1-1     By:  Naishtat, Averitt, Kitchen                       H.B. No. 2430
 1-2          (Senate Sponsor - Carona)
 1-3           (In the Senate - Received from the House May 11, 2001;
 1-4     May 11, 2001, read first time and referred to Committee on Business
 1-5     and Commerce; May 11, 2001, reported favorably by the following
 1-6     vote:  Yeas 5, Nays 0; May 11, 2001, sent to printer.)
 1-7                            A BILL TO BE ENTITLED
 1-8                                   AN ACT
 1-9     relating to a consumer assistance program for health benefit plan
1-10     consumers.
1-11           BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-12           SECTION 1. Subchapter E, Chapter 21, Insurance Code, is
1-13     amended by adding Article 21.53Z to read as follows:
1-14           Art. 21.53Z.  HEALTH BENEFIT PLAN CONSUMERS ASSISTANCE
1-15     PROGRAM
1-16           Sec. 1.  DEFINITION. In this article, "consumer" means a
1-17     person who is entitled to coverage under a health benefit plan or
1-18     who is seeking coverage under a health benefit plan.
1-19           Sec. 2.  HEALTH BENEFIT PLAN DEFINED. (a)  In this article,
1-20     "health benefit plan" means:
1-21                 (1)  a plan that provides benefits for medical,
1-22     surgical, or other treatment expenses incurred as a result of a
1-23     health condition, a mental health condition, an accident, sickness,
1-24     or substance abuse, including an individual, group, blanket, or
1-25     franchise insurance policy or insurance agreement, a group hospital
1-26     service contract, or an individual or group evidence of coverage or
1-27     similar coverage document that is offered by:
1-28                       (A)  an insurance company;
1-29                       (B)  a group hospital service corporation
1-30     operating under Chapter 20 of this code;
1-31                       (C)  a fraternal benefit society operating under
1-32     Chapter 10 of this code;
1-33                       (D)  a stipulated premium insurance company
1-34     operating under Chapter 22 of this code;
1-35                       (E)  a reciprocal exchange operating under
1-36     Chapter 19 of this code;
1-37                       (F)  a health maintenance organization operating
1-38     under the Texas Health Maintenance Organization Act (Chapter 20A,
1-39     Vernon's Texas Insurance Code);
1-40                       (G)  a self-insured employee benefit plan that is
1-41     subject to the Employee Retirement Income Security Act of 1974 (29
1-42     U.S.C. Section 1001 et seq.), as amended, including a multiple
1-43     employer welfare arrangement that holds a certificate of authority
1-44     under Article 3.95-2 of this code; or
1-45                       (H)  an approved nonprofit health corporation
1-46     that holds a certificate of authority under Article 21.52F of this
1-47     code;
1-48                 (2)  the state medical assistance program, including
1-49     Medicaid managed care;
1-50                 (3)  the child health plan established under Chapter
1-51     62, Health and Safety Code; or
1-52                 (4)  the federal Medicare program.
1-53           (b)  The term includes:
1-54                 (1)  a small employer health benefit plan written under
1-55     Chapter 26 of this code;
1-56                 (2)  a Medicare supplemental policy as defined by
1-57     Section 1881(g)(1), Social Security Act (42 U.S.C. Section 1395ss),
1-58     as amended; and
1-59                 (3)  a health benefit plan offered under the Texas
1-60     Employees Uniform Group Insurance Benefits Act (Article 3.50-2,
1-61     Vernon's Texas Insurance Code), the Texas State College and
1-62     University Employees Uniform Insurance Benefits Act (Article
1-63     3.50-3, Vernon's Texas Insurance Code), or Article 3.50-4 of this
1-64     code.
 2-1           Sec. 3.  HEALTH BENEFIT PLAN CONSUMERS ASSISTANCE PROGRAM.
 2-2     (a)  The health benefit plan consumers assistance program is
 2-3     established in the office of public insurance counsel.  The office
 2-4     of public insurance counsel may contract, through a request for
 2-5     proposals, with a nonprofit organization to operate the program.
 2-6     If the office of public insurance counsel enters into a contract
 2-7     under this subsection, the office of public insurance counsel shall
 2-8     monitor the performance of the nonprofit organization that operates
 2-9     the program.
