AN ACT
1-1 relating to a child health plan for certain low-income children.
1-2 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-3 SECTION 1. Subtitle C, Title 2, Health and Safety Code, is
1-4 amended by adding Chapters 62 and 63 to read as follows:
1-5 CHAPTER 62. CHILD HEALTH PLAN FOR CERTAIN LOW-INCOME CHILDREN
1-6 SUBCHAPTER A. GENERAL PROVISIONS
1-7 Sec. 62.001. OBJECTIVE OF THE STATE CHILD HEALTH PLAN. The
1-8 principal objective of the state child health plan is to provide
1-9 primary and preventative health care to low-income, uninsured
1-10 children of this state, including children with special health care
1-11 needs, who are not served by or eligible for other state assisted
1-12 health insurance programs.
1-13 Sec. 62.002. DEFINITIONS. In this chapter:
1-14 (1) "Commission" means the Health and Human Services
1-15 Commission.
1-16 (2) "Commissioner" means the commissioner of health
1-17 and human services.
1-18 (3) "Health plan provider" means an insurance company,
1-19 health maintenance organization, or other entity that provides
1-20 health benefits coverage under the child health plan program. The
1-21 term includes a primary care case management provider network.
1-22 (4) "Net family income" means the amount of income
1-23 established for a family after reduction for offsets for expenses
1-24 such as child care and work-related expenses, in accordance with
2-1 standards applicable under the Medicaid program.
2-2 Sec. 62.003. NOT AN ENTITLEMENT; TERMINATION OF PROGRAM.
2-3 (a) This chapter does not establish an entitlement to assistance
2-4 in obtaining health benefits for a child.
2-5 (b) The program established under this chapter terminates at
2-6 the time that federal funding terminates under Title XXI of the
2-7 Social Security Act (42 U.S.C. Section 1397aa et seq.), as amended,
2-8 unless a successor program providing federal funding for a
2-9 state-designed child health plan program is created.
2-10 (c) Unless the legislature authorizes the expenditure of
2-11 other revenue for the program established under this chapter, the
2-12 program terminates on the date that money obtained by the state as
2-13 a result of the Comprehensive Settlement Agreement and Release
2-14 filed in the case styled The State of Texas v. The American Tobacco
2-15 Co., et al., No. 5-96CV-91, in the United States District Court,
2-16 Eastern District of Texas, is no longer available to provide state
2-17 funding for the program.
2-18 Sec. 62.004. FEDERAL LAW AND REGULATIONS. The commissioner
2-19 shall monitor federal legislation affecting Title XXI of the Social
2-20 Security Act (42 U.S.C. Section 1397aa et seq.) and changes to the
2-21 federal regulations implementing that law. If the commissioner
2-22 determines that a change to Title XXI of the Social Security Act
2-23 (42 U.S.C. Section 1397aa et seq.) or the federal regulations
2-24 implementing that law conflicts with this chapter, the commissioner
2-25 shall report the changes to the governor, lieutenant governor, and
2-26 speaker of the house of representatives, with recommendations for
3-1 legislation necessary to implement the federal law or regulations,
3-2 seek a waiver, or withdraw from participation.
3-3 (Sections 62.005 to 62.050 reserved for expansion
3-4 SUBCHAPTER B. ADMINISTRATION OF CHILD HEALTH PLAN PROGRAM
3-5 Sec. 62.051. DUTIES OF COMMISSION. (a) The commission
3-6 shall develop a state-designed child health plan program to obtain
3-7 health benefits coverage for children in low-income families. The
3-8 commission shall ensure that the child health plan program is
3-9 designed and administered in a manner that qualifies for federal
3-10 funding under Title XXI of the Social Security Act (42 U.S.C.
3-11 Section 1397aa et seq.), as amended, and any other applicable law
3-12 or regulations.
3-13 (b) The commission is the agency responsible for making
3-14 policy for the child health plan program, including policy related
3-15 to covered benefits provided under the child health plan. The
3-16 commission may not delegate this duty to another agency or entity.
3-17 (c) The commission shall oversee the implementation of the
3-18 child health plan program and coordinate the activities of each
3-19 agency necessary to the implementation of the program, including
3-20 the Texas Department of Health, Texas Department of Human Services,
3-21 and Texas Department of Insurance.
3-22 (d) The commission shall adopt rules as necessary to
3-23 implement this chapter. The commission may require the Texas
3-24 Department of Health, the Texas Department of Human Services, or
3-25 any other health and human services agency to adopt, with the
3-26 approval of the commission, any rules that may be necessary to
4-1 implement the program. With the consent of another agency,
4-2 including the Texas Department of Insurance, the commission may
4-3 delegate to that agency the authority to adopt, with the approval
4-4 of the commission, any rules that may be necessary to implement the
4-5 program.
4-6 (e) The commission shall conduct a review of each entity
4-7 that enters into a contract under Section 62.055 or Section 62.155,
4-8 to ensure that the entity is available, prepared, and able to
4-9 fulfill the entity's obligations under the contract in compliance
4-10 with the contract, this chapter, and rules adopted under this
4-11 chapter.
