By Janek H.B. No. 1498
Line and page numbers may not match official copy.
Bill not drafted by TLC or Senate E&E.
A BILL TO BE ENTITLED
1-1 AN ACT
1-2 relating to the availability of health benefit coverage options for
1-3 health maintenance organization eligible enrollees.
1-4 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-5 SECTION 1. Subchapter E, Chapter 21, Insurance Code, is
1-6 amended by adding Article 21.74 to read as follows:
1-7 Art. 21.74. AVAILABILITY OF HEALTH BENEFIT COVERAGE OPTIONS.
1-8 SECTION 1. DEFINITIONS. In this article:
1-9 (a) "non-network plan" means health benefit coverage which
1-10 provides enrollees an opportunity to obtain health care services
1-11 through a health delivery system other than a health maintenance
1-12 organization delivery network as defined in Article 20A.02(z). A
1-13 non-network plan may include but is not limited to a
1-14 point-of-service plan or a preferred provider benefit plan.
1-15 (b) "point-of-service plan" means a plan under which an
1-16 enrollee may choose to obtain benefits and services, or both
1-17 benefits and services through either a health maintenance
1-18 organization delivery network or through a non-network delivery
1-19 system outside the health maintenance organization's health care
1-20 delivery network, and which are administered through an indemnity
1-21 benefit arrangement for the cost of health care services.
2-1 (c) "preferred provider benefit plan" means an insurance
2-2 policy issued and licensed under Article 3.70-3C, Insurance Code.
2-3 SECTION 2. OFFERING OF HEALTH BENEFIT COVERAGE OPTIONS. (a)
2-4 A health maintenance organization whose network based delivery
2-5 system of coverage is the only health benefit coverage being
2-6 offered under an employer's health benefit plan, must offer to all
2-7 eligible employees the opportunity to obtain health benefit
2-8 coverage through a non-network plan at the time of enrollment and
2-9 at least annually. Such coverage may be provided through a point
2-10 of service plan, a preferred provider benefit plan or any coverage
2-11 arrangement that allows access to services outside the health
2-12 maintenance organization's delivery network.
2-13 (b) The premium for the optional non-network plan shall be
2-14 based on the actuarial value of that coverage, and accordingly such
2-15 premium may be different than the premium for the health
2-16 maintenance organization coverage.
2-17 (c) Different cost sharing provisions may be imposed for the
2-18 point of service option. Those cost sharing provisions may be
2-19 higher than cost sharing provisions for in network health
2-20 maintenance organization coverage.
2-21 (d) Any additional costs for the non-network plan are the
2-22 responsibility of the employee who chooses the non-network plan,
2-23 and the employer may impose a reasonable administrative cost for
2-24 providing the non-network plan option.
2-25 (e) This article does not apply to a small employer as
3-1 defined in Texas Insurance Code Article 26.02(28).
3-2 SECTION 3. Subchapter F, Chapter 3, Insurance Code, is
3-3 amended by adding Article 3.64 to read as follows:
3-4 Art. 3.64. INSURERS CONTRACTING WITH HEALTH MAINTENANCE
3-5 ORGANIZATIONS. (a) DEFINITIONS. In this article:
3-6 (1) "Insurance Carrier" means an insurance company,
3-7 group hospital service corporation, association, or organization
3-8 authorized to do business in this state under this chapter or
3-9 Chapter 8, 10, 11, 12, 13, 14, 15, 18, 19, 20, or 22 of this code.
3-10 (2) "Health maintenance organization" has the meaning
3-11 assigned by Section 2, Texas Health Maintenance Organization Act
3-12 (Article 20A.02, Vernon's Texas Insurance Code).
3-13 (3) "Point of Service Plan" means an arrangement under
3-14 which:
3-15 (A) an enrollee may choose to obtain benefits
3-16 and services, or both benefits and services through either a health
3-17 maintenance organization delivery network or through a non-network
3-18 delivery system outside the health maintenance organization's
3-19 health care delivery network, and which are administered through an
3-20 indemnity benefit arrangement for the cost of health care services.
