By Gallego H.B. No. 3444
77R7477 AJA-D
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; or
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 (b) "Health benefit plan" does not include:
3-1 (1) a plan that provides coverage only:
3-2 (A) for benefits for a specified disease or for
3-3 another limited benefit other than for cancer;
3-4 (B) for accidental death or dismemberment;
3-5 (C) for wages or payments in lieu of wages for a
3-6 period during which an employee is absent from work because of
3-7 sickness or injury;
3-8 (D) as a supplement to a liability insurance
3-9 policy;
3-10 (E) for credit insurance;
3-11 (F) for dental or vision care; or
3-12 (G) for indemnity for hospital confinement;
3-13 (2) a Medicare supplemental policy as defined by
3-14 Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss),
3-15 as amended;
3-16 (3) a workers' compensation insurance policy;
3-17 (4) medical payment insurance coverage provided under
3-18 a motor vehicle insurance policy; or
3-19 (5) a long-term care insurance policy, including a
3-20 nursing home fixed indemnity policy, unless the commissioner
3-21 determines that the policy provides benefit coverage so
3-22 comprehensive that the policy is a health benefit plan as described
3-23 by Subsection (a) of this article.
3-24 (Articles 28.003-28.050 reserved for expansion
3-25 SUBCHAPTER B. IMPACT ASSESSMENT OF PROPOSED MANDATE
3-26 BY LEGISLATIVE BUDGET BOARD
3-27 Art. 28.051. REQUEST FOR IMPACT ASSESSMENT. If the chair of
4-1 a standing committee of the legislature determines that a bill
4-2 would, if enacted, create a health care benefit mandate or an offer
4-3 of coverage mandate, the chair shall send a copy of the bill to the
4-4 Legislative Budget Board and request that an impact assessment of
4-5 the mandate be prepared.
4-6 Art. 28.052. PREPARATION OF IMPACT ASSESSMENT; ACTUARIAL
4-7 ASSISTANCE REQUIRED. (a) On receipt of a bill under Article 28.051
4-8 of this code, the Legislative Budget Board shall prepare a written
4-9 impact assessment of the mandate in accordance with this
4-10 subchapter.
4-11 (b) In preparing an impact assessment, the director of the
4-12 Legislative Budget Board may:
4-13 (1) use any information supplied by any person,
4-14 agency, organization, or governmental unit that the director
4-15 determines is reliable; and
4-16 (2) obtain assistance in preparing the assessment from
4-17 any state agency or by contract with a private entity.
4-18 (c) The Legislative Budget Board shall obtain the assistance
4-19 of at least one certified actuary who is qualified to provide an
4-20 opinion relating to an impact assessment under this subchapter.
4-21 (d) An impact assessment prepared under this subchapter must
4-22 include:
4-23 (1) any report relating to the mandate produced by an
4-24 actuary or other expert retained by the Legislative Budget Board;
4-25 and
4-26 (2) a description of all underlying assumptions, data,
4-27 and studies on which the evaluation was based.
5-1 (e) The director of the Legislative Budget Board shall
5-2 submit an impact assessment requested under Article 28.051 of this
5-3 code not later than the 21st day after the date of the request.
