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A BILL TO BE ENTITLED
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AN ACT
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relating to the Texas Health Insurance Risk Pool. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Section 1506.001, Insurance Code, is amended by |
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adding Subdivisions (1-a) through (1-e) and (8) to read as follows: |
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(1-a) "Church plan" has the meaning assigned by |
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Section 3(33), Employee Retirement Income Security Act of 1974 (29 |
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U.S.C. Section 1002(33)). |
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(1-b) "Creditable coverage" means, with respect to an |
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individual, coverage of the individual provided under any of the |
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following: |
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(A) a group health plan; |
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(B) health insurance coverage; |
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(C) Part A or Part B, Title XVIII, Social |
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Security Act (42 U.S.C. Section 1395c et seq.); |
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(D) Title XIX, Social Security Act (42 U.S.C. |
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Section 1396 et seq.), other than coverage consisting solely of |
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benefits under Section 1928 of that Act (42 U.S.C. Section 1396s); |
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(E) 10 U.S.C. Section 1071 et seq.; |
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(F) a medical care program of the Indian Health |
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Service or a tribal organization; |
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(G) a state health benefits risk pool; |
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(H) a health benefits plan offered under 5 U.S.C. |
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Section 8901 et seq.; |
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(I) a public health plan as defined in federal |
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regulations; |
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(J) a health benefit plan under Section 5(e), |
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Peace Corps Act (22 U.S.C. Section 2504(e)); or |
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(K) a state child health plan provided under |
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Title XXI, Social Security Act (42 U.S.C. Section 1397aa et seq.). |
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(1-c) "Federally defined eligible individual" means |
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an individual: |
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(A) for whom, as of the date on which the |
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individual seeks coverage under this chapter, the aggregate period |
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of creditable coverage is 18 months or more; |
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(B) whose most recent prior creditable coverage |
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was under: |
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(i) a group health plan, governmental plan, |
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or church plan; or |
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(ii) health insurance coverage offered in |
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connection with a plan described by Subparagraph (i); |
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(C) who is not eligible for coverage under a |
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group health plan, Part A or Part B, Title XVIII, Social Security |
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Act (42 U.S.C. Section 1395c et seq.), or a state plan under Title |
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XIX, Social Security Act (42 U.S.C. Section 1396 et seq.), or any |
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successor program, and who does not have other health benefit plan |
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coverage; |
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(D) with respect to whom the most recent coverage |
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within the aggregate creditable coverage was not terminated based |
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on a factor relating to nonpayment of premiums or fraud; |
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(E) who, if offered the option of continuation |
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coverage under a continuation provision required by Title X, |
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Consolidated Omnibus Budget Reconciliation Act of 1985 (29 U.S.C. |
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Section 1161 et seq.) (COBRA), or under a similar state program, |
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elected that coverage; and |
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(F) who has exhausted continuation coverage, if |
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elected, under Paragraph (E). |
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(1-d) "Governmental plan" has the meaning assigned by |
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Section 3(32), Employee Retirement Income Security Act of 1974 (29 |
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U.S.C. Section 1002(32)), and includes any United States |
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governmental plan. |
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(1-e) "Group health plan" means an employee welfare |
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benefit plan as defined by Section 3(1), Employee Retirement Income |
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Security Act of 1974 (29 U.S.C. Section 1002(1)), to the extent that |
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the plan provides health benefit plan coverage to employees or |
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their dependents as defined under the terms of the plan, directly or |
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through insurance, reimbursement, or otherwise. |
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(8) "Significant break in coverage" means a period of |
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63 consecutive days during all of which the individual does not have |
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health benefit plan coverage, except that a waiting period or an |
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affiliation period is not considered in determining a significant |
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break in coverage. |
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SECTION 2. Section 1506.002, Insurance Code, is amended by |
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amending Subsection (b) and adding Subsections (c) and (d) to read |
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as follows: |
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(b) In this chapter, "health benefit plan" does not include |
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one or more or any combination of the following: |
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(1) coverage only for accident or disability income |
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insurance or any combination of those coverages; |
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(2) credit-only [a plan providing coverage only for
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dental or vision care;
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[(3) fixed indemnity insurance, including hospital
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indemnity insurance;
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[(4)credit] insurance; |
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(3) [(5)long-term care insurance;
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[(6)disability income insurance;
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[(7) other limited benefit coverage, including
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specified disease coverage;
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[(8)] coverage issued as a supplement to liability |
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insurance; |
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(4) liability insurance, including general liability |
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insurance and automobile liability insurance; |
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(5) [(9)insurance arising out of a] workers' |
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compensation [law] or similar insurance [law]; |
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(6) coverage for on-site medical clinics; |
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(7) [(10)] automobile medical payment insurance; [or] |
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(8) [(11)] insurance coverage under which benefits |
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are payable with or without regard to fault and that is statutorily |
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required to be contained in a liability insurance policy or |
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equivalent self-insurance; or |
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(9) other similar insurance coverage, specified by |
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federal regulations issued under the Health Insurance Portability |
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and Accountability Act of 1996 (Pub. L. No. 104-191), under which |
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benefits for medical care are secondary or incidental to other |
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insurance benefits. |
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(c) In this chapter, "health benefit plan" does not include |
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the following benefits if they are provided under a separate |
