|
|
|
A BILL TO BE ENTITLED
|
|
AN ACT
|
|
relating to creation of the Texas Health Insurance Connector. |
|
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
|
SECTION 1. The legislature finds that: |
|
(1) the small employer and individual health benefit |
|
plan markets in this state are a fundamental and integral component |
|
of the economy of this state that create significant employment and |
|
business opportunity, including enabling more than 1.5 million |
|
individuals, and 110,000 small businesses with more than 650,000 |
|
employees, to obtain health benefit plan coverage in 2009; |
|
(2) the United States Congress exceeded its |
|
constitutional authority by passing the Patient Protection and |
|
Affordable Care Act, which contained a number of provisions that |
|
have the potential to significantly undermine the operations of the |
|
small employer and individual health benefit plan markets in this |
|
state; |
|
(3) the Patient Protection and Affordable Care Act |
|
includes an option for a state to create a health insurance exchange |
|
to facilitate the purchase of individual and small group health |
|
coverage and to provide assistance with enrollment of eligible |
|
individuals in qualified health plans in lieu of the federal |
|
government operating a health insurance exchange in the state for |
|
that purpose; |
|
(4) the federal government operating a health |
|
insurance exchange in this state would significantly hinder the |
|
operation of the small employer and individual health benefit plan |
|
markets in this state so as to cause significant economic harm |
|
throughout the state, to a greater extent than would be the case |
|
under a health insurance exchange administered in or by this state; |
|
(5) a federal health insurance exchange operating in |
|
this state would infringe on powers reserved to this state under the |
|
Tenth Amendment to the United States Constitution; and |
|
(6) it is in the best interest of the citizens of this |
|
state that the State of Texas create a health insurance exchange, |
|
the Texas Health Insurance Connector, to facilitate, and make |
|
transparent the purchase of, small employer and individual health |
|
benefit plan coverage in this state, to provide assistance with |
|
enrollment of eligible individuals in qualified health plans, and |
|
to protect the economy of and the insurance markets in this state. |
|
SECTION 2. Subtitle G, Title 8, Insurance Code, is amended |
|
by adding Chapter 1509 to read as follows: |
|
CHAPTER 1509. TEXAS HEALTH INSURANCE CONNECTOR |
|
SUBCHAPTER A. GENERAL PROVISIONS |
|
Sec. 1509.001. DEFINITIONS. In this chapter: |
|
(1) "Board" means the board of directors of the |
|
connector. |
|
(2) "Connector" means the Texas Health Insurance |
|
Connector. |
|
(3) "Enrollee" means an individual who is enrolled in |
|
a qualified health plan. |
|
(4) "Executive commissioner" means the executive |
|
commissioner of the Health and Human Services Commission. |
|
(5) "Qualified health plan" means a health benefit |
|
plan that the board has certified under Section 1509.108. |
|
(6) "Qualified individual" means an individual who is |
|
eligible to become an enrollee in accordance with the criteria |
|
adopted by the board under Section 1509.109. |
|
(7) "Secretary" means the secretary of the United |
|
States Department of Health and Human Services. |
|
(8) "Small employer" has the meaning assigned by |
|
Section 1501.002, except that the term does not include |
|
governmental entities described by that section. |
|
Sec. 1509.002. DEFINITION OF HEALTH BENEFIT PLAN. (a) In |
|
this chapter, "health benefit plan" means an insurance policy, |
|
insurance agreement, evidence of coverage, or other similar |
|
coverage document that provides coverage for medical or surgical |
|
expenses incurred as a result of a health condition, accident, or |
|
sickness that is issued by: |
|
(1) an insurance company; |
|
(2) a group hospital service corporation operating |
|
under Chapter 842; |
|
(3) a fraternal benefit society operating under |
|
Chapter 885; |
|
(4) a stipulated premium company operating under |
|
Chapter 884; |
|
