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SENATE RESOLUTION
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BE IT RESOLVED by the Senate of the State of Texas, 81st |
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Legislature, Regular Session, 2009, That Senate Rule 12.03 be |
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suspended in part as provided by Senate Rule 12.08 to enable the |
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conference committee appointed to resolve the differences on |
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Senate Bill No. 78, relating to promoting awareness and education |
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about the purchase and availability of health coverage, to |
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consider and take action on the following matter: |
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Senate Rule 12.03(4) is suspended to permit the committee |
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to add text that is not in disagreement to Subtitle G, Title 8, |
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Insurance Code, by adding Chapter 1508 to read as follows: |
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ARTICLE 2. HEALTHY TEXAS PROGRAM |
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SECTION 2.01. Subtitle G, Title 8, Insurance Code, is |
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amended by adding Chapter 1508 to read as follows: |
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CHAPTER 1508. HEALTHY TEXAS PROGRAM |
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SUBCHAPTER A. GENERAL PROVISIONS |
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Sec. 1508.001. PURPOSE. (a) The purposes of the Healthy |
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Texas Program are to: |
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(1) provide access to quality small employer health |
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benefit plans at an affordable price; |
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(2) encourage small employers to offer health |
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benefit plan coverage to employees and the dependents of |
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employees; and |
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(3) maximize reliance on proven managed care |
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strategies and procedures. |
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(b) The Healthy Texas Program is not intended to diminish |
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the availability of traditional small employer health benefit |
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plan coverage under Chapter 1501. |
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Sec. 1508.002. DEFINITIONS. In this chapter: |
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(1) "Dependent" has the meaning assigned by Section |
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1501.002(2). |
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(2) "Eligible employee" has the meaning assigned by |
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Section 1501.002(3). |
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(3) "Fund" means the healthy Texas small employer |
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premium stabilization fund established under Subchapter F. |
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(4) "Health benefit plan" and "health benefit plan |
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issuer" have the meanings assigned by Sections 1501.002(5) and |
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1501.002(6), respectively. |
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(5) "Program" means the Healthy Texas Program |
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established under this chapter. |
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(6) "Qualifying health benefit plan" means a health |
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benefit plan that provides benefits for health care services in |
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the manner described by this chapter. |
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(7) "Small employer" has the meaning assigned by |
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Section 1501.002(14). |
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Sec. 1508.003. RULES. The commissioner may adopt rules |
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as necessary to implement this chapter. |
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[Sections 1508.004-1508.050 reserved for expansion] |
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SUBCHAPTER B. EMPLOYER ELIGIBILITY; CONTRIBUTIONS |
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Sec. 1508.051. EMPLOYER ELIGIBILITY TO PARTICIPATE. |
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(a) A small employer may participate in the program if: |
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(1) during the 12-month period immediately |
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preceding the date of application for a qualifying health benefit |
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plan, the small employer does not offer employees group health |
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benefits on an expense-reimbursed or prepaid basis; and |
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(2) at least 30 percent of the small employer's |
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eligible employees receive annual wages from the employer in an |
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amount that is equal to or less than 300 percent of the poverty |
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guidelines for an individual, as defined and updated annually by |
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the United States Department of Health and Human Services. |
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(b) A small employer ceases to be eligible to participate |
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in the program if any health benefit plan that provides employee |
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benefits on an expense-reimbursed or prepaid basis, other than |
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another qualifying health benefit plan, is purchased or |
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otherwise takes effect after the purchase of a qualifying health |
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benefit plan. |
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Sec. 1508.052. COMMISSIONER ADJUSTMENTS AUTHORIZED. |
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(a) The commissioner by rule may adjust the 12-month period |
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described by Section 1508.051(a)(1) to an 18-month period if the |
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commissioner determines that the 12-month period is insufficient |
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to prevent inappropriate substitution of other health benefit |
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plans for qualifying health benefit plan coverage under this |
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chapter. |
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(b) The commissioner by rule may adjust the percentage of |
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the poverty guidelines described by Section 1508.051(a)(2) to a |
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higher or lower percentage if the commissioner determines that |
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the adjustment is necessary to fulfill the purposes of this |
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chapter. An adjustment made by the commissioner under this |
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subsection takes effect on the first July 1 following the |
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adjustment. |
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Sec. 1508.053. MINIMUM EMPLOYER PARTICIPATION |
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REQUIREMENTS. A small employer that meets the eligibility |
