79R11507 KCR-F
By: Taylor H.B. No. 1570
Substitute the following for H.B. No. 1570:
By: Keffer of Dallas C.S.H.B. No. 1570
A BILL TO BE ENTITLED
AN ACT
relating to certain health benefit plans.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Section 2, Article 3.80, Insurance Code, is
amended by amending Subdivision (2) and adding Subdivision (3) to
read as follows:
(2) "Standard health benefit plan" means an accident
or sickness insurance policy that, in whole or in part, does not
offer or provide state-mandated health benefits, but that provides
creditable coverage as defined by Section 1205.004 [Article
26.035(a)] of this code [or Section 1(H)(4)(b), Chapter 397, Acts
of the 54th Legislature, Regular Session, 1955 (Article 3.70-1,
Vernon's Texas Insurance Code)].
(3) "Exclusive provider benefit plan" means a standard
health benefit plan offered by a health carrier that:
(A) arranges for or provides benefits to covered
persons through a network of exclusive providers; and
(B) limits or excludes, except in cases of
emergency or approved referral, benefits to covered persons for
services provided by a provider who is not part of the network of
exclusive providers.
SECTION 2. Section 4, Article 3.80, Insurance Code, is
amended by adding Subsection (c) to read as follows:
(c) A health carrier offering a standard health benefit plan
may offer an exclusive provider benefit plan. Except as provided by
this section, Chapter 1301 applies to an exclusive provider benefit
plan. The following sections of this code do not apply to an
exclusive provider benefit plan offered under this subsection:
(1) requirements of Chapter 1301 imposed under
Sections 1301.003 and 1301.005(a);
(2) Subchapter C, Chapter 1451; and
(3) Sections 1451.053 and 1451.054.
SECTION 3. Section 1271.151, Insurance Code, is amended to
read as follows:
Sec. 1271.151. PROVISION OF BASIC HEALTH CARE SERVICES.
(a) A health maintenance organization that offers a basic health
care plan shall provide or arrange for basic health care services to
its enrollees as needed and may impose limitations [without
limitation] as to time and cost [other than any limitation
prescribed by rule of the commissioner].
(b) A health maintenance organization may:
(1) impose on enrollees copayment or coinsurance
charges for arranging to provide:
(A) any single care service to its enrollees; or
(B) in the aggregate, all basic health care
services to enrollees; or
(2) charge enrollees a deductible or coinsurance
requirement for a basic, limited, or single health care service.
(c) The commissioner may adopt reasonable copayment,
deductible, and coinsurance restrictions for health benefit plans
offered by a health maintenance organization in amounts or
percentages not to exceed similar restrictions adopted for
preferred provider benefit plans.
SECTION 4. Section 1501.108, Insurance Code, is amended by
adding Subsection (d) to read as follows:
(d) A small or large employer health benefit plan issuer may
modify a particular small or large employer health benefit plan at
the time of coverage renewal if the modification applies uniformly
to all small or large employers whose employees are covered by that
health benefit plan.
SECTION 5. Section 1501.153(a), Insurance Code, is amended
to read as follows:
(a) This chapter does not require a small employer to make
an employer contribution to the premium paid to a small employer
health benefit plan issuer, but the issuer may require an employer
contribution in accordance with the issuer's usual and customary
practices applicable to each of the issuer's small employer group
health benefit plans in this state. The issuer shall apply the
employer contribution level uniformly to each small employer
offered or issued coverage under a small employer health benefit
plan by the issuer in this state.
SECTION 6. Sections 1501.155(a) and (b), Insurance Code,
are amended to read as follows:
(a) A small employer health benefit plan issuer may offer a
small employer health benefit plan to a small employer with a
participation level of less than 75 percent of the employer's
eligible employees if the issuer permits the same qualifying
participation level for each of the small employer health benefit
plans [plan] offered by the issuer in this state.
(b) A small employer health benefit plan issuer may offer a
small employer health benefit plan to a small employer even if the
employer's participation level is less than the issuer's qualifying
participation level for a small employer health benefit plan
established in accordance with Subsection (a) if:
(1) the employer obtains a written waiver from each
eligible employee who declines coverage under a health benefit plan
offered to the employer stating that the employee was not induced or
pressured to decline coverage because of the employee's risk
characteristics; and
(2) the issuer accepts or rejects the entire group of
eligible employees who choose to participate and excludes only
those employees who have declined coverage.
SECTION 7. Section 1501.255, Insurance Code, is amended by
adding Subsections (d), (e), and (f) to read as follows:
(d) A health maintenance organization may:
(1) impose on enrollees of a health benefit plan
offered by a health maintenance organization under Subsection
(b)(1) copayment or coinsurance charges for arranging to provide:
(A) any single care service to enrollees of the
health benefit plan; or
(B) in the aggregate, all basic health care
services to enrollees of the health benefit plan; or
(2) charge enrollees of a health benefit plan offered
by a health maintenance organization under Subsection (b)(1) a
deductible or coinsurance requirement for a basic, limited, or
single health care service.
(e) A health benefit plan offered by a health maintenance
organization under Subsection (b)(1) is not subject to any
restrictions or limitations on cost sharing.
(f) The commissioner may adopt reasonable copayment,
deductible, and coinsurance restrictions for health benefit plans
offered by a health maintenance organization under Subsection
(b)(1) in amounts or percentages not to exceed similar restrictions
adopted for preferred provider benefit plans.
SECTION 8. Sections 1501.605(a) and (d), Insurance Code,
are amended to read as follows:
(a) A large employer health benefit plan issuer may require
a large employer to meet a minimum contribution or participation
requirement as a condition of issuance or renewal in accordance
with the issuer's usual and customary practices for each of [all]
the issuer's large employer health benefit plans in this state.
(d) A participation requirement must be stated in the health
benefit plan contract and must be applied uniformly to each large
employer offered or issued coverage under a large employer health
benefit plan by a large employer health benefit plan issuer in this
state.
SECTION 9. The changes in law made by this Act in amending
Chapter 1501, Insurance Code, apply only to a health benefit plan
the contract or evidence of coverage for which is delivered, issued
for delivery, or renewed on or after the effective date of this Act.
A health benefit plan, the contract or evidence of coverage for
which is delivered, issued for delivery, or renewed before the
effective date of this Act, is covered by the law in effect at the
time the contract or evidence of coverage is delivered, issued for
delivery, or renewed, and that law is continued in effect for that
purpose.
SECTION 10. This Act takes effect immediately if it
receives a vote of two-thirds of all the members elected to each
house, as provided by Section 39, Article III, Texas Constitution.
If this Act does not receive the vote necessary for immediate
effect, this Act takes effect September 1, 2005.