(5) an exchange operating under Chapter 942; |
|
(6) a health maintenance organization operating under |
|
Chapter 843; |
|
(7) a multiple employer welfare arrangement that holds |
|
a certificate of authority under Chapter 846; or |
|
(8) an approved nonprofit health corporation that |
|
holds a certificate of authority under Chapter 844. |
|
(b) In this chapter, "health benefit plan" does not include: |
|
(1) a plan that provides coverage: |
|
(A) for wages or payments in lieu of wages for a |
|
period during which an employee is absent from work because of |
|
sickness or injury; |
|
(B) as a supplement to a liability insurance |
|
policy; |
|
(C) for credit insurance; |
|
(D) only for vision care; |
|
(E) only for hospital expenses; or |
|
(F) only for indemnity for hospital confinement; |
|
(2) a Medicare supplemental policy as defined by |
|
Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss); |
|
(3) a workers' compensation insurance policy; or |
|
(4) medical payment insurance coverage provided under |
|
a motor vehicle insurance policy. |
|
Sec. 1509.003. RULES. (a) The board may adopt rules |
|
necessary and proper to implement this chapter. |
|
(b) The board may adopt rules necessary to implement state |
|
responsibility in compliance with a federal law or regulation or |
|
action of a federal court relating to a person or activity under |
|
the purview of the connector if: |
|
(1) the federal law, regulation, or action of the |
|
federal court requires: |
|
(A) a state to adopt the rules; or |
|
(B) action by a state to ensure protection of the |
|
citizens of the state; |
|
(2) the rules will avoid federal preemption of state |
|
insurance regulation; or |
|
(3) the rules will prevent the loss of federal funds to |
|
this state. |
|
(c) The board may adopt a rule under Subsection (b) only if |
|
the federal action requiring the adoption of a rule occurs or takes |
|
effect between sessions of the legislature or at such a time during |
|
a session of a legislature that sufficient time does not remain to |
|
permit the preparation of a recommendation for legislative action |
|
or permit the legislature to act. A rule adopted under this section |
|
remains in effect until the 30th day after the end of the first |
|
regular session of the legislature that follows the adoption of the |
|
rule unless a law is enacted that authorizes the subject matter of |
|
the rule. If a law is enacted that authorizes the subject matter of |
|
the rule, the rule continues in effect. |
|
Sec. 1509.004. AGENCY COOPERATION. (a) The connector, the |
|
department, and the Health and Human Services Commission shall |
|
cooperate fully in performing their respective duties under this |
|
code or another law of this state relating to the operation of the |
|
connector. |
|
(b) The connector and the department shall cooperate to |
|
promote a stable health benefit plan market in this state. |
|
Sec. 1509.005. SUNSET PROVISION. The connector is subject |
|
to review under Chapter 325, Government Code (Texas Sunset Act). |
|
Unless continued in existence as provided by that chapter, the |
|
connector is abolished and this chapter expires September 1, 2019. |
|
Sec. 1509.006. CONNECTOR NOT INSURER. The connector is not |
|
an insurer or health maintenance organization and is not subject to |
|
regulation by the department. |
|
Sec. 1509.007. EXEMPTION FROM STATE TAXES AND FEES. The |
|
connector is not subject to any state tax, regulatory fee, or |
|
surcharge, including a premium or maintenance tax or fee. |
|
Sec. 1509.008. COMPLIANCE WITH FEDERAL LAW. The connector |
|
shall comply with all applicable federal law and regulations. |
|
[Sections 1509.009-1509.050 reserved for expansion] |
|
SUBCHAPTER B. ESTABLISHMENT AND GOVERNANCE |
|
Sec. 1509.051. ESTABLISHMENT. The Texas Health Insurance |
|
Connector is established as the American Health Benefit Exchange |
|
and the Small Business Health Options Program (SHOP) Exchange |
|
required by Section 1311, Patient Protection and Affordable Care |
|
Act (Pub. L. No. 111-148). |
|
Sec. 1509.052. GOVERNANCE OF CONNECTOR; BOARD MEMBERSHIP. |
|
(a) The connector is governed by a board of directors. |
