1-1 By: Averitt (Senate Sponsor - Fraser) H.B. No. 2191
1-2 (In the Senate - Received from the House May 11, 2001;
1-3 May 11, 2001, read first time and referred to Committee on Business
1-4 and Commerce; May 11, 2001, reported favorably by the following
1-5 vote: Yeas 6, Nays 0; May 11, 2001, sent to printer.)
1-6 A BILL TO BE ENTITLED
1-7 AN ACT
1-8 relating to availability of health benefit plan coverage under the
1-9 Texas Health Insurance Risk Pool.
1-10 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-11 SECTION 1. Section 2(17), Article 3.77, Insurance Code, is
1-12 amended to read as follows:
1-13 (17) "Resident" means:
1-14 (A) an individual who has been legally domiciled
1-15 in Texas for a minimum of 30 days for persons eligible for
1-16 enrollment in the pool under Section 10(b) [10(a)(1), (2), (3), or
1-17 (5)] of this article; or
1-18 (B) an individual who is legally domiciled in
1-19 Texas for persons eligible for enrollment in the pool under Section
1-20 10(a) [10(a)(4)] of this article.
1-21 SECTION 2. Section 10, Article 3.77, Insurance Code, is
1-22 amended to read as follows:
1-23 Sec. 10. ELIGIBILITY FOR COVERAGE. (a) An individual who is
1-24 a resident, as defined by Section 2(17)(B) of this article, and who
1-25 continues to be a resident, is eligible for coverage from the pool
1-26 if the individual:
1-27 (1) provides to the pool evidence that the individual
1-28 has maintained health insurance coverage for the previous 18
1-29 months, with no gap in coverage greater than 63 days, of which the
1-30 most recent coverage was through an employer-sponsored plan, church
1-31 plan, or government plan; or
1-32 (2) provides to the pool evidence that the individual
1-33 had health insurance coverage under another state's qualified
1-34 Health Insurance Portability and Accountability Act health program
1-35 that was terminated because the individual did not reside in that
1-36 state and submits an application for pool coverage not later than
1-37 the 63rd day after the date that coverage was terminated.
1-38 (b) Any individual [person] who is and continues to be a
1-39 resident, as defined by Section 2(17)(A) of this article, [of
1-40 Texas] and who is a citizen of the United States or has been a
1-41 permanent resident of the United States for at least three
1-42 continuous years is [shall be] eligible for coverage from the pool
1-43 if the individual provides to the pool:
1-44 (1) a notice of rejection or refusal to issue
1-45 substantially similar individual insurance for health reasons by
1-46 one insurer, other than a rejection or refusal by an insurer
1-47 offering only stop-loss, excess loss, or reinsurance coverage;
1-48 (2) a certification from an agent or salaried
1-49 representative of an insurer, on a form developed by the board and
1-50 approved by the commissioner, that states that the agent or
1-51 salaried representative is unable to obtain substantially similar
1-52 individual insurance for the individual with any state-licensed
1-53 insurer that the agent or salaried representative represents
1-54 because the individual will be declined for coverage as a result of
1-55 a medical condition of the individual under the underwriting
1-56 guidelines of the insurer;
1-57 (3) an offer to issue substantially similar individual
1-58 insurance only with conditional riders;
1-59 (4) a refusal by an insurer to issue substantially
1-60 similar individual insurance except at a rate exceeding the pool
1-61 rate; or
1-62 (5) [evidence of the individual's maintenance of
1-63 health insurance coverage for the previous 18 months with no gap in
1-64 coverage greater than 63 days of which the most recent coverage was
2-1 through an employer sponsored plan; or]
2-2 [(6)] diagnosis of the individual with one of the
2-3 medical or health conditions listed by the board under Section 6(c)
2-4 of this article and for which a person shall be eligible for pool
2-5 coverage.
2-6 (c) [(b)] Each dependent of a person who is eligible for
2-7 coverage from the pool shall also be eligible for coverage from the
2-8 pool. In the instance of a child who is the primary insured,
2-9 resident family members shall also be eligible for coverage.
2-10 (d) [(c)] A person may maintain pool coverage for the period
2-11 of time the person is satisfying a preexisting waiting period under
2-12 another health insurance policy or insurance arrangement intended
2-13 to replace the pool policy.
