By: Brimer H.B. No. 179
73R1743 DLF-F
A BILL TO BE ENTITLED
1-1 AN ACT
1-2 relating to basic group health insurance coverage for certain small
1-3 employers.
1-4 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-5 SECTION 1. Subchapter E, Chapter 3, Insurance Code, is
1-6 amended by adding Article 3.51-6E to read as follows:
1-7 Art. 3.51-6E. GROUP HEALTH INSURANCE POLICIES OR PLANS FOR
1-8 CERTAIN SMALL EMPLOYERS
1-9 Sec. 1. PURPOSE. The legislature finds that an increasing
1-10 number of small employers and their employees are uninsured or
1-11 unable to continue group health insurance in part because of the
1-12 cost of mandated benefits. This article authorizes insurers to
1-13 offer group health insurance policies to certain small employers
1-14 providing basic health care benefits. The purpose of this
1-15 authorization is to reduce the number of uninsured people in this
1-16 state, to increase access to necessary health care, and to reduce
1-17 the amount of uncompensated care.
1-18 Sec. 2. DEFINITIONS. In this article:
1-19 (1) "Eligible employer" means a person who employs not
1-20 fewer than three nor more than 50 full-time employees at the time
1-21 the group policy or plan initially takes effect.
1-22 (2) "Enrollee or certificate holder" means an
1-23 individual who is an officer, partner, or sole proprietor of an
1-24 eligible employer, an employee of an eligible employer who works at
2-1 least 20 hours per week, or the spouse or dependent child of such
2-2 an individual.
2-3 (3) "Insurer" means a company, exchange, society,
2-4 association, or other person authorized to engage in the business
2-5 of insurance in this state that delivers or issues for delivery in
2-6 this state a policy or contract of group health insurance or a
2-7 group health care plan. The term includes a group hospital service
2-8 corporation under Chapter 20 of this code or a health maintenance
2-9 organization under the Texas Health Maintenance Organization Act
2-10 (Chapter 20A, Vernon's Texas Insurance Code).
2-11 (4) "Person" means an individual, association,
2-12 corporation, partnership, or other private legal entity.
2-13 (5) "Physician" means a person licensed under the
2-14 Medical Practice Act (Article 4495b, Vernon's Texas Civil
2-15 Statutes).
2-16 Sec. 3. BASIC HEALTH CARE POLICY OR PLAN. (a) An insurer
2-17 may offer to eligible employers a group health insurance policy or
2-18 plan that provides coverage for basic health care needs to
2-19 enrollees or certificate holders. If an otherwise eligible
2-20 employer is covered by a group health insurance policy or plan,
2-21 that employer is not entitled to obtain coverage under this article
2-22 until the existing policy or plan has expired.
2-23 (b) A basic health care policy or plan offered under this
2-24 article must include the following minimum coverage:
2-25 (1) inpatient hospital care of 14 days per policy
2-26 year;
2-27 (2) reasonable, medically necessary outpatient
3-1 hospital care, including surgery, anesthesia, preadmission testing,
3-2 radiation therapy, and chemotherapy as defined in the policy or
3-3 plan;
3-4 (3) emergency care as defined by Section 2(I), Chapter
3-5 397, Acts of the 54th Legislature, Regular Session, 1955 (Article
3-6 3.70-2, Vernon's Texas Insurance Code) or Section 2(t), Texas
3-7 Health Maintenance Organization Act (Article 20A.02, Vernon's Texas
3-8 Insurance Code), including licensed ground ambulance
3-9 transportation, emergency room care and emergency admissions, but
3-10 excluding care for conditions that are not life-threatening and
3-11 subject to the limitations of Subsection (b)(1) of this section;
3-12 (4) physician office visits or community health center
3-13 visits for primary care or sick care of at least four visits per
3-14 policy year per enrollee or certificate holder, including
3-15 laboratory fees and diagnostic X rays, in addition to physician
3-16 care in a hospital inpatient or outpatient setting; and
3-17 (5) home nursing care, not to exceed 14 visits per
3-18 year, in lieu of or to reduce the length of inpatient hospital
3-19 care.