|
(b) The board consists of seven members composed as follows: |
|
(1) five members appointed by the governor: |
|
(A) two of whom must be chosen from a list |
|
submitted to the governor by the lieutenant governor; and |
|
(B) two of whom must be chosen from a list |
|
submitted to the governor by the speaker of the house of |
|
representatives; |
|
(2) the commissioner, as a nonvoting ex officio |
|
member; and |
|
(3) the executive commissioner, as a nonvoting ex |
|
officio member. |
|
(c) At least three of the five board members appointed by |
|
the governor must have experience in health care administration, |
|
health care economics, or health insurance or be knowledgeable |
|
concerning general business or actuarial principles. One of the |
|
board members appointed by the governor must represent the |
|
interests of health benefit plan consumers in this state, one must |
|
represent the interests of small employers in this state, and one |
|
must be an enrollee or be reasonably expected to qualify for |
|
coverage under a qualified health plan in this state. |
|
(d) A person may not serve as a member of the board if the |
|
person is required to register as a lobbyist under Chapter 305, |
|
Government Code, because of the person's activities for |
|
compensation related to the operation of the connector or the |
|
business of insurance in this state. |
|
Sec. 1509.053. PRESIDING OFFICER. The governor shall |
|
designate one member of the board to serve as presiding officer at |
|
the pleasure of the governor. |
|
Sec. 1509.054. TERMS; VACANCY. (a) Appointed members of |
|
the board serve staggered six-year terms. |
|
(b) The governor shall fill a vacancy on the board by |
|
appointing, for the unexpired term, an individual who has the |
|
appropriate qualifications to fill that position. |
|
Sec. 1509.055. CONFLICT OF INTEREST. (a) A board member, |
|
or a member of a committee formed by the board, with a direct |
|
interest in a matter before the board, personally or through an |
|
employer, shall abstain from deliberations and actions on the |
|
matter in which the conflict of interest arises, shall abstain from |
|
any vote on the matter, and may not in any manner participate in a |
|
decision on the matter. |
|
(b) Each board member shall file a conflict of interest |
|
statement and a statement of ownership interests with the board to |
|
ensure disclosure of all existing and potential personal interests |
|
related to board business. |
|
Sec. 1509.056. REIMBURSEMENT. A member of the board is not |
|
entitled to compensation but is entitled to reimbursement for |
|
travel or other expenses incurred while performing duties as a |
|
board member in the amount provided by the General Appropriations |
|
Act for state officials. |
|
Sec. 1509.057. MEMBER'S IMMUNITY. (a) A member of the |
|
board is not liable for an act or omission made in good faith in the |
|
performance of powers and duties under this chapter. |
|
(b) A cause of action does not arise against a member of the |
|
board for an act or omission described by Subsection (a). |
|
Sec. 1509.058. OPEN RECORDS AND OPEN MEETINGS. (a) The |
|
board is subject to Chapter 551, Government Code. The board may |
|
meet in executive session in accordance with Chapter 551, |
|
Government Code, to discuss confidential or proprietary |
|
information, including contract decisions and qualified health |
|
plan rates. |
|
(b) The board is subject to Chapter 552, Government Code, |
|
except that, notwithstanding any other law, documents that contain |
|
proprietary information, relate to deliberative processes or |
|
communications, relate to contracting decisions, or reveal work |
|
product, plans, or strategy that would influence decisions in the |
|
health benefit plan marketplace are not public information. |
|
Sec. 1509.059. RECORDS. The board shall keep records of the |
|
board's proceedings for at least seven years. |
|
Sec. 1509.060. BIENNIAL REPORT. Not later than January 1 of |
|
each odd-numbered year, the board shall provide a report to the |
|
governor, the legislature, the commissioner, and the executive |
|
