By Averitt H.B. No. 1212
76R4408 DLF-F
A BILL TO BE ENTITLED
1-1 AN ACT
1-2 relating to catastrophic care and basic coverage benefit plans for
1-3 large employers.
1-4 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-5 SECTION 1. Article 26.02(16), Insurance Code, is amended to
1-6 read as follows:
1-7 (16) "Large employer health benefit plan" means:
1-8 (A) the catastrophic care benefit plan or the
1-9 basic coverage benefit plan adopted under Article 26.82A of this
1-10 code; or
1-11 (B) any other [a] health benefit plan offered to
1-12 a large employer in accordance with Article 26.82A(d) or 26.82D of
1-13 this code.
1-14 SECTION 2. Subchapter H, Chapter 26, Insurance Code, is
1-15 amended by adding Articles 26.82A, 26.82B, 26.82C, and 26.82D to
1-16 read as follows:
1-17 Art. 26.82A. LARGE EMPLOYER HEALTH BENEFIT PLANS. (a) A
1-18 large employer carrier shall offer the following two health benefit
1-19 plans as adopted by rule by the commissioner:
1-20 (1) the catastrophic care benefit plan; and
1-21 (2) the basic coverage benefit plan.
1-22 (b) A large employer carrier may not offer a rider to the
1-23 catastrophic care benefit plan or the basic coverage benefit plan.
1-24 (c) Except as expressly provided in this subchapter or as
2-1 required by federal law or a state law that expressly references
2-2 the plans described by Subsection (a) of this article, these plans
2-3 are not subject to a law that requires coverage or the offer of
2-4 coverage of a health care service or benefit.
2-5 (d) Subject to the provisions of this subchapter, a large
2-6 employer carrier may also offer to large employers any other health
2-7 benefit plan authorized under this code. Subsection (c) of this
2-8 article does not apply to a health benefit plan offered to a large
2-9 employer under this subsection.
2-10 Art. 26.82B. FORMS. (a) The commissioner shall promulgate
2-11 the benefits section of the catastrophic care benefit plan and the
2-12 basic coverage benefit plan forms in accordance with Article 26.82C
2-13 of this code and shall develop prototype policies or evidences of
2-14 coverage for each of the benefit plans. For all other portions of
2-15 these policy or evidence of coverage forms, a large employer
2-16 carrier shall comply with Article 3.42 of this code as it relates
2-17 to policy form approval and with the Texas Health Maintenance
2-18 Organization Act (Chapter 20A, Vernon's Texas Insurance Code) as it
2-19 relates to approval of an evidence of coverage. A large employer
2-20 carrier may not offer these benefit plans through a policy form or
2-21 evidence of coverage that does not comply with this subchapter.
2-22 (b) A health carrier may not issue and the commissioner may
2-23 not approve a health benefit plan certificate or policy unless it
2-24 is written in plain language.
2-25 (c) Each provision of a health benefit plan certificate or
2-26 policy relating to renewal of coverage, conditions of coverage, or
2-27 per occurrence or aggregate dollar limitations on coverage must be
3-1 clearly explained in plain language.
3-2 (d) A health carrier may not use and the commissioner may
3-3 not approve a health benefit plan application form unless it is in
3-4 plain language.
3-5 (e) Subsections (b) through (d) of this article do not apply
3-6 if the specific language to be used is mandated by federal law or
3-7 state statute or by rules implementing federal law.
3-8 (f) For purposes of Subsections (b) through (e) of this
3-9 article, a health benefit plan certificate or policy, a provision
3-10 of a health benefit plan certificate or policy, or a health benefit
3-11 plan application form is written in plain language if it achieves
3-12 the minimum score established by the commissioner on the Flesch
3-13 reading ease test or an equivalent test selected by the
3-14 commissioner.
3-15 (g) The provisions of Subsections (b) through (f) of this
3-16 article requiring the use of plain language do not apply to a
3-17 health benefit plan group master policy or group subscriber
3-18 contract or to a policy application or enrollment form for a health
3-19 benefit plan group master policy or group subscriber contract.
3-20 Art. 26.82C. BENEFIT PLANS. (a) The commissioner by rule
3-21 shall establish the coverage requirements for the catastrophic care
3-22 benefit plan and the basic coverage benefit plan. The commissioner
3-23 shall develop prototype policies and evidences of coverage for use
3-24 by large employer carriers that include all contractual provisions
3-25 required to produce an entire contract in accordance with this
3-26 article and this code.
