This website will be unavailable from Thursday, May 30, 2024 at 6:00 p.m. through Monday, June 3, 2024 at 7:00 a.m. due to data center maintenance.
78R2836 DLF-D
By: Smithee H.B. No. 2258
A BILL TO BE ENTITLED
AN ACT
relating to certain large employer health benefit plans.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Subchapter H, Chapter 26, Insurance Code, is
amended by adding Articles 26.82A, 26.82B, 26.82C, and 26.82D to
read as follows:
Art. 26.82A. LARGE EMPLOYER HEALTH BENEFIT PLANS. (a) A
large employer carrier may offer the following two large employer
health benefit plans as adopted by the commissioner:
(1) the large employer catastrophic care benefit plan;
and
(2) the large employer basic coverage benefit plan.
(b) A large employer carrier may offer to a large employer
additional benefit riders to either of the benefit plans.
(c) Subject to the provisions of this chapter, a large
employer carrier may also offer to large employers any other health
benefit plan authorized under this code. Article 26.82B of this
code does not apply to a health benefit plan offered to a large
employer under this subsection.
Art. 26.82B. APPLICABILITY OF CERTAIN LAW; MANDATED SERVICE
OR BENEFIT. Except as expressly provided in this chapter or by
rules or policy forms adopted by the commissioner, the large
employer catastrophic care benefit plan and the large employer
basic coverage benefit plan described by Article 26.82D of this
code are not subject to a law that requires coverage or the offer of
coverage of a health care service or benefit.
Art. 26.82C. POLICY FORMS. (a) The commissioner shall
promulgate the benefits section of the large employer catastrophic
care benefit plan and the large employer basic coverage benefit
plan policy forms in accordance with Article 26.82D of this code and
shall develop prototype policies for each of the benefit plans. For
all other portions of these policy forms, a large employer carrier
shall comply with Article 3.42 of this code as it relates to policy
form approval and with the Texas Health Maintenance Organization
Act (Article 20A.01 et seq., Vernon's Texas Insurance Code) as it
relates to approval of an evidence of coverage. A large employer
carrier may not offer these benefit plans through a policy form or
evidence of coverage that does not comply with this chapter and
other applicable law.
(b) A health carrier may not issue and the commissioner may
not approve a certificate or policy for the large employer
catastrophic care benefit plan and the large employer basic
coverage benefit plan, or a rider to a certificate or policy for
these plans, unless it is written in plain language.
(c) Each provision of the large employer catastrophic care
benefit plan and the large employer basic coverage benefit plan
certificate or policy, or a rider to a certificate or policy for
these plans, relating to renewal of coverage, conditions of
coverage, or per occurrence or aggregate dollar limitations on
coverage must be clearly explained in plain language.
(d) A health carrier may not use and the commissioner may
not approve an application form for the large employer catastrophic
care benefit plan and the large employer basic coverage benefit
plan unless it is in plain language.
(e) Subsections (b)-(d) of this article do not apply if the
specific language to be used is mandated by federal law or state
statute or by rules implementing federal law.
(f) For purposes of Subsections (b)-(e) of this article, a
health benefit plan certificate or policy, a rider to or a provision
of a health benefit plan certificate or policy, or a health benefit
plan application form is written in plain language if it achieves
the minimum score established by the commissioner on the Flesch
reading ease test or an equivalent test selected by the
commissioner.
(g) The provisions of Subsections (b)-(f) of this article
requiring the use of plain language do not apply to a health benefit
plan group master policy or to a policy application or enrollment
form for a health benefit plan group master policy.
Art. 26.82D. LARGE EMPLOYER CATASTROPHIC CARE AND BASIC
COVERAGE BENEFIT PLANS. (a) The commissioner by rule shall
establish the coverage requirements for the large employer
catastrophic care benefit plan and the large employer basic
coverage benefit plan. The commissioner shall develop prototype
policies for use by large employer carriers that include all
contractual provisions required to produce an entire contract in
accordance with this article and this code.