commissioner. The report must include information regarding the |
|
development and implementation of the connector, specifically |
|
detailing progress made by the connector in implementing the |
|
requirements of this chapter. |
|
Sec. 1509.061. ADDITIONAL REPORT. (a) The board shall |
|
issue a report that meets the requirements of Section 1509.060 to |
|
the entities described by that section not later than January 1, |
|
2014. |
|
(b) This section expires January 31, 2014. |
|
[Sections 1509.062-1509.100 reserved for expansion] |
|
SUBCHAPTER C. POWERS AND DUTIES OF CONNECTOR |
|
Sec. 1509.101. EMPLOYEES; COMMITTEES. (a) The board may |
|
employ, and determine the compensation of, an executive director, a |
|
chief fiscal officer, a general counsel, a technology officer, and |
|
any other agent or employee the board considers necessary to assist |
|
the connector in carrying out the connector's responsibilities and |
|
functions. |
|
(b) The connector may appoint appropriate legal, actuarial, |
|
and other committees necessary to provide technical assistance in |
|
operating the connector and performing any of the functions of the |
|
connector. |
|
Sec. 1509.102. CONTRACTS. The connector may enter into any |
|
contract that the connector considers necessary to implement or |
|
administer this chapter, including a contract with the department |
|
or the Health and Human Services Commission for the department or |
|
commission, in exchange for payment, to perform functions or |
|
provide services in connection with the operation of the connector. |
|
Sec. 1509.103. INFORMATION SHARING AND CONFIDENTIALITY. |
|
The connector may enter into information-sharing agreements with |
|
federal and state agencies to carry out the connector's |
|
responsibilities under this chapter. An agreement entered into |
|
under this section must include adequate protection with respect to |
|
the confidentiality of any information shared and comply with all |
|
applicable state and federal law. |
|
Sec. 1509.104. MEMORANDUM OF UNDERSTANDING. The connector |
|
shall enter into a memorandum of understanding with the department |
|
and the Health and Human Services Commission regarding the exchange |
|
of information and the division of regulatory functions among the |
|
connector, the department, and the commission. |
|
Sec. 1509.105. LEGAL ACTION. (a) The connector may sue or |
|
be sued. |
|
(b) The connector may take any legal action necessary to |
|
recover or collect amounts due the connector, including: |
|
(1) assessments due the connector; |
|
(2) amounts erroneously or improperly paid by the |
|
connector; and |
|
(3) amounts paid by the connector as a mistake of fact |
|
or law. |
|
Sec. 1509.106. FUNCTIONS. The connector shall: |
|
(1) by rule establish procedures consistent with |
|
federal law and regulations for the certification, |
|
recertification, and decertification of health benefit plans as |
|
qualified health plans; |
|
(2) provide for the operation of a toll-free telephone |
|
hotline to respond to requests for assistance; |
|
(3) maintain an Internet website through which an |
|
enrollee or prospective enrollee may: |
|
(A) obtain standardized, comparative information |
|
concerning qualified health plans issued in this state; and |
|
(B) locate comparative coverage information |
|
concerning qualified health plans through a searchable database of |
|
diseases, disabilities, or other medical conditions; |
|
(4) assign a rating to each qualified health plan |
|
certified by the connector based on criteria developed by the |
|
secretary; |
|
(5) use a standard format for presenting information |
|
concerning qualified health plan options; |
|
(6) inform individuals of the eligibility |
|
requirements for Medicaid, the state child health plan program, or |
|
any other similar federal, state, or local public health benefit |
|
program; |
|
(7) if the connector determines that an individual is |
|
eligible for Medicaid, the state child health plan program, or any |
|
other similar federal, state, or local public health benefit |
|
program, coordinate with the Health and Human Services Commission |
|
