By Gallego H.B. No. 3444
A BILL TO BE ENTITLED
1-1 AN ACT
1-2 relating to health care benefit mandates and offer of coverage
1-3 mandates.
1-4 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-5 SECTION 1. Title 1, Insurance Code, is amended by adding
1-6 Chapter 28 to read as follows:
1-7 CHAPTER 28. ASSESSMENT OF HEALTH CARE BENEFIT AND OFFER OF
1-8 COVERAGE MANDATES
1-9 SUBCHAPTER A. GENERAL PROVISIONS
1-10 Art. 28.001. GENERAL DEFINITIONS. In this chapter:
1-11 (1) "Certified actuary" means:
1-12 (A) a fellow of the Society of Actuaries;
1-13 (B) a fellow of the Casualty Actuarial Society;
1-14 or
1-15 (C) a member of the American Academy of
1-16 Actuaries.
1-17 (2) "Health care benefit mandate" means a state law
1-18 that requires a health benefit plan to provide coverage or
1-19 reimbursement for a specific health care service, treatment, or
1-20 procedure, a specific medical condition or illness, or a particular
1-21 group of people who would otherwise be excluded, or to reimburse a
1-22 specific type of health care provider directly or in a specific
1-23 amount. The term does not include an offer of coverage mandate.
1-24 (3) "Offer of coverage mandate" means a state law that
2-1 requires a health benefit plan to offer as part of the plan's
2-2 benefit schedule coverage that may be rejected by the contract
2-3 holder and for which an additional premium may be charged.
2-4 Art. 28.002. DEFINITION OF HEALTH BENEFIT PLAN. (a) In this
2-5 chapter, "health benefit plan" means a plan that provides benefits
2-6 for medical or surgical expenses incurred as a result of a health
2-7 condition, accident, or sickness, including an individual, group,
2-8 blanket, or franchise insurance policy or insurance agreement, a
2-9 group hospital service contract, or an individual or group evidence
2-10 of coverage or similar coverage document that is offered by:
2-11 (1) an insurance company;
2-12 (2) a group hospital service corporation operating
2-13 under Chapter 20 of this code;
2-14 (3) a fraternal benefit society operating under
2-15 Chapter 10 of this code;
2-16 (4) a stipulated premium insurance company operating
2-17 under Chapter 22 of this code;
2-18 (5) a reciprocal exchange operating under Chapter 19
2-19 of this code;
2-20 (6) a health maintenance organization operating under
2-21 the Texas Health Maintenance Organization Act (Chapter 20A,
2-22 Vernon's Texas Insurance Code);
2-23 (7) a multiple employer welfare arrangement that holds
2-24 a certificate of authority under Article 3.95-2 of this code;
2-25 (8) an approved nonprofit health corporation that
2-26 holds a certificate of authority under Article 21.52F of this code;
2-27 or
3-1 (9) a Lloyd's plan.
3-2 (b) "Health benefit plan" does not include:
3-3 (1) a plan that provides coverage only:
3-4 (A) for benefits for a specified disease or for
3-5 another limited benefit other than for cancer;
3-6 (B) for accidental death or dismemberment;
3-7 (C) for wages or payments in lieu of wages for a
3-8 period during which an employee is absent from work because of
3-9 sickness or injury;
3-10 (D) as a supplement to a liability insurance
3-11 policy;
3-12 (E) for credit insurance;
3-13 (F) for dental or vision care; or
3-14 (G) for indemnity for hospital confinement;
3-15 (2) a Medicare supplemental policy as defined by
3-16 Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss),
3-17 as amended;
3-18 (3) a workers' compensation insurance policy;
3-19 (4) medical payment insurance coverage provided under
3-20 a motor vehicle insurance policy; or
3-21 (5) a long-term care insurance policy, including a
3-22 nursing home fixed indemnity policy, unless the commissioner
3-23 determines that the policy provides benefit coverage so
3-24 comprehensive that the policy is a health benefit plan as described
3-25 by Subsection (a) of this article.