5-4 Art. 28.053. CONTENTS OF IMPACT ASSESSMENT. (a) An impact
5-5 assessment of a health care benefit mandate or offer of coverage
5-6 mandate prepared under this subchapter must include, as applicable:
5-7 (1) the level of demand in the state for the coverage
5-8 that is the subject of the mandate, including the number and
5-9 percentage of people in the state who are affected by the medical
5-10 condition or illness that is the subject of the mandate or who
5-11 would be likely to use the coverage that is the subject of the
5-12 mandate;
5-13 (2) the extent to which the coverage is available
5-14 under health benefit plans that are in effect at the time the
5-15 impact assessment is made;
5-16 (3) the extent to which any health care service,
5-17 treatment, or procedure that would be required under the mandate
5-18 would be available in the absence of health benefit plan coverage;
5-19 (4) the epidemiological impact and medical efficacy of
5-20 the health care service, treatment, or procedure, including the
5-21 impact of the service, treatment, or procedure on an individual's
5-22 health status and the effect on an individual's health status of
5-23 not providing the service, treatment, or procedure;
5-24 (5) the direct impact of the mandate on health benefit
5-25 plan premiums;
5-26 (6) the net impact of the mandate on premiums,
5-27 considering the extent to which the coverage is already provided
6-1 under health benefit plans that are in effect at the time the
6-2 impact assessment is made and the extent to which other costs are
6-3 offset by the mandate;
6-4 (7) the costs to an individual of obtaining the health
6-5 care service, treatment, or procedure in the absence of health
6-6 benefit plan coverage;
6-7 (8) the fiscal impact on the state associated with
6-8 enacting the mandate and with not enacting the mandate;
6-9 (9) the impact on the economy and society of not
6-10 providing the health care service, treatment, or procedure;
6-11 (10) the impact of the health care service, treatment,
6-12 or procedure on the use of sick days and disability costs;
6-13 (11) the relative quality and cost-efficiency of the
6-14 care that is the subject of the mandate in the absence of health
6-15 benefit plan coverage; and
6-16 (12) a description of the extent to which the health
6-17 care benefit mandate or offer of coverage mandate is required by
6-18 federal law and the consequences of not enacting a mandate that
6-19 includes the minimum requirements of the federal law.
6-20 (b) For an offer of coverage mandate, the impact assessment
6-21 must also estimate the difference in the cost of a health benefit
6-22 plan that provides the coverage and a comparable health benefit
6-23 plan that does not provide the coverage.
6-24 (c) For a health care benefit mandate, the impact assessment
6-25 must also estimate the impact of the mandate if the mandate was an
6-26 offer of coverage mandate.
6-27 (d) An impact assessment must provide a separate analysis of
7-1 the cost to the Employees Retirement System of Texas of providing
7-2 the coverage that is the subject of the mandate being assessed to
7-3 the population covered by the uniform group insurance program or a
7-4 successor program, even if the program would not be subject to the
7-5 mandate.
7-6 (e) An impact assessment must provide a separate analysis of
7-7 the costs of the health benefit plan mandate or offer of coverage
7-8 mandate for:
7-9 (1) group health benefit plans, collectively and
7-10 according to the type of plan;
7-11 (2) individual health benefit plans; and
7-12 (3) small employer health benefit plans written under
7-13 Chapter 26 of this code, even if those plans would not be subject
7-14 to the mandate.
7-15 Art. 28.054. IMPACT ASSESSMENT IN CERTAIN CIRCUMSTANCES. If
7-16 the director of the Legislative Budget Board determines that the
7-17 impact of a proposed health benefit plan mandate or offer of
7-18 coverage mandate cannot be fully ascertained or the director is
7-19 unable to acquire or develop sufficient information to prepare a
7-20 complete impact assessment within 21 days of receiving the bill
7-21 from the chair of a committee, the director shall:
7-22 (1) report that fact in writing to the chair of the
7-23 committee; and
7-24 (2) prepare an impact assessment that:
7-25 (A) complies as much as possible with the
7-26 requirements of Article 28.053 of this code; and
7-27 (B) explains which of the applicable
8-1 requirements of that article are not met and why they are not met.
8-2 Art. 28.055. DISTRIBUTION OF IMPACT ASSESSMENT. Copies of an
8-3 impact assessment prepared under this subchapter must be
8-4 distributed to the members of the committee before the committee
8-5 votes on the bill to which the assessment relates. The assessment
8-6 shall be attached to the bill on first printing. If the bill is
8-7 amended by the committee in a way that alters a mandate, the chair
8-8 shall obtain an updated impact assessment, which shall also be
8-9 attached to the bill on first printing.
