicaid, and the | ||
state child health plan program, and developing coverage terms and | ||
quality standards in order to ensure maximum continuity and quality | ||
of care; | ||
(B) promoting participation by health benefit | ||
plans that satisfy both qualified health plan and Medicaid managed | ||
care plan criteria, in order to minimize disruption in care as a | ||
result of enrollment shifts between subsidy sources; | ||
(C) developing incentives, including quality | ||
ratings, default enrollment preferences, and other approaches, in | ||
order to encourage health benefit plans to participate in both | ||
Medicaid and the exchange; and | ||
(D) coordinating health benefit plan payments | ||
and timely adjustments in all markets that may result from | ||
enrollment changes. | ||
Sec. 1509.006. EXEMPTION FROM STATE TAXES AND FEES. The | ||
exchange is not subject to any state tax, regulatory fee, or | ||
surcharge, including a premium or maintenance tax or fee. | ||
Sec. 1509.007. COMPLIANCE WITH FEDERAL LAW. The exchange | ||
shall comply with all applicable federal law and regulations. | ||
Sec. 1509.008. TEMPORARY EXEMPTION FROM STATE PURCHASING | ||
PROCEDURES. (a) The exchange is not subject to state purchasing or | ||
procurement requirements under Subtitle D, Title 10, Government | ||
Code, or any other law. | ||
(b) This section expires January 1, 2016. | ||
[Sections 1509.009-1509.050 reserved for expansion] | ||
SUBCHAPTER B. ESTABLISHMENT AND GOVERNANCE | ||
Sec. 1509.051. ESTABLISHMENT. The Texas Health Insurance | ||
Exchange is established as the American Health Benefit Exchange and | ||
the Small Business Health Options Program (SHOP) Exchange | ||
authorized and required by Section 1311, Patient Protection and | ||
Affordable Care Act (Pub. L. No. 111-148). | ||
Sec. 1509.052. GOVERNANCE OF EXCHANGE; BOARD MEMBERSHIP. | ||
(a) The exchange is governed by a board of directors. | ||
(b) The board consists of seven members as follows: | ||
(1) five appointed members: | ||
(A) one of whom is appointed by the governor; | ||
(B) two of whom are appointed by the lieutenant | ||
governor; and | ||
(C) two of whom are appointed by the speaker of | ||
the house of representatives; | ||
(2) the commissioner as an ex officio voting member; | ||
and | ||
(3) the executive commissioner as an ex officio voting | ||
member. | ||
(c) Each of the five board members appointed under | ||
Subsection (b)(1) must have demonstrated experience in at least two | ||
of the following areas: | ||
(1) individual health care coverage; | ||
(2) small employer health care coverage; | ||
(3) health benefit plan administration; | ||
(4) health care finance or economics; | ||
(5) actuarial science; | ||
(6) administration of a public or private health care | ||
delivery system; and | ||
(7) purchasing health plan coverage. | ||
(d) The board must include members who are health care | ||
consumers or small business owners. | ||
(e) In making appointments under this section, the | ||
governor, lieutenant governor, and speaker of the house of | ||
representatives shall attempt to make appointments that increase | ||
the board's diversity of expertise. | ||
Sec. 1509.053. PRESIDING OFFICER. The board shall annually | ||
designate one member of the board to serve as presiding officer. | ||
Sec. 1509.054. TERMS; VACANCY. (a) Appointed members of | ||
the board serve two-year terms. | ||
(b) The appropriate appointing authority 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. 1509.055. CONFLICT OF INTEREST. (a) Any board member | ||
or a member of a committee formed by the board with a direct | ||
interest in a matter, personally or through an employer, before the | ||
board shall abstain from deliberations and actions on the matter in | ||
which the conflict of interest arises and shall further abstain | ||
from any vote on the matter, and may not otherwise participate in a | ||
decision on the matter. | ||
(b) Each board member shall file a conflict of interest | ||
statement and a statement of ownership interests with the board to | ||
ensure disclosure of all existing and potential personal interests | ||
related to board business. | ||
(c) A member of the board or of the staff of the exchange may | ||
not be employed by, affiliated with, a consultant to, a member of | ||
the board of directors of, or otherwise a representative of an | ||
issuer or other insurer, an agent or broker, a health care provider, | ||
or a health care facility or health clinic while serving on the | ||
board or on the staff of the exchange. | ||
(d) A member of the board or of the staff of the exchange may | ||
not be a member, a board member, or an employee of a trade | ||
association of issuers, health facilities, health clinics, or | ||
health care providers while serving on the board or on the staff of | ||
the exchange. | ||
(e) A member of the board or of the staff of the exchange may | ||
not be a health care provider unless the member receives no | ||
compensation for rendering services as a health care provider and | ||
does not have an ownership interest in a professional health care | ||
practice. | ||
Sec. 1509.056. GENERAL DUTIES OF BOARD MEMBERS. (a) Each | ||
board member has the responsibility and duty to meet the | ||
requirements of this title and applicable state and federal laws | ||
and regulations, to serve the public interest of the individuals | ||
and small businesses seeking health care coverage through the | ||
exchange, and to ensure the operational well-being and fiscal | ||
solvency of the exchange. | ||
(b) A member of the board may not make, participate in | ||
making, or in any way attempt to use the board member's official | ||
position to influence the making of any decision that the board | ||
member knows or has reason to know will have a material financial | ||
effect, distinguishable from its effect on the public generally, on | ||
the board member or the board member's immediate family, or on: | ||
(1) any source of income, other than gifts and loans by | ||
a commercial lending institution in the regular course of business | ||
on terms available to the public generally, aggregating $250 or | ||
more in value, provided or promised to the member within the 12 | ||
months immediately preceding the date the decision is made; or | ||
(2) any business entity in which the member is a | ||
director, officer, partner, trustee, or employee, or holds any | ||
position of management. | ||
Sec. 1509.057. REIMBURSEMENT. A member of the board is not | ||
entitled to compensation but is entitled to reimbursement for | ||
travel or other expenses incurred while performing duties as a | ||
board member in the amount provided by the General Appropriations | ||
Act for state officials. | ||
Sec. 1509.058. MEMBER'S IMMUNITY. (a) A member of the | ||
board is not liable for an act or omission made in good faith in the | ||
performance of powers and duties under this chapter. | ||
(b) A cause of action does not arise against a member of the | ||
board for an act or omission described by Subsection (a). | ||
Sec. 1509.059. OPEN RECORDS AND OPEN MEETINGS. The board is | ||
subject to Chapters 551 and 552, Government Code. | ||
Sec. 1509.060. RECORDS. The board shall keep records of the | ||
board's proceedings for at least seven years. | ||
[Sections 1509.061-1509.100 reserved for expansion] | ||
SUBCHAPTER C. POWERS AND DUTIES OF EXCHANGE | ||
Sec. 1509.101. EMPLOYEES; COMMITTEES. (a) The board may | ||
employ an executive director, a chief fiscal officer, a chief | ||
operations officer, a director of health plan contracting, a chief | ||
technology and information officer, a general counsel, and any | ||
other agents and employees that the board considers necessary to | ||
assist the exchange in carrying out its responsibilities and | ||
functions. | ||
(b) The executive director shall organize, administer, and | ||
manage the operations of the exchange. The executive director may | ||
hire other employees as necessary to carry out the responsibilities | ||
of the exchange. | ||
(c) The exchange 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. | ||
(d) The board shall set the salary for an agent or employee | ||
position under this section in an amount reasonably necessary to | ||
attract and retain individuals of superior qualifications. In | ||
determining the compensation for these positions, the board shall | ||
conduct, through the use of independent outside advisors, salary | ||
surveys of both other state and federal health insurance exchanges | ||
that are most comparable to the exchange and other relevant labor | ||
pools. | ||
(e) The salaries established by the board under this section | ||
may not exceed the highest comparable salary for a position of that | ||
type, as determined by the salary surveys in Subsection (d). | ||
(f) The board shall publish the salaries under this section | ||
in the board's annual budget and post the budget on an Internet | ||
website maintained by the exchange. | ||
Sec. 1509.102. ADVISORY COMMITTEE. The board shall appoint | ||
an advisory committee to allow for the involvement of the health | ||
care and health insurance industries and other stakeholders in the | ||
operation of the exchange. The advisory committee may provide | ||
expertise and recommendations to the board but may not adopt rules | ||
or enter into contracts on behalf of the exchange. | ||
Sec. 1509.103. CONTRACTS. (a) Except as provided by | ||
Subsection (b), the exchange may enter into any contract that the | ||
exchange considers necessary to implement or administer this | ||
chapter, including a contract with the Health and Human Services | ||
Commission or an entity that has experience in individual and small | ||
group health insurance, benefit administration, or other | ||
experience relevant to the responsibilities assumed by the entity, | ||
to perform functions or provide services in connection with the | ||
operation of the exchange. | ||
(b) This exchange may not enter into a contract with a | ||
health benefit plan issuer under this section. | ||
Sec. 1509.104. INFORMATION SHARING AND CONFIDENTIALITY. | ||
The exchange may enter into information-sharing agreements with | ||
federal and state agencies to carry out the exchange's | ||
responsibilities under this chapter. 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. 1509.105. MEMORANDUM OF UNDERSTANDING. The exchange | ||
