By Naishtat H.B. No. 2430
77R4323 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 multiple employer welfare arrangement that
2-10 holds a certificate of authority under Article 3.95-2 of this code;
2-11 or
2-12 (H) an approved nonprofit health corporation
2-13 that holds a certificate of authority under Article 21.52F of this
2-14 code;
2-15 (2) the state medical assistance program, including
2-16 Medicaid managed care;
2-17 (3) the child health plan established under Chapter
2-18 62, Health and Safety Code; or
2-19 (4) the federal Medicare program.
2-20 (b) The term includes:
2-21 (1) a small employer health benefit plan written under
2-22 Chapter 26 of this code;
2-23 (2) a Medicare supplemental policy as defined by
2-24 Section 1881(g)(1), Social Security Act (42 U.S.C. Section 1395ss),
2-25 as amended; and
2-26 (3) a health benefit plan offered under the Texas
2-27 Employees Uniform Group Insurance Benefits Act (Article 3.50-2,
3-1 Vernon's Texas Insurance Code), the Texas State College and
3-2 University Employees Uniform Insurance Benefits Act (Article
3-3 3.50-3, Vernon's Texas Insurance Code), or Article 3.50-4 of this
3-4 code.
3-5 Sec. 3. HEALTH BENEFIT PLAN CONSUMERS ASSISTANCE PROGRAM.
3-6 (a) The health benefit plan consumers assistance program is
3-7 established. The commissioner may contract, through a request for
3-8 proposals, with a nonprofit organization to operate the program.
3-9 (b) The program shall:
3-10 (1) assist individual consumers who desire to appeal
3-11 the denial, termination, or reduction of health care services by
3-12 the issuer of a health benefit plan or the refusal by the issuer of
3-13 a health benefit plan to pay for health care services, including
3-14 appeals under Article 21.58A of this code or in Medicaid and
3-15 Medicare fair hearings;
3-16 (2) provide information to consumers in this state
3-17 about health benefit plans available in this state and about the
3-18 rights and responsibilities of enrollees in those plans;
3-19 (3) establish a statewide toll-free telephone number
3-20 and an interactive Internet site that consumers can use to obtain
3-21 information, advice, or assistance from the program;
3-22 (4) collect data concerning inquiries, problems, and
3-23 grievances handled by the program and periodically distribute a
3-24 compilation and analysis of the data to employers, issuers of
3-25 health benefit plans, regulatory agencies, and the public; and
3-26 (5) refer consumers to appropriate private or public
3-27 individuals or entities as necessary to ensure that inquiries,
4-1 problems, or grievances involving health benefit plans are handled
4-2 promptly and efficiently.
4-3 (c) The program may:
4-4 (1) operate a statewide clearinghouse for objective
4-5 consumer information about health benefit plan coverage, including
4-6 options for obtaining health benefit plan coverage;
4-7 (2) accept gifts, grants, or donations from any source
4-8 for the purpose of operating the program; and
4-9 (3) charge reasonable fees to consumers to support the
4-10 program.
4-11 (d) The commissioner or an entity contracting with the
4-12 commissioner to implement this article may establish an advisory
4-13 committee composed of consumers, health care providers, and
4-14 representatives of health benefit plan issuers.
4-15 (e) A nonprofit organization contracting with the
4-16 commissioner pursuant to Subsection (a) of this section must not be
4-17 involved in providing health care or issuing health benefit plans
4-18 and must demonstrate that the organization has expertise in
4-19 providing direct assistance to consumers who have concerns or
4-20 problems involving health benefit plans.
4-21 Sec. 4. SCOPE OF PROGRAM; REFERRAL. The health benefit plan
4-22 consumers assistance program shall supplement and not duplicate
4-23 services provided by existing public and private programs or state
4-24 agencies, including the department, and shall refer consumers to
4-25 other programs or agencies as appropriate.
4-26 Sec. 5. PROVISION OF CERTAIN INFORMATION BY ISSUER OF HEALTH
4-27 BENEFIT PLAN REQUIRED. (a) The issuer of a health benefit plan
5-1 shall include in the plan's enrollment information materials notice
5-2 of the availability of the health benefit plan consumers assistance
5-3 program and describe the services provided by the program. The
5-4 membership information materials must include the program's
5-5 toll-free telephone number and state that a consumer can call the
5-6 program for information or assistance in resolving a problem or
5-7 filing a complaint involving the health benefit plan.
5-8 (b) The issuer of a health benefit plan shall provide the
5-9 information required under Subsection (a) of this section in
5-10 writing to any person who makes an oral or written complaint to the
5-11 issuer involving the plan.
5-12 (c) This section does not apply to the medical assistance
5-13 program, except that this section applies to a Medicaid managed
5-14 care organization. This section does not apply to the federal
5-15 Medicare program.
5-16 Sec. 6. REFERRAL BY DEPARTMENT. If the department receives a
5-17 complaint from a consumer involving a health benefit plan that is
5-18 not subject to regulation by the department, the department shall
5-19 inform the consumer about the services provided by the health
5-20 benefit plan consumers assistance program and provide the consumer
5-21 with the program's toll-free telephone number.
5-22 SECTION 2. Sections 5 and 6, Chapter 1457, Acts of the 76th
5-23 Legislature, Regular Session, 1999, are repealed.
5-24 SECTION 3. This Act takes effect September 1, 2001.