2-10           (b)  The program shall:
2-11                 (1)  assist individual consumers who desire to appeal
2-12     the denial, termination, or reduction of health care services by
2-13     the issuer of a health benefit plan or the refusal by the issuer of
2-14     a health benefit plan to pay for health care services, including
2-15     appeals under Article 21.58A of this code or in Medicaid and
2-16     Medicare fair hearings;
2-17                 (2)  provide information to consumers in this state
2-18     about health benefit plans available in this state and about the
2-19     rights and responsibilities of enrollees in those plans;
2-20                 (3)  establish a statewide toll-free telephone number
2-21     and an interactive Internet site that consumers can use to obtain
2-22     information, advice, or assistance from the program;
2-23                 (4)  collect data concerning inquiries, problems, and
2-24     grievances handled by the program and periodically distribute a
2-25     compilation and analysis of the data to employers, issuers of
2-26     health benefit plans, regulatory agencies, and the public; and
2-27                 (5)  refer consumers to appropriate private or public
2-28     individuals or entities as necessary to ensure that inquiries,
2-29     problems, or grievances involving health benefit plans are handled
2-30     promptly and efficiently.
2-31           (c)  The program may:
2-32                 (1)  operate a statewide clearinghouse for objective
2-33     consumer information about health benefit plan coverage, including
2-34     options for obtaining health benefit plan  coverage; and
2-35                 (2)  accept gifts, grants, or donations from any source
2-36     for the purpose of operating the program.
2-37           (d)  The office of public insurance counsel or an entity
2-38     contracting with the office of public insurance counsel to
2-39     implement this article may establish an advisory committee composed
2-40     of consumers, health care providers, and representatives of health
2-41     benefit plan issuers.
2-42           (e)  A nonprofit organization contracting with the office of
2-43     public insurance counsel under Subsection (a) of this section may
2-44     not be involved in providing health care or issuing health benefit
2-45     plans and must demonstrate that the organization has expertise in
2-46     providing direct assistance to consumers who have concerns or
2-47     problems involving health benefit plans.
2-48           Sec. 4.  SCOPE OF PROGRAM; REFERRAL. The health benefit plan
2-49     consumers assistance program shall supplement and not duplicate
2-50     services provided by existing public and private programs or state
2-51     agencies, including the department and the office of public
2-52     insurance counsel, and shall refer consumers to other programs or
2-53     agencies as appropriate.
2-54           Sec. 5.  PROVISION OF CERTAIN INFORMATION BY ISSUER OF HEALTH
2-55     BENEFIT PLAN REQUIRED. (a)  The issuer of a health benefit plan
2-56     shall include in the plan's enrollment information materials notice
2-57     of the availability of the health benefit plan consumers assistance
2-58     program and describe the services provided by the program.  The
2-59     membership information materials must include the program's
2-60     toll-free telephone number and state that a consumer can call the
2-61     program for information or assistance in resolving a problem or
2-62     filing a complaint involving the health benefit plan.
2-63           (b)  The issuer of a health benefit plan shall provide the
2-64     information required under Subsection (a)  of this section in
2-65     writing to any person who makes an oral or written complaint to the
2-66     issuer involving the plan.
2-67           (c)  This section does not apply to the medical assistance
2-68     program, except that this section applies to a Medicaid managed
2-69     care organization.  This section does not apply to the federal
 3-1     Medicare program or to a self-insured employee benefit plan that is
 3-2     subject to the Employee Retirement Income Security Act of 1974 (29
 3-3     U.S.C. Section 1001 et seq.), as amended, other than a multiple
 3-4     employer welfare arrangement that holds a certificate of authority
 3-5     under Article 3.95-2 of this code.
 3-6           Sec. 6.  REFERRAL BY DEPARTMENT. If the department receives a
 3-7     complaint from a consumer involving a health benefit plan that is
 3-8     not subject to regulation by the department,  the department shall
 3-9     inform the consumer about the services provided by the health
3-10     benefit plan consumers assistance program and provide the consumer
3-11     with the program's toll-free telephone number.
3-12           Sec. 7.  APPLICABILITY OF SUNSET ACT. If the health benefit
3-13     plan consumers assistance program is not continued in existence as
3-14     provided by Chapter 325, Government Code (Texas Sunset Act), as
3-15     that Act applies to the performance of the functions of the office
3-16     of public insurance counsel under Section 7, Article 1.35A of this
3-17     code, the program is abolished and this article expires September
3-18     1, 2005.
3-19           SECTION 2.  Sections 5 and 6, Chapter 1457, Acts of the 76th
3-20     Legislature, Regular Session, 1999, are repealed.
3-21           SECTION 3.  This Act takes effect September 1, 2001.
3-22                                  * * * * *