4-12 (f) The commission shall ensure that the amounts spent for
4-13 administration of the child health plan program do not exceed any
4-14 limit on those expenditures imposed by federal law.
4-15 Sec. 62.052. DUTIES OF TEXAS DEPARTMENT OF HEALTH. (a) The
4-16 commission may direct the Texas Department of Health to:
4-17 (1) implement contracts with health plan providers
4-18 under Section 62.155;
4-19 (2) monitor the health plan providers, through
4-20 reporting requirements and other means, to ensure performance under
4-21 the contracts and quality delivery of services;
4-22 (3) monitor the quality of services delivered to
4-23 enrollees through outcome measurements including:
4-24 (A) rate of hospitalization for ambulatory
4-25 sensitive conditions, including asthma, diabetes, epilepsy,
4-26 dehydration, gastroenteritis, pneumonia, and UTI/kidney infection;
5-1 (B) rate of hospitalization for injuries;
5-2 (C) percent of enrolled adolescents reporting
5-3 risky health behavior such as injuries, tobacco use, alcohol/drug
5-4 use, dietary behavior, physical activity, or other health related
5-5 behaviors; and
5-6 (D) percent of adolescents reporting attempted
5-7 suicide; and
5-8 (4) provide payment under the contracts to the health
5-9 plan providers.
5-10 (b) The commission, or the Texas Department of Health under
5-11 the direction of and in consultation with the commission, shall
5-12 adopt rules as necessary to implement this section.
5-13 Sec. 62.053. DUTIES OF TEXAS DEPARTMENT OF HUMAN SERVICES.
5-14 (a) Under the direction of the commission, the Texas Department of
5-15 Human Services may:
5-16 (1) accept applications for coverage under the child
5-17 health plan and implement the child health plan program eligibility
5-18 screening and enrollment procedures;
5-19 (2) resolve grievances relating to eligibility
5-20 determinations; and
5-21 (3) coordinate the child health plan program with the
5-22 Medicaid program.
5-23 (b) If the commission contracts with a third party
5-24 administrator under Section 62.055, the commission may direct the
5-25 Texas Department of Human Services to:
5-26 (1) implement the contract;
6-1 (2) monitor the third party administrator, through
6-2 reporting requirements and other means, to ensure performance under
6-3 the contract and quality delivery of services; and
6-4 (3) provide payment under the contract to the third
6-5 party administrator.
6-6 (c) The commission, or the Texas Department of Human
6-7 Services under the direction of and in consultation with the
6-8 commission, shall adopt rules as necessary to implement this
6-9 section.
6-10 Sec. 62.054. DUTIES OF TEXAS DEPARTMENT OF INSURANCE.
6-11 (a) At the request of the commission, the Texas Department of
6-12 Insurance shall provide any necessary assistance with the
6-13 development of the child health plan. The department shall monitor
6-14 the quality of the services provided by health plan providers and
6-15 resolve grievances relating to the health plan providers.
6-16 (b) The commission and the Texas Department of Insurance may
6-17 adopt a memorandum of understanding that addresses the
6-18 responsibilities of each agency in developing the plan.
6-19 (c) The Texas Department of Insurance, in consultation with
6-20 the commission, shall adopt rules as necessary to implement this
6-21 section.
6-22 Sec. 62.055. CONTRACTS FOR IMPLEMENTATION OF CHILD HEALTH
6-23 PLAN. (a) It is the intent of the legislature that the commission
6-24 maximize the use of private resources in administering the child
6-25 health plan created under this chapter. In administering the child
6-26 health plan, the commission may contract with:
7-1 (1) a third party administrator to provide enrollment
7-2 and related services under the state child health plan; or
7-3 (2) another entity, including the Texas Healthy Kids
7-4 Corporation under Subchapter F, Chapter 109, to obtain health
7-5 benefit plan coverage for children who are eligible for coverage
7-6 under the state child health plan.
7-7 (b) If the commission contracts with the Texas Healthy Kids
7-8 Corporation under Subchapter F, Chapter 109, to administer any part
7-9 of the child health plan created under this chapter, the
7-10 commission, prior to entering into any contract with the
7-11 corporation, shall conduct a readiness review of the corporation to
7-12 determine that the corporation and its contractors are able to
7-13 implement the child health plan on a statewide basis.
7-14 Notwithstanding the foregoing, if the board of directors of the
7-15 corporation, by a vote of the board, determines that the
7-16 corporation is unable to implement the child health plan on a
7-17 statewide basis, the commission may not contract with the
7-18 corporation under this section.
7-19 (c) The commission's review of the corporation and its
7-20 contractors under Subsection (b) shall be based at a minimum on the
7-21 following criteria:
7-22 (1) adequate and appropriate staffing, including
7-23 contracts with third parties;
7-24 (2) adequate and properly documented policies and
7-25 procedures;
7-26 (3) fiscal soundness;
8-1 (4) compliance with all applicable federal and state
8-2 standards, rules, and regulations;
8-3 (5) necessary accommodations for the needs of families
8-4 with special needs children;
8-5 (6) necessary partnerships with other programs
8-6 addressing children's health care needs; and
8-7 (7) adequate information systems, electronic
8-8 interfaces, and business processes.
