By Carona                                             S.B. No. 1757
         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.