3-26 (Articles 28.003-28.050 reserved for expansion
3-27 SUBCHAPTER B. IMPACT ASSESSMENT OF PROPOSED MANDATE
4-1 BY LEGISLATIVE BUDGET BOARD
4-2 Art. 28.051. REQUEST FOR IMPACT ASSESSMENT. If the chair of
4-3 a standing committee of the legislature determines that a bill
4-4 would, if enacted, create a health care benefit mandate or an offer
4-5 of coverage mandate, the chair shall send a copy of the bill to the
4-6 Legislative Budget Board and request that an impact assessment of
4-7 the mandate be prepared.
4-8 Art. 28.052. PREPARATION OF IMPACT ASSESSMENT; ACTUARIAL
4-9 ASSISTANCE REQUIRED. (a) On receipt of a bill under Article 28.051
4-10 of this code, the Legislative Budget Board shall prepare a written
4-11 impact assessment of the mandate in accordance with this
4-12 subchapter.
4-13 (b) In preparing an impact assessment, the director of the
4-14 Legislative Budget Board may:
4-15 (1) use any information supplied by any person,
4-16 agency, organization, or governmental unit that the director
4-17 determines is reliable; and
4-18 (2) obtain assistance in preparing the assessment from
4-19 any state agency or by contract with a private entity.
4-20 (c) The Legislative Budget Board shall obtain the assistance
4-21 of at least one certified actuary who is qualified to provide an
4-22 opinion relating to an impact assessment under this subchapter.
4-23 (d) An impact assessment prepared under this subchapter must
4-24 include:
4-25 (1) any report relating to the mandate produced by an
4-26 actuary or other expert retained by the Legislative Budget Board;
4-27 and
5-1 (2) a description of all underlying assumptions, data,
5-2 and studies on which the evaluation was based.
5-3 (e) The director of the Legislative Budget Board shall
5-4 submit an impact assessment requested under Article 28.051 of this
5-5 code not later than the 21st day after the date of the request.
5-6 Art. 28.053. CONTENTS OF IMPACT ASSESSMENT. (a) An impact
5-7 assessment of a health care benefit mandate or offer of coverage
5-8 mandate prepared under this subchapter must include, as applicable:
5-9 (1) the level of demand in the state for the coverage
5-10 that is the subject of the mandate, including the number and
5-11 percentage of people in the state who are affected by the medical
5-12 condition or illness that is the subject of the mandate or who
5-13 would be likely to use the coverage that is the subject of the
5-14 mandate;
5-15 (2) the extent to which the coverage is available
5-16 under health benefit plans that are in effect at the time the
5-17 impact assessment is made;
5-18 (3) the extent to which any health care service,
5-19 treatment, or procedure that would be required under the mandate
5-20 would be available in the absence of health benefit plan coverage;
5-21 (4) the epidemiological impact and medical efficacy of
5-22 the health care service, treatment, or procedure, including the
5-23 impact of the service, treatment, or procedure on an individual's
5-24 health status and the effect on an individual's health status of
5-25 not providing the service, treatment, or procedure;
5-26 (5) the direct impact of the mandate on health benefit
5-27 plan premiums;
6-1 (6) the net impact of the mandate on premiums,
6-2 considering the extent to which the coverage is already provided
6-3 under health benefit plans that are in effect at the time the
6-4 impact assessment is made and the extent to which other costs are
6-5 offset by the mandate;
6-6 (7) the costs to an individual of obtaining the health
6-7 care service, treatment, or procedure in the absence of health
6-8 benefit plan coverage;
6-9 (8) the fiscal impact on the state associated with
6-10 enacting the mandate and with not enacting the mandate;
6-11 (9) the impact on the economy and society of not
6-12 providing the health care service, treatment, or procedure;
6-13 (10) the impact of the health care service, treatment,
6-14 or procedure on the use of sick days and disability costs;
6-15 (11) the relative quality and cost-efficiency of the
6-16 care that is the subject of the mandate in the absence of health
6-17 benefit plan coverage; and
6-18 (12) a description of the extent to which the health
6-19 care benefit mandate or offer of coverage mandate is required by
6-20 federal law and the consequences of not enacting a mandate that
6-21 includes the minimum requirements of the federal law.
