By Averitt H.B. No. 2191
A BILL TO BE ENTITLED
1-1 AN ACT
1-2 relating to availability of health benefit plan coverage under the
1-3 Texas Health Insurance Risk Pool.
1-4 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-5 SECTION 1. Section 2(17), Article 3.77, Insurance Code, is
1-6 amended to read as follows:
1-7 (17) "Resident" means:
1-8 (A) an individual who has been legally domiciled
1-9 in Texas for a minimum of 30 days for persons eligible for
1-10 enrollment in the pool under Section 10(b) [10(a)(1), (2), (3), or
1-11 (5)] of this article; or
1-12 (B) an individual who is legally domiciled in
1-13 Texas for persons eligible for enrollment in the pool under Section
1-14 10(a) [10(a)(4)] of this article.
1-15 SECTION 2. Section 10, Article 3.77, Insurance Code, is
1-16 amended to read as follows:
1-17 Sec. 10. ELIGIBILITY FOR COVERAGE. (a) An individual who is
1-18 a resident, as defined by Section 2(17)(B) of this article, and who
1-19 continues to be a resident, is eligible for coverage from the pool
1-20 if the individual:
1-21 (1) provides to the pool evidence that the individual
1-22 has maintained health insurance coverage for the previous 18
1-23 months, with no gap in coverage greater than 63 days, of which the
1-24 most recent coverage was through an employer-sponsored plan, church
2-1 plan, or government plan; or
2-2 (2) provides to the pool evidence that the individual
2-3 had health insurance coverage under another state's qualified
2-4 Health Insurance Portability and Accountability Act health program
2-5 that was terminated because the individual did not reside in that
2-6 state and submits an application for pool coverage not later than
2-7 the 63rd day after the date that coverage was terminated.
2-8 (b) Any individual [person] who is and continues to be a
2-9 resident, as defined by Section 2(17)(A) of this article, [of
2-10 Texas] and who is a citizen of the United States or has been a
2-11 permanent resident of the United States for at least three
2-12 continuous years is [shall be] eligible for coverage from the pool
2-13 if the individual provides to the pool:
2-14 (1) a notice of rejection or refusal to issue
2-15 substantially similar individual insurance for health reasons by
2-16 one insurer, other than a rejection or refusal by an insurer
2-17 offering only stop-loss, excess loss, or reinsurance coverage;
2-18 (2) a certification from an agent or salaried
2-19 representative of an insurer, on a form developed by the board and
2-20 approved by the commissioner, that states that the agent or
2-21 salaried representative is unable to obtain substantially similar
2-22 individual insurance for the individual with any state-licensed
2-23 insurer that the agent or salaried representative represents
2-24 because the individual will be declined for coverage as a result of
2-25 a medical condition of the individual under the underwriting
2-26 guidelines of the insurer;
2-27 (3) an offer to issue substantially similar individual
3-1 insurance only with conditional riders;
3-2 (4) a refusal by an insurer to issue substantially
3-3 similar individual insurance except at a rate exceeding the pool
3-4 rate; or
3-5 (5) [evidence of the individual's maintenance of
3-6 health insurance coverage for the previous 18 months with no gap in
3-7 coverage greater than 63 days of which the most recent coverage was
3-8 through an employer sponsored plan; or]
3-9 [(6)] diagnosis of the individual with one of the
3-10 medical or health conditions listed by the board under Section 6(c)
3-11 of this article and for which a person shall be eligible for pool
3-12 coverage.
3-13 (c) [(b)] Each dependent of a person who is eligible for
3-14 coverage from the pool shall also be eligible for coverage from the
3-15 pool. In the instance of a child who is the primary insured,
3-16 resident family members shall also be eligible for coverage.
3-17 (d) [(c)] A person may maintain pool coverage for the period
3-18 of time the person is satisfying a preexisting waiting period under
3-19 another health insurance policy or insurance arrangement intended
3-20 to replace the pool policy.
