By Hochberg H.B. No. 2802
A BILL TO BE ENTITLED
1-1 AN ACT
1-2 relating to the provision of evidence of coverage and charges for
1-3 certain group health insurance policies.
1-4 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-5 SECTION 1. Section 1, Article 3.51-6, Insurance Code, is
1-6 amended by adding paragraph (g) to read as follows:
1-7 (g)(1) An insurer issuing a group policy under this article,
1-8 including those that self-insure, shall furnish to the policyholder
1-9 evidence of coverage and charges. The eligible employee may
1-10 request delivery of evidence of coverage and charges prior to
1-11 enrollment in a plan.
1-12 (2) No evidence of coverage, or amendment thereto,
1-13 shall be issued or delivered to any person in this state until a
1-14 copy of the form of evidence of coverage, or amendment thereto, has
1-15 been filed with and approved by the commissioner.
1-16 (3) An evidence of coverage shall contain:
1-17 (A) no provisions or statements which are
1-18 unjust, unfair, inequitable, misleading, deceptive or which
1-19 encourage misrepresentation; and
1-20 (B) a clear and complete statement, if a
1-21 contract, or a reasonably complete facsimile, if a certificate, of:
1-22 (i) the medical, health care services, or
1-23 single health care service and the issuance of other benefits, if
2-1 any, to which the enrollee is entitled under the health care plan;
2-2 (ii) any limitation on the services, kinds
2-3 of services, benefits, or kinds of benefits to be provided,
2-4 including any deductible or co-payment feature;
2-5 (iii) where and in what manner information
2-6 is available as to how services may be obtained;
2-7 (iv) a clear and understandable
2-8 description of methods for resolving enrollee complaints. Any
2-9 subsequent changes may be evidenced in a separate document issued
2-10 to the enrollee.
2-11 (4) Any form of the evidence of coverage or group
2-12 contract to be used in this state, and any amendments thereto, are
2-13 subject to the filing and approval requirements of Subsection (c)
2-14 of this section, unless it is subject to the jurisdiction of the
2-15 commissioner under the laws governing health insurance or group
2-16 hospital service corporations, in which event the filing and
2-17 approval provisions of such law shall apply. To the extent,
2-18 however, that such provisions do not apply to the requirements of
2-19 Subdivision (3), Subsection (a) of this section, the requirements
2-20 of Subdivision (3) shall be applicable.
2-21 (5) The commissioner shall, within a reasonable
2-22 period, approve any form of the evidence of coverage or group
2-23 contract, or amendment thereto, if the requirements of this section
2-24 are met. After notice and hearing, the commissioner may withdraw
2-25 previous approval of any form, if the commissioner determines that
3-1 it violates or does not comply with this Act or a rule adopted by
3-2 the State Board of Insurance. It shall be unlawful to issue such
3-3 form until approved. If the commissioner disapproves such form,
3-4 the commissioner shall notify the filer. In the notice, the
3-5 commissioner shall specify the reason for the disapproval. A
3-6 hearing shall be granted within 30 days after a request in writing
3-7 by the person filing. If the commissioner does not disapprove any
3-8 form within 30 days after the filing of such form it shall be
3-9 considered approved; provided that the commissioner may by written
3-10 notice extend the period for approval or disapproval of any filing
3-11 for such further time, not exceeding an additional 30 days, as
3-12 necessary for proper consideration of the filing.
3-13 (6) The commissioner may require the submission of
3-14 whatever relevant information he or she deems necessary in
3-15 determining whether to approve or disapprove a filing made pursuant
3-16 to this section.
3-17 SECTION 2. Section 6, Article 3.50-2, Insurance Code, is
3-18 amended to read as follows:
3-19 Sec. 6. (a) The trustee shall provide upon request to each
3-20 employee evidence of coverage and charges, as defined under Article
3-21 3.51-6(g) of this code, for each health benefits plan available to
3-22 the employee as basic coverage. The evidence of coverage and
3-23 charges shall be provided before or at the time the employee is
3-24 given the form to be used by the employee to select a health
3-25 benefits plan.
4-1 (b) Each state department and each participating school
4-2 district, on request by an employee, shall, prior to the deadline
4-3 for the employee to select one of several health benefits plans,
4-4 provide the employee a reasonable opportunity to examine a copy of
4-5 any or all health benefits plans eligible for selection by the
4-6 employee.
4-7 (c) The trustees shall provide for the issuance to each
4-8 employee insured under this Act a certificate of insurance setting
4-9 forth the benefits to which the employee is entitled, to whom the
4-10 benefits are payable, to whom the claims shall be submitted, and
4-11 summarizing the provisions of the policy principally affecting the
4-12 employee.
4-13 SECTION 3. Section 5, Article 3.50-3, Insurance Code, is
4-14 amended to read as follows:
4-15 Sec. 5. (a) The administrative council shall provide for
4-16 the issuance to each employee insured under this Act an evidence of
4-17 coverage and charges, as defined under Article 3.51-6(g) of this
4-18 code, for each health benefits plan available to the employee as
4-19 basic coverage. The evidence of coverage and charges shall be
4-20 provided before or at the time the employee is given the form to be
4-21 used by the employee to select a health benefits plan.
4-22 (b) Each institution, on request by an employee, shall,
4-23 prior to the deadline for the employee to select one of several
4-24 health benefits plans, provide the employee a reasonable
4-25 opportunity to examine a copy of any or all health benefits plans
5-1 eligible for selection by the employee.
5-2 (c) The administrative council shall assure that each
5-3 employee insured under this Act is issued a certificate of
5-4 insurance setting forth the benefits to which the employee is
5-5 entitled, to whom the benefits are payable, to whom the claims
5-6 shall be submitted, and summarizing the provisions of the policy
5-7 principally affecting the employee.
5-8 SECTION 4. This Act takes effect September 1, 1993.
5-9 SECTION 5. The importance of this legislation and the
5-10 crowded condition of the calendars in both houses create an
5-11 emergency and an imperative public necessity that the
5-12 constitutional rule requiring bills to be read on three several
5-13 days in each house be suspended, and this rule is hereby suspended.