By Naishtat, Averitt, Kitchen H.B. No. 2430
77R12555 AJA-D
A BILL TO BE ENTITLED
1-1 AN ACT
1-2 relating to a consumer assistance program for health benefit plan
1-3 consumers.
1-4 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-5 SECTION 1. Subchapter E, Chapter 21, Insurance Code, is
1-6 amended by adding Article 21.53Z to read as follows:
1-7 Art. 21.53Z. HEALTH BENEFIT PLAN CONSUMERS ASSISTANCE
1-8 PROGRAM
1-9 Sec. 1. DEFINITION. In this article, "consumer" means a
1-10 person who is entitled to coverage under a health benefit plan or
1-11 who is seeking coverage under a health benefit plan.
1-12 Sec. 2. HEALTH BENEFIT PLAN DEFINED. (a) In this article,
1-13 "health benefit plan" means:
1-14 (1) a plan that provides benefits for medical,
1-15 surgical, or other treatment expenses incurred as a result of a
1-16 health condition, a mental health condition, an accident, sickness,
1-17 or substance abuse, including an individual, group, blanket, or
1-18 franchise insurance policy or insurance agreement, a group hospital
1-19 service contract, or an individual or group evidence of coverage or
1-20 similar coverage document that is offered by:
1-21 (A) an insurance company;
1-22 (B) a group hospital service corporation
1-23 operating under Chapter 20 of this code;
1-24 (C) a fraternal benefit society operating under
2-1 Chapter 10 of this code;
2-2 (D) a stipulated premium insurance company
2-3 operating under Chapter 22 of this code;
2-4 (E) a reciprocal exchange operating under
2-5 Chapter 19 of this code;
2-6 (F) a health maintenance organization operating
2-7 under the Texas Health Maintenance Organization Act (Chapter 20A,
2-8 Vernon's Texas Insurance Code);
2-9 (G) a self-insured employee benefit plan that is
2-10 subject to the Employee Retirement Income Security Act of 1974 (29
2-11 U.S.C. Section 1001 et seq.), as amended, including a multiple
2-12 employer welfare arrangement that holds a certificate of authority
2-13 under Article 3.95-2 of this code; or
2-14 (H) an approved nonprofit health corporation
2-15 that holds a certificate of authority under Article 21.52F of this
2-16 code;
2-17 (2) the state medical assistance program, including
2-18 Medicaid managed care;
2-19 (3) the child health plan established under Chapter
2-20 62, Health and Safety Code; or
2-21 (4) the federal Medicare program.
2-22 (b) The term includes:
2-23 (1) a small employer health benefit plan written under
2-24 Chapter 26 of this code;
2-25 (2) a Medicare supplemental policy as defined by
2-26 Section 1881(g)(1), Social Security Act (42 U.S.C. Section 1395ss),
2-27 as amended; and
3-1 (3) a health benefit plan offered under the Texas
3-2 Employees Uniform Group Insurance Benefits Act (Article 3.50-2,
3-3 Vernon's Texas Insurance Code), the Texas State College and
3-4 University Employees Uniform Insurance Benefits Act (Article
3-5 3.50-3, Vernon's Texas Insurance Code), or Article 3.50-4 of this
3-6 code.
3-7 Sec. 3. HEALTH BENEFIT PLAN CONSUMERS ASSISTANCE PROGRAM.
3-8 (a) The health benefit plan consumers assistance program is
3-9 established in the office of public insurance counsel. The office
3-10 of public insurance counsel may contract, through a request for
3-11 proposals, with a nonprofit organization to operate the program.
3-12 If the office of public insurance counsel enters into a contract
3-13 under this subsection, the office of public insurance counsel shall
3-14 monitor the performance of the nonprofit organization that operates
3-15 the program.