shall enter into a memorandum of understanding with the department | ||
and the Health and Human Services Commission regarding the exchange | ||
of information and the division of regulatory functions among the | ||
exchange, the department, and the commission. | ||
Sec. 1509.106. LEGAL ACTION. (a) The exchange may sue or | ||
be sued. | ||
(b) The exchange may take any legal action necessary to | ||
recover or collect amounts due the exchange, including: | ||
(1) assessments due the exchange; | ||
(2) amounts erroneously or improperly paid by the | ||
exchange; and | ||
(3) amounts paid by the exchange as a mistake of fact | ||
or law. | ||
Sec. 1509.107. FUNCTIONS. (a) The exchange shall make | ||
qualified health plans available to qualified individuals and | ||
qualified employers. | ||
(b) The exchange may not make available any health benefit | ||
plan that is not a qualified health plan. | ||
(c) The exchange may allow a health benefit plan issuer to | ||
offer a plan that provides limited scope dental benefits meeting | ||
the requirements of Section 9832(c)(2)(A), Internal Revenue Code of | ||
1986, through the exchange, either separately or in conjunction | ||
with a qualified health plan, if the plan provides pediatric dental | ||
benefits meeting the requirements of Section 1302(b)(1)(J), | ||
Patient Protection and Affordable Care Act (Pub. L. No. 111-148). | ||
(d) The exchange, or an issuer offering a health benefit | ||
plan through the exchange, may not charge an individual a fee or | ||
penalty for termination of coverage if the individual enrolls in | ||
another type of minimum essential coverage because the individual | ||
has become eligible for that coverage or because the individual's | ||
employer-sponsored coverage has become affordable under the | ||
standards of Section 36B(c)(2)(C), Internal Revenue Code of 1986. | ||
(e) In implementing the requirements of this section, the | ||
exchange shall: | ||
(1) by rule establish procedures consistent with | ||
federal law and regulations for the certification, | ||
recertification, and decertification of health benefit plans as | ||
qualified health plans; | ||
(2) provide for the operation of a toll-free telephone | ||
hotline to respond to requests for assistance, utilizing staff that | ||
is trained to provide assistance in a culturally and linguistically | ||
appropriate manner; | ||
(3) provide oral interpretation services in any | ||
language for individuals seeking coverage through the exchange and | ||
make available a toll-free telephone number for the hearing and | ||
speech impaired; | ||
(4) maintain an Internet website through which an | ||
enrollee or prospective enrollee may obtain standardized | ||
comparative information on a qualified health plan's premiums, | ||
coverage, cost-sharing, ratings, enrollee satisfaction, quality | ||
measures, and other relevant information; | ||
(5) use a standardized format for presenting health | ||
benefit options in the exchange, including the use of the uniform | ||
outline of coverage established under Section 2715, Public Health | ||
Service Act (42 U.S.C. Section 300gg-51); | ||
(6) assign a rating to each qualified health plan | ||
certified by the exchange based on criteria developed by the | ||
secretary; | ||
(7) ensure that written information made available by | ||
the exchange is presented in a plainly worded, easily | ||
understandable format and made available in prevalent languages; | ||
(8) determine each qualified health plan's level of | ||
coverage in accordance with regulations issued by the secretary | ||
under Section 1302(d)(2)(A), Patient Protection and Affordable | ||
Care Act (Pub. L. No. 111-148); and | ||
(9) in accordance with federal law and regulations, | ||
inform individuals of eligibility requirements for Medicaid, the | ||
state child health plan program, or any applicable state or local | ||
public program and if through screening of the application by the | ||
exchange, the exchange determines that an individual is eligible | ||
for such program, enroll the individual in the program. | ||
(f) In addition to performing the duties described by | ||
Subsection (e), and consistent with Section 1413, Patient | ||
Protection and Affordable Care Act (Pub. L. No. 111-148), the | ||
exchange shall: | ||
(1) enter into data-sharing agreements with relevant | ||
state and federal agencies to facilitate eligibility | ||
determinations and enrollment; | ||
(2) provide enrollment information and other relevant | ||
data, consistent with federal and state privacy rules, to the | ||
qualified health plan in which a qualified individual or qualified | ||
small employer is enrolled; | ||
(3) conduct redeterminations of eligibility for | ||
subsidies and assist in reenrollment as necessary, if an individual | ||
experiences changes in income or circumstances; | ||
(4) inform individuals of the potential for | ||
overpayments of advance premium tax credits and of procedures by | ||
which individuals can report a change of income that may affect the | ||
subsequent level of premium tax credits, including the availability | ||
of any safe harbor from recoupment of any overpayment, to the extent | ||
permitted by that Act or any federal regulations promulgated under | ||
that Act; | ||
(5) establish, and make available electronically, a | ||
calculator designed to: | ||
(A) enable consumers to determine the actual cost | ||
of coverage after the application of any premium tax credit or | ||
cost-sharing subsidy available under federal law; and | ||
(B) provide consumers with information on | ||
out-of-pocket costs for in-network and, if feasible, | ||
out-of-network services, taking into account any cost-sharing | ||
reductions; | ||
(6) establish capability through which qualified | ||
employers may access coverage for their employees, and which shall | ||
enable any qualified employer to specify a level of coverage so that | ||
any of its employees may enroll in any qualified health plan offered | ||
through the exchange at the specified level of coverage; | ||
(7) subject to Section 1411, Patient Protection and | ||
Affordable Care Act (Pub. L. No. 111-148), grant a certification | ||
attesting that, for purposes of the individual responsibility | ||
penalty under Section 5000A, Internal Revenue Code of 1986, an | ||
individual is exempt from the individual responsibility | ||
requirement or from the penalty imposed by that section because: | ||
(A) there is no affordable qualified health plan | ||
available through the exchange, or the individual's employer, | ||
covering the individual; or | ||
(B) the individual meets the requirements for any | ||
other such exemption from the individual responsibility | ||
requirement or penalty; | ||
(8) transfer to the United States secretary of the | ||
treasury the following: | ||
(A) a list of the individuals who are issued a | ||
certification under Subdivision (7), including the name and | ||
taxpayer identification number of each individual; | ||
(B) the name and taxpayer identification number | ||
of each individual who was an employee of an employer but who was | ||
determined to be eligible for the premium tax credit under Section | ||
36B, Internal Revenue Code of 1986, because the employer did not | ||
provide minimum essential coverage, or the employer provided the | ||
minimum essential coverage, but it was determined under Section | ||
36B(c)(2)(C) of that code to be either unaffordable to the employee | ||
or not provide the required minimum actuarial value; and | ||
(C) the name and taxpayer identification number | ||
of each individual who notifies the exchange under Section | ||
1411(b)(4), Patient Protection and Affordable Care Act (Pub. L. No. | ||
111-148), that he or she has changed employers and each individual | ||
who ceases coverage under a qualified health plan during a plan | ||
year, and the effective date of that cessation; | ||
(9) provide to each employer the name of each employee | ||
of the employer described above who ceases coverage under a | ||
qualified health plan during a plan year and the effective date of | ||
the cessation; | ||
(10) perform duties required of the exchange by the | ||
secretary or the United States secretary of the treasury related to | ||
determining eligibility for premium tax credits, reduced | ||
cost-sharing, or individual responsibility requirement exemptions; | ||
(11) select entities qualified to serve as Navigators | ||
in accordance with Section 1311(i), Patient Protection and | ||
Affordable Care Act (Pub. L. No. 111-148), and standards developed | ||
by the secretary; and | ||
(12) award grants to enable Navigators to: | ||
(A) conduct public education activities to raise | ||
awareness of the availability of qualified health plans; | ||
(B) distribute fair and impartial information | ||
concerning enrollment in qualified health plans, and the | ||
availability of premium tax credits under Section 36B, Internal | ||
Revenue Code of 1986, and cost-sharing reductions under Section | ||
1402, Patient Protection and Affordable Care Act (Pub. L. No. | ||
111-148); | ||
(C) facilitate enrollment in qualified health | ||
plans; | ||
(D) provide referrals to any applicable office of | ||
health insurance consumer assistance or health insurance ombudsman | ||
established under Section 2793, Public Health Service Act (42 | ||
U.S.C. Section 300gg-93), or any other appropriate state agency or | ||
agencies, for any enrollee with a grievance, complaint, or question | ||
regarding the enrollee's health benefit plan or coverage or a | ||
determination under that plan or coverage; | ||
(E) provide information in a manner that is | ||
culturally and linguistically appropriate to the needs of the | ||
population being served by the exchange; and | ||
(F) counsel exchange participants about the | ||
exchange, Medicaid, and the state child health plan program | ||
markets, including selection of plans and transition procedures for | ||
transitioning among Medicaid, the state child health plan program, | ||
exchange plans, and other coverage; | ||
(13) ensure that there is a sufficient number of | ||
Navigators that possess the experience and capacity to serve | ||
disadvantaged, hard-to-reach, and culturally or linguistically | ||
isolated populations; | ||
(14) certify Navigators as able to carry out the | ||
duties required by Section 1311(i)(3), Patient Protection and | ||