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requirements described by Section 1508.051(a) may apply to |
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purchase a qualifying health benefit plan if 60 percent or more |
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of the employer's eligible employees elect to participate in the |
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plan. |
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Sec. 1508.054. EMPLOYER CONTRIBUTION REQUIREMENTS. |
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(a) A small employer that purchases a qualifying health benefit |
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plan must: |
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(1) pay 50 percent or more of the premium for each |
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employee covered under the qualifying health benefit plan; |
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(2) offer coverage to all eligible employees |
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receiving annual wages from the employer in an amount described |
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by Section 1508.051(a)(2) or 1508.052(b), as applicable; and |
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(3) contribute the same percentage of premium for |
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each covered employee. |
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(b) A small employer that purchases a qualifying health |
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benefit plan under the program may elect to pay, but is not |
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required to pay, all or any portion of the premium paid for |
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dependent coverage under the qualifying health benefit plan. |
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[Sections 1508.055-1508.100 reserved for expansion] |
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SUBCHAPTER C. PROGRAM PARTICIPATION; REQUIRED COVERAGE AND |
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BENEFITS |
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Sec. 1508.101. PARTICIPATING PLAN ISSUERS. (a) Subject |
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to Subsection (b), any health benefit plan issuer may participate |
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in the program. |
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(b) The commissioner by rule may limit which health |
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benefit plan issuers may participate in the program if the |
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commissioner determines that the limitation is necessary to |
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achieve the purposes of this chapter. |
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(c) If the commissioner limits participation in the |
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program under Subsection (b), the commissioner shall contract on |
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a competitive procurement basis with one or more health benefit |
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plan issuers to provide qualifying health benefit plan coverage |
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under the program. |
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(d) Nothing in this chapter prohibits a regional or local |
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health care program described by Chapter 75, Health and Safety |
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Code, from participating in the program. The commissioner by |
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rule shall establish participation requirements applicable to |
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regional and local health care programs that consider the unique |
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plan designs, benefit levels, and participation criteria of each |
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program. |
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Sec. 1508.102. PREEXISTING CONDITION PROVISION |
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REQUIRED. A health benefit plan offered under the program must |
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include a preexisting condition provision that meets the |
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requirements described by Section 1501.102. |
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Sec. 1508.103. EXCEPTION FROM MANDATED BENEFIT |
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REQUIREMENTS. Except as expressly provided by this chapter, a |
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small employer health benefit plan issued under the program is |
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not subject to a law of this state that requires coverage or the |
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offer of coverage of a health care service or benefit. |
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Sec. 1508.104. CERTAIN COVERAGE PROHIBITED OR REQUIRED. |
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(a) A qualifying health benefit plan may only provide coverage |
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for in-plan services and benefits, except for: |
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(1) emergency care; or |
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(2) other services not available through a plan |
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provider. |
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(b) In-plan services and benefits provided under a |
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qualifying health benefit plan must include the following: |
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(1) inpatient hospital services; |
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(2) outpatient hospital services; |
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(3) physician services; and |
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(4) prescription drug benefits. |
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(c) The commissioner may approve in-plan benefits other |
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than those required under Subsection (b) or emergency care or |
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other services not available through a plan provider if the |
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commissioner determines the inclusion to be essential to achieve |
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the purposes of this chapter. |
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(d) The commissioner may, with respect to the categories |
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of services and benefits described by Subsections (b) and (c): |
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(1) prepare specifications for a coverage provided |
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under this chapter; |
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(2) determine the methods and procedures of claims |
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administration; |
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(3) establish procedures to decide contested cases |
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arising from coverage provided under this chapter; |
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(4) study, on an ongoing basis, the operation of all |
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coverages provided under this chapter, including gross and net |
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costs, administration costs, benefits, utilization of benefits, |
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and claims administration; |
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(5) administer the healthy Texas small employer |
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premium stabilization fund established under Subchapter F; |
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(6) provide the beginning and ending dates of |