6-22 (b) For an offer of coverage mandate, the impact assessment
6-23 must also estimate the difference in the cost of a health benefit
6-24 plan that provides the coverage and a comparable health benefit
6-25 plan that does not provide the coverage.
6-26 (c) For a health care benefit mandate, the impact assessment
6-27 must also estimate the impact of the mandate if the mandate was an
7-1 offer of coverage mandate.
7-2 (d) An impact assessment must provide a separate analysis of
7-3 the cost to the Employees Retirement System of Texas of providing
7-4 the coverage that is the subject of the mandate being assessed to
7-5 the population covered by the uniform group insurance program or a
7-6 successor program, even if the program would not be subject to the
7-7 mandate.
7-8 (e) An impact assessment must provide a separate analysis of
7-9 the costs of the health benefit plan mandate or offer of coverage
7-10 mandate for:
7-11 (1) group health benefit plans, collectively and
7-12 according to the type of plan;
7-13 (2) individual health benefit plans; and
7-14 (3) small employer health benefit plans written under
7-15 Chapter 26 of this code, even if those plans would not be subject
7-16 to the mandate.
7-17 Art. 28.054. IMPACT ASSESSMENT IN CERTAIN CIRCUMSTANCES. If
7-18 the director of the Legislative Budget Board determines that the
7-19 impact of a proposed health benefit plan mandate or offer of
7-20 coverage mandate cannot be fully ascertained or the director is
7-21 unable to acquire or develop sufficient information to prepare a
7-22 complete impact assessment within 21 days of receiving the bill
7-23 from the chair of a committee, the director shall:
7-24 (1) report that fact in writing to the chair of the
7-25 committee; and
7-26 (2) prepare an impact assessment that:
7-27 (A) complies as much as possible with the
8-1 requirements of Article 28.053 of this code; and
8-2 (B) explains which of the applicable
8-3 requirements of that article are not met and why they are not met.
8-4 Art. 28.055. DISTRIBUTION OF IMPACT ASSESSMENT. Copies of an
8-5 impact assessment prepared under this subchapter must be
8-6 distributed to the members of the committee before the committee
8-7 votes on the bill to which the assessment relates. The assessment
8-8 shall be attached to the bill on first printing. If the bill is
8-9 amended by the committee in a way that alters a mandate, the chair
8-10 shall obtain an updated impact assessment, which shall also be
8-11 attached to the bill on first printing.
8-12 Art. 28.056. IMPACT ASSESSMENT REMAINS WITH BILL. An impact
8-13 assessment prepared under this subchapter shall remain with the
8-14 bill to which the assessment relates throughout the entire
8-15 legislative process, including submission to the governor.
8-16 (Articles 28.057-28.100 reserved for expansion
8-17 SUBCHAPTER C. ASSESSMENT OF ENACTED MANDATE BY SUNSET
8-18 ADVISORY COMMISSION; EXPIRATION OF MANDATE
8-19 Art. 28.101. DEFINITION. In this subchapter, "review date"
8-20 means the review date assigned by the commissioner to a health care
8-21 benefit mandate or offer of coverage mandate under Article 28.103
8-22 of this code.
8-23 Art. 28.102. APPLICABILITY OF SUBCHAPTER. This subchapter
8-24 applies to a health care benefit mandate or offer of coverage
8-25 mandate provided for:
8-26 (1) in a statute; or
8-27 (2) in a rule adopted by the commissioner.
9-1 Art. 28.103. REVIEW DATES. (a) The commissioner shall
9-2 assign a review date to each health care benefit mandate or offer
9-3 of coverage mandate.
9-4 (b) In assigning review dates, the commissioner shall:
9-5 (1) consider the amount of time a mandate has been in
9-6 effect and whether the mandate has been substantially amended since
9-7 the mandate became effective; and
9-8 (2) except as provided by Subsection (c) of this
9-9 article, and to the extent possible while complying with Subsection
9-10 (d) of this article, assign review dates to mandates according to
9-11 the amount of time the mandates have been in effect in
9-12 substantially the same form, with the mandates that have been in
9-13 effect in substantially the same form for the longest period having
9-14 the earliest review dates.