Affordable Care Act (Pub. L. No. 111-148); | ||
(15) review the rate of premium growth within the | ||
exchange and outside the exchange and consider the information in | ||
developing recommendations on whether to continue limiting | ||
qualified employer status to small employers; | ||
(16) credit the amount of any free choice voucher to | ||
the monthly premium of the plan in which a qualified employee is | ||
enrolled, in accordance with Section 10108, Patient Protection and | ||
Affordable Care Act (Pub. L. No. 111-148), and collect the amount | ||
credited from the offering employer; | ||
(17) consult with stakeholders relevant to carrying | ||
out the activities required under this chapter, including: | ||
(A) educated health care consumers who are | ||
enrollees in qualified health plans; | ||
(B) individuals and entities with experience in | ||
facilitating enrollment in qualified health plans; | ||
(C) representatives of small businesses and | ||
self-employed individuals; | ||
(D) the Health and Human Services Commission; and | ||
(E) advocates for enrolling hard-to-reach | ||
populations; | ||
(18) meet the following financial integrity | ||
requirements: | ||
(A) keep an accurate accounting of all | ||
activities, receipts, and expenditures and annually submit to the | ||
secretary, the governor, the commissioner, and the legislature a | ||
report concerning such accountings; and | ||
(B) fully cooperate with any investigation | ||
conducted by the secretary pursuant to the secretary's authority | ||
under the Patient Protection and Affordable Care Act (Pub. L. No. | ||
111-148) and allow the secretary, in coordination with the | ||
inspector general of the United States Department of Health and | ||
Human Services, to investigate the affairs of the exchange, examine | ||
the books and records of the exchange, and require periodic reports | ||
in relation to the activities undertaken by the exchange; | ||
(19) use a single application for enrollment in | ||
Medicaid, the state child health plan program, and health benefit | ||
plans offered in the exchange, including establishing eligibility | ||
for premium tax credits and cost-sharing reductions, that may be: | ||
(A) the single application form developed by the | ||
secretary under Section 1413(b), Patient Protection and Affordable | ||
Care Act (Pub. L. No. 111-148); or | ||
(B) an application form developed in cooperation | ||
with the Health and Human Services Commission for that purpose; | ||
(20) undertake activities necessary to market and | ||
publicize the availability of health care coverage and federal | ||
subsidies through the exchange; | ||
(21) undertake outreach and enrollment activities | ||
that seek to assist enrollees and potential enrollees with | ||
enrolling and reenrolling in the exchange in the least burdensome | ||
manner, including populations that may experience barriers to | ||
enrollment, such as the disabled and those with limited English | ||
language proficiency; | ||
(22) provide for: | ||
(A) the processing of applications for coverage | ||
under a qualified health plan; | ||
(B) the enrollment of persons in qualified health | ||
plans; | ||
(C) the disenrollment of enrollees from | ||
qualified health plans; and | ||
(D) for individual coverage, the collection of | ||
premiums and assistance in the administration of subsidies, as the | ||
board considers appropriate; and | ||
(23) for small employers, collect and aggregate | ||
premiums and administer all other necessary and related tasks, | ||
including enrollment and plan payment, in order to make the | ||
offering of employee plan choice as simple as possible for | ||
qualified small employers. | ||
Sec. 1509.108. CERTIFICATION OF PLAN. The exchange shall | ||
certify a health benefit plan as a qualified health plan if: | ||
(1) the plan provides the essential health benefits | ||
package described by Section 1302(a), Patient Protection and | ||
Affordable Care Act (Pub. L. No. 111-148), except that the plan is | ||
not required to provide essential benefits that duplicate the | ||
minimum benefits of qualified dental plans, if: | ||
(A) the exchange has determined that at least one | ||
qualified dental plan is available to supplement the plan's | ||
coverage; and | ||
(B) the issuer makes prominent disclosure at the | ||
time it offers the plan, in a form approved by the exchange, that | ||
the plan does not provide the full range of essential pediatric | ||
benefits and that qualified dental plans providing those benefits | ||
and other dental benefits not covered by the plan are offered | ||
through the exchange; | ||
(2) the premium rates and contract language have been | ||
approved by the commissioner; | ||
(3) the plan provides at least a bronze level of | ||
coverage, as described by Section 1302(d), Patient Protection and | ||
Affordable Care Act (Pub. L. No. 111-148), unless the plan is a | ||
catastrophic plan and is offered only to individuals eligible for | ||
catastrophic coverage; | ||
(4) the plan's cost-sharing requirements do not exceed | ||
the limits established under Section 1302(c)(1), Patient | ||
Protection and Affordable Care Act (Pub. L. No. 111-148), and if the | ||
plan is offered to small employers, the plan's deductible does not | ||
exceed the limits established under Section 1302(c)(2) of that Act; | ||
(5) the health benefit plan issuer offering the plan: | ||
(A) is licensed and in good standing to offer | ||
health insurance coverage in this state; | ||
(B) offers at least one qualified health plan in | ||
the silver level and at least one plan in the gold level as | ||
described by Section 1302(d), Patient Protection and Affordable | ||
Care Act (Pub L. No. 111-148); | ||
(C) charges the same premium rate for each | ||
qualified health plan without regard to whether the plan is offered | ||
through the exchange and without regard to whether the plan is | ||
offered directly from the issuer or through an insurance producer; | ||
and | ||
(D) complies with the regulations developed by | ||
the secretary under Section 1311(d), Patient Protection and | ||
Affordable Care Act (Pub. L. No. 111-148), and other requirements | ||
the exchange establishes; | ||
(6) the plan meets the requirements of certification | ||
under this chapter and any rules promulgated by the secretary under | ||
Section 1311(c), Patient Protection and Affordable Care Act (Pub. | ||
L. No. 111-148), including minimum standards in the areas of | ||
marketing practices, network adequacy, essential community | ||
providers in underserved areas, accreditation, quality | ||
improvement, uniform enrollment forms and descriptions of | ||
coverage, and information on quality measures for health benefit | ||
plan performance; and | ||
(7) the exchange determines that making the plan | ||
available through the exchange is in the interest of qualified | ||
individuals and qualified employers in this state. | ||
Sec. 1509.109. PROHIBITED BASES FOR DENIAL OF | ||
CERTIFICATION. The exchange may not deny certification to a health | ||
benefit plan on the ground that the plan: | ||
(1) is a fee-for-service plan; or | ||
(2) provides treatments necessary to prevent patients' | ||
deaths in circumstances the exchange determines are inappropriate | ||
or too costly. | ||
Sec. 1509.110. PREREQUISITES TO CERTIFICATION. (a) The | ||
exchange shall require each health benefit plan issuer seeking | ||
certification of a plan as a qualified health plan to: | ||
(1) submit a justification for any premium increase | ||
before implementation of that increase; | ||
(2) prominently display the justification for any | ||
premium increase on the health benefit plan issuer's Internet | ||
website; | ||
(3) make available to the public, in plain language as | ||
that term is defined in Section 1311(e)(3)(B), Patient Protection | ||
and Affordable Care Act (Pub. L. No. 111-148), and submit to the | ||
exchange, the secretary, and the commissioner, accurate and timely | ||
disclosure of: | ||
(A) claims payment policies and practices; | ||
(B) periodic financial disclosures; | ||
(C) data on enrollment; | ||
(D) data on disenrollment; | ||
(E) data on the number of claims that are denied; | ||
(F) data on rating practices; | ||
(G) information on cost-sharing and payments | ||
with respect to any out-of-network coverage; | ||
(H) information on enrollee and participant | ||
rights under Title I, Patient Protection and Affordable Care Act | ||
(Pub. L. No. 111-148); and | ||
(I) other information as determined appropriate | ||
by the secretary; | ||
(4) on request, inform an individual of the amount of | ||
cost-sharing, including deductibles, copayments, and coinsurance, | ||
under the individual's plan or coverage that the individual would | ||
be responsible for paying with respect to the furnishing of a | ||
specific item or service by a participating provider; | ||
(5) make the information required to be disclosed | ||
under Subdivision (4) made available to the individual on an | ||
Internet website and by other means for individuals without access | ||
to the Internet; | ||
(6) promptly notify affected individuals of price and | ||
benefit changes or other changes in circumstance that could | ||
materially impact enrollment or coverage; | ||
(7) make available to the exchange and regularly | ||
update an electronic directory of contracting health care providers | ||
so that individuals seeking coverage through the exchange can | ||
search by health care provider name to determine which health plans | ||
in the exchange include that health care provider in their network; | ||
and | ||
(8) as the board considers necessary, provide | ||
regularly updated information to the exchange as to whether a | ||
health care provider is accepting new patients for a particular | ||
health plan. | ||
(b) In determining whether to certify an issuer, the | ||
exchange shall consider premium increase justification information | ||
obtained under Subsection (a), together with information and | ||
recommendations provided by the commissioner under Section | ||
2794(b), Public Health Service Act (42 U.S.C. Section 300gg-94(b)). | ||
Sec. 1509.111. ADDITIONAL REQUIREMENTS RELATING TO | ||
RULEMAKING BY BOARD. In adopting rules under this chapter, the | ||
board shall: | ||
(1) standardize benefits and cost-sharing within | ||
tiers for products to be offered through the exchange; | ||
