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.