77R12555 AJA-D                           
         By Naishtat, Averitt                                  H.B. No. 2430
         Substitute the following for H.B. No. 2430:
         By Eiland                                         C.S.H.B. No. 2430
                                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.