(2) establish and use a competitive process, which is | ||
not required to comply with Chapter 2151, Government Code, to | ||
select participating health benefit plan issuers; | ||
(3) determine the minimum requirements an issuer must | ||
meet to be considered for participation in the exchange and the | ||
standards and criteria for selecting qualified health plans to be | ||
offered through the exchange that are in the best interests of | ||
qualified individuals and qualified small employers; | ||
(4) consistently and uniformly apply any | ||
requirements, standards, and criteria under this chapter to all | ||
issuers; | ||
(5) in the course of selectively contracting for | ||
health care coverage offered to qualified individuals and qualified | ||
small employers through the exchange, seek to contract with issuers | ||
to provide health care coverage choices that offer the optimal | ||
combination of choice, value, quality, and service; | ||
(6) ensure, in each region of the state, a choice of | ||
qualified health plans at each of the five tiers of coverage | ||
contained in Sections 1302(d) and (e), Patient Protection and | ||
Affordable Care Act (Pub. L. No. 111-148); | ||
(7) require issuers, as a condition of participation | ||
in the exchange, to fairly and affirmatively offer, market, and | ||
sell in the exchange at least one product within each of the five | ||
levels of coverage described by Sections 1302(d) and (e), Patient | ||
Protection and Affordable Care Act (Pub. L. No. 111-148), and, as | ||
the board considers necessary, to offer additional products within | ||
each of the five levels of coverage described by Section 1302(d) of | ||
that Act; and | ||
(8) require, as a condition of participation in the | ||
exchange, issuers that sell any products outside the exchange to | ||
fairly and affirmatively offer, market, and sell: | ||
(A) all products made available to individuals in | ||
the exchange to individuals purchasing coverage outside the | ||
exchange; or | ||
(B) all products made available to small | ||
employers in the exchange to small employers purchasing coverage | ||
outside the exchange. | ||
Sec. 1509.112. EXEMPTION FROM STANDARDS PROHIBITED. (a) | ||
The exchange may not exempt any health benefit plan issuer seeking | ||
certification of a qualified health plan, regardless of the type or | ||
size of the issuer, from state licensing or solvency requirements. | ||
(b) The exchange shall apply the criteria of this section in | ||
a manner that assures a fair competitive market between or among | ||
health benefit plan issuers participating in the exchange. | ||
Sec. 1509.113. DENTAL PLANS. (a) This chapter applies to | ||
dental plans as provided in this section. | ||
(b) A health benefit plan issuer may be certified to offer | ||
dental coverage, without being certified to offer other health | ||
coverages. | ||
(c) A plan may be limited to dental and oral health benefits | ||
without substantially duplicating the benefits typically offered | ||
by health benefit plans that do not offer dental coverage. | ||
(d) To be certified under this chapter, a dental plan must | ||
include, at a minimum, the essential pediatric dental benefits | ||
prescribed by the secretary pursuant to Section 1302(b)(1)(J), | ||
Patient Protection and Affordable Care Act (Pub. L. No. 111-148), | ||
and any other dental benefits the exchange or the secretary | ||
specifies by regulation. | ||
(e) An issuer may offer jointly with another issuer a | ||
comprehensive plan through the exchange in which dental benefits | ||
are provided by an issuer through a qualified dental plan and the | ||
other benefits are provided by an issuer through a qualified health | ||
plan. Plans offered under this subsection must be priced | ||
separately and made available for purchase separately at the same | ||
price at which they are offered together. | ||
Sec. 1509.114. (a) The exchange may provide an integrated | ||
and uniform consumer directory of health care providers indicating | ||
which health benefit plan issuers the providers contract with and | ||
whether the providers are currently accepting new patients. | ||
(b) The exchange may establish methods by which health care | ||
providers may transmit relevant information directly to the | ||
exchange, rather than through an issuer. | ||
[Sections 1509.115-1509.150 reserved for expansion] | ||
SUBCHAPTER D. ASSESSMENTS FOR OPERATION OF EXCHANGE | ||
Sec. 1509.151. ASSESSMENTS; PENALTY FOR NONPAYMENT. (a) | ||
The exchange may charge the issuers of health benefit plans in this | ||
state, including qualified health plans, an assessment as | ||
reasonable and necessary for the exchange's organizational and | ||
operating expenses. Assessments must be determined annually. The | ||
exchange may charge interest for late assessments. | ||
(b) The exchange may refuse to recertify or may decertify a | ||
health benefit plan as a qualified health plan if the issuer of the | ||
plan fails or refuses to pay an assessment under this section. | ||
(c) The commissioner shall adopt rules to implement and | ||
enforce the assessment of health benefit plan issuers under this | ||
section. | ||
Sec. 1509.152. GRANTS AND FEDERAL FUNDS. (a) The exchange | ||
may accept a grant from a public or private organization and may | ||
spend those funds to pay the costs of program administration and | ||
operations. | ||
(b) The exchange may accept federal funds and shall use | ||
those funds in compliance with applicable federal law, regulations, | ||
and guidelines. | ||
Sec. 1509.153. USE OF EXCHANGE ASSETS; ANNUAL REPORT. (a) | ||
The assets of the exchange may be used only to pay the costs of the | ||
administration and operation of the exchange. | ||
(b) The exchange shall prepare annually a complete and | ||
detailed written report accounting for all funds received and | ||
disbursed by the exchange during the preceding fiscal year. The | ||
report must meet any reporting requirements provided in the General | ||
Appropriations Act, regardless of whether the exchange receives any | ||
funds under that Act. The exchange shall submit the report to the | ||
governor, the legislature, the commissioner, and the executive | ||
commissioner not later than January 31 of each year. | ||
(c) General revenue may not be appropriated for the | ||
exchange. | ||
Sec. 1509.154. PUBLICATION OF FINANCIAL INFORMATION. The | ||
exchange shall publish the average costs of licensing, regulatory | ||
fees, and any other payments required by the exchange, and the | ||
administrative costs of the exchange, on an Internet website to | ||
educate consumers on those costs. This information must include | ||
information on losses due to waste, fraud, and abuse. | ||
[Sections 1509.155-1509.200 reserved for expansion] | ||
SUBCHAPTER E. TRUST FUND | ||
Sec. 1509.201. TRUST FUND. (a) The exchange fund is | ||
established as a special trust fund outside of the state treasury in | ||
the custody of the comptroller separate and apart from all public | ||
money or funds of this state. | ||
(b) The exchange may deposit assessments, gifts or | ||
donations, and any federal funding obtained by the exchange in the | ||
exchange fund in accordance with procedures established by the | ||
comptroller. | ||
(c) Interest or other income from the investment of the fund | ||
shall be deposited to the credit of the fund. | ||
[Sections 1509.202-1509.250 reserved for expansion] | ||
SUBCHAPTER F. LEVEL PLAYING FIELD | ||
Sec. 1509.251. LEVEL PLAYING FIELD. (a) The commissioner | ||
shall adopt rules to ensure a level playing field and a fair | ||
competitive market environment among issuers that offer qualified | ||
health plans through the exchange and issuers that offer health | ||
benefit plans or other health insurance coverage outside of the | ||
exchange. Notwithstanding any other law, the rules shall, to the | ||
extent practicable, ensure against adverse selection either in | ||
favor of or against exchange-participating issuers. | ||
(b) To discourage adverse selection or steering of | ||
enrollees to or from the exchange, if the board opts to pay agents | ||
helping people enroll in exchange-participating, qualified plans a | ||
fee, instead of using existing compensation structures directly | ||
from issuers, the exchange shall survey the market outside of the | ||
exchange to determine prevailing agent commission rates and set | ||
exchange fees in a manner that is consistent with prevailing rates | ||
in the market outside of the exchange. This section does not | ||
prohibit the exchange from paying a per member per month fee or | ||
using another fee structure if: | ||
(1) prevailing rates in the market outside of the | ||
exchange are paid a percentage of premiums; and | ||
(2) the total fee amounts earned are reasonably | ||
expected to be similar. | ||
(c) The department shall coordinate with the exchange as | ||
necessary to survey the market on commission rates and identify | ||
prevailing practices. Agent fees paid inside or outside of the | ||
exchange must be fully transparent and clearly disclosed to the | ||
purchaser. | ||
SECTION 1.02. Effective January 1, 2014, Section 1509.004, | ||
Insurance Code, as added by this Act, is amended by adding | ||
Subsection (a-1) to read as follows: | ||
(a-1) For purposes of this chapter, "small employer" means a | ||
person who employed an average of not more than 100 employees during | ||
the preceding calendar year. | ||
SECTION 1.03. (a) As soon as practicable after the | ||
effective date of this Act, but not later than October 31, 2011, the | ||
governor, lieutenant governor, and speaker of the house of | ||
representatives shall appoint the initial members of the board of | ||
directors of the Texas Health Insurance Exchange. | ||
(b) As soon as practicable after the appointments required | ||
by Subsection (a) of this section are made, but not later than | ||
November 30, 2011, the board of directors of the Texas Health | ||
Insurance Exchange shall hold a special meeting to discuss the | ||
adoption of rules and procedures necessary to implement Chapter | ||
1509, Insurance Code, as added by this Act. | ||
(c) As soon as practicable after the effective date of this | ||
Act, but not later than January 31, 2012, the board of directors of | ||
the Texas Health Insurance Exchange shall adopt rules and | ||
procedures necessary to implement Chapter 1509, Insurance Code, as | ||