8-9 (d) A third party administrator or other entity may perform
8-10 tasks under the contract that would otherwise be performed by the
8-11 Texas Department of Health or Texas Department of Human Services
8-12 under this chapter.
8-13 (e) The commission shall:
8-14 (1) retain all policymaking authority over the state
8-15 child health plan;
8-16 (2) procure all contracts with a third party
8-17 administrator or other entity through a competitive procurement
8-18 process in compliance with all applicable federal and state laws or
8-19 regulations; and
8-20 (3) ensure that all contracts with child health plan
8-21 providers under Section 62.155 are procured through a competitive
8-22 procurement process in compliance with all applicable federal and
8-23 state laws or regulations.
8-24 Sec. 62.056. COMMUNITY OUTREACH CAMPAIGN; TOLL-FREE HOTLINE.
8-25 (a) The commission shall conduct a community outreach and
8-26 education campaign to provide information relating to the
9-1 availability of health benefits for children under this chapter.
9-2 The commission shall conduct the campaign in a manner that promotes
9-3 enrollment in, and minimizes duplication of effort among, all state
9-4 administered child health programs and, subject to the approval of
9-5 the board of the Texas Healthy Kids Corporation, the program
9-6 offered under Chapter 109.
9-7 (b) The community outreach campaign must include:
9-8 (1) outreach efforts that involve school-based health
9-9 clinics; and
9-10 (2) a toll-free telephone number through which
9-11 families may obtain information about health benefits coverage for
9-12 children.
9-13 (c) The commission shall contract with community-based
9-14 organizations or coalitions of community-based organizations to
9-15 implement the community outreach campaign and shall also promote
9-16 and encourage voluntary efforts to implement the community outreach
9-17 campaign. The commission shall procure the contracts through a
9-18 process designed by the commission to encourage broad participation
9-19 of organizations, including those organizations that target
9-20 population groups with high levels of uninsured children.
9-21 (d) The commission may direct that the Texas Department of
9-22 Health or the Texas Department of Human Services perform all or
9-23 part of the community outreach campaign.
9-24 Sec. 62.057. REGIONAL ADVISORY COMMITTEES. (a) Not later
9-25 than the 180th day before the date on which the commission plans to
9-26 begin to provide health coverage to recipients through the child
10-1 health plan program, the commission shall appoint regional advisory
10-2 committees to provide recommendations on the implementation and
10-3 operation of the child health plan program.
10-4 (b) The advisory committees, to the extent possible, must be
10-5 composed of representatives of:
10-6 (1) hospitals;
10-7 (2) insurance companies and health maintenance
10-8 organizations eligible to offer the health benefits coverage under
10-9 the child health plan;
10-10 (3) primary care providers;
10-11 (4) consumer advocates, including advocates for
10-12 children with special health care needs;
10-13 (5) parents of children who are enrolled in the child
10-14 health plan;
10-15 (6) rural health care providers;
10-16 (7) specialty health care providers, including
10-17 pediatric providers;
10-18 (8) community-based organizations that provide
10-19 community outreach under Section 62.056; and
10-20 (9) state agencies.
10-21 (c) The commission shall establish the regional advisory
10-22 committees, consistent with Subsection (b), in regions of this
10-23 state in a manner that ensures geographic representation.
10-24 (d) In implementing this section, the commission may use
10-25 other regional advisory structures, augmented to ensure the
10-26 representation required by Subsection (b), to the extent necessary
11-1 to avoid duplication of administrative activities.
11-2 (e) The advisory committees shall meet at least quarterly
11-3 and are subject to Chapter 551, Government Code.
11-4 (f) Section 2110.008, Government Code, does not apply to
11-5 the advisory committees.
11-6 Sec. 62.058. FRAUD PREVENTION. The commission shall develop
11-7 and implement rules for the prevention and detection of fraud in
11-8 the child health plan program.
11-9 (Sections 62.059 to 62.100 reserved for expansion
11-10 SUBCHAPTER C. ELIGIBILITY FOR COVERAGE UNDER CHILD HEALTH PLAN
11-11 Sec. 62.101. ELIGIBILITY. (a) A child is eligible for
11-12 health benefits coverage under the child health plan if the child:
11-13 (1) is younger than 19 years of age;
11-14 (2) is not eligible for medical assistance under the
11-15 Medicaid program;
11-16 (3) is not covered by a health benefits plan offering
11-17 adequate benefits, as determined by the commission;
11-18 (4) has a family income that is less than or equal to
11-19 the income eligibility level established under Subsection (b); and
11-20 (5) satisfies any other eligibility standard imposed
11-21 under the child health plan program in accordance with 42 U.S.C.
11-22 Section 1397bb, as amended, and any other applicable law or
11-23 regulations.