3-21 (e) [(d)] A person is not eligible for coverage from the
3-22 pool if the person:
3-23 (1) has in effect on the date pool coverage takes
3-24 effect health insurance coverage from an insurer or insurance
3-25 arrangement;
3-26 (2) is eligible for other health care benefits at the
3-27 time application is made to the pool, including COBRA continuation,
4-1 except:
4-2 (A) coverage, including COBRA continuation,
4-3 other continuation or conversion coverage, maintained for the
4-4 period of time the person is satisfying any pre-existing condition
4-5 waiting period under a pool policy; or
4-6 (B) employer group coverage conditioned by the
4-7 type of limitations described by Subsections (b)(1) or (2) [(a)(1)
4-8 and (2)] of this section; or
4-9 (C) individual coverage conditioned by the
4-10 limitations described by Subsections (b)(3) or (4) [(a)(1)-(3)] of
4-11 this section;
4-12 (3) has terminated coverage in the pool within 12
4-13 months of the date that application is made to the pool, unless the
4-14 person demonstrates a good faith reason for the termination;
4-15 (4) is confined in a county jail or imprisoned in a
4-16 state prison;
4-17 (5) has premiums that are paid for or reimbursed under
4-18 any government sponsored program or by any government agency or
4-19 health care provider, except as an otherwise qualifying full-time
4-20 employee, or dependent thereof, of a government agency or health
4-21 care provider; [or]
4-22 (6) has [not] had prior coverage with the pool
4-23 terminated during the 12 months immediately preceding the date of
4-24 application for nonpayment of premiums; or
4-25 (7) has had prior coverage with the pool terminated
4-26 for fraud.
4-27 (f) [(e)] Pool coverage shall cease:
5-1 (1) on the date a person is no longer a resident of
5-2 this state, except for a child who is a student under the age of 23
5-3 years and who is financially dependent upon the parent, a child for
5-4 whom a person may be obligated to pay child support, or a child of
5-5 any age who is disabled and dependent upon the parent;
5-6 (2) on the date a person requests coverage to end;
5-7 (3) upon the death of the covered person;
5-8 (4) on the date state law requires cancellation of the
5-9 policy;
5-10 (5) at the option of the pool, 30 days after the pool
5-11 sends to the person any inquiry concerning the person's
5-12 eligibility, including an inquiry concerning the person's
5-13 residence, to which the person does not reply;
5-14 (6) on the 31st day after the day on which a premium
5-15 payment for pool coverage becomes due if the payment is not made
5-16 before that date; or
5-17 (7) at such time as the person ceases to meet the
5-18 eligibility requirements of this section.
5-19 (g) Coverage of a [(f) A] person who ceases to meet the
5-20 eligibility requirements of this section shall be [may have his
5-21 coverage] terminated on the earlier of the premium due date that
5-22 follows the date the pool determines the person does not meet the
5-23 eligibility requirements or the first day of the month that follows
5-24 the month in which the pool determines the person does not meet the
5-25 eligibility requirements [at the end of the policy period]. The
5-26 pool has the sole discretion to determine that a person does not
5-27 meet the eligibility requirements.
6-1 (h) A person who is eligible for health insurance benefits
6-2 provided in connection with a policy, plan, or program paid for or
6-3 sponsored by an employer, even though the employer coverage is
6-4 declined, is not eligible for pool coverage. An insurer, agent,
6-5 third party administrator, or other person licensed under this code
6-6 may not arrange or assist in or attempt to arrange or assist in the
6-7 application for pool coverage by, or placement in the pool of a
6-8 person who is ineligible under this subsection for the purpose of
6-9 separating the person from health insurance benefits offered or
6-10 provided in connection with employment that would be available to
6-11 the person as an employee or dependent of an employee. A violation
6-12 of this section is an unfair method of competition and an unfair or
6-13 deceptive act or practice under Article 21.21 of this code.
6-14 SECTION 3. Section 13(d), Article 3.77, Insurance Code, is
6-15 amended to read as follows:
6-16 (d) The assessment imposed against each insurer shall be in
6-17 an amount that is equal to the ratio of the gross premiums
6-18 collected by the insurer for health insurance in this state during
6-19 the preceding calendar year, except for Medicare supplement
6-20 premiums subject to Article 3.74 and small group health insurance
6-21 premiums subject to Articles 26.01 through 26.76, to the gross
6-22 premiums collected by all insurers for health insurance, except for
6-23 Medicare supplement premiums subject to Article 3.74 and small
6-24 group health insurance premiums subject to Articles 26.01 through
6-25 26.76, in this state during the preceding calendar year. An
6-26 assessment is due on a date specified by the board that may not be
6-27 earlier than the 30th day after the date on which prior written
7-1 notice of the assessment due is transmitted to the insurer.
7-2 Interest accrues on the unpaid amount at a rate equal to the prime
7-3 lending rate, as stated in the most recent issue of the Wall Street
7-4 Journal, plus three percent, determined as of the date such
7-5 assessment is delinquent.
7-6 SECTION 4. This Act takes effect September 1, 2001.