3-16 (b) The program shall:
3-17 (1) assist individual consumers who desire to appeal
3-18 the denial, termination, or reduction of health care services by
3-19 the issuer of a health benefit plan or the refusal by the issuer of
3-20 a health benefit plan to pay for health care services, including
3-21 appeals under Article 21.58A of this code or in Medicaid and
3-22 Medicare fair hearings;
3-23 (2) provide information to consumers in this state
3-24 about health benefit plans available in this state and about the
3-25 rights and responsibilities of enrollees in those plans;
3-26 (3) establish a statewide toll-free telephone number
3-27 and an interactive Internet site that consumers can use to obtain
4-1 information, advice, or assistance from the program;
4-2 (4) collect data concerning inquiries, problems, and
4-3 grievances handled by the program and periodically distribute a
4-4 compilation and analysis of the data to employers, issuers of
4-5 health benefit plans, regulatory agencies, and the public; and
4-6 (5) refer consumers to appropriate private or public
4-7 individuals or entities as necessary to ensure that inquiries,
4-8 problems, or grievances involving health benefit plans are handled
4-9 promptly and efficiently.
4-10 (c) The program may:
4-11 (1) operate a statewide clearinghouse for objective
4-12 consumer information about health benefit plan coverage, including
4-13 options for obtaining health benefit plan coverage; and
4-14 (2) accept gifts, grants, or donations from any source
4-15 for the purpose of operating the program.
4-16 (d) The office of public insurance counsel or an entity
4-17 contracting with the office of public insurance counsel to
4-18 implement this article may establish an advisory committee composed
4-19 of consumers, health care providers, and representatives of health
4-20 benefit plan issuers.
4-21 (e) A nonprofit organization contracting with the office of
4-22 public insurance counsel under Subsection (a) of this section may
4-23 not be involved in providing health care or issuing health benefit
4-24 plans and must demonstrate that the organization has expertise in
4-25 providing direct assistance to consumers who have concerns or
4-26 problems involving health benefit plans.
4-27 Sec. 4. SCOPE OF PROGRAM; REFERRAL. The health benefit plan
5-1 consumers assistance program shall supplement and not duplicate
5-2 services provided by existing public and private programs or state
5-3 agencies, including the department and the office of public
5-4 insurance counsel, and shall refer consumers to other programs or
5-5 agencies as appropriate.
5-6 Sec. 5. PROVISION OF CERTAIN INFORMATION BY ISSUER OF HEALTH
5-7 BENEFIT PLAN REQUIRED. (a) The issuer of a health benefit plan
5-8 shall include in the plan's enrollment information materials notice
5-9 of the availability of the health benefit plan consumers assistance
5-10 program and describe the services provided by the program. The
5-11 membership information materials must include the program's
5-12 toll-free telephone number and state that a consumer can call the
5-13 program for information or assistance in resolving a problem or
5-14 filing a complaint involving the health benefit plan.
5-15 (b) The issuer of a health benefit plan shall provide the
5-16 information required under Subsection (a) of this section in
5-17 writing to any person who makes an oral or written complaint to the
5-18 issuer involving the plan.
5-19 (c) This section does not apply to the medical assistance
5-20 program, except that this section applies to a Medicaid managed
5-21 care organization. This section does not apply to the federal
5-22 Medicare program or to a self-insured employee benefit plan that is
5-23 subject to the Employee Retirement Income Security Act of 1974 (29
5-24 U.S.C. Section 1001 et seq.), as amended, other than a multiple
5-25 employer welfare arrangement that holds a certificate of authority
5-26 under Article 3.95-2 of this code.
5-27 Sec. 6. REFERRAL BY DEPARTMENT. If the department receives a
6-1 complaint from a consumer involving a health benefit plan that is
6-2 not subject to regulation by the department, the department shall
6-3 inform the consumer about the services provided by the health
6-4 benefit plan consumers assistance program and provide the consumer
6-5 with the program's toll-free telephone number.
6-6 Sec. 7. APPLICABILITY OF SUNSET ACT. If the health benefit
6-7 plan consumers assistance program is not continued in existence as
6-8 provided by Chapter 325, Government Code (Texas Sunset Act), as
6-9 that Act applies to the performance of the functions of the office
6-10 of public insurance counsel under Section 7, Article 1.35A of this
6-11 code, the program is abolished and this article expires September
6-12 1, 2005.
6-13 SECTION 2. Sections 5 and 6, Chapter 1457, Acts of the 76th
6-14 Legislature, Regular Session, 1999, are repealed.
6-15 SECTION 3. This Act takes effect September 1, 2001.