added by this Act. | ||
(d) Not later than January 1, 2017, the board shall issue a | ||
report to the 85th Legislature recommending whether to adopt the | ||
option in Section 1312(c), Patient Protection and Affordable Care | ||
Act (Pub. L. No. 111-148), to merge the individual and small | ||
employer markets. In the report, the board shall provide | ||
information, based on at least two years of data from the exchange, | ||
on the potential impact on rates paid by individuals and by small | ||
employers in a merged individual and small employer market, as | ||
compared to the rates paid by individuals and small employers if a | ||
separate individual and small employer market is maintained. | ||
(e) If, after the effective date of this Act but before the | ||
initial members of the board of directors of the Texas Health | ||
Insurance Exchange have been appointed as required by Subsection | ||
(a), the Texas Department of Insurance becomes aware of any | ||
planning and establishment grants as described by Section 1311, | ||
Patient Protection and Affordable Care Act (Pub. L. No. 111-148), | ||
or any other public or private funding source, the department may | ||
apply for funding from that source. | ||
(f) The exchange may not begin operations without adequate | ||
funding. | ||
(g) The board of directors of the Texas Health Insurance | ||
Exchange may adopt rules on an emergency basis in accordance with | ||
Section 2001.034, Government Code. Notwithstanding Section | ||
2001.034(c), Government Code, a rule adopted under this subsection | ||
may remain in effect until January 1, 2015. Rules adopted under | ||
this subsection shall be deemed necessary for the immediate | ||
preservation of the public peace, health, safety, and general | ||
welfare and an additional finding under Sections 2001.034(a)(1) and | ||
(2), Government Code, is not required. The authority to adopt rules | ||
under this subsection expires January 1, 2015. | ||
ARTICLE 2. EMERGENCY COVERAGE UNDER CERTAIN MANAGED CARE PLANS | ||
SECTION 2.01. Section 843.107, Insurance Code, is amended | ||
to read as follows: | ||
Sec. 843.107. INDEMNITY BENEFITS; POINT-OF-SERVICE | ||
PROVISIONS. (a) A health maintenance organization may offer: | ||
(1) indemnity benefits covering out-of-area emergency | ||
care; | ||
(2) indemnity benefits, in addition to those relating | ||
to out-of-area and emergency care, provided through an insurer or | ||
group hospital service corporation; | ||
(3) a point-of-service plan under Subchapter A, | ||
Chapter 1273; or | ||
(4) a point-of-service rider under Section 843.108. | ||
(b) A health maintenance organization that offers indemnity | ||
benefits covering out-of-area emergency care under this section | ||
shall apply the same cost-sharing requirement to the emergency care | ||
as it applies to emergency care provided in-area. | ||
SECTION 2.02. Section 843.348, Insurance Code, is amended | ||
by adding Subsection (k) to read as follows: | ||
(k) A health maintenance organization may not require | ||
preauthorization for emergency care. | ||
SECTION 2.03. Sections 1271.155(a) and (b), Insurance Code, | ||
are amended to read as follows: | ||
(a) A health maintenance organization shall pay for | ||
emergency care performed by non-network physicians or providers at | ||
the same rate the health maintenance organization pays for | ||
emergency care performed by network physicians or providers [ |
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(b) A health care plan of a health maintenance organization | ||
must provide the following coverage of emergency care: | ||
(1) a medical screening examination or other | ||
evaluation required by state or federal law necessary to determine | ||
whether an emergency medical condition exists shall be provided to | ||
covered enrollees in a hospital emergency facility or comparable | ||
facility; | ||
(2) necessary emergency care shall be provided to | ||
covered enrollees, including the treatment and stabilization of an | ||
emergency medical condition; [ |
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(3) services originated in a hospital emergency | ||
facility, freestanding emergency medical care facility, or | ||
comparable emergency facility following treatment or stabilization | ||
of an emergency medical condition shall be provided to covered | ||
enrollees as approved by the health maintenance organization, | ||
subject to Subsections (c) and (d); and | ||
(4) as required by Section 1867, Social Security Act | ||
(42 U.S.C. Section 1395dd), medical screening examinations that are | ||
within the capability of the emergency department of a hospital, | ||
including ancillary services routinely available to the emergency | ||
department to evaluate the patient's condition and any further | ||
medical examination and treatment necessary to stabilize the | ||
patient within the capabilities of the staff and facilities | ||
available at the hospital shall be provided to covered enrollees. | ||
SECTION 2.04. Section 1273.004, Insurance Code, is amended | ||
to read as follows: | ||
Sec. 1273.004. LIMITED BENEFITS AND SERVICES; COST-SHARING | ||
PROVISIONS. (a) Indemnity benefits and services provided under a | ||
point-of-service plan may be limited to those services described by | ||
the blended contract and may be subject to different cost-sharing | ||
provisions. The cost-sharing provisions for indemnity benefits may | ||
be higher than the cost-sharing provisions for in-network health | ||
maintenance organization coverage. For an enrollee in a limited | ||
provider network, higher cost-sharing may be imposed only when the | ||
enrollee obtains benefits or services outside the health | ||
maintenance organization delivery network. | ||
(b) Notwithstanding Subsection (a), indemnity benefits and | ||
services provided under a point-of-service plan that covers | ||
emergency care may not be subject to different cost-sharing | ||
provisions. The cost-sharing provisions for indemnity benefits | ||
related to emergency care may not be higher than the cost-sharing | ||
provisions for in-network health maintenance organization | ||
coverage. For an enrollee in a limited provider network, higher | ||
cost-sharing provisions may not be imposed when the enrollee | ||
obtains emergency care outside the health maintenance organization | ||
delivery network. | ||
SECTION 2.05. Section 1301.135, Insurance Code, is amended | ||
by adding Subsection (i) to read as follows: | ||
(i) An insurer that uses a preauthorization process for | ||
medical care and health care services may not require | ||
preauthorization for emergency care. | ||
SECTION 2.06. Section 1301.155(b), Insurance Code, is | ||
amended to read as follows: | ||
(b) If an insured cannot reasonably reach a preferred | ||
provider, an insurer shall provide reimbursement for the following | ||
emergency care services at the preferred level of benefits until | ||
the insured can reasonably be expected to transfer to a preferred | ||
provider: | ||
(1) a medical screening examination or other | ||
evaluation required by state or federal law to be provided in the | ||
emergency facility of a hospital that is necessary to determine | ||
whether a medical emergency condition exists; | ||
(2) necessary emergency care services, including the | ||
treatment and stabilization of an emergency medical condition; | ||
[ |
||
(3) services originating in a hospital emergency | ||
facility or freestanding emergency medical care facility following | ||
treatment or stabilization of an emergency medical condition; and | ||
(4) as required by Section 1867, Social Security Act | ||
(42 U.S.C. Section 1395dd), medical screening examinations that are | ||
within the capability of the emergency department of a hospital, | ||
including ancillary services routinely available to the emergency | ||
department to evaluate the patient's condition and any further | ||
medical examination and treatment necessary to stabilize the | ||
patient within the capabilities of the staff and facilities | ||
available at the hospital. | ||
SECTION 2.07. The changes in law made by this article apply | ||
only to a health insurance policy or contract or health maintenance | ||
organization contract or agreement that is delivered, issued for | ||
delivery, or renewed on or after January 1, 2012. A health | ||
insurance policy or contract or health maintenance organization | ||
contract or agreement that is delivered, issued for delivery, or | ||
renewed before January 1, 2012, is covered by the law in effect | ||
immediately before the effective date of this Act, and that law is | ||
continued in effect for that purpose. | ||
ARTICLE 3. SELECTION OF PRIMARY CARE PHYSICIANS AND PROVIDERS | ||
UNDER PREFERRED PROVIDER BENEFIT PLANS AND HEALTH MAINTENANCE | ||
ORGANIZATIONS | ||
SECTION 3.01. Section 843.203, Insurance Code, is amended | ||
by amending Subsection (b) and adding Subsections (d) and (e) to | ||
read as follows: | ||
(b) An enrollee shall at all times have the right to select | ||
or change a primary care physician or primary care provider within | ||
the health maintenance organization network of available primary | ||
care physicians and primary care providers[ |
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physician or primary care provider who is available to accept the | ||
individual. | ||
(d) For an enrollee who is a child, the health maintenance | ||
organization must allow the child's parent or guardian to designate | ||
as the child's primary care physician or primary care provider a | ||
participating physician who specializes in pediatrics. | ||
(e) A health maintenance organization shall notify each | ||
enrollee of the enrollee's rights under Subsections (b) and (d). | ||
SECTION 3.02. Subchapter D, Chapter 1301, Insurance Code, | ||
is amended by adding Section 1301.164 to read as follows: | ||
Sec. 1301.164. SELECTION OF PRIMARY CARE PHYSICIAN OR | ||
PROVIDER. (a) If a preferred provider benefit plan requires or | ||
provides for designation by an insured of a participating primary | ||
care physician or primary care provider, the insurer shall allow an | ||
insured to designate any participating primary care physician or | ||
primary care provider who is available to accept the individual. | ||
(b) For an enrollee who is a child, the insurer must allow | ||
the child's parent or guardian to designate as the child's primary | ||