11-24 (b) The commission shall establish income eligibility levels
11-25 consistent with Title XXI, Social Security Act (42 U.S.C. Section
11-26 1397aa et seq.), as amended, and any other applicable law or
12-1 regulations, and subject to the availability of appropriated money,
12-2 so that a child who is younger than 19 years of age and whose net
12-3 family income is at or below 200 percent of the federal poverty
12-4 level is eligible for health benefits coverage under the program.
12-5 (c) The commissioner shall evaluate enrollment levels and
12-6 program impact every six months during the first 12 months of
12-7 implementation and at least annually thereafter and shall submit a
12-8 finding of fact to the Legislative Budget Board and the Governor's
12-9 Office of Budget and Planning as to the adequacy of funding and the
12-10 ability of the program to sustain enrollment at the eligibility
12-11 level established by Subsection (b). In the event that
12-12 appropriated money is insufficient to sustain enrollment at the
12-13 authorized eligibility level, the commissioner shall:
12-14 (1) suspend enrollment in the child health plan;
12-15 (2) establish a waiting list for applicants for
12-16 coverage; and
12-17 (3) establish a process for periodic or continued
12-18 enrollment of applicants in the child health plan program as the
12-19 availability of money allows.
12-20 Sec. 62.102. CONTINUOUS COVERAGE. The commission shall
12-21 provide that an individual who is determined to be eligible for
12-22 coverage under the child health plan remains eligible for those
12-23 benefits until the earlier of:
12-24 (1) the end of a period, not to exceed 12 months,
12-25 following the date of the eligibility determination; or
12-26 (2) the individual's 19th birthday.
13-1 Sec. 62.103. APPLICATION FORM AND PROCEDURES. (a) The
13-2 commission, or the Texas Department of Human Services at the
13-3 direction of and in consultation with the commission, shall adopt
13-4 an application form and application procedures for requesting child
13-5 health plan coverage under this chapter.
13-6 (b) The form and procedures must be coordinated with forms
13-7 and procedures under the Medicaid program and those used by the
13-8 Texas Healthy Kids Corporation to ensure that, to the extent
13-9 possible, there is a single consolidated application to seek
13-10 assistance under this chapter or the Medicaid program or from the
13-11 corporation.
13-12 (c) To the extent possible, the application form shall be
13-13 made available in languages other than English.
13-14 (d) The commission may permit application to be made by
13-15 mail, over the telephone, or through the Internet.
13-16 Sec. 62.104. ELIGIBILITY SCREENING AND ENROLLMENT. (a) The
13-17 commission, or the Texas Department of Human Services at the
13-18 direction of and in consultation with the commission, shall develop
13-19 eligibility screening and enrollment procedures for children that
13-20 comply with the requirements of 42 U.S.C. Section 1397bb, as
13-21 amended, and any other applicable law or regulations. The
13-22 procedures shall ensure that Medicaid-eligible children are
13-23 identified and referred to the Medicaid program.
13-24 (b) The Texas Integrated Enrollment Services eligibility
13-25 determination system or a compatible system may be used to screen
13-26 and enroll children under the child health plan.
14-1 (c) The eligibility screening and enrollment procedures
14-2 shall ensure that children who appear to be Medicaid-eligible are
14-3 identified and that their families are assisted in applying for
14-4 Medicaid coverage.
14-5 (d) A child who applies for enrollment in the child health
14-6 plan, who is denied Medicaid coverage after completion of a
14-7 Medicaid application under Subsection (c), but who is eligible for
14-8 enrollment in the child health plan, shall be enrolled in the child
14-9 health plan without further application or qualification.
14-10 (e) The commission shall report semi-annually to the
14-11 committees of both houses of the legislature with jurisdiction over
14-12 the child health plan:
14-13 (1) the number of individuals referred for Medicaid
14-14 application under this section who are enrolled in the Medicaid
14-15 program; and
14-16 (2) the number of individuals who are denied coverage
14-17 under the Medicaid program because they failed to complete the
14-18 application process.
14-19 (f) A determination of whether a child is eligible for child
14-20 health plan coverage under the program and the enrollment of an
14-21 eligible child with a health plan provider must be completed, and
14-22 information on the family's available choice of health plan
14-23 providers must be provided, in a timely manner, as determined by
14-24 the commission. The commission must require that the determination
14-25 be made and the information be provided not later than the 30th day
14-26 after the date a complete application is submitted on behalf of the
15-1 child, unless the child is referred for Medicaid application under
15-2 this section.
15-3 (g) In the first year of implementation of the child health
15-4 plan, enrollment shall be open. Thereafter, the commission may
15-5 establish enrollment periods.
15-6 Sec. 62.105. COVERAGE FOR QUALIFIED ALIENS. The commission
15-7 shall provide coverage under the state Medicaid program and under
15-8 the program established under this chapter to a child who is a
15-9 qualified alien, as that term is defined by 8 U.S.C. Section
15-10 1641(b), if the federal government authorizes the state to provide
15-11 that coverage. The commission shall comply with any prerequisite
15-12 imposed under the federal law to providing that coverage.