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policy, certificate, or contract of insurance, or are otherwise not |
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an integral part of the coverage: |
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(1) limited scope dental or vision benefits; |
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(2) benefits for long-term care, nursing home care, |
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home health care, community-based care, or any combination of these |
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benefits; or |
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(3) other similar, limited benefits specified by |
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federal regulations issued under the Health Insurance Portability |
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and Accountability Act of 1996 (Pub. L. No. 104-191). |
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(d) In this chapter, "health benefit plan" does not include |
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the following benefits if the benefits are provided under a |
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separate policy, certificate, or contract of insurance, there is no |
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coordination between the provision of the benefits and any |
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exclusion of benefits under any group health plan maintained by the |
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same plan sponsor, and the benefits are paid with respect to an |
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event without regard to whether benefits are provided with respect |
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to such an event under any group health plan maintained by the same |
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plan sponsor: |
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(1) coverage only for a specified disease or illness; |
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or |
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(2) hospital indemnity or other fixed indemnity |
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insurance. |
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SECTION 3. Section 1506.151(a), Insurance Code, is amended |
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to read as follows: |
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(a) The pool shall offer coverage consistent with major |
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medical expense coverage to each eligible individual [who is under
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the age of 65]. |
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SECTION 4. Section 1506.152(a), Insurance Code, is amended |
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to read as follows: |
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(a) An individual who is a legally domiciled resident of |
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this state is eligible for coverage from the pool if the individual: |
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(1) provides to the pool evidence that the individual |
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is a federally defined eligible individual who has not experienced |
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a significant break in coverage [maintained health benefit plan
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coverage for the preceding 18 months with no gap in coverage longer
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than 63 days and with the most recent coverage being provided
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through an employer-sponsored plan, church plan, or government
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plan]; |
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(2) is younger than 65 years of age and provides to the |
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pool evidence that the individual maintained health benefit plan |
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coverage under another state's qualified Health Insurance |
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Portability and Accountability Act health program that was |
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terminated because the individual did not reside in that state and |
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submits an application for pool coverage not later than the 63rd day |
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after the date the coverage described by this subdivision was |
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terminated; |
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(3) is younger than 65 years of age and has been a |
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legally domiciled resident of this state for the preceding 30 days, |
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is a citizen of the United States or has been a permanent resident |
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of the United States for at least three continuous years, and |
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provides to the pool: |
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(A) a notice of rejection of, or refusal to |
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issue, substantially similar individual health benefit plan |
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coverage from a health benefit plan issuer, other than an insurer |
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that offers only stop-loss, excess loss, or reinsurance coverage, |
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if the rejection or refusal was for health reasons; |
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(B) certification from an agent or salaried |
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representative of a health benefit plan issuer that states that the |
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agent or salaried representative cannot obtain substantially |
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similar individual coverage for the individual from any health |
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benefit plan issuer that the agent or salaried representative |
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represents because, under the underwriting guidelines of the health |
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benefit plan issuer, the individual will be denied coverage as a |
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result of a medical condition of the individual; |
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(C) an offer to issue substantially similar |
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individual coverage only with conditional riders; |
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(D) a diagnosis of the individual with one of the |
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medical or health conditions on the list adopted under Section |
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1506.154; or |
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(E) evidence that the individual is covered by |
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substantially similar individual coverage that excludes one or more |
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conditions by rider; or |
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(4) provides to the pool evidence that, on the date of |
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application to the pool, the individual is certified as eligible |
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for trade adjustment assistance or for pension benefit guaranty |
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corporation assistance, as provided by the Trade Adjustment |
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Assistance Reform Act of 2002 (Pub. L. No. 107-210). |
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SECTION 5. Section 1506.153, Insurance Code, as amended by |
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Chapters 728 and 824, Acts of the 79th Legislature, Regular |
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Session, 2005, is amended to read as follows: |
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Sec. 1506.153. INELIGIBILITY FOR COVERAGE. |
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Notwithstanding Section 1506.152 [Sections 1506.152(a)-(d)], an |
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individual is not eligible for coverage from the pool if: |
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(1) on the date pool coverage is to take effect, the |
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individual has health benefit plan coverage from a health benefit |
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plan issuer or health benefit arrangement in effect, except as |
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provided by Section 1506.152(a)(3)(E); |
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(2) at the time the individual applies to the pool, the |
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individual is eligible for other health care benefits, including an |
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offer of benefits from the continuation of coverage under Title X, |
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Consolidated Omnibus Budget Reconciliation Act of 1985 (29 U.S.C. |
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Section 1161 et seq.), as amended (COBRA), other than: |
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(A) coverage, including COBRA or other |
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continuation coverage or conversion coverage, maintained for any |
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preexisting condition waiting period under a pool policy or during |
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any preexisting condition waiting period or other waiting period of |
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the other coverage; |
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(B) employer group coverage conditioned by a |
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limitation of the kind described by Section 1506.152(a)(3)(A) or |
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(C); or |
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(C) individual coverage conditioned by a |
