By: Naishtat H.B. No. 1489
A BILL TO BE ENTITLED
relating to a consumer assistance program for health benefit plan
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
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
(F) an exchange operating under Chapter 942 of
(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
(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
(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
SECTION 2. Article 3.70-3D, Insurance Code, is repealed.
SECTION 3. This Act takes effect September 1, 2003.