9-15 (c) The commissioner may assign the same review date to
9-16 mandates that are substantially similar or substantively related to
9-17 each other.
9-18 (d) Except as provided by this subsection, the commissioner
9-19 may not assign the same review date to more than five mandates. If
9-20 the commissioner assigns the same review date to mandates that are
9-21 substantially similar or substantively related to each other, the
9-22 commissioner may count those mandates as one mandate for the
9-23 purposes of this subsection.
9-24 (e) The review date:
9-25 (1) must be September 1 of an even-numbered year; and
9-26 (2) may not be earlier than September 1 of the
9-27 even-numbered year following the fifth anniversary of the date the
10-1 mandate is adopted.
10-2 (f) Notwithstanding Subsection (e) of this article, for a
10-3 mandate that was adopted on or before September 1, 1999, the review
10-4 date may not be earlier than September 1, 2004. This subsection
10-5 expires December 31, 2005.
10-6 Art. 28.104. ASSESSMENT OF MANDATE. (a) Before the review
10-7 date for a health care benefit mandate or an offer of coverage
10-8 mandate, the Sunset Advisory Commission shall:
10-9 (1) review and take action necessary to verify the
10-10 reports relating to the mandate submitted by the department and the
10-11 Texas Department of Health under Article 28.156 of this code;
10-12 (2) conduct an assessment of the mandate based on the
10-13 criteria provided by Article 28.107 of this code and prepare a
10-14 written report; and
10-15 (3) review any prior commission recommendations
10-16 relating to the mandate in reports presented to the legislature
10-17 under this subchapter in a preceding legislative session.
10-18 (b) A report prepared by the Sunset Advisory Commission
10-19 under this article is a public record.
10-20 Art. 28.105. PUBLIC HEARINGS. (a) Between the review date
10-21 for a health care benefit mandate or offer of coverage mandate and
10-22 December 1 of the calendar year in which the review date occurs,
10-23 the Sunset Advisory Commission shall conduct public hearings
10-24 concerning the assessment of the mandate provided by Article 28.107
10-25 of this code.
10-26 (b) The Sunset Advisory Commission may hold public hearings
10-27 under this article before the review date if the report required
11-1 under Article 28.104 is complete and available to the public.
11-2 Art. 28.106. REPORT; RECOMMENDATION. (a) Not later than
11-3 January 1 of the year of a regular legislative session, the Sunset
11-4 Advisory Commission shall present to the legislature and the
11-5 governor a report on each health care benefit mandate or offer of
11-6 coverage mandate that was assessed under this subchapter during the
11-7 previous year.
11-8 (b) In the report the Sunset Advisory Commission shall
11-9 include:
11-10 (1) the specific findings of the commission regarding
11-11 each of the criteria considered under Article 28.107 of this code;
11-12 (2) recommendations of the commission regarding
11-13 whether the mandate should be continued, modified, or repealed; and
11-14 (3) any other information the commission considers
11-15 necessary for a complete assessment of the mandate.
11-16 Art. 28.107. CRITERIA FOR ASSESSMENT. (a) The Sunset
11-17 Advisory Commission and the commission's staff, in determining
11-18 whether a health care benefit mandate or an offer of coverage
11-19 mandate should be continued, modified, or repealed, shall consider,
11-20 as applicable:
11-21 (1) the level of demand in the state for the coverage
11-22 that is the subject of the mandate, including the number and
11-23 percentage of people, statewide and among distinct population
11-24 groups, who are affected by the medical condition or illness that
11-25 is the subject of the mandate or who use the coverage that is the
11-26 subject of the mandate;
11-27 (2) the extent to which any health care service,
12-1 treatment, or procedure that would be required under the mandate
12-2 would be available in the absence of health benefit plan coverage;
12-3 (3) the epidemiological impact and medical efficacy of
12-4 the health care service, treatment, or procedure, including the
12-5 impact of the service, treatment, or procedure on an individual's
12-6 health status and the effect on an individual's health status of
12-7 not providing the service, treatment, or procedure;
12-8 (4) the direct impact of the mandate on health benefit
12-9 plan premiums;
12-10 (5) the net impact of the mandate on premiums,
12-11 considering the extent to which other costs are offset by the
12-12 mandate;
12-13 (6) the costs to an individual of obtaining the health
12-14 care service, treatment, or procedure in the absence of health
12-15 benefit plan coverage;
12-16 (7) the fiscal impact on the state associated with
12-17 continuing the mandate and with repealing the mandate;
12-18 (8) the impact on the economy and society of not
12-19 providing the health care service, treatment, or procedure;
12-20 (9) the impact of the health care service, treatment,
12-21 or procedure on the use of sick days and disability costs;
12-22 (10) the relative quality and cost-efficiency of the
12-23 care that is the subject of the mandate in the absence of health
12-24 benefit plan coverage; and
12-25 (11) the extent to which the mandate being assessed is
12-26 required by federal law and the consequences of repealing the
12-27 mandate or continuing the mandate in a form that does not include
13-1 the minimum requirements of the federal law.