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limitation described by Section 1506.152(a)(3)(C) or (D); |
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(3) within 12 months before the date the individual |
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applies to the pool, the individual terminated coverage in the |
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pool, unless the individual: |
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(A) demonstrates a good faith reason for the |
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termination; or |
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(B) is a federally defined eligible individual; |
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(4) the individual is confined in a county jail or |
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imprisoned in a state or federal prison; |
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(5) any of the individual's premiums are paid for or |
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reimbursed under a government-sponsored program or by a government |
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agency or health care provider[, other than as an otherwise
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qualifying full-time employee of a government agency or health care
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provider or as a dependent of such an employee]; |
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(6) the individual's prior coverage with the pool was |
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terminated: |
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(A) during the 12-month period preceding the date |
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of application for nonpayment of premiums; or |
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(B) for fraud; or |
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(7) the individual is eligible for health benefit plan |
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coverage provided in connection with a policy, plan, or program |
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paid for or sponsored by an employer, even though the employer |
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coverage is declined. |
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SECTION 6. Section 1506.154(a), Insurance Code, is amended |
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to read as follows: |
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(a) The board shall adopt a list of medical or health |
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conditions for which an individual is eligible for pool coverage |
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under Section 1506.152(a)(3)(D) [1506.152(a)(3)(E)] without |
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applying for health benefit plan coverage. |
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SECTION 7. Sections 1506.155(b) and (c), Insurance Code, |
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are amended to read as follows: |
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(b) The exclusion provided by Subsection (a) does not apply |
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to a federally defined eligible individual or an individual who: |
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(1) was continuously covered for a period of at least |
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12 months, excluding any waiting period, by creditable [health
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benefit plan] coverage that terminated not earlier than the 63rd |
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day before the effective date of coverage under the pool; and |
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(2) applied for pool coverage not later than the 63rd |
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day after the date the creditable [health benefit plan] coverage |
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described by Subdivision (1) terminated. |
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(c) If an individual was covered by creditable [health
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benefit plan] coverage that was in effect at any time during the |
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12-month period preceding the effective date of the individual's |
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coverage under the pool, the pool shall subtract from the exclusion |
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period required under Subsection (a) the period that the individual |
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was covered under that creditable coverage [health benefit plan] |
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and any waiting period that applied before that creditable [health
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benefit plan] coverage became effective. |
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SECTION 8. Section 1506.202(a), Insurance Code, is amended |
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to read as follows: |
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(a) The board may, on a competitive bid basis, contract with |
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[select] one or more health benefit plan issuers or [a] third-party |
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administrators [administrator] authorized by the department to |
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administer the pool. [The selection must be made under a
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competitive bidding process in accordance with the plan of
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operation.] |
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SECTION 9. Section 1506.203, Insurance Code, is amended to |
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read as follows: |
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Sec. 1506.203. ADMINISTRATOR'S CONTRACT [TERM; SUCCEEDING
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TERM]. (a) A person selected as a pool administrator shall serve |
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[serves] in that capacity for a period specified in the contract |
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between the pool and the pool administrator, subject to removal for |
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cause and subject to any terms, conditions, and limitations of the |
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contract between the pool and the pool administrator. The term of |
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the contract must be at least three years and may be extended, in |
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the board's sole discretion, for up to a total term of six years |
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[three-year term beginning on the date the board issues its order
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making the selection]. |
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(b) Not later than one year before the expiration date of a |
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pool administrator's contract, including any board-authorized |
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extensions of that contract [term], the board shall invite all |
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health benefit plan issuers, including the pool administrator, to |
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submit bids to serve as a pool administrator for the succeeding |
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administration period. The selection of the succeeding pool |
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administrator must be made not later than the sixth calendar month |
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preceding the month in which the pool administrator's contract |
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[term] expires. |
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SECTION 10. Section 1506.254(b), Insurance Code, is amended |
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to read as follows: |
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(b) Interest accrues on the unpaid amount of an assessment |
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at a rate equal to the prime lending rate, as published in the most |
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recent issue of the Wall Street Journal and determined as of the |
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first day of each month during which [date] the assessment is |
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[becomes] delinquent, plus three percent. |
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SECTION 11. (a) This Act applies only to an application for |
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initial or renewal coverage through the Texas Health Insurance Risk |
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Pool under Chapter 1506, Insurance Code, as amended by this Act, |
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that is filed with the pool on or after the effective date of this |
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Act. An application filed before the effective date of this Act is |
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governed by the law in effect on the date on which the application |
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was filed, and the former law is continued in effect for that |
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purpose. |
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(b) The change in law made by this Act to Section |
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1506.254(b), Insurance Code, applies to an assessment under |
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Subchapter F, Chapter 1506, Insurance Code, for a calendar year |
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beginning on or after January 1, 2008. An assessment for a calendar |
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year before January 1, 2008, is governed by the law in effect during |
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the period for which the assessment is made, and the former law is |
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continued in effect for that purpose. |
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SECTION 12. This Act takes effect January 1, 2008. |