3-27 (b) Coverage under the catastrophic care benefit plan must
4-1 be designed to provide necessary coverage in the event of
4-2 catastrophic illness or injury. The commissioner shall establish
4-3 deductibles and coinsurance requirements at levels that permit
4-4 options for the enrollee to obtain affordable catastrophic
4-5 coverage.
4-6 (c) Coverage under the basic coverage benefit plan must be
4-7 designed to provide basic hospital, medical, and surgical
4-8 coverages. Benefits under the plan are limited to basic care
4-9 requirements for illness and injury.
4-10 (d) The benefits provisions of the benefit plan must include
4-11 the following:
4-12 (1) all required or applicable definitions;
4-13 (2) a list of any exclusions or limitations to
4-14 coverage;
4-15 (3) a description of covered services required under
4-16 the plan; and
4-17 (4) the deductible and coinsurance options that are
4-18 required or permitted under the plan.
4-19 Art. 26.82D. HEALTH MAINTENANCE ORGANIZATION PLANS. (a) A
4-20 health maintenance organization may offer:
4-21 (1) a state-approved health benefit plan that complies
4-22 with this subchapter, the Texas Health Maintenance Organization Act
4-23 (Chapter 20A, Vernon's Texas Insurance Code), Title XIII, Public
4-24 Health Service Act (42 U.S.C. Section 300e et seq.), and its
4-25 subsequent amendments, and rules adopted under these laws;
4-26 (2) a plan developed by the commissioner under Article
4-27 26.82C of this code; or
5-1 (3) a point-of-service contract in connection with an
5-2 insurance carrier that includes optional coverage for out-of-area
5-3 services, emergency care, or out-of-network care.
5-4 (b) A contract offered by an insurance carrier under
5-5 Subsection (a)(3) of this article is subject to all provisions of
5-6 this subchapter unless specifically exempted. The insurance
5-7 carrier with which the health maintenance organization contracts
5-8 for a point-of-service contract is not required to otherwise make
5-9 available the benefit plans adopted under this subchapter if the
5-10 insurance carrier's large employer products are limited to the
5-11 point-of-service contract.
5-12 SECTION 3. Article 26.91, Insurance Code, is amended by
5-13 amending Subsection (a) and adding Subsection (c) to read as
5-14 follows:
5-15 (a) Each large employer carrier shall market the large
5-16 employer health benefit plan through properly licensed agents to
5-17 eligible large employers in this state. Each large employer
5-18 purchasing a large employer health benefit plan shall be given a
5-19 summary of the catastrophic care and basic coverage benefit plans
5-20 established by the commissioner under this subchapter. The
5-21 commissioner shall prescribe the format of the summary. On
5-22 request, each large employer purchasing health benefit plans shall
5-23 be given a summary of all other plans for which the employer is
5-24 eligible. The agent shall offer and explain each of the plans to
5-25 the large employer on inquiry and request by the large employer.
5-26 (c) The commissioner may adopt rules setting forth
5-27 additional standards to provide for the fair marketing and broad
6-1 availability of large employer health benefit plans to large
6-2 employers in this state.
6-3 SECTION 4. (a) The commissioner of insurance shall develop
6-4 the catastrophic care and the basic coverage benefit plans for
6-5 large employers under Articles 26.82A, 26.82B, 26.82C, and 26.82D,
6-6 Insurance Code, as added by this Act, and shall adopt necessary
6-7 rules to implement the change in law made by this Act, not later
6-8 than June 1, 2000.
6-9 (b) A large employer carrier shall offer the catastrophic
6-10 care and basic coverage benefit plans developed by the commissioner
6-11 of insurance under Subchapter H, Chapter 26, Insurance Code, as
6-12 amended by this Act, beginning January 1, 2001.
6-13 SECTION 5. This Act takes effect September 1, 1999.
6-14 SECTION 6. The importance of this legislation and the
6-15 crowded condition of the calendars in both houses create an
6-16 emergency and an imperative public necessity that the
6-17 constitutional rule requiring bills to be read on three several
6-18 days in each house be suspended, and this rule is hereby suspended.