13-2 (b) In considering a mandate's impact on health benefit plan
13-3 premiums under Subsection (a) of this article, the Sunset Advisory
13-4 Commission and the commission's staff shall, if applicable, provide
13-5 a separate analysis of the impact of a health care benefit mandate
13-6 or offer of coverage mandate on:
13-7 (1) group health benefit plans collectively and
13-8 according to the type of plan;
13-9 (2) individual health benefit plans; and
13-10 (3) small employer health benefit plans written under
13-11 Chapter 26 of this code.
13-12 Art. 28.108. PREPARATION OF REPORT; ACTUARIAL ASSISTANCE
13-13 REQUIRED. (a) The Sunset Advisory Commission may contract with any
13-14 person to provide actuarial, medical, or economic expertise or
13-15 other expertise or services as necessary to allow the commission to
13-16 prepare a report required under this subchapter.
13-17 (b) The Sunset Advisory Commission shall obtain the
13-18 assistance of at least one certified actuary who is qualified to
13-19 provide an opinion relating to a report under this subchapter.
13-20 Art. 28.109. CONTINUATION OF MANDATE. (a) A health care
13-21 benefit mandate or offer of coverage mandate shall continue in
13-22 effect until such time as the legislature acts on the
13-23 recommendation of the commission according to Article 28.106 of
13-24 this code.
13-25 (b) A subsequent review date of the health care benefit
13-26 mandate or offer of coverage mandate may not exceed 12 years. A
13-27 mandate may be modified at the time the mandate is continued.
14-1 (c) This subchapter does not prohibit the legislature from:
14-2 (1) repealing a health care benefit mandate or offer
14-3 of coverage mandate; or
14-4 (2) considering any other legislation relating to a
14-5 mandate.
14-6 (Articles 28.110-28.150 reserved for expansion
14-7 SUBCHAPTER D. COLLECTION AND REPORTING OF DATA
14-8 Art. 28.151. DEFINITION OF LARGE HEALTH BENEFIT PLAN
14-9 CARRIER. The commissioner by rule shall define "large health
14-10 benefit plan carrier" for the purposes of Article 28.152 of this
14-11 code. The commissioner shall obtain the assistance of the advisory
14-12 committee established under Article 28.153 of this code in
14-13 formulating the definition. The definition must:
14-14 (1) be based on the carrier's premium volume or number
14-15 of enrollees covered by the carrier's plans; and
14-16 (2) describe a sufficient number of carriers to
14-17 fulfill the purposes of this subchapter, but not less than the
14-18 lesser of:
14-19 (A) 15 carriers; or
14-20 (B) all carriers operating in this state.
14-21 Art. 28.152. REQUIRED INFORMATION. (a) The commissioner by
14-22 rule shall require each large health benefit plan carrier and the
14-23 Employees Retirement System of Texas to submit annually information
14-24 that the commissioner, with the assistance of the advisory
14-25 committee established under Article 28.153 of this code, determines
14-26 is necessary for the assessment of health care benefit mandates and
14-27 offer of coverage mandates under this chapter.
15-1 (b) A large health benefit plan carrier shall submit
15-2 information required by the commissioner under this article.