care physician or primary care provider a participating physician | ||
who specializes in pediatrics. | ||
(c) An insurer shall notify each insured of the insured's | ||
rights under this section. | ||
SECTION 3.03. The change in law made by this article applies | ||
only to a health insurance policy or contract or health maintenance | ||
organization contract or agreement that is delivered or issued for | ||
delivery on or after January 1, 2012. An insurance policy or | ||
contract or health maintenance organization contract or agreement | ||
that is delivered or issued for delivery before January 1, 2012, 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. | ||
ARTICLE 4. HEALTH BENEFIT PLAN COVERAGE OF CERTAIN DEPENDENTS | ||
SECTION 4.01. 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 [ |
||
age. | ||
SECTION 4.02. 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 [ |
||
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 | ||
issued under Chapter 154, Family Code, or enforceable by a court in | ||
this state, a foster child, a stepchild, a child of a domestic | ||
partner if the domestic partner is eligible to be insured and is | ||
insured under the policy, and any other individual dependent on the | ||
adult. | ||
SECTION 4.03. 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 [ |
||
(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 under an order issued under Chapter | ||
154, Family Code, or enforceable by a court in this state. | ||
SECTION 4.04. 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 [ |
||
SECTION 4.05. 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 [ |
||
(3) a dependent of the insured for federal income tax | ||
purposes at the time the application for coverage of the grandchild | ||
is made. | ||
SECTION 4.06. Section 1251.152(a), Insurance Code, is | ||
amended to read as follows: | ||
(a) For purposes of this section: | ||
(1) "Child," with respect to an individual, includes | ||
the individual's stepchild or foster child or a child of the | ||
individual's domestic partner if the domestic partner is eligible | ||
for coverage and is covered under the group policy or contract. | ||
(2) "Dependent" [ |
||
(A) [ |
||
is: | ||
(i) [ |
||
(ii) [ |
||
age; and | ||
(B) [ |
||
who is: | ||
(i) [ |
||
(ii) [ |
||
age; and | ||
(iii) [ |
||
federal income tax purposes at the time the application for | ||
coverage of the grandchild is made. | ||
SECTION 4.07. 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, a stepchild of an enrollee, a child of an enrollee's | ||
domestic partner if the domestic partner is eligible to be enrolled | ||
and is enrolled, an adopted child of an enrollee, and a foster child | ||
of an enrollee, is 26 [ |
||
applicable to a child must be stated in the evidence of coverage. | ||
SECTION 4.08. Section 1501.002(2), Insurance Code, is | ||
amended to read as follows: | ||
(2) "Dependent" means: | ||
(A) a spouse; | ||
(B) a child younger than 26 [ |
||
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, a stepchild, a child of an employee's domestic partner if | ||
the domestic partner is eligible to receive and does receive | ||
coverage under the plan, or a foster child. | ||
SECTION 4.09. 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 [ |
||
years of age. | ||
SECTION 4.10. 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 [ |
||
enrolled at an educational institution. | ||
(b) A health benefit plan that requires as a condition of | ||
coverage for a child 26 [ |
||
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 4.11. Section 1506.003, Insurance Code, is amended | ||
to read as follows: | ||
Sec. 1506.003. DEFINITION OF DEPENDENT. In this chapter: | ||
(1) "Child," with respect to an individual, includes | ||
the individual's stepchild or foster child. | ||
(2) "Dependent" [ |
||
(A) [ |
||
younger than 26 [ |
||
(B) [ |
||
(i) [ |
||
26 [ |
||
(ii) [ |
||
an individual for whom a person may be obligated to pay child | ||
support; or | ||
(iii) [ |
||
parent regardless of the age of the child. | ||
SECTION 4.12. Section 1506.158(a), Insurance Code, is | ||
amended to read as follows: | ||
(a) An individual's pool coverage ends: | ||
(1) on the date the individual ceases to be a legally | ||
domiciled resident of this state, unless the individual: | ||
(A) is a student younger than 26 [ |
||
and is financially dependent on a parent covered by the pool; | ||
(B) is a child for whom an individual covered by | ||
the pool may be obligated to pay child support; or | ||
(C) is a child who is disabled and dependent on a | ||
parent covered by the pool, regardless of the age of the child; | ||
(2) on the first day of the month following the date | ||
the individual requests coverage to end; | ||
(3) on the date the individual covered by the pool | ||
dies; | ||
(4) on the date state law requires cancellation of the | ||
coverage; | ||
(5) at the option of the pool, on the 31st day after | ||
the date the pool sends to the individual any inquiry concerning the | ||
individual's eligibility, including an inquiry concerning the | ||
individual's residence, to which the individual does not reply; | ||
(6) on the 31st day after the date a premium payment | ||
for pool coverage becomes due if the payment is not made before that | ||
day; | ||
(7) on the date the individual is 65 years of age and | ||
eligible for coverage under Medicare, unless the coverage received | ||
from the pool is Medicare supplement coverage issued by the pool; or | ||
(8) at the time the individual ceases to meet the | ||
eligibility requirements for coverage. | ||
SECTION 4.13. Section 1551.004(a), Insurance Code, is | ||
amended to read as follows: | ||
(a) In this chapter, "dependent" with respect to an | ||
individual eligible to participate in the group benefits program | ||
under Section 1551.101 or 1551.102 means the individual's: | ||
(1) spouse; | ||
(2) unmarried child younger than 26 [ |
||
(3) child of any age who the board of trustees | ||
determines lives with or has the child's care provided by the | ||
individual on a regular basis if: | ||
(A) the child 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 board of | ||
trustees; | ||
(B) the child's coverage under this chapter has | ||
not lapsed; and | ||
(C) the child is at least 26 [ |
||
was enrolled as a participant in the health benefits coverage under | ||
the group benefits program on the date of the child's 26th [ |
||
birthday; | ||
(4) child of any age who is unmarried, for purposes of | ||
health benefit coverage under this chapter, on expiration of the | ||
child's continuation coverage under the Consolidated Omnibus | ||
Budget Reconciliation Act of 1985 (Pub. L. No. 99-272) and its | ||
subsequent amendments; and | ||
(5) ward, as that term is defined by Section 601, Texas | ||
Probate Code. | ||
SECTION 4.14. Section 1551.158(a), Insurance Code, is | ||
amended to read as follows: | ||
(a) A dependent child who is unmarried and whose coverage | ||
under this chapter ends when the child becomes 26 [ |
||
may, on expiration of continuation coverage under the Consolidated | ||
Omnibus Budget Reconciliation Act of 1985 (Pub. L. No. 99-272), | ||
reinstate health benefit plan coverage under this chapter if the | ||
child, or the child's participating parent or guardian, pays the | ||
full cost of the health benefit plan coverage. | ||
SECTION 4.15. Section 1575.003(1), Insurance Code, is | ||
amended to read as follows: | ||
(1) "Dependent" means: | ||
(A) the spouse of a retiree; | ||
(B) an unmarried child of a retiree or deceased | ||
active member if the child is younger than 26 [ |
||
including: | ||
(i) an adopted child; | ||
(ii) a foster child, stepchild, or other | ||
child who is in a regular parent-child relationship; or | ||
(iii) a recognized natural child; | ||
(C) a retiree's recognized natural child, | ||
adopted child, foster child, stepchild, or other child who is in a | ||
regular parent-child relationship and who lives with or has his or | ||
her care provided by the retiree or surviving spouse on a regular | ||
basis regardless of the child's age, if the child is mentally | ||
retarded or physically incapacitated to an extent that the child is | ||
dependent on the retiree or surviving spouse for care or support, as | ||
determined by the trustee; or | ||
(D) a deceased active member's recognized | ||
natural child, adopted child, foster child, stepchild, or other | ||
child who is in a regular parent-child relationship, without regard | ||
to the age of the child, if, while the active member was alive, the | ||
child: | ||
(i) lived with or had the child's care | ||
provided by the active member on a regular basis; and | ||
(ii) was mentally retarded or physically | ||
incapacitated to an extent that the child was dependent on the | ||
active member or surviving spouse for care or support, as | ||
determined by the trustee. | ||
SECTION 4.16. Section 1579.004, Insurance Code, is amended | ||
to read as follows: | ||
Sec. 1579.004. DEFINITION OF DEPENDENT. In this chapter, | ||
"dependent" means: | ||
(1) a spouse of a full-time employee or part-time | ||
employee; | ||
(2) an unmarried child of a full-time or part-time | ||
employee if the child is younger than 26 [ |
||
including: | ||
(A) an adopted child; | ||
(B) a foster child, stepchild, or other child who | ||
is in a regular parent-child relationship; and | ||
(C) a recognized natural child; | ||
(3) a full-time or part-time employee's recognized | ||
natural child, adopted child, foster child, stepchild, or other | ||
child who is in a regular parent-child relationship and who lives | ||
with or has his or her care provided by the employee or the | ||
surviving spouse on a regular basis, regardless of the child's age, | ||
if the child is mentally retarded or physically incapacitated to an | ||
extent that the child is dependent on the employee or surviving | ||
spouse for care or support, as determined by the board of trustees; | ||
and | ||
(4) notwithstanding any other provision of this code, | ||
any other dependent of a full-time or part-time employee specified | ||
by rules adopted by the board of trustees. | ||
SECTION 4.17. 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 [ |
||
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 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. | ||
SECTION 4.18. The changes in law made by this article apply | ||