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coverages for enrollees in a qualifying health benefit plan; |
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(7) develop basic group coverage plans applicable |
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to all individuals eligible to participate in the program; |
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(8) provide for optional group coverage plans in |
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addition to the basic group coverage plans described by |
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Subdivision (7); |
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(9) provide, as determined to be appropriate by the |
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commissioner, additional statewide optional coverage plans; |
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(10) develop specific health benefit plans that |
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permit access to high-quality, cost-effective health care; |
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(11) design, implement, and monitor health benefit |
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plan features intended to discourage excessive utilization, |
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promote efficiency, and contain costs for qualifying health |
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benefit plans; |
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(12) develop and refine, on an ongoing basis, a |
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health benefit strategy for the program that is consistent with |
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evolving benefits delivery systems; |
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(13) develop a funding strategy that efficiently |
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uses employer contributions to achieve the purposes of this |
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chapter; and |
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(14) modify the copayment and deductible amounts |
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for prescription drug benefits under a qualifying health benefit |
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plan, if the commissioner determines that the modification is |
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necessary to achieve the purposes of this chapter. |
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[Sections 1508.105-1508.150 reserved for expansion] |
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SUBCHAPTER D. PROGRAM ADMINISTRATION |
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Sec. 1508.151. EMPLOYER CERTIFICATION. (a) At the time |
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of initial application, a health benefit plan issuer shall obtain |
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from a small employer that seeks to purchase a qualifying health |
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benefit plan a written certification that the employer meets the |
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eligibility requirements described by Section 1508.051 and the |
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minimum employer participation requirements described by Section |
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1508.053. |
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(b) Not later than the 90th day before the renewal date of |
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a qualifying health benefit plan, a health benefit plan issuer |
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shall obtain from the small employer that purchased the |
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qualifying health benefit plan a written certification that the |
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employer continues to meet the eligibility requirements |
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described by Section 1508.051 and the minimum employer |
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participation requirements described by Section 1508.053. |
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(c) A participating health benefit plan issuer may |
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require a small employer to submit appropriate documentation in |
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support of a certification described by Subsection (a) or (b). |
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Sec. 1508.152. APPLICATION PROCESS. (a) Subject to |
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Subsection (b), a health benefit plan issuer shall accept |
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applications for qualifying health benefit plan coverage from |
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small employers at all times throughout the calendar year. |
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(b) The commissioner may limit the dates on which a |
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health benefit plan issuer must accept applications for |
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qualifying health benefit plan coverage if the commissioner |
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determines the limitation to be necessary to achieve the purposes |
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of this chapter. |
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Sec. 1508.153. EMPLOYEE ENROLLMENT; WAITING PERIOD. |
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(a) A qualifying health benefit plan must provide employees |
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with an initial enrollment period that is 31 days or longer, and |
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annually at least one open enrollment period that is 31 days or |
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longer. The commissioner by rule may require an additional open |
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enrollment period if the commissioner determines that the |
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additional open enrollment period is necessary to achieve the |
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purposes of this chapter. |
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(b) A small employer may establish a waiting period for |
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employees during which an employee is not eligible for coverage |
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under a qualifying health benefit plan. The last day of a waiting |
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period established under this subsection may not be later than |
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the 90th day after the date on which the employee begins |
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employment with the small employer. |
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(c) A health benefit plan issuer may not deny coverage |
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under a qualifying health benefit plan to a new employee of a |
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small employer that purchased the qualifying health benefit plan |
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if the health benefit plan issuer receives an application for |
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coverage from the employee not later than the 31st day after the |
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latter of: |
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(1) the first day of the employee's employment; or |
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(2) the first day after the expiration of a waiting |
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period established under Subsection (b). |
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(d) Subject to Subsection (e), a health benefit plan |
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issuer may deny coverage under a qualifying health benefit plan |
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to an employee of a small employer who applies for coverage after |
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the period described by Subsection (c). |
