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.