only to a health benefit plan that is delivered, issued for | ||
delivery, or renewed on or after January 1, 2012. A health benefit | ||
plan that is delivered, issued for delivery, or renewed before | ||
January 1, 2012, is covered by the law in effect immediately before | ||
the effective date of this Act, and that law is continued in effect | ||
for that purpose. | ||
ARTICLE 5. RESCISSION OF HEALTH BENEFIT PLAN | ||
SECTION 5.01. Chapter 1202, Insurance Code, is amended by | ||
adding Subchapter C to read as follows: | ||
SUBCHAPTER C. RESCISSION OF HEALTH BENEFIT PLAN | ||
Sec. 1202.101. DEFINITION. In this subchapter, | ||
"rescission" means the termination of an insurance agreement, | ||
contract, evidence of coverage, insurance policy, or other similar | ||
coverage document in which the health benefit plan issuer, as | ||
applicable, refunds premium payments or demands the recoupment of | ||
any benefit already paid under the plan. | ||
Sec. 1202.102. APPLICABILITY. (a) This subchapter applies | ||
only to a health benefit plan, including a small or large employer | ||
health benefit plan written under Chapter 1501, 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 | ||
offered by: | ||
(1) an insurance company; | ||
(2) a group hospital service corporation operating | ||
under Chapter 842; | ||
(3) a fraternal benefit society operating under | ||
Chapter 885; | ||
(4) a stipulated premium company operating under | ||
Chapter 884; | ||
(5) a reciprocal exchange operating under Chapter 942; | ||
(6) a Lloyd's plan operating under Chapter 941; | ||
(7) a health maintenance organization operating under | ||
Chapter 843; | ||
(8) a multiple employer welfare arrangement that holds | ||
a certificate of authority under Chapter 846; or | ||
(9) an approved nonprofit health corporation that | ||
holds a certificate of authority under Chapter 844. | ||
(b) This subchapter does not apply to: | ||
(1) a health benefit plan that provides coverage: | ||
(A) only for a specified disease or for another | ||
limited benefit other than an accident policy; | ||
(B) only for accidental death or dismemberment; | ||
(C) for wages or payments in lieu of wages for a | ||
period during which an employee is absent from work because of | ||
sickness or injury; | ||
(D) as a supplement to a liability insurance | ||
policy; | ||
(E) for credit insurance; | ||
(F) only for dental or vision care; | ||
(G) only for hospital expenses; or | ||
(H) 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), | ||
as amended; | ||
(3) a workers' compensation insurance policy; | ||
(4) medical payment insurance coverage provided under | ||
a motor vehicle insurance policy; | ||
(5) a long-term care insurance 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 described by | ||
Subsection (a); | ||
(6) a Medicaid managed care plan offered under Chapter | ||
533, Government Code; | ||
(7) any policy or contract of insurance with a state | ||
agency, department, or board providing health services to eligible | ||
individuals under Chapter 32, Human Resources Code; or | ||
(8) a child health plan offered under Chapter 62, | ||
Health and Safety Code, or a health benefits plan offered under | ||
Chapter 63, Health and Safety Code. | ||
Sec. 1202.103. RESCISSION PROHIBITED; EXCEPTION. (a) | ||
Notwithstanding any other law, except as provided by Subsection | ||
(b), a health benefit plan issuer may not rescind coverage under a | ||
health benefit plan with respect to an enrollee in the plan. | ||
(b) A health benefit plan issuer may rescind coverage under | ||
a health benefit plan with respect to an enrollee if the enrollee | ||
engages in conduct that constitutes fraud or makes an intentional | ||
misrepresentation of a material fact. | ||
Sec. 1202.104. NOTICE OF INTENT TO RESCIND. (a) A health | ||
benefit plan issuer may not rescind a health benefit plan on the | ||
basis of a material misrepresentation without first notifying the | ||
affected enrollee in writing of the issuer's intent to rescind the | ||
health benefit plan. | ||
(b) The notice required under Subsection (a) must include, | ||
as applicable: | ||
(1) the principal reasons for the decision to rescind | ||
the health benefit plan; | ||
(2) the date on which the rescission is effective and | ||
the prior date to which the rescission retroactively reaches; | ||
(3) an itemized list of any pending or paid claims the | ||
health benefit plan issuer intends to recoup following the | ||
rescission; | ||
(4) an explanation of how the enrollee may obtain any | ||
documentation used by the health benefit plan issuer to justify the | ||
rescission; | ||
(5) a statement that the enrollee is entitled to | ||
appeal a rescission decision to an independent review organization | ||
and that the health benefit plan issuer bears the burden of proof on | ||
appeal; | ||
(6) an explanation of any time limit with which the | ||
enrollee must comply to appeal the rescission decision to an | ||
independent review organization, and a description of the | ||
consequences of failure to appeal within that time limit; and | ||
(7) a statement that there is no cost to the individual | ||
to appeal the rescission decision to an independent review | ||
organization. | ||
Sec. 1202.105. INDEPENDENT REVIEW PROCESS; PAYMENT OF | ||
CLAIMS. (a) An enrollee may appeal a health benefit plan issuer's | ||
rescission decision to an independent review organization in the | ||
manner prescribed by the commissioner by rule. | ||
(b) A health benefit plan issuer shall comply with all | ||
requests for information made by the independent review | ||
organization and with the independent review organization's | ||
determination regarding the appropriateness of the issuer's | ||
decision to rescind. | ||
(c) A health benefit plan issuer shall pay all otherwise | ||
valid medical claims under an individual's plan until the later of: | ||
(1) the date on which an independent review | ||
organization determines that the decision to rescind is | ||
appropriate; or | ||
(2) the time to appeal to an independent review | ||
organization has expired without an affected individual initiating | ||
an appeal. | ||
(d) The commissioner shall adopt rules necessary to | ||
implement and enforce this section, including rules establishing | ||
certification standards for independent review organizations for | ||
purposes of this chapter. | ||
Sec. 1202.106. BURDEN OF PROOF. In an appeal to an | ||
independent review organization under Section 1202.105 or an | ||
enforcement action or cause of action based on a violation of this | ||
subchapter by a health benefit plan issuer, the health benefit plan | ||
issuer must prove that the issuer did not violate this subchapter. | ||
SECTION 5.02. The change in law made by this article applies | ||
only to a health benefit plan that is delivered, issued for | ||
delivery, or renewed on or after January 1, 2012. A health benefit | ||
plan that is delivered, issued for delivery, or renewed before | ||
January 1, 2012, 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. | ||
ARTICLE 6. HEALTH BENEFIT PLAN COVERAGE FOR CERTAIN CHILDREN | ||
SECTION 6.01. Subtitle G, Title 8, Insurance Code, is | ||
amended by adding Chapter 1521 to read as follows: | ||
CHAPTER 1521. COVERAGE FOR CHILDREN; PREEXISTING CONDITIONS; | ||
ENROLLMENT IN PLANS | ||
Sec. 1521.001. DEFINITION. In this chapter, "preexisting | ||
condition" means a condition present before the effective date of | ||
an individual's coverage under a health benefit plan. | ||
Sec. 1521.002. 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 offered by: | ||
(1) an insurance company; | ||
(2) a group hospital service corporation operating | ||
under Chapter 842; | ||
(3) a fraternal benefit society operating under | ||
Chapter 885; | ||
(4) a stipulated premium company operating under | ||
Chapter 884; | ||
(5) an exchange operating under Chapter 942; | ||
(6) a health maintenance organization operating under | ||
Chapter 843; | ||
(7) a multiple employer welfare arrangement that holds | ||
a certificate of authority under Chapter 846; or | ||
(8) an approved nonprofit health corporation that | ||
holds a certificate of authority under Chapter 844. | ||
(b) This chapter applies to group health coverage made | ||
available by a school district in accordance with Section 22.004, | ||
Education Code. | ||
(c) Notwithstanding Section 172.014, Local Government Code, | ||
or any other law, this chapter applies to health and accident | ||
coverage provided by a risk pool created under Chapter 172, Local | ||
Government Code. | ||
(d) Notwithstanding any provision in Chapter 1551, 1575, | ||
1579, or 1601 or any other law, this chapter 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; | ||
and | ||
(4) basic coverage under Chapter 1601. | ||
(e) Notwithstanding Section 1501.251 or any other law, this | ||
chapter applies to coverage under a small or large employer health | ||
benefit plan subject to Chapter 1501. | ||
(f) Notwithstanding Section 1507.003 or 1507.053, this | ||
chapter applies to a standard health benefit plan provided under | ||
Chapter 1507. | ||
Sec. 1521.003. EXCEPTION. 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); | ||
(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 1521.002. | ||
Sec. 1521.004. PREEXISTING CONDITION PROVISION PROHIBITED. | ||
A health benefit plan issuer may not, with respect to an individual | ||
younger than 19 years of age: | ||
(1) deny the individual's application for coverage due | ||
to a preexisting condition; | ||
(2) limit or deny coverage under the health benefit | ||
plan to the individual on the basis that the benefits requested are | ||
required to treat a preexisting condition; or | ||
(3) charge the individual a premium in an amount that | ||
is more than two times the premium charged by the health benefit | ||
plan issuer to an individual younger than 19 years of age who does | ||
not have a preexisting condition, if the individual enrolls in a | ||
health benefit plan described by Section 1521.006 during an | ||
enrollment period described by Section 1521.006. | ||
Sec. 1521.005. COVERAGE FOR CERTAIN DEPENDENTS REQUIRED. | ||
If a health benefit plan includes dependent coverage, the health | ||
benefit plan issuer shall approve the enrollment of an individual | ||
who is the minor child of an enrollee in the health benefit plan. | ||