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(e) A health benefit plan issuer that denies an employee |
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coverage under Subsection (d): |
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(1) may only deny the employee coverage until the |
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next open enrollment period; and |
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(2) may subject the enrollee to a one-year |
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preexisting condition provision, as described by Section |
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1508.102, if the period during which the preexisting condition |
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provision applies does not exceed 18 months from the date of the |
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initial application for coverage under the qualifying health |
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benefit plan. |
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Sec. 1508.154. REPORTS. A health benefit plan issuer |
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that participates in the program shall submit reports to the |
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department in the form and at the time the commissioner |
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prescribes. |
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[Sections 1508.155-1508.200 reserved for expansion] |
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SUBCHAPTER E. RATING OF QUALIFIED HEALTH BENEFIT PLANS |
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Sec. 1508.201. RATING; PREMIUM PRACTICES IN GENERAL. |
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(a) A health benefit plan issuer participating in the program |
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must: |
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(1) use rating practices for qualifying health |
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benefit plans that are consistent with the purposes of this |
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chapter; and |
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(2) in setting premiums for qualifying health |
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benefit plans, consider the availability of reimbursement from |
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the fund. |
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(b) A health benefit plan issuer participating in the |
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program shall apply rating factors consistently with respect to |
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all small employers in a class of business. |
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(c) Differences in premium rates charged for qualifying |
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health benefit plans must be reasonable and reflect objective |
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differences in plan design. |
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Sec. 1508.202. PREMIUM RATE DEVELOPMENT AND CALCULATION. |
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(a) Rating factors used to underwrite qualifying health benefit |
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plans must produce premium rates for identical groups that: |
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(1) differ only by the amounts attributable to |
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health benefit plan design; and |
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(2) do not reflect differences because of the nature |
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of the groups assumed to select a particular health benefit plan. |
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(b) A health benefit plan issuer shall treat each |
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qualifying health benefit plan that is issued or renewed in a |
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calendar month as having the same rating period. |
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(c) A health benefit plan issuer may use only age and |
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gender as case characteristics, as defined by Section |
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1501.201(2), in setting premium rates for a qualifying health |
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benefit plan. |
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(d) The commissioner by rule may establish additional |
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rating criteria and requirements for qualifying health benefit |
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plans if the commissioner determines that the criteria and |
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requirements are necessary to achieve the purposes of this |
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chapter. |
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Sec. 1508.203. FILING; APPROVAL. (a) A health benefit |
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plan issuer shall file with the department, for review and |
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approval by the commissioner, premium rates to be charged for |
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qualifying health benefit plans. |
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(b) If the commissioner limits health benefit plan issuer |
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participation in the program under Section 1508.101(b), premium |
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rates proposed to be charged for each qualifying health benefit |
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plan will be considered as an element in the contract procurement |
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process required under that section. |
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[Sections 1508.204-1508.250 reserved for expansion] |
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SUBCHAPTER F. HEALTHY TEXAS SMALL EMPLOYER PREMIUM |
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STABILIZATION FUND |
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Sec. 1508.251. ESTABLISHMENT OF FUND. (a) To the extent |
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that funds appropriated to the department are available for this |
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purpose, the commissioner shall establish a fund from which |
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health benefit plan issuers may receive reimbursement for claims |
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paid by the health benefit plan issuers for individuals covered |
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under qualifying group health plans. |
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(b) The fund established under this section shall be |
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known as the healthy Texas small employer premium stabilization |
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fund. |
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(c) The commissioner shall adopt rules necessary to |
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implement and administer the fund, including rules that set out |
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the procedures for operation of the fund and distribution of |
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money from the fund. |
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Sec. 1508.252. OPERATION OF FUND; CLAIM ELIGIBILITY. |
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(a) A health benefit plan issuer is eligible to receive |
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reimbursement in an amount that is equal to 80 percent of the |
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dollar amount of claims paid between $5,000 and $75,000 in a |
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calendar year for an enrollee in a qualifying health benefit |
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plan. |
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(b) A health benefit plan issuer is eligible for |
