By Averitt H.B. No. 3273 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 health insurance availability and providing for the 1-3 creation of HealthMarts. 1-4 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: 1-5 SECTION 1. Subchapter B of Chapter 26, Texas Insurance Code 1-6 is amended by adding Section 26.15A to read as follows: 1-7 Art. 26.15A. HEALTHMARTS. (a) In addition to the powers 1-8 and duties set forth in this subchapter, a cooperative may make 1-9 available health benefit coverage as a HealthMart within this 1-10 state, as described in this article. 1-11 (b) If a cooperative elects to operate as a HealthMart, 1-12 then, at least for that purpose alone, the board of trustees of the 1-13 cooperative shall include representatives of health care providers 1-14 and representatives of health carriers. 1-15 (c) A HealthMart is a group health plan for the purposes of 1-16 the Employee Retirement Income Security Act of 1974 (ERISA) and its 1-17 amendments, for as long as that statute and its amendments and 1-18 successor statutes shall be effective. 1-19 (d) A HealthMart is a program of group health insurance in 1-20 which: 1-21 (1) health carriers contract with a cooperative to 2-1 offer coverage to small and large employers, their eligible 2-2 employees, and their eligible employees' dependents; 2-3 (2) the rates at which coverages are made available 2-4 are established by the health carriers on a product- or 2-5 policy-specific basis and are determined by the board of trustees 2-6 of the cooperative to be actuarially sound; 2-7 (3) the same health benefits coverage is offered by 2-8 the contracting health carriers through the cooperative to all 2-9 eligible small and large employers, their employees, and their 2-10 employees' dependents within the geographic area or areas 2-11 identified by the cooperative; 2-12 (4) the cooperative provides health benefits coverage 2-13 only through contracts with health carriers and does not assume 2-14 insurance risk with respect to such coverage; 2-15 (5) the cooperative does not vary conditions of 2-16 eligibility (including premium rates and membership fees) of an 2-17 employer to participate in the HealthMart; 2-18 (6) the cooperative provides administrative services 2-19 for purchasers, including accounting, billing, publication and 2-20 dissemination of enrollment information, and preparation and 2-21 publication of employee coverage status reports; 2-22 (7) the cooperative collects and disseminates (or 2-23 arranges for the collection and dissemination of) consumer 2-24 information on the scope, cost, and enrollee satisfaction of all 2-25 coverage options offered through the HealthMart to its members and 3-1 eligible individuals, including information relating to: 3-2 (A) provider performance, 3-3 (B) locations and hours of operation of 3-4 providers, 3-5 (C) outcome of treatment, 3-6 (D) and such other information as may be 3-7 required by the board of trustees of the cooperative; 3-8 (e) Any health benefits coverage offered through a 3-9 HealthMart: 3-10 (1) must be underwritten by a health carrier, 3-11 (2) is subject to all consumer protection provisions 3-12 of this Code and other state and federal law, 3-13 (3) shall not be subject to any health benefits that 3-14 are mandated to be offered or provided under the terms of this 3-15 Code, other than those required under federal law, and 3-16 (4) shall provide full portability of creditable 3-17 coverage for individuals who remain members of the same HealthMart 3-18 notwithstanding that they may change the employer through which 3-19 they are members, in accordance with the provisions of ERISA, so 3-20 long as both employers are purchasers in the same HealthMart. 3-21 (f) The health benefits coverage made available through a 3-22 HealthMart may include, but is not limited to any of the following, 3-23 as long as such forms of coverage are offered by health carriers 3-24 and meet the other requirements of this article: 3-25 (1) coverage through a health maintenance 4-1 organization, 4-2 (2) indemnity coverage through an insurance company, 4-3 including a preferred provider option, 4-4 (3) coverage that includes a a point-of-service 4-5 option, 4-6 (4) coverage offered in connection with a contribution 4-7 into a medical savings account or flexible spending account, 4-8 (5) coverage offered through a community health 4-9 organization, as that term is defined in this Code or in section 4-10 330B(e) of the federal Public Service Health Act; and 4-11 (6) any combination of such types of coverage. 4-12 (g) Subject to the provisions of this article, a HealthMart: 4-13 (1) shall permit any large or small employer to 4-14 contract with the HealthMart for the purchase of health benefits 4-15 coverage for its employees and dependents of those employees, and 4-16 (2) may not vary conditions of eligibility, including 4-17 premium rates and membership fees of an employer to be a purchaser. 