Sec. 1521.006. CHILD-ONLY PLANS REQUIRED; PENALTY. (a) A | ||
health benefit plan issuer shall offer, market, and sell health | ||
benefit plans in this state that exclusively cover individuals | ||
younger than 19 years of age. | ||
(b) A health benefit plan issuer that does not comply with | ||
Subsection (a) may not issue new individual health benefit plans of | ||
any nature in this state. | ||
(c) The department by rule shall require a health benefit | ||
plan issuer to have, and shall adopt rules concerning, enrollment | ||
periods for applicants described by Subsection (a). A health | ||
benefit plan issuer must have at least two enrollment periods per | ||
year of at least 60 days each. | ||
(d) During a required enrollment period, a health benefit | ||
plan issuer must issue individual health benefit plan coverage on a | ||
guaranteed issue basis to an applicant younger than 19 years of age | ||
and may not issue a health benefit plan with a preexisting condition | ||
exclusion rider or endorsement described by Section 1521.004. | ||
(e) The department by rule shall adopt standard special | ||
enrollment procedures in which an applicant described by Subsection | ||
(a) may enroll in an individual health benefit plan under this | ||
section on a guaranteed issue basis during a period other than an | ||
enrollment period under Subsection (c) if the applicant or a | ||
parent, managing conservator, or legal guardian of the applicant | ||
experiences a qualifying event under the Health Insurance | ||
Portability and Accountability Act of 1996 (42 U.S.C. Section 1320d | ||
et seq.). | ||
Sec. 1521.007. CONFLICT WITH OTHER LAW. If this chapter | ||
conflicts with another law relating to coverage provided by a | ||
health benefit plan to an individual who is younger than 19 years of | ||
age, including a provision of Chapter 846, 1201, 1251, 1252, 1501, | ||
1504, 1507, 1508, 1575, 1579, 1625, 1651, or 1652, this chapter | ||
controls. | ||
SECTION 6.02. Each health benefit plan issuer required to | ||
issue individual health benefit plan coverage under Section | ||
1521.005, Insurance Code, as added by this article, shall offer an | ||
initial enrollment period satisfying the requirements of Section | ||
1521.006(d), Insurance Code, as added by this article, beginning | ||
not later than March 1, 2012. Notwithstanding Section 1521.005, | ||
Insurance Code, as added by this article, the initial enrollment | ||
period required by this section must be at least 90 days. | ||
SECTION 6.03. This article applies only to a health benefit | ||
plan that is delivered, issued for delivery, or renewed on or after | ||
January 1, 2012. A health benefit plan that is delivered, issued | ||
for delivery, or renewed before January 1, 2012, 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. | ||
ARTICLE 7. HEALTH BENEFIT PLAN COVERAGE FOR CERTAIN PREVENTIVE | ||
CARE SERVICES | ||
SECTION 7.01. Subtitle G, Title 8, Insurance Code, is | ||
amended by adding Chapter 1522 to read as follows: | ||
CHAPTER 1522. PREVENTIVE CARE SERVICES | ||
Sec. 1522.001. 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 offered by: | ||
(1) an insurance company; | ||
(2) a group hospital service corporation operating | ||
under Chapter 842; | ||
(3) a fraternal benefit society operating under | ||
Chapter 885; | ||
(4) a stipulated premium company operating under | ||
Chapter 884; | ||
(5) an exchange operating under Chapter 942; | ||
(6) a health maintenance organization operating under | ||
Chapter 843; | ||
(7) a multiple employer welfare arrangement that holds | ||
a certificate of authority under Chapter 846; or | ||
(8) an approved nonprofit health corporation that | ||
holds a certificate of authority under Chapter 844. | ||
(b) This chapter applies to group health coverage made | ||
available by a school district in accordance with Section 22.004, | ||
Education Code. | ||
(c) Notwithstanding Section 172.014, Local Government Code, | ||
or any other law, this chapter applies to health and accident | ||
coverage provided by a risk pool created under Chapter 172, Local | ||
Government Code. | ||
(d) Notwithstanding any provision in Chapter 1551, 1575, | ||
1579, or 1601 or any other law, this chapter 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; | ||
and | ||
(4) basic coverage under Chapter 1601. | ||
(e) Notwithstanding Section 1501.251 or any other law, this | ||
chapter applies to coverage under a small or large employer health | ||
benefit plan subject to Chapter 1501. | ||
(f) Notwithstanding Section 1507.003 or 1507.053, this | ||
chapter applies to a standard health benefit plan provided under | ||
Chapter 1507. | ||
Sec. 1522.002. EXCEPTION. 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); | ||
(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 1522.001. | ||
Sec. 1522.003. CERTAIN COST-SHARING PROVISIONS 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. 1522.004. CONFLICT WITH OTHER LAW. If this chapter | ||
conflicts with another law relating to the imposition of a | ||
deductible, copayment, coinsurance, or other cost-sharing | ||
provision, this chapter controls. | ||
SECTION 7.02. This article applies only to a health benefit | ||
plan that is delivered or issued for delivery on or after January 1, | ||
2012. A health benefit plan that is delivered or issued for | ||
delivery before January 1, 2012, 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. | ||
ARTICLE 8. CERTAIN LIFETIME AND ANNUAL LIMITATIONS ON HEALTH | ||
BENEFIT PLAN COVERAGE | ||
SECTION 8.01. Subtitle G, Title 8, Insurance Code, is | ||
amended by adding Chapter 1523 to read as follows: | ||
CHAPTER 1523. CERTAIN LIFETIME AND ANNUAL LIMITATIONS ON COVERAGE | ||
PROHIBITED | ||
Sec. 1523.001. 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 offered by: | ||
(1) an insurance company; | ||
(2) a group hospital service corporation operating | ||
under Chapter 842; | ||
(3) a fraternal benefit society operating under | ||
Chapter 885; | ||
(4) a stipulated premium company operating under | ||
Chapter 884; | ||
(5) an exchange operating under Chapter 942; | ||
(6) a health maintenance organization operating under | ||
Chapter 843; | ||
(7) a multiple employer welfare arrangement that holds | ||
a certificate of authority under Chapter 846; or | ||
(8) an approved nonprofit health corporation that | ||
holds a certificate of authority under Chapter 844. | ||
(b) This chapter applies to group health coverage made | ||
available by a school district in accordance with Section 22.004, | ||
Education Code. | ||
(c) Notwithstanding Section 172.014, Local Government Code, | ||
or any other law, this chapter applies to health and accident | ||
coverage provided by a risk pool created under Chapter 172, Local | ||
Government Code. | ||
(d) Notwithstanding any provision in Chapter 1551, 1575, | ||
1579, or 1601 or any other law, this chapter 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; | ||
and | ||
(4) basic coverage under Chapter 1601. | ||
(e) Notwithstanding Section 1501.251 or any other law, this | ||
chapter applies to coverage under a small or large employer health | ||
benefit plan subject to Chapter 1501. | ||
(f) Notwithstanding Section 1507.003 or 1507.053, this | ||
chapter applies to a standard health benefit plan provided under | ||
Chapter 1507. | ||
Sec. 1523.002. EXCEPTION. 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); | ||
(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 1523.001. | ||
Sec. 1523.003. CERTAIN ANNUAL AND LIFETIME LIMITS | ||
PROHIBITED; REENROLLMENT REQUIRED. A health benefit plan issuer | ||
may not establish: | ||
(1) a lifetime or annual benefit amount for an | ||
enrollee in relation to essential health benefits listed in 42 | ||
U.S.C. Section 18022(b)(1) and other benefits identified by the | ||
United States secretary of health and human services as essential | ||
health benefits; or | ||
(2) an annual limit on the services for which the | ||
health benefit plan will provide coverage, including an annual | ||
limit on an enrollee's number of: | ||
(A) visits to a physician; | ||
(B) days of inpatient or outpatient treatment; or | ||
(C) prescription refills. | ||
Sec. 1523.004. REINSTATEMENT OF COVERAGE. (a) A health | ||
benefit plan issuer, with relation to a former enrollee whose | ||
participation in or benefits under a health benefit plan terminated | ||
by reason of the enrollee exceeding a lifetime maximum benefit, | ||
shall: | ||
(1) notify the former enrollee: | ||
(A) that the lifetime maximum benefit no longer | ||
applies to the former enrollee; and | ||
(B) that the former enrollee is eligible to | ||
reenroll in a health benefit plan issued by the health benefit plan | ||
issuer; and | ||
(2) on request of the former enrollee, enroll the | ||
former enrollee in a health benefit plan that is identical or | ||
substantially similar to the enrollee's former health benefit plan. | ||
(b) The notice required by Subsection (a) must be mailed to | ||
the former enrollee at the enrollee's last known address as shown in | ||
the records of the health benefit plan issuer. | ||
Sec. 1523.005. CONFLICT WITH OTHER LAW. If this chapter | ||
conflicts with another law relating to lifetime or annual benefit | ||
limits or annual limits for specified services under a health | ||
benefit plan, this chapter controls. | ||
SECTION 8.02. Each health benefit plan issuer required to | ||
offer to former enrollees reenrollment in a health benefit plan | ||
under Section 1523.004, Insurance Code, as added by this article, | ||
shall send to each former enrollee entitled to a notice under that | ||
section the notice required by that section not later than December | ||
1, 2011. | ||
SECTION 8.03. (a) Except as provided by Subsection (b) of | ||
this section, this article applies only to a health benefit plan | ||
that is delivered, issued for delivery, or renewed on or after | ||
January 1, 2012. A health benefit plan that is delivered, issued | ||
for delivery, or renewed before January 1, 2012, 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. | ||
(b) The change in law made by Section 1523.004, Insurance | ||
Code, as added by this article, applies to a health benefit plan | ||
that is delivered, issued for delivery, or renewed before, on, or | ||
after January 1, 2012. | ||
ARTICLE 9. EFFECTIVE DATE | ||
SECTION 9.01. 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, 2011. |