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reimbursement from the fund only for the calendar year in which |
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claims are paid. |
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(c) Once the dollar amount of claims paid on behalf of a |
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covered individual reaches or exceeds $75,000 in a given calendar |
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year, a health benefit plan issuer may not receive reimbursement |
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for any other claims paid on behalf of the individual in that |
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calendar year. |
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Sec. 1508.253. REIMBURSEMENT REQUEST SUBMISSION. (a) A |
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health benefit plan issuer seeking reimbursement from the fund |
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shall submit a request for reimbursement in the form prescribed |
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by the commissioner by rule. |
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(b) A health benefit plan issuer must request |
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reimbursement from the fund annually, not later than the date |
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determined by the commissioner, following the end of the calendar |
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year for which the reimbursement requests are made. |
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(c) The commissioner may require a health benefit plan |
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issuer participating in the program to submit claims data in |
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connection with reimbursement requests as the commissioner |
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determines to be necessary to ensure appropriate distribution of |
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reimbursement funds and oversee the operation of the fund. The |
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commissioner may require that the data be submitted on a per |
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covered individual, aggregate, or categorical basis. |
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Sec. 1508.254. FUND AVAILABILITY. (a) The commissioner |
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shall compute the total claims reimbursement amount for all |
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health benefit plan issuers participating in the program for the |
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calendar year for which claims are reported and reimbursement |
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requested. |
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(b) If the total amount requested by health benefit plan |
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issuers participating in the program for reimbursement for a |
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calendar year exceeds the amount of funds available for |
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distribution for claims paid during that same calendar year, the |
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commissioner shall provide for the pro rata distribution of any |
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available funds. A health benefit plan issuer participating in |
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the program is eligible to receive a proportional amount of any |
|
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available funds that is equal to the proportion of total eligible |
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claims paid by all participating health benefit plan issuers that |
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the requesting health benefit plan issuer paid. |
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(c) If the amount of funds available for distribution for |
|
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claims paid by all health benefit plan issuers participating in |
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the program during a calendar year exceeds the total amount |
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requested for reimbursement by all participating health benefit |
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plan issuers during that calendar year, the commissioner shall |
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carry forward any excess funds and make those excess funds |
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available for distribution in the next calendar year. Excess |
|
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funds carried over under this section are added to the fund in |
|
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addition to any other money appropriated for the fund for the |
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calendar year into which the funds are carried forward. |
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Sec. 1508.255. PROGRAM REPORTING. (a) Each health |
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benefit plan issuer participating in the program shall provide |
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the department, in the form prescribed by the commissioner, |
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monthly reports of total enrollment under qualifying health |
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benefit plans. |
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(b) On the request of the commissioner, each health |
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benefit plan issuer participating in the program shall furnish to |
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the department, in the form prescribed by the commissioner, data |
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other than data described by Subsection (a) that the commissioner |
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determines necessary to oversee the operation of the fund. |
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Sec. 1508.256. CLAIMS EXPERIENCE DATA. (a) Based on |
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available data and appropriate actuarial assumptions, the |
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commissioner shall separately estimate the per covered |
|
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individual annual cost of total claims reimbursement from the |
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fund for qualifying health benefit plans. |
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(b) On request, a health benefit plan issuer |
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participating in the program shall furnish to the department |
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claims experience data for use in the estimates described by |
|
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Subsection (a). |
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Sec. 1508.257. TOTAL ELIGIBLE ENROLLMENT DETERMINATION. |
|
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(a) The commissioner shall determine total eligible enrollment |
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under qualifying health benefit plans by dividing the total funds |
|
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available for distribution from the fund by the estimated per |
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covered individual annual cost of total claims reimbursement |
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from the fund. |
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(b) At the end of the first year of enrollment and |
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|
annually thereafter, the commissioner shall submit a report to |
|
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the governor and the legislature regarding enrollment for the |
|
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previous year and limitations on future enrollment that ensure |
|
|
that the Healthy Texas Program does not necessitate a substantial |
|
|
increase in funding to continue the program, as consistent with |
|