3-20 (c) A basic health care policy or plan is subject to
3-21 approval under Article 3.42 of this code or Subsections (a)-(d),
3-22 Section 9, Texas Health Maintenance Organization Act (Article
3-23 20A.09, Vernon's Texas Insurance Code), as applicable.
3-24 (d) A policy or plan authorized by this section, except an
3-25 evidence of coverage issued by a health maintenance organization,
3-26 must comply with Subsections (b), (c), (d), (e), and (f), Section
3-27 1, Article 3.51-6 of this code and with Section 3, Article 3.51-6,
4-1 of this code.
4-2 (e) This article does not prevent an insurer from providing
4-3 to an eligible employer a basic health care policy or plan that
4-4 includes one or more mandatory benefits, coverages, or providers.
4-5 The inclusion of a mandatory benefit, coverage, or provider does
4-6 not waive the exemption from all mandatory benefits, coverages, and
4-7 providers established under Section 4 of this article.
4-8 (f) This article does not affect the authority of a health
4-9 maintenance organization to:
4-10 (1) determine the categories and types of providers
4-11 that participate as providers in a health maintenance organization
4-12 in compliance with the Texas Health Maintenance Organization Act
4-13 (Chapter 20A, Vernon's Texas Insurance Code); or
4-14 (2) limit the use by enrollees or certificate holders
4-15 to the services of those providers in compliance with the health
4-16 care services offered by the health maintenance organization.
4-17 Sec. 4. EXEMPTION FROM MANDATED BENEFITS, COVERAGES, AND
4-18 PROVIDERS. A basic health care policy or plan offered under this
4-19 article is exempt from all mandatory benefits, coverages, and
4-20 providers required under other provisions of this code or other
4-21 laws of this state and is not required to provide coverage of any
4-22 services, treatments, tests, or extensions of coverage not
4-23 specifically required by this article.
4-24 Sec. 5. TERMINATION OF COVERAGE. An insurer may not
4-25 terminate coverage under a health care policy or plan for an
4-26 enrollee or certificate holder unless the enrollee or certificate
4-27 holder:
5-1 (1) is no longer eligible for coverage under the terms
5-2 of the policy or plan;
5-3 (2) failed to pay a required premium or premium
5-4 contribution; or
5-5 (3) committed fraud or misrepresentation in connection
5-6 with the policy or plan.
5-7 Sec. 6. BOARD POWERS AND DUTIES. (a) The board shall
5-8 monitor the policies or plans offered under this article. The
5-9 board may require periodic reports by insurers issuing basic health
5-10 care policies or plans under this article.
5-11 (b) The board may adopt rules as necessary to implement this
5-12 article.
5-13 (c) The board shall report to the legislature not later than
5-14 February 1 of each odd-numbered year relating to the effectiveness
5-15 of the insurance policies or plans authorized under this article in
5-16 meeting the purposes of this article.
5-17 Sec. 7. RATES. A basic health care policy or plan offered
5-18 under this article may not be delivered or issued for delivery in
5-19 this state unless the commissioner determines that the benefits are
5-20 reasonable in relation to the premium charged. As regards health
5-21 maintenance organizations, the commissioner shall make the
5-22 determination in compliance with Section 9, Texas Health
5-23 Maintenance Organization Act (Article 20A.09, Vernon's Texas
5-24 Insurance Code).
5-25 Sec. 8. COST CONTAINMENT. An insurer that offers a basic
5-26 health care policy or plan under this article may use cost
5-27 containment mechanisms in that policy or plan.
6-1 SECTION 2. This Act takes effect September 1, 1993, and
6-2 applies only to a basic health care policy or plan that is
6-3 delivered, issued for delivery, or renewed on or after January 1,
6-4 1994. A policy or plan that is delivered, issued for delivery, or
6-5 renewed before January 1, 1994, is governed by the law as it
6-6 existed immediately before the effective date of this Act, and that
6-7 law is continued in effect for that purpose.
6-8 SECTION 3. The importance of this legislation and the
6-9 crowded condition of the calendars in both houses create an
6-10 emergency and an imperative public necessity that the
6-11 constitutional rule requiring bills to be read on three several
6-12 days in each house be suspended, and this rule is hereby suspended.