8-10 Art. 28.056. IMPACT ASSESSMENT REMAINS WITH BILL. An impact
8-11 assessment prepared under this subchapter shall remain with the
8-12 bill to which the assessment relates throughout the entire
8-13 legislative process, including submission to the governor.
8-14 (Articles 28.057-28.100 reserved for expansion
8-15 SUBCHAPTER C. ASSESSMENT OF ENACTED MANDATE BY SUNSET
8-16 ADVISORY COMMISSION
8-17 Art. 28.101. DEFINITION. In this subchapter, "review date"
8-18 means the review date assigned by the commissioner to a health care
8-19 benefit mandate or offer of coverage mandate under Article 28.103
8-20 of this code.
8-21 Art. 28.102. APPLICABILITY OF SUBCHAPTER. This subchapter
8-22 applies to a health care benefit mandate or offer of coverage
8-23 mandate provided for:
8-24 (1) in a statute; or
8-25 (2) in a rule adopted by the commissioner.
8-26 Art. 28.103. REVIEW DATES. The commissioner shall assign a
8-27 review date to each health care benefit mandate or offer of
9-1 coverage mandate. The review date of a mandate must be September 1
9-2 of an even-numbered year.
9-3 Art. 28.104. ASSESSMENT OF MANDATE. (a) Before the review
9-4 date for a health care benefit mandate or an offer of coverage
9-5 mandate, the Sunset Advisory Commission shall:
9-6 (1) review and take action necessary to verify the
9-7 reports relating to the mandate submitted by the department and the
9-8 Texas Department of Health under Article 28.156 of this code;
9-9 (2) conduct an assessment of the mandate based on the
9-10 criteria provided by Article 28.107 of this code and prepare a
9-11 written report; and
9-12 (3) review any prior commission recommendations
9-13 relating to the mandate in reports presented to the legislature
9-14 under this subchapter in a preceding legislative session.
9-15 (b) A report prepared by the Sunset Advisory Commission
9-16 under this article is a public record.
9-17 Art. 28.105. PUBLIC HEARINGS. (a) Between the review date
9-18 for a health care benefit mandate or offer of coverage mandate and
9-19 December 1 of the calendar year in which the review date occurs,
9-20 the Sunset Advisory Commission shall conduct public hearings
9-21 concerning the assessment of the mandate provided by Article 28.107
9-22 of this code.
9-23 (b) The Sunset Advisory Commission may hold public hearings
9-24 under this article before the review date if the report required
9-25 under Article 28.104 is complete and available to the public.
9-26 Art. 28.106. REPORT; RECOMMENDATION. (a) Not later than
9-27 January 1 of the year of a regular legislative session, the Sunset
10-1 Advisory Commission shall present to the legislature and the
10-2 governor a report on each health care benefit mandate or offer of
10-3 coverage mandate that was assessed under this subchapter during the
10-4 previous year.
10-5 (b) In the report the Sunset Advisory Commission shall
10-6 include:
10-7 (1) the specific findings of the commission regarding
10-8 each of the criteria considered under Article 28.107 of this code;
10-9 (2) recommendations of the commission regarding
10-10 whether the mandate should be continued, modified, or repealed; and
10-11 (3) any other information the commission considers
10-12 necessary for a complete assessment of the mandate.