15-13 (Sections 62.106 to 62.150 reserved for expansion
15-14 SUBCHAPTER D. CHILD HEALTH PLAN
15-15 Sec. 62.151. CHILD HEALTH PLAN COVERAGE. (a) The child
15-16 health plan must comply with this chapter and the coverage
15-17 requirements prescribed by 42 U.S.C. Section 1397cc, as amended,
15-18 and any other applicable law or regulations.
15-19 (b) In developing the covered benefits, the commission shall
15-20 consider the health care needs of healthy children and children
15-21 with special health care needs. At the time the child health plan
15-22 program is first implemented, the child health plan must provide a
15-23 benefits package that is actuarially equivalent, as determined in
15-24 accordance with 42 U.S.C. Section 1397cc, to the basic plan for
15-25 active state employees offered through health maintenance
15-26 organizations under the Texas Employees Uniform Group Insurance
16-1 Benefits Act (Article 3.50-2, Vernon's Texas Insurance Code), as
16-2 determined by the commission. The child health plan must provide
16-3 at least the covered benefits described by the recommended benefits
16-4 package described for a state-designed child health plan by the
16-5 Texas House of Representatives Committee on Public Health "CHIP"
16-6 Interim Report to the Seventy-Sixth Texas Legislature dated
16-7 December, 1998, and the Senate Interim Committee on Children's
16-8 Health Insurance Report to the Seventy-Sixth Texas Legislature
16-9 dated December 1, 1998.
16-10 (c) In developing the plan, the commission shall ensure that
16-11 primary and preventive health benefits do not include reproductive
16-12 services, other than prenatal care and care related to diseases,
16-13 illnesses, or abnormalities related to the reproductive system.
16-14 (d) The child health plan must allow an enrolled child with
16-15 a chronic, disabling, or life-threatening illness to select an
16-16 appropriate specialist as a primary care physician.
16-17 Sec. 62.152. APPLICATION OF INSURANCE LAW. To provide the
16-18 flexibility necessary to satisfy the requirements of Title XXI of
16-19 the Social Security Act (42 U.S.C. Section 1397aa et seq.), as
16-20 amended, and any other applicable law or regulations, the child
16-21 health plan is not subject to a law that requires:
16-22 (1) coverage or the offer of coverage of a health care
16-23 service or benefit;
16-24 (2) coverage or the offer of coverage for the
16-25 provision of services by a particular health care services
16-26 provider, except as provided by Section 62.155(b); or
17-1 (3) the use of a particular policy or contract form or
17-2 of particular language in a policy or contract form.
17-3 Sec. 62.153. COST SHARING. (a) To the extent permitted
17-4 under 42 U.S.C. Section 1397cc, as amended, and any other
17-5 applicable law or regulations, the commission shall require
17-6 enrollees to share the cost of the child health plan, including
17-7 provisions requiring enrollees under the child health plan to pay:
17-8 (1) a copayment for services provided under the plan;
17-9 (2) an enrollment fee; or
17-10 (3) a portion of the plan premium.
17-11 (b) Cost-sharing provisions adopted under this section shall
17-12 ensure that families with higher levels of income are required to
17-13 pay progressively higher percentages of the cost of the plan.
17-14 (c) If cost-sharing provisions imposed under Subsection (a)
17-15 include requirements that enrollees pay a portion of the plan
17-16 premium, the commission shall specify the manner in which the
17-17 premium is paid. The commission may require that the premium be
17-18 paid to the Texas Department of Health, the Texas Department of
17-19 Human Services, or the health plan provider.
17-20 Sec. 62.154. CROWD OUT. (a) To the extent permitted under
17-21 Title XXI of the Social Security Act (42 U.S.C. Section 1397aa et
17-22 seq.), as amended, and any other applicable law or regulations, the
17-23 child health plan must include a waiting period and may include
17-24 copayments and other provisions intended to discourage:
17-25 (1) employers and other persons from electing to
17-26 discontinue offering coverage for children under employee or other
18-1 group health benefit plans; and
18-2 (2) individuals with access to adequate health benefit
18-3 plan coverage, other than coverage under the child health plan,
18-4 from electing not to obtain or to discontinue that coverage for a
18-5 child.
18-6 (b) A child is not subject to a waiting period adopted under
18-7 Subsection (a) if:
18-8 (1) the family lost coverage for the child as a result
18-9 of:
18-10 (A) termination of employment because of a
18-11 layoff or business closing;
18-12 (B) termination of continuation coverage under
18-13 the Consolidated Omnibus Budget Reconciliation Act of 1985 (Pub. L.
18-14 No. 99-272);
18-15 (C) change in marital status of a parent of the
18-16 child;
18-17 (D) termination of the child's Medicaid
18-18 eligibility because:
18-19 (i) the child's family's earnings or
18-20 resources increased; or
18-21 (ii) the child reached an age at which
18-22 Medicaid coverage is not available; or
18-23 (E) a similar circumstance resulting in the
18-24 involuntary loss of coverage;
18-25 (2) the family terminated health benefits plan
18-26 coverage for the child because the cost to the child's family for
19-1 the coverage exceeded 10 percent of the family's net income; or
19-2 (3) the commission has determined that other grounds
19-3 exist for a good cause exception.