(b) Coverage under the large employer catastrophic care
benefit plan must be designed to provide necessary coverage in the
event of catastrophic illness or injury. The commissioner shall
establish deductibles and coinsurance requirements at levels that
permit options for the insured to obtain affordable catastrophic
coverage.
(c) The commissioner by rule shall establish coverage
requirements for the large employer basic coverage benefit plan.
Coverage under the basic coverage benefit plan must be designed to
provide basic hospital, medical, and surgical coverages. Benefits
under the plan are limited to basic care requirements for illness
and injury.
(d) The benefits provisions of the benefit plan policies
must include the following:
(1) all required or applicable definitions;
(2) a list of any exclusions or limitations to
coverage;
(3) a description of covered services required under
the plan; and
(4) the deductible and coinsurance options that are
required or permitted under the plan.
SECTION 2. Article 26.42(a), Insurance Code, is amended to
read as follows:
(a) A small employer carrier shall offer the following two
health benefit plans as adopted by the commissioner:
(1) the small employer catastrophic care benefit plan;
and
(2) the small employer basic coverage benefit plan.
SECTION 3. Article 26.43(a), Insurance Code, is amended to
read as follows:
(a) The commissioner shall promulgate the benefits section
of the small employer catastrophic care benefit plan and the small
employer basic coverage benefit plan policy forms in accordance
with Article 26.44A of this code and shall develop prototype
policies for each of the benefit plans. For all other portions of
these policy forms, a small employer carrier shall comply with
Article 3.42 of this code as it relates to policy form approval and
with the Texas Health Maintenance Organization Act (Article 20A.01
et seq., Vernon's Texas Insurance Code) as it relates to approval of
an evidence of coverage. A small employer carrier may not offer
these benefit plans through a policy form or evidence of coverage
that does not comply with this chapter.
SECTION 4. The heading to Article 26.44A, Insurance Code,
is amended to read as follows:
Art. 26.44A. SMALL EMPLOYER CATASTROPHIC CARE AND BASIC
COVERAGE BENEFIT PLANS.
SECTION 5. Articles 26.44A(a), (b), and (c), Insurance
Code, are amended to read as follows:
(a) The commissioner by rule shall establish the coverage
requirements for the small employer catastrophic care benefit plan
and the small employer basic coverage benefit plan. The
commissioner shall develop prototype policies for use by small
employer carriers that include all contractual provisions required
to produce an entire contract in accordance with this article and
this code.
(b) Coverage under the small employer catastrophic care
benefit plan must be designed to provide necessary coverage in the
event of catastrophic illness or injury. The commissioner shall
establish deductibles and coinsurance requirements at levels that
permit options for the insured to obtain affordable catastrophic
coverage.
(c) The commissioner by rule shall establish coverage
requirements for the small employer basic coverage benefit plan.
Coverage under the basic coverage benefit plan must be designed to
provide basic hospital, medical, and surgical coverages. Benefits
under the plan are limited to basic care requirements for illness
and injury.
SECTION 6. Article 3.70-13, Insurance Code, is amended to
read as follows:
Art. 3.70-13. CERTAIN POLICIES CONTINUOUS. A guaranteed
renewable policy or a noncancellable policy shall be deemed to be a
continuous policy, subject only to the terms and conditions
thereof, including payment of policy premiums, and such policies
shall be considered to be continued in force by the payment of the
policy premium in accordance with the policy terms and conditions,
and such policies shall not be deemed or treated as renewed policies
by the payment of such contracted policy premiums. This article
does not apply to a small employer or large employer health benefit
plan adopted in accordance with Article 26.44A or 26.82D [Chapter
26] of this code[, as added by H.B. No. 2055, Acts of the 73rd
Legislature, Regular Session, 1993].
SECTION 7. Not later than December 1, 2003, the
commissioner of insurance shall adopt rules and policy forms as
necessary to implement this Act. A health carrier may not offer a
large employer catastrophic care benefit plan or large employer
basic coverage benefit plan in accordance with the change in law
made by this Act before January 1, 2004.
SECTION 8. This Act takes effect September 1, 2003.