10-13 Art. 28.107. CRITERIA FOR ASSESSMENT. (a) The Sunset
10-14 Advisory Commission and the commission's staff, in determining
10-15 whether a health care benefit mandate or an offer of coverage
10-16 mandate should be continued, modified, or repealed, shall consider,
10-17 as applicable:
10-18 (1) the level of demand in the state for the coverage
10-19 that is the subject of the mandate, including the number and
10-20 percentage of people, statewide and among distinct population
10-21 groups, who are affected by the medical condition or illness that
10-22 is the subject of the mandate or who use the coverage that is the
10-23 subject of the mandate;
10-24 (2) the extent to which any health care service,
10-25 treatment, or procedure that would be required under the mandate
10-26 would be available in the absence of health benefit plan coverage;
10-27 (3) the epidemiological impact and medical efficacy of
11-1 the health care service, treatment, or procedure, including the
11-2 impact of the service, treatment, or procedure on an individual's
11-3 health status and the effect on an individual's health status of
11-4 not providing the service, treatment, or procedure;
11-5 (4) the direct impact of the mandate on health benefit
11-6 plan premiums;
11-7 (5) the net impact of the mandate on premiums,
11-8 considering the extent to which other costs are offset by the
11-9 mandate;
11-10 (6) the costs to an individual of obtaining the health
11-11 care service, treatment, or procedure in the absence of health
11-12 benefit plan coverage;
11-13 (7) the fiscal impact on the state associated with
11-14 continuing the mandate and with repealing the mandate;
11-15 (8) the impact on the economy and society of not
11-16 providing the health care service, treatment, or procedure;
11-17 (9) the impact of the health care service, treatment,
11-18 or procedure on the use of sick days and disability costs;
11-19 (10) the relative quality and cost-efficiency of the
11-20 care that is the subject of the mandate in the absence of health
11-21 benefit plan coverage; and
11-22 (11) the extent to which the mandate being assessed is
11-23 required by federal law and the consequences of repealing the
11-24 mandate or continuing the mandate in a form that does not include
11-25 the minimum requirements of the federal law.
11-26 (b) In considering a mandate's impact on health benefit plan
11-27 premiums under Subsection (a) of this article, the Sunset Advisory
12-1 Commission and the commission's staff shall, if applicable, provide
12-2 a separate analysis of the impact of a health care benefit mandate
12-3 or offer of coverage mandate on:
12-4 (1) group health benefit plans collectively and
12-5 according to the type of plan;
12-6 (2) individual health benefit plans; and
12-7 (3) small employer health benefit plans written under
12-8 Chapter 26 of this code.
12-9 Art. 28.108. PREPARATION OF REPORT; ACTUARIAL ASSISTANCE
12-10 REQUIRED. (a) The Sunset Advisory Commission may contract with any
12-11 person to provide actuarial, medical, or economic expertise or
12-12 other expertise or services as necessary to allow the commission to
12-13 prepare a report required under this subchapter.
12-14 (b) The Sunset Advisory Commission shall obtain the
12-15 assistance of at least one certified actuary who is qualified to
12-16 provide an opinion relating to a report under this subchapter.
12-17 (Articles 28.109-28.150 reserved for expansion
12-18 SUBCHAPTER D. COLLECTION AND REPORTING OF DATA
12-19 Art. 28.151. DEFINITION OF LARGE HEALTH BENEFIT PLAN
12-20 CARRIER. The commissioner by rule shall define "large health
12-21 benefit plan carrier" for the purposes of Article 28.152 of this
12-22 code. The commissioner shall obtain the assistance of the advisory
12-23 committee established under Article 28.153 of this code in
12-24 formulating the definition. The definition must:
12-25 (1) be based on the carrier's premium volume or number
12-26 of enrollees covered by the carrier's plans; and
12-27 (2) describe a sufficient number of carriers to
13-1 fulfill the purposes of this subchapter, but not less than two
13-2 carriers.
13-3 Art. 28.152. REQUIRED INFORMATION. (a) The commissioner by
13-4 rule shall require each large health benefit plan carrier and the
13-5 Employees Retirement System of Texas to submit annually information
13-6 that the commissioner, with the assistance of the advisory
13-7 committee established under Article 28.153 of this code, determines
13-8 is necessary for the assessment of health care benefit mandates and
13-9 offer of coverage mandates under this chapter.
13-10 (b) A large health benefit plan carrier shall submit
13-11 information required by the commissioner under this article.
13-12 (c) The Employees Retirement System of Texas shall submit
13-13 information required by the commissioner under this article.