19-4 (c) A child described by Subsection (b) may enroll in the
19-5 child health plan program at any time, without regard to any open
19-6 enrollment period established under the enrollment procedures.
19-7 (d) The waiting period required by Subsection (a) must:
19-8 (1) extend for a period of 90 days after the last date
19-9 on which the applicant was covered under a health benefits plan;
19-10 and
19-11 (2) apply to a child who was covered by a health
19-12 benefits plan at any time during the 90 days before the date of
19-13 application for coverage under the child health plan, other than a
19-14 child who was covered under a health benefits plan provided under
19-15 Chapter 109.
19-16 Sec. 62.155. HEALTH PLAN PROVIDERS. (a) The commission, or
19-17 the Texas Department of Health at the direction of and in
19-18 consultation with the commission, shall select the health plan
19-19 providers under the program through a competitive procurement
19-20 process. A health plan provider, other than a state administered
19-21 primary care case management network, must hold a certificate of
19-22 authority or other appropriate license issued by the Texas
19-23 Department of Insurance that authorizes the health plan provider to
19-24 provide the type of child health plan offered and must satisfy,
19-25 except as provided by this chapter, any applicable requirement of
19-26 the Insurance Code or another insurance law of this state.
20-1 (b) A managed care organization or other entity shall seek
20-2 to obtain, in the organization's or entity's provider network, the
20-3 participation of significant traditional providers, as defined by
20-4 commission rule, if that organization or entity:
20-5 (1) contracts with the commission or with another
20-6 agency or entity to operate a part of the child health plan under
20-7 this chapter; and
20-8 (2) uses a provider network to provide or arrange for
20-9 health care services under the child health plan.
20-10 (c) In selecting a health plan provider, the commission:
20-11 (1) may give preference to a person who provides
20-12 similar coverage under the Medicaid program or through the Texas
20-13 Healthy Kids Corporation; and
20-14 (2) shall provide for a choice of at least two health
20-15 plan providers in each metropolitan area.
20-16 (d) The commissioner may authorize an exception to
20-17 Subsection (c)(2) if there is only one acceptable applicant to
20-18 become a health plan provider in the metropolitan area.
20-19 Sec. 62.156. HEALTH CARE PROVIDERS. Health care providers
20-20 who provide health care services under the child health plan must
20-21 satisfy certification and licensure requirements, as required by
20-22 the commission, consistent with law.
20-23 CHAPTER 63. HEALTH BENEFITS PLAN FOR CERTAIN CHILDREN
20-24 Sec. 63.001. DEFINITION. In this chapter, "commission"
20-25 means the Health and Human Services Commission.
20-26 Sec. 63.002. NOT AN ENTITLEMENT. This chapter does not
21-1 establish an entitlement to assistance in obtaining health benefits
21-2 for a child.
21-3 Sec. 63.003. HEALTH BENEFITS PLAN COVERAGE FOR CERTAIN
21-4 CHILDREN. The commission shall develop and implement a program to
21-5 provide health benefits plan coverage for a child who:
21-6 (1) is a qualified alien, as that term is defined by 8
21-7 U.S.C. Section 1641(b);
21-8 (2) is younger than 19 years of age;
21-9 (3) entered the United States after August 22, 1996;
21-10 (4) has resided in the United States for less than
21-11 five years; and
21-12 (5) meets the income eligibility requirement of, but
21-13 is not eligible for assistance under:
21-14 (A) the child health plan program under Chapter
21-15 62; or
21-16 (B) the medical assistance program under Chapter
21-17 32, Human Resources Code.
21-18 Sec. 63.004. BENEFITS COVERAGE REQUIRED. To the extent
21-19 possible, the program required by Section 63.003 must provide
21-20 benefits comparable to the benefits provided under the child health
21-21 plan program under Chapter 62.
21-22 Sec. 63.005. HEALTH BENEFITS PLAN PROVIDER. (a) A health
21-23 benefits plan provider under this chapter must:
21-24 (1) hold a certificate of authority or other
21-25 appropriate license issued by the Texas Department of Insurance
21-26 that authorizes the health benefits plan provider to provide the
22-1 type of coverage to be offered through the program required by
22-2 Section 63.003; and
22-3 (2) satisfy, except as provided by Subsection (b), any
22-4 other applicable requirement of the Insurance Code or another
22-5 insurance law of this state.
22-6 (b) Except as required by the commission, a health benefits
22-7 plan provider under this chapter is not subject to a law that
22-8 requires coverage or the offer of coverage of a health care service
22-9 or benefit.
22-10 Sec. 63.006. COST-SHARING PAYMENTS. (a) Except as provided
22-11 by Subsection (b), the commission may not require a child who is
22-12 provided health benefits plan coverage under Section 63.003 and who
22-13 meets the income eligibility requirement of the medical assistance
22-14 program under Chapter 32, Human Resources Code, to pay a premium,
22-15 deductible, coinsurance, or other cost-sharing payment as a
22-16 condition of health benefits plan coverage under this chapter.