15-3 (c) The Employees Retirement System of Texas shall submit
15-4 information required by the commissioner under this article.
15-5 Art. 28.153. ADVISORY COMMITTEE. (a) The commissioner shall
15-6 appoint an advisory committee of at least 7 and not more than 11
15-7 members to assist the department in implementing this subchapter.
15-8 (b) The members of the committee must include at least one
15-9 representative from each of the following groups or entities:
15-10 (1) large health benefit plan carriers that are
15-11 insurers;
15-12 (2) large health benefit plan carriers that are health
15-13 maintenance organizations;
15-14 (3) consumers;
15-15 (4) health care providers;
15-16 (5) the Texas Department of Health; and
15-17 (6) the Texas Health Care Information Council.
15-18 (c) The committee must also include members who have
15-19 demonstrated actuarial, economic, and information systems
15-20 expertise.
15-21 (d) The committee shall work with the department to ensure
15-22 that:
15-23 (1) data collected under this subchapter is
15-24 sufficient to properly evaluate each health benefit mandate and
15-25 offer of coverage mandate under Subchapter C of this chapter;
15-26 (2) compliance with requests for data made under this
15-27 subchapter is both feasible for health benefit plan carriers and as
16-1 cost-effective as possible; and
16-2 (3) to the extent possible, data collection formats
16-3 under this subchapter are compatible with data collection formats
16-4 required under Section 221(a), Health Insurance Portability and
16-5 Accountability Act of 1996 (42 U.S.C. Section 1320a-7e).
16-6 (e) Chapter 2110, Government Code, applies to the advisory
16-7 committee created under this article.
16-8 Art. 28.154. CERTAIN INFORMATION EXCLUDED. The department
16-9 may not collect information under this subchapter that could
16-10 reasonably be expected to reveal the identity of a patient or a
16-11 health care provider other than a hospital.
16-12 Art. 28.155. APPLICABILITY OF OPEN RECORDS LAW. Information
16-13 submitted under this subchapter by an individual health benefit
16-14 plan carrier is not subject to disclosure under Chapter 552,
16-15 Government Code. The department shall aggregate information
16-16 submitted by all health benefit plan carriers under this
16-17 subchapter, and that aggregated information is subject to
16-18 disclosure under Chapter 552, Government Code.
16-19 Art. 28.156. REPORTING OF DATA. (a) Before July 1 of the
16-20 calendar year in which the review date assigned to a health care
16-21 benefit mandate or an offer of coverage mandate under Article
16-22 28.103 of this code occurs:
16-23 (1) the department shall report to the Sunset Advisory
16-24 Commission:
16-25 (A) information regarding the costs associated
16-26 with the mandate, including the claims paid under health benefit
16-27 plans that are related to the mandate and the premiums charged for
17-1 coverage required by the mandate; and
17-2 (B) any other information that the commissioner
17-3 considers appropriate or that is requested by the Sunset Advisory
17-4 Commission to the extent that the information is available; and
17-5 (2) the Texas Department of Health shall report to the
17-6 Sunset Advisory Commission:
17-7 (A) information regarding the epidemiological
17-8 impact and the medical efficacy of the coverage required by the
17-9 mandate, if applicable; and
17-10 (B) any other information that the commissioner
17-11 of public health considers appropriate or that is requested by the
17-12 Sunset Advisory Commission.
17-13 (b) The department and the Texas Department of Health shall
17-14 provide, to the extent the information is available to the agency,
17-15 any information requested by the Legislative Budget Board for the
17-16 purpose of preparing an impact assessment under Subchapter B of
17-17 this chapter.
17-18 SECTION 2. (a) This Act takes effect September 1, 2001.
17-19 (b) Not later than December 1, 2001, the commissioner of
17-20 insurance shall appoint all members to the advisory committee
17-21 authorized under Article 28.153, Insurance Code, as added by this
17-22 Act. Not later than June 1, 2002, the commissioner of insurance
17-23 shall adopt rules as necessary to implement Subchapters C and D,
17-24 Chapter 28, Insurance Code, as added by this Act.