2-14 (e) [(d)] A person is not eligible for coverage from the
2-15 pool if the person:
2-16 (1) has in effect on the date pool coverage takes
2-17 effect health insurance coverage from an insurer or insurance
2-18 arrangement;
2-19 (2) is eligible for other health care benefits at the
2-20 time application is made to the pool, including COBRA continuation,
2-21 except:
2-22 (A) coverage, including COBRA continuation,
2-23 other continuation or conversion coverage, maintained for the
2-24 period of time the person is satisfying any pre-existing condition
2-25 waiting period under a pool policy; or
2-26 (B) employer group coverage conditioned by the
2-27 type of limitations described by Subsections (b)(1) or (2) [(a)(1)
2-28 and (2)] of this section; or
2-29 (C) individual coverage conditioned by the
2-30 limitations described by Subsections (b)(3) or (4) [(a)(1)-(3)] of
2-31 this section;
2-32 (3) has terminated coverage in the pool within 12
2-33 months of the date that application is made to the pool, unless the
2-34 person demonstrates a good faith reason for the termination;
2-35 (4) is confined in a county jail or imprisoned in a
2-36 state prison;
2-37 (5) has premiums that are paid for or reimbursed under
2-38 any government sponsored program or by any government agency or
2-39 health care provider, except as an otherwise qualifying full-time
2-40 employee, or dependent thereof, of a government agency or health
2-41 care provider; [or]
2-42 (6) has [not] had prior coverage with the pool
2-43 terminated during the 12 months immediately preceding the date of
2-44 application for nonpayment of premiums; or
2-45 (7) has had prior coverage with the pool terminated
2-46 for fraud.
2-47 (f) [(e)] Pool coverage shall cease:
2-48 (1) on the date a person is no longer a resident of
2-49 this state, except for a child who is a student under the age of 23
2-50 years and who is financially dependent upon the parent, a child for
2-51 whom a person may be obligated to pay child support, or a child of
2-52 any age who is disabled and dependent upon the parent;
2-53 (2) on the date a person requests coverage to end;
2-54 (3) upon the death of the covered person;
2-55 (4) on the date state law requires cancellation of the
2-56 policy;
2-57 (5) at the option of the pool, 30 days after the pool
2-58 sends to the person any inquiry concerning the person's
2-59 eligibility, including an inquiry concerning the person's
2-60 residence, to which the person does not reply;
2-61 (6) on the 31st day after the day on which a premium
2-62 payment for pool coverage becomes due if the payment is not made
2-63 before that date; or
2-64 (7) at such time as the person ceases to meet the
2-65 eligibility requirements of this section.
2-66 (g) Coverage of a [(f) A] person who ceases to meet the
2-67 eligibility requirements of this section shall be [may have his
2-68 coverage] terminated on the earlier of the premium due date that
2-69 follows the date the pool determines the person does not meet the
3-1 eligibility requirements or the first day of the month that follows
3-2 the month in which the pool determines the person does not meet the
3-3 eligibility requirements [at the end of the policy period]. The
3-4 pool has the sole discretion to determine that a person does not
3-5 meet the eligibility requirements.
3-6 (h) A person who is eligible for health insurance benefits
3-7 provided in connection with a policy, plan, or program paid for or
3-8 sponsored by an employer, even though the employer coverage is
3-9 declined, is not eligible for pool coverage. An insurer, agent,
3-10 third party administrator, or other person licensed under this code
3-11 may not arrange or assist in or attempt to arrange or assist in the
3-12 application for pool coverage by, or placement in the pool of a
3-13 person who is ineligible under this subsection for the purpose of
3-14 separating the person from health insurance benefits offered or
3-15 provided in connection with employment that would be available to
3-16 the person as an employee or dependent of an employee. A violation
3-17 of this section is an unfair method of competition and an unfair or
3-18 deceptive act or practice under Article 21.21 of this code.
3-19 SECTION 3. Section 13(d), Article 3.77, Insurance Code, is
3-20 amended to read as follows:
3-21 (d) The assessment imposed against each insurer shall be in
3-22 an amount that is equal to the ratio of the gross premiums
3-23 collected by the insurer for health insurance in this state during
3-24 the preceding calendar year, except for Medicare supplement
3-25 premiums subject to Article 3.74 and small group health insurance
3-26 premiums subject to Articles 26.01 through 26.76, to the gross
3-27 premiums collected by all insurers for health insurance, except for
3-28 Medicare supplement premiums subject to Article 3.74 and small
3-29 group health insurance premiums subject to Articles 26.01 through
3-30 26.76, in this state during the preceding calendar year. An
3-31 assessment is due on a date specified by the board that may not be
3-32 earlier than the 30th day after the date on which prior written
3-33 notice of the assessment due is transmitted to the insurer.
3-34 Interest accrues on the unpaid amount at a rate equal to the prime
3-35 lending rate, as stated in the most recent issue of the Wall Street
3-36 Journal, plus three percent, determined as of the date such
3-37 assessment is delinquent.
3-38 SECTION 4. This Act takes effect September 1, 2001.
3-39 * * * * *