13-14 Art. 28.153. ADVISORY COMMITTEE. (a) The commissioner shall
13-15 appoint an advisory committee of at least 7 and not more than 11
13-16 members to assist the department in implementing this subchapter.
13-17 (b) The members of the committee must include at least one
13-18 representative from each of the following groups or entities:
13-19 (1) large health benefit plan carriers that are
13-20 insurers;
13-21 (2) large health benefit plan carriers that are health
13-22 maintenance organizations;
13-23 (3) consumers;
13-24 (4) health care providers;
13-25 (5) the Texas Department of Health; and
13-26 (6) the Texas Health Care Information Council.
13-27 (c) The committee must also include members who have
14-1 demonstrated actuarial, economic, and information systems
14-2 expertise.
14-3 (d) The committee shall work with the department to ensure
14-4 that:
14-5 (1) data collected under this subchapter is
14-6 sufficient to properly evaluate each health benefit mandate and
14-7 offer of coverage mandate under Subchapter C of this chapter;
14-8 (2) compliance with requests for data made under this
14-9 subchapter is both feasible for health benefit plan carriers and as
14-10 cost-effective as possible; and
14-11 (3) to the extent possible, data collection formats
14-12 under this subchapter are compatible with data collection formats
14-13 required under the Health Insurance Portability and Accountability
14-14 Act of 1996 (42 U.S.C. Section 1320a-7e).
14-15 (e) Chapter 2110, Government Code, applies to the advisory
14-16 committee created under this article.
14-17 Art. 28.154. CERTAIN INFORMATION EXCLUDED. The department
14-18 may not collect information under this subchapter that could
14-19 reasonably be expected to reveal the identity of a patient or a
14-20 health care provider other than a hospital.
14-21 Art. 28.155. APPLICABILITY OF OPEN RECORDS LAW. Information
14-22 submitted under this subchapter by an individual health benefit
14-23 plan carrier is not subject to disclosure under Chapter 552,
14-24 Government Code. The department shall aggregate information
14-25 submitted by all health benefit plan carriers under this subchapter
14-26 and that aggregated information is subject to disclosure under
14-27 Chapter 552, Government Code.
15-1 Art. 28.156. REPORTING OF DATA. (a) Before March 1 of the
15-2 calendar year in which the review date assigned to a health care
15-3 benefit mandate or an offer of coverage mandate under Article
15-4 28.103 of this code occurs:
15-5 (1) the department shall report to the Sunset Advisory
15-6 Commission:
15-7 (A) information regarding the costs associated
15-8 with the mandate, including the claims paid under health benefit
15-9 plans that are related to the mandate and the premiums charged for
15-10 coverage required by the mandate; and
15-11 (B) any other information that the commissioner
15-12 considers appropriate or that is requested by the Sunset Advisory
15-13 Commission to the extent that the information is available; and
15-14 (2) the Texas Department of Health shall report to the
15-15 Sunset Advisory Commission:
15-16 (A) information regarding the epidemiological
15-17 impact and the medical efficacy of the coverage required by the
15-18 mandate, if applicable; and
15-19 (B) any other information that the commissioner
15-20 of public health considers appropriate or that is requested by the
15-21 Sunset Advisory Commission.
15-22 (b) The department and the Texas Department of Health shall
15-23 provide, to the extent the information is available to the agency,
15-24 any information requested by the Legislative Budget Board for the
15-25 purpose of preparing an impact assessment under Subchapter B of
15-26 this chapter.
15-27 SECTION 2. (a) This Act takes effect September 1, 2001.
16-1 (b) Not later than December 1, 2001, the commissioner of
16-2 insurance shall appoint all members to the advisory committee
16-3 authorized under Article 28.153, Insurance Code, as added by this
16-4 Act. Not later than June 1, 2002, the commissioner of insurance
16-5 shall adopt rules as necessary to implement Subchapters C and D,
16-6 Chapter 28, Insurance Code, as added by this Act.