22-17 (b) The commission may require a child described by
22-18 Subsection (a) to pay a copayment as a condition of health benefits
22-19 plan coverage under this chapter that is equal to any copayment
22-20 required under the child health plan program under Chapter 62.
22-21 (c) The commission may require a child who is provided
22-22 health benefits plan coverage under Section 63.003 and who meets
22-23 the income eligibility requirement of the child health plan program
22-24 under Chapter 62 to pay a premium, deductible, coinsurance, or
22-25 other cost-sharing payment as a condition of health benefits plan
22-26 coverage under this chapter. The payment must be equal to any
23-1 premium, deductible, coinsurance, or other cost-sharing payment
23-2 required under the child health plan program under Chapter 62.
23-3 Sec. 63.007. DISALLOWANCE OF MATCHING FUNDS FROM FEDERAL
23-4 GOVERNMENT. Expenditures made to provide health benefits plan
23-5 coverage under this chapter may not be included for the purpose of
23-6 determining the state children's health insurance expenditures, as
23-7 that term is defined by 42 U.S.C. Section 1397ee(d)(2)(B), as
23-8 amended.
23-9 SECTION 2. Chapter 109, Health and Safety Code, is amended
23-10 by adding Subchapter F to read as follows:
23-11 SUBCHAPTER F. STATE CHILD HEALTH PLAN
23-12 Sec. 109.201. DEFINITIONS. In this subchapter:
23-13 (1) "Commission" means the Health and Human Services
23-14 Commission.
23-15 (2) "State child health plan" means the child health
23-16 plan program established under Chapter 62.
23-17 Sec. 109.202. CHILD HEALTH PLAN COVERAGE. (a) The
23-18 commission may use appropriated funds, in accordance with the
23-19 General Appropriations Act, to purchase coverage under a health
23-20 benefit plan provided through the corporation for children who are
23-21 eligible for coverage under the state child health plan and to
23-22 contract with the corporation for other services under this
23-23 subchapter.
23-24 (b) State child health plan coverage offered under this
23-25 subchapter must be approved by the commission. The commission
23-26 shall ensure that coverage provided under this subchapter complies
24-1 with Chapter 62.
24-2 Sec. 109.203. ELIGIBILITY. Notwithstanding any other
24-3 provision of this chapter or the eligibility criteria established
24-4 under Section 109.061, an individual who is eligible for coverage
24-5 under the state child health plan, as determined by the commission,
24-6 is eligible for state child health plan coverage provided through
24-7 the corporation under this subchapter.
24-8 Sec. 109.204. COMMUNITY OUTREACH; ELIGIBILITY SCREENING.
24-9 (a) In connection with offering state child health plan coverage
24-10 under this subchapter, the corporation, under the direction of the
24-11 commission, may:
24-12 (1) conduct all or part of the community outreach and
24-13 education campaign required under Section 62.056; and
24-14 (2) perform eligibility screening and enrollment
24-15 services.
24-16 (b) The eligibility screening and enrollment procedures used
24-17 by the corporation must comply with Chapter 62.
24-18 Sec. 109.205. COMPETITIVE PROCUREMENT. (a) If the
24-19 corporation is selected to offer state child health plan coverage
24-20 under this subchapter and subsequently as required by the
24-21 commission or otherwise appropriate, the corporation shall use a
24-22 competitive procurement process, satisfactory to the commission, to
24-23 ensure that the state receives the best value with respect to:
24-24 (1) a contract with any third party administrator that
24-25 may provide services with respect to the state child health plan;
24-26 and
25-1 (2) any eligible coverage providers providing health
25-2 benefits through the state child health plan.
25-3 (b) As part of the competitive procurement process, the
25-4 corporation shall evaluate the demonstrated capacity of any third
25-5 party administrator to administer programs of similar size and
25-6 complexity.
25-7 Sec. 109.206. REPORTING AND ACCOUNTABILITY. (a) The
25-8 corporation shall report to the commission as required by the
25-9 commission with respect to coverage and services provided under
25-10 this subchapter.
25-11 (b) The commission shall establish a procedure to monitor
25-12 the provision of coverage and services under this subchapter.
25-13 SECTION 3. Section 4, Article 3.51-6, Insurance Code, is
25-14 amended to read as follows:
25-15 Sec. 4. EXEMPTIONS. The provisions of this article shall
25-16 not be applicable to:
25-17 (1) credit accident and health insurance policies
25-18 subject to Article 3.53 of the Insurance Code, as amended;
25-19 (2) any group specifically provided for or authorized
25-20 by law in existence and covered under a policy filed with the State
25-21 Board of Insurance prior to April 1, 1975;
25-22 (3) accident and health coverages that are incidental
25-23 to any form of group automobile, casualty, property, or workmen's
25-24 compensation--employers' liability policies promulgated or approved
25-25 by the State Board of Insurance;
25-26 (4) any policy or contract of insurance with a state
26-1 agency, department, or board providing health services to [all]
26-2 eligible persons under Chapter 32, Human Resources Code, or in
26-3 accordance with 42 U.S.C. Sections 1396-1396g, as amended, or 42
26-4 U.S.C. Section 1397aa et seq., as amended, [Section 6, The Medical
26-5 Assistance Act of 1967, as amended (Article 695j--1, Vernon's Texas
26-6 Civil Statutes), 343-353 (42 U.S.C.A. 1396-1396g), providing health
26-7 care and services] under a state plan.