3-21 (B) indemnity benefits for the cost of the
3-22 health care services may be provided by an insurer or group
3-23 hospital service corporation in conjunction with network benefits
3-24 arranged or provided by a health maintenance organization.
3-25 (4) "Blended contract" means a single document,
4-1 including a single contract policy, certificate, or evidence of
4-2 coverage, that provides a combination of indemnity and health
4-3 maintenance organization benefits.
4-4 (b) An insurance carrier may contract with a health
4-5 maintenance organization to provide a point of service benefit,
4-6 including optional coverage for out-of-area services or
4-7 out-of-network care.
4-8 (c) An insurance carrier and a health maintenance
4-9 organization may offer a blended contract if indemnity benefits are
4-10 combined with health maintenance organization benefits. The use of
4-11 a blended contract is limited to point of service arrangements
4-12 between an insurance carrier and a health maintenance organization.
4-13 (d) A blended contract delivered, issued, or used in this
4-14 state is subject to and must be filed with the department for
4-15 approval as provided by 3.42 of this code and Article 20A.09(a)(5).
4-16 (e) Indemnity benefits and services provided under a point
4-17 of service plan may be limited to those services as defined by the
4-18 blended contract and may be subject to different cost sharing
4-19 provisions. The cost sharing provisions for the indemnity benefits
4-20 may be higher than cost sharing provisions for in network health
4-21 maintenance organization coverage.
4-22 (f) The commissioner may adopt rules to implement this
4-23 article.
4-24 SECTION 4. Section 2, Texas Health Maintenance Organization
4-25 Act, (Article 20A.02, Vernon's Texas Insurance Code) is amended by
5-1 amending subsection (i) and by adding Subsections (aa) and (bb) to
5-2 read as follows.
5-3 (i) "Evidence of Coverage" means any certificate, agreement,
5-4 or contract, including a blended contract, issued to an enrollee
5-5 setting out the coverage to which the enrollee is entitled.
5-6 (aa) "Blended contract" means a single document, including a
5-7 single contract policy, certificate, or evidence of coverage, that
5-8 provides a combination of indemnity and health maintenance
5-9 organization benefits.
5-10 (bb) "Point of Service Plan" means an arrangement under
5-11 which:
5-12 (A) an enrollee may choose to obtain benefits
5-13 and services, or both benefits and services through either a health
5-14 maintenance organization delivery network or through a non-network
5-15 delivery system outside the health maintenance organization's
5-16 health care delivery network, and which are administered through an
5-17 indemnity benefit arrangement for the cost of health care services.
5-18 (B) indemnity benefits for the cost of the
5-19 health care services may be provided by an insurer or group
5-20 hospital service corporation in conjunction with corresponding
5-21 benefits arranged or provided by a health maintenance organization
5-22 or indemnity benefits for the cost of the health care services
5-23 provided by a health maintenance organization through a point of
5-24 service rider as provided by Article 20A.06(6)(D) in conjunction
5-25 with corresponding benefits arranged or provided by a health
6-1 maintenance organization.
6-2 SECTION 5. This act takes effect September 1, 1999, and
6-3 applies only to an evidence of coverage for a health benefit plan
6-4 that is delivered, issued for delivery, or renewed on or after
6-5 January 1, 2000. An evidence of coverage for a health benefit plan
6-6 that is delivered, issued for delivery, or renewed before January
6-7 1, 2000, is governed by the law as it existed immediately before
6-8 the effective date of this Act, and that law is continued in effect
6-9 for this purpose.
6-10 SECTION 6. The importance of this legislation and the
6-11 crowded condition of the calendars in both houses create an
6-12 emergency and an imperative public necessity that the
6-13 constitutional rule requiring bills to be read on three several
6-14 days in each house be suspended, and this rule is hereby suspended.