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.