78R6283 AJA-D

By:  Naishtat                                                     H.B. No. 1489


A BILL TO BE ENTITLED
AN ACT
relating to a consumer assistance program for health benefit plan consumers. BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: SECTION 1. Subchapter E, Chapter 21, Insurance Code, is amended by adding Article 21.53Z to read as follows: Art. 21.53Z. HEALTH BENEFIT PLAN CONSUMERS ASSISTANCE PROGRAM Sec. 1. DEFINITION. In this article, "consumer" means a person who is entitled to coverage under a health benefit plan or who is seeking coverage under a health benefit plan. Sec. 2. HEALTH BENEFIT PLAN DEFINED. (a) In this article, "health benefit plan" means: (1) a plan that provides benefits for medical, surgical, or other treatment expenses incurred as a result of a health condition, a mental health condition, an accident, sickness, or substance abuse, including an individual, group, blanket, or franchise insurance policy or insurance agreement, a group hospital service contract, or an individual or group evidence of coverage or similar coverage document that is offered by: (A) an insurance company; (B) a group hospital service corporation operating under Chapter 842 of this code; (C) a fraternal benefit society operating under Chapter 885 of this code; (D) a stipulated premium insurance company operating under Chapter 884 of this code; (E) a Lloyd's plan operating under Chapter 941 of this code; (F) an exchange operating under Chapter 942 of this code; (G) a health maintenance organization operating under Chapter 843 of this code; (H) a self-insured employee benefit plan that is subject to the Employee Retirement Income Security Act of 1974 (29 U.S.C. Section 1001 et seq.), as amended, including a multiple employer welfare arrangement that holds a certificate of authority under Chapter 846 of this code; or (I) an approved nonprofit health corporation that holds a certificate of authority under Chapter 844 of this code; (2) the state medical assistance program, including Medicaid managed care; (3) the child health plan established under Chapter 62, Health and Safety Code; or (4) the federal Medicare program. (b) The term includes: (1) a small employer health benefit plan written under Chapter 26 of this code; (2) a Medicare supplemental policy as defined by Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss), as amended; and (3) a health benefit plan offered under Chapter 1551, 1575, or 1601 of this code or Article 3.50–7 of this code. Sec. 3. HEALTH BENEFIT PLAN CONSUMERS ASSISTANCE PROGRAM. (a) The health benefit plan consumers assistance program is established in the office of public insurance counsel. The office of public insurance counsel may contract, through a request for proposals, with a nonprofit organization to operate the program. If the office of public insurance counsel enters into a contract under this subsection, the office of public insurance counsel shall monitor the performance of the nonprofit organization that operates the program. (b) The program shall: (1) assist individual consumers who desire to appeal the denial, termination, or reduction of health care services by the issuer of a health benefit plan or the refusal by the issuer of a health benefit plan to pay for health care services, including appeals under Article 21.58A of this code or in Medicaid and Medicare fair hearings; (2) provide information to consumers in this state about health benefit plans available in this state and about the rights and responsibilities of enrollees in those plans; (3) establish a statewide toll-free telephone number and an interactive Internet site that consumers can use to obtain information, advice, or assistance from the program; (4) collect data concerning inquiries, problems, and grievances handled by the program and periodically distribute a compilation and analysis of the data to employers, issuers of health benefit plans, regulatory agencies, and the public; and (5) refer consumers to appropriate private or public individuals or entities as necessary to ensure that inquiries, problems, or grievances involving health benefit plans are handled promptly and efficiently. (c) The program may: (1) operate a statewide clearinghouse for objective consumer information about health benefit plan coverage, including options for obtaining health benefit plan coverage; and (2) accept gifts, grants, or donations from any source for the purpose of operating the program. (d) The office of public insurance counsel or an entity contracting with the office of public insurance counsel to implement this article may establish an advisory committee composed of consumers, health care providers, and representatives of health benefit plan issuers. (e) A nonprofit organization contracting with the office of public insurance counsel under Subsection (a) of this section may not be involved in providing health care or issuing health benefit plans and must demonstrate that the organization has expertise in providing direct assistance to consumers who have concerns or problems involving health benefit plans. Sec. 4. SCOPE OF PROGRAM; REFERRAL. The health benefit plan consumers assistance program shall supplement and not duplicate services provided by existing public and private programs or state agencies, including the department and the office of public insurance counsel, and shall refer consumers to other programs or agencies as appropriate. Sec. 5. PROVISION OF CERTAIN INFORMATION BY ISSUER OF HEALTH BENEFIT PLAN REQUIRED. (a) The issuer of a health benefit plan shall include in the plan's enrollment information materials notice of the availability of the health benefit plan consumers assistance program and describe the services provided by the program. The membership information materials must include the program's toll-free telephone number and state that a consumer can call the program for information or assistance in resolving a problem or filing a complaint involving the health benefit plan. (b) The issuer of a health benefit plan shall provide the information required under Subsection (a) of this section in writing to any person who makes an oral or written complaint to the issuer involving the plan. (c) This section does not apply to the medical assistance program. This section does not apply to the federal Medicare program or to a self-insured employee benefit plan that is subject to the Employee Retirement Income Security Act of 1974 (29 U.S.C. Section 1001 et seq.), as amended, other than a multiple employer welfare arrangement that holds a certificate of authority under Chapter 846 of this code. Sec. 6. REFERRAL BY DEPARTMENT. If the department receives a complaint from a consumer involving a health benefit plan that is not subject to regulation by the department, the department shall inform the consumer about the services provided by the health benefit plan consumers assistance program and provide the consumer with the program's toll-free telephone number. Sec. 7. APPLICABILITY OF SUNSET ACT. If the health benefit plan consumers assistance program is not continued in existence as provided by Chapter 325, Government Code (Texas Sunset Act), as that Act applies to the performance of the functions of the office of public insurance counsel under Section 7, Article 1.35A of this code, the program is abolished and this article expires September 1, 2005. SECTION 2. Article 3.70-3D, Insurance Code, is repealed. SECTION 3. This Act takes effect September 1, 2003.