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Section 1508.001. |
|
|
Sec. 1508.258. EVALUATION AND PROTECTION OF FUND; |
|
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EMPLOYER ENROLLMENT SUSPENSION. (a) The commissioner shall |
|
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suspend the enrollment of new employers in qualifying health |
|
|
benefit plans if the commissioner determines that the total |
|
|
enrollment reported by all health benefit plan issuers under |
|
|
qualifying health benefit plans exceeds the total eligible |
|
|
enrollment determined under Section 1508.257 and is likely to |
|
|
result in anticipated annual expenditures from the fund in excess |
|
|
of the total funds available for distribution from the fund. |
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(b) The commissioner shall provide a health benefit plan |
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issuer participating in the program with notification of any |
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enrollment suspension under Subsection (a) as soon as |
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practicable after: |
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|
(1) receipt of all enrollment data; and |
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|
(2) determination of the need to suspend |
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|
enrollment. |
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|
(c) A suspension of issuance of qualifying health benefit |
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|
plans to employers under Subsection (a) does not preclude the |
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|
addition of new employees of an employer already covered under a |
|
|
qualifying health benefit plan or new dependents of employees |
|
|
already covered under a qualifying health benefit plan. |
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Sec. 1508.259. EMPLOYER ENROLLMENT REACTIVATION. If, at |
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any point during a suspension of enrollment under Section |
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|
1508.258, the commissioner determines that funds are sufficient |
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|
to provide for the addition of new enrollments, the commissioner: |
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|
(1) may reactivate new enrollments; and |
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|
(2) shall notify all participating group health |
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|
benefit plan issuers that enrollment of new employers may be |
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|
resumed. |
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|
Sec. 1508.260. FUND ADMINISTRATOR. (a) The |
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|
commissioner may obtain the services of an independent |
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|
organization to administer the fund. |
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|
(b) The commissioner shall establish guidelines for the |
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|
submission of proposals by organizations for the purposes of |
|
|
administering the fund and may approve, disapprove, or recommend |
|
|
modification to the proposal of an applicant to administer the |
|
|
fund. |
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|
(c) An organization approved to administer the fund shall |
|
|
submit reports to the commissioner, in the form and at the times |
|
|
required by the commissioner, as necessary to facilitate |
|
|
evaluation and ensure orderly operation of the fund, including an |
|
|
annual report of the affairs and operations of the fund. The |
|
|
annual report must also be delivered to the governor, the |
|
|
lieutenant governor, and the speaker of the house of |
|
|
representatives. |
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|
(d) An organization approved to administer the fund shall |
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|
maintain records in the form prescribed by the commissioner and |
|
|
make those records available for inspection by or at the request |
|
|
of the commissioner. |
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|
(e) The commissioner shall determine the amount of |
|
|
compensation to be allocated to an approved organization as |
|
|
payment for fund administration. Compensation is payable only |
|
|
from the fund. |
|
|
(f) The commissioner may remove an organization approved |
|
|
to administer the fund from fund administration. An organization |
|
|
removed from fund administration under this subsection must |
|
|
cooperate in the orderly transition of services to another |
|
|
approved organization or to the commissioner. |
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|
Sec. 1508.261. STOP-LOSS INSURANCE; REINSURANCE. |
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|
(a) The administrator of the fund, on behalf of and with the |
|
|
prior approval of the commissioner, may purchase stop-loss |
|
|
insurance or reinsurance from an insurance company licensed to |
|
|
write that coverage in this state. |
|
|
(b) Stop-loss insurance or reinsurance may be purchased |
|
|
to the extent that the commissioner determines funds are |
|
|
available for the purchase of that insurance. |
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|
Sec. 1508.262. PUBLIC EDUCATION AND OUTREACH. (a) The |
|
|
commissioner may use an amount of the fund, not to exceed eight |
|
|
percent of the annual amount of the fund, for purposes of |
|
|
developing and implementing public education, outreach, and |
|
|
facilitated enrollment strategies targeted to small employers |
|
|
who do not provide health insurance. |
|
|
(b) The commissioner shall solicit and accept |
|
|
recommendations concerning the development and implementation of |
|
|
education, outreach, and enrollment strategies under Subsection |
|
|
(a) from agents licensed under Title 13 to write health benefit |
|
|
plans in this state. |
|
|
(c) The commissioner may contract with marketing |
|
|
organizations to perform or provide assistance with education, |
|
|
outreach, and enrollment strategies described by Subsection (a). |
|
|
SECTION 2.02. The commissioner of insurance shall adopt |
|
|
any rules necessary to implement the change in law made by |
|
|
Chapter 1508, Insurance Code, as added by this article, not later |
|
|
than January 4, 2010. |
|
|
SECTION 2.03. (a) The commissioner of insurance shall |
|
|
make an initial determination concerning limitation of health |
|
|
benefit plan issuer participation in the program established |
|
|
under Chapter 1508, Insurance Code, as added by this article, not |
|
|
later than January 18, 2010. If the commissioner determines that |
|
|
limited participation is necessary to achieve the purposes of |
|
|
Chapter 1508, Insurance Code, as added by this article, the |
|
|
commissioner shall issue a request for proposal from health |
|
|
benefit plan issuers to participate in the program not later than |
|
|
May 1, 2010. |
|
|
(b) The commissioner of insurance shall ensure that the |
|
|
Healthy Texas Program is fully operational in a manner that |
|
|
allows health benefit plan issuers participating in the program |
|
|
to make the first annual request for reimbursement on January 1, |
|
|
2011. |
|
|
SECTION 2.04. This Act does not make an appropriation. |
|
|
This Act takes effect only if a specific appropriation for the |
|
|
implementation of the Act is provided in a general appropriations |
|
|
act of the 81st Legislature. |
|
|
Explanation: This addition is necessary to authorize the |
|
|
creation of the Healthy Texas Program to enhance the availability |
|
|
of health coverage. |
|
|
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| |
|
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|
_______________________________ |
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|
President of the Senate |
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|
|
I hereby certify that the |
|
|
|
above Resolution was adopted by |
|
|
|
the Senate on June 1, 2009. |
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|
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|
_______________________________ |
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|
Secretary of the Senate |