26-8 SECTION 4. Not later than September 1, 1999, the Health and
26-9 Human Services Commission shall:
26-10 (1) develop the child health plan required under
26-11 Chapter 62, Health and Safety Code, as added by this Act; and
26-12 (2) submit for approval a plan amendment relating to
26-13 the child health plan under 42 U.S.C. Section 1397ff, as amended.
26-14 SECTION 5. Notwithstanding Subsection (f), Section 62.051,
26-15 Health and Safety Code, as added by this Act, the Health and Human
26-16 Services Commission shall ensure that, consistent with federal law
26-17 and Chapter 62, Health and Safety Code, as added by this Act, the
26-18 aggregate amount of general revenue spent for administration during
26-19 the first 24 months of operation of the child health plan program
26-20 is matched with federal funds.
26-21 SECTION 6. If, before implementing any provision of Chapter
26-22 62, Health and Safety Code, as added by this Act, the Health and
26-23 Human Services Commission determines that a waiver or authorization
26-24 from a federal agency is necessary for implementation of that
26-25 provision, the commission shall request the waiver or authorization
26-26 and may delay implementing that provision until the waiver or
27-1 authorization is granted.
27-2 SECTION 7. The first money becoming available to the state
27-3 each fiscal year as a result of the Comprehensive Settlement
27-4 Agreement and Release filed in the case styled The State of Texas
27-5 v. The American Tobacco Co., et al., No. 5-96CV-91, in the United
27-6 States District Court, Eastern District of Texas, shall be used to
27-7 fund the child health plan program established by this state under
27-8 Title XXI of the Social Security Act (42 U.S.C. Section 1397aa et
27-9 seq.), as amended.
27-10 SECTION 8. The standing or other committees of the House of
27-11 Representatives and Senate of the 76th Legislature that have
27-12 jurisdiction over the Health and Human Services Commission and
27-13 other agencies related to the implementation of Chapter 62, Health
27-14 and Safety Code, as added by this Act, as identified by the speaker
27-15 of the house of representatives and the lieutenant governor, shall:
27-16 (1) monitor the implementation of Chapter 62, Health
27-17 and Safety Code, as added by this Act; and
27-18 (2) perform other related duties as required by the
27-19 speaker of the house of representatives and lieutenant governor, as
27-20 appropriate.
27-21 SECTION 9. (a) Not later than September 1, 2000, the Health
27-22 and Human Services Commission shall establish and implement the
27-23 health benefits plan coverage program required by Chapter 63,
27-24 Health and Safety Code, as added by this Act.
27-25 (b) The commission may delay implementation of the health
27-26 benefits plan coverage program until a plan amendment relating to
28-1 the child health plan under 42 U.S.C. Section 1397ff, as amended,
28-2 is approved.
28-3 SECTION 10. The state shall provide coverage under the state
28-4 Medicaid program or under a program established under Title XXI of
28-5 the Social Security Act (42 U.S.C. Section 1397aa et seq.), as
28-6 amended, to a child described by Section 63.003, Health and Safety
28-7 Code, as added by this Act, if the federal government authorizes
28-8 the state to provide that coverage. The Health and Human Services
28-9 Commission or any other appropriate agency shall comply with any
28-10 prerequisites under the federal law to providing the coverage.
28-11 SECTION 11. The importance of this legislation and the
28-12 crowded condition of the calendars in both houses create an
28-13 emergency and an imperative public necessity that the
28-14 constitutional rule requiring bills to be read on three several
28-15 days in each house be suspended, and this rule is hereby suspended,
28-16 and that this Act take effect and be in force from and after its
28-17 passage, and it is so enacted.
S.B. No. 445
________________________________ ________________________________
President of the Senate Speaker of the House
I hereby certify that S.B. No. 445 passed the Senate on
March 11, 1999, by the following vote: Yeas 31, Nays 0;
May 5, 1999, Senate refused to concur in House amendments and
requested appointment of Conference Committee; May 6, 1999, House
granted request of the Senate; May 24, 1999, Senate adopted
Conference Committee Report by the following vote: Yeas 30,
Nays 0.
_______________________________
Secretary of the Senate
I hereby certify that S.B. No. 445 passed the House, with
amendments, on May 3, 1999, by the following vote: Yeas 123,
Nays 14, four present not voting; May 6, 1999, House granted
request of the Senate for appointment of Conference Committee;
May 22, 1999, House adopted Conference Committee Report by a
non-record vote.
_______________________________
Chief Clerk of the House
Approved:
________________________________
Date
________________________________
Governor