By Berlanga H.B. No. 3270 75R5165 PB-D A BILL TO BE ENTITLED 1-1 AN ACT 1-2 relating to claims information regarding certain group health 1-3 benefit plans. 1-4 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: 1-5 SECTION 1. Subchapter C, Chapter 21, Insurance Code, is 1-6 amended by adding Article 21.24-3 to read as follows: 1-7 Art. 21.24-3. CLAIMS INFORMATION REGARDING CERTAIN GROUP 1-8 HEALTH BENEFIT PLANS 1-9 Sec. 1. DEFINITIONS. In this article: 1-10 (1) "Health benefit plan" means a plan described by 1-11 Section 2 of this article. 1-12 (2) "Insurer" means an insurance company or other 1-13 entity that offers a health benefit plan. 1-14 Sec. 2. SCOPE OF ARTICLE. (a) This article applies to a 1-15 health benefit plan that: 1-16 (1) provides group benefits for medical or surgical 1-17 expenses incurred as a result of a health condition, accident, or 1-18 sickness, including: 1-19 (A) a group, blanket, or franchise insurance 1-20 policy or insurance agreement, a group hospital service contract, 1-21 or a group evidence of coverage that is offered by: 1-22 (i) an insurance company; 1-23 (ii) a group hospital service corporation 1-24 operating under Chapter 20 of this code; 2-1 (iii) a fraternal benefit society 2-2 operating under Chapter 10 of this code; 2-3 (iv) a stipulated premium insurance 2-4 company operating under Chapter 22 of this code; or 2-5 (v) a health maintenance organization 2-6 operating under the Texas Health Maintenance Organization Act 2-7 (Chapter 20A, Vernon's Texas Insurance Code); 2-8 (B) a plan written under Chapter 26 of this 2-9 code; or 2-10 (C) to the extent permitted by the Employee 2-11 Retirement Income Security Act of 1974 (29 U.S.C. Section 1001 et 2-12 seq.), a health benefit plan that is offered by: 2-13 (i) a multiple employer welfare 2-14 arrangement as defined by Section 3, Employee Retirement Income 2-15 Security Act of 1974 (29 U.S.C. Section 1002); or 2-16 (ii) another analogous benefit 2-17 arrangement; 2-18 (2) is offered by an approved nonprofit health 2-19 corporation that is certified under Section 5.01(a), Medical 2-20 Practice Act (Article 4495b, Vernon's Texas Civil Statutes), and 2-21 that holds a certificate of authority issued by the commissioner 2-22 under Article 21.52F of this code; or 2-23 (3) is offered by any other entity not licensed under 2-24 this code or another insurance law of this state that contracts 2-25 directly for health care services on a risk-sharing basis, 2-26 including an entity that contracts for health care services on a 2-27 capitation basis. 3-1 (b) This article does not apply to: 3-2 (1) a plan that provides coverage: 3-3 (A) only for a specified disease; 3-4 (B) only for accidental death or dismemberment; 3-5 (C) for wages or payments in lieu of wages for a 3-6 period during which an employee is absent from work because of 3-7 sickness or injury; or 3-8 (D) as a supplement to liability insurance; 3-9 (2) a Medicare supplemental policy as defined by 3-10 Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss); 3-11 (3) workers' compensation insurance coverage; 3-12 (4) medical payment insurance issued as part of a 3-13 motor vehicle insurance policy; or 3-14 (5) a long-term care policy, including a nursing home 3-15 fixed indemnity policy, unless the commissioner determines that the 3-16 policy provides benefit coverage so comprehensive that the policy 3-17 is a health benefit plan as described by Subsection (a) of this 3-18 section. 3-19 Sec. 3. NOTIFICATION REQUIRED. (a) An insurer, other than 3-20 a health maintenance organization or other managed care entity, 3-21 that issues a health benefit plan in this state shall notify each 3-22 group policyholder in writing of: 3-23 (1) each claim that is filed against the policy; 3-24 (2) any proposal to settle a claim; and 3-25 (3) any administrative or judicial proceeding relating 3-26 to the resolution of a claim. 3-27 (b) The information supplied to a group policyholder under 4-1 Subsection (a) of this section must include: 4-2 (1) the name of each claimant; 4-3 (2) details relating to the amount paid on the claim, 4-4 settlement of the claim, or judgment on the claim; 4-5 (3) details as to how the claim, settlement, or 4-6 judgment is to be paid; 4-7 (4) the effect of the claim on premium rates, if any; 4-8 and 4-9 (5) any other information required by rule of the 4-10 commissioner. 4-11 (c) The insurer shall provide the report to each group 4-12 policyholder semiannually. 4-13 Sec. 4. MANAGED CARE PLANS; NOTIFICATION REQUIRED. Each 4-14 health maintenance organization and other managed care entity that 4-15 offers a health benefit plan that provides group benefits shall 4-16 notify the employer or other group contract holder semiannually in 4-17 writing of any amounts paid for benefits that are charged to the 4-18 group contract holder, other than the basic charges negotiated in 4-19 the contract. 4-20 Sec. 5. RULES; ADDITIONAL INFORMATION. (a) The 4-21 commissioner may adopt rules providing the format for information 4-22 supplied by an insurer under this article. 4-23 (b) The commissioner, by rule, may require information in 4-24 addition to that required by Section 3 or 4 of this article that 4-25 the commissioner considers necessary to adequately inform a group 4-26 policyholder with regard to any claim under a health benefit plan. 4-27 SECTION 2. Article 21.24-3, Insurance Code, as added by this 5-1 Act, applies only to a health benefit plan that is delivered, 5-2 issued for delivery, or renewed on or after January 1, 1998. A 5-3 health benefit plan that is delivered, issued for delivery, or 5-4 renewed before January 1, 1998, is governed by the law as it 5-5 existed immediately before the effective date of this Act, and that 5-6 law is continued in effect for this purpose. 5-7 SECTION 3. This Act takes effect September 1, 1997. 5-8 SECTION 4. The importance of this legislation and the 5-9 crowded condition of the calendars in both houses create an 5-10 emergency and an imperative public necessity that the 5-11 constitutional rule requiring bills to be read on three several 5-12 days in each house be suspended, and this rule is hereby suspended.