4-18 (h) Nothing in this article shall be construed as preventing 4-19 an association or a licensed health insurance agent from assisting 4-20 or representing a Health Mart or large or small employers from 4-21 entering into appropriate arrangements to carry out this title. 4-22 (i) The contract between a HealthMart and a purchaser shall 4-23 provided that the purchaser agrees not to obtain or to sponsor 4-24 health benefits coverage on behalf of any eligible employees and 4-25 their dependents, other than through the HealthMart. This 5-1 provision does not apply to an eligible individual who resides in 5-2 an area for which no coverage is offered by any health carrier 5-3 through the HealthMart. 5-4 (j) Membership rights of persons enrolled in a HealthMart 5-5 shall include the following: 5-6 (1) Individuals who are employees of the employer that 5-7 has contracted with the HealthMart may enroll for health benefits 5-8 for themselves and eligible dependents, under the rules established 5-9 by the HealthMart; 5-10 (2) The HealthMart may not deny enrollment to an 5-11 individual who is an employee or dependent of such an employee who 5-12 is eligible to be enrolled if such denial is based on health 5-13 status-related factors; 5-14 (3) The HealthMart shall provide for an open 5-15 enrollment period of 30 days, during which members may change the 5-16 coverage option under which the members are enrolled; 5-17 (4) The HealthMart may establish rules of employees 5-18 eligibility for enrollment and reenrollment during the annual open 5-19 enrollment period; and 5-20 (5) Any rules adopted by the HealthMart about 5-21 membership and eligibility shall be applied consistently to all 5-22 purchasers and members within the HealthMart and shall not be based 5-23 in any manner on health status-related factors. 5-24 (k) The contract between a HealthMart and a health carrier 5-25 shall provide for the payment of the premiums collected by the 6-1 HealthMart (or its contractor) for coverage for enrolled members. 6-2 The contract may also provide for a pre-determined administrative 6-3 charge negotiated by the HealthMart and the carrier. 6-4 (l) A HealthMart shall enter into contracts with one or more 6-5 health carriers so that members are provided least two health 6-6 insurance options in each geographic area covered by the 6-7 HealthMart. 6-8 (m) A member of a board of trustees of a cooperative acting 6-9 as a HealthMart may not serve as an employee or paid consultant to 6-10 the HealthMart, but he or she may receive reasonable reimbursement 6-11 for travel and other expenses relating to service on the board of 6-12 trustees. 6-13 (n) An individual is not eligible to serve in any capacity 6-14 on the board of trustees or as an employee of a HealthMart, if the 6-15 individual is employed by, represents, owns, or controls any 6-16 ownership interest in an organization from which the HealthMart 6-17 receives contributions, grants, or other funds not connected with a 6-18 contract for coverage through the HealthMart. 6-19 (o) Without limitation of its other rights under this 6-20 subchapter, a cooperative may engage in any of the following: 6-21 (1) Coordinating the offering of the same or similar 6-22 health benefits in different areas served by different HealthMarts; 6-23 (2) Providing for crediting or deductibles and other 6-24 cost-sharing for individuals who are provided health benefit 6-25 coverage through HealthMarts after: 7-1 (A) a change of employers through which the 7-2 coverage is provided; or 7-3 (B) a change in placement of employment to an 7-4 area not served by the HealthMart through which coverage was 7-5 originally provided; 7-6 (3) Providing for adjustments in amounts distributed 7-7 among the health insurance issuers offering health benefits 7-8 coverage through the HealthMart based on factors such as the 7-9 relative health care risk of members enrolled under the coverage 7-10 offered by the different health carriers; and 7-11 (4) Establishing minimum participation and 7-12 contribution rules for employers that become purchasers in the 7-13 HealthMart, so long as such rules are applied uniformly and 7-14 consistently for all health carriers. 7-15 SECTION 2. This Act takes effect September 1, 1999. 7-16 SECTION 3. The importance of this legislation and the 7-17 crowded condition of the calendars in both houses create an 7-18 emergency and an imperative public necessity that the 7-19 constitutional rule requiring bills to be read on three several 7-20 days in each house be suspended, and this rule is hereby suspended.