to enroll the individual in the program for which the individual is |
|
eligible; |
|
(8) establish, and make available electronically, a |
|
calculator to determine the actual cost of coverage after the |
|
application of any premium tax credit or cost-sharing subsidy |
|
available under federal law; |
|
(9) as applicable, certify that an individual is |
|
exempt from the individual responsibility penalty under Section |
|
5000A, Internal Revenue Code of 1986, and notify the secretary of |
|
the exemption; |
|
(10) establish a navigator program as described by |
|
Section 1311(i), Patient Protection and Affordable Care Act (Pub. |
|
L. No. 111-148); |
|
(11) provide for the processing of applications for |
|
coverage under a qualified health plan, the enrollment of persons |
|
in qualified health plans, and the disenrollment of enrollees from |
|
qualified health plans; |
|
(12) establish billing and payment policies for |
|
issuers of qualified health plans; |
|
(13) engage in marketing and outreach activities; and |
|
(14) collect and maintain information concerning |
|
qualified health plans, including data concerning enrollment, |
|
disenrollment, claims, and claims denials. |
|
Sec. 1509.107. TYPES OF PLANS. The connector shall, in a |
|
manner consistent with federal law, establish certification |
|
requirements for at least six different types of qualified health |
|
plans, at least two of which must include a health savings account |
|
described by Section 223, Internal Revenue Code of 1986, at least |
|
one of which must offer benchmark coverage or benchmark equivalent |
|
coverage described by Section 1937(b), Social Security Act (42 |
|
U.S.C. Section 1396u-7), and at least one of which must offer |
|
limited scope dental benefits either separately or in conjunction |
|
with another type of plan. |
|
Sec. 1509.108. CERTIFICATION OF PLAN. The board shall |
|
certify a health benefit plan as a qualified health plan if the |
|
health benefit plan meets the requirements for certification set |
|
forth by the secretary. The connector may not, as a condition of |
|
certification, require a health benefit plan issuer to: |
|
(1) participate in both the individual and small |
|
employer markets; or |
|
(2) offer benefit levels that exceed benefit levels |
|
required under federal law. |
|
Sec. 1509.109. QUALIFICATION OF INDIVIDUALS. The board by |
|
rule shall establish criteria for eligibility for a potential |
|
enrollee to be considered a qualified individual. At a minimum, the |
|
criteria must require that the individual: |
|
(1) seek to enroll in a qualified health plan in the |
|
individual health benefit plan market offered through the |
|
connector; |
|
(2) reside in and be a citizen or lawful resident of |
|
this state, except as provided by Section 1312, Patient Protection |
|
and Affordable Care Act (Pub. L. No. 111-148); and |
|
(3) at the time of enrollment, not be incarcerated, |
|
other than being incarcerated pending the disposition of any |
|
criminal charges. |
|
Sec. 1509.110. PREMIUM COLLECTION AND AGGREGATION. The |
|
board by rule shall establish a mechanism for the collection and |
|
aggregation of premium payments directly or indirectly from |
|
enrollees and the payment of premiums to issuers of qualified |
|
health plans. Rules adopted under this section must include rules |
|
regarding an employer's authority to withhold premium payments from |
|
an enrollee's paycheck and to submit those premium payments to |
|
issuers of qualified health plans. |
|
Sec. 1509.111. PREMIUM INCREASE JUSTIFICATION. (a) The |
|
connector shall require an issuer of a qualified health plan to file |
|
with the connector an explanation of any premium increase before |
|
implementation of the increase. |
|
(b) A health benefit plan issuer shall prominently display |
|
the explanation of any premium increase on the health benefit plan |
|
issuer's Internet website. |
|
[Sections 1509.112-1509.150 reserved for expansion] |
|
SUBCHAPTER D. COVERAGE REQUIREMENTS OR LIMITATIONS |
|
Sec. 1509.151. PROHIBITED COVERAGE THROUGH CONNECTOR. A |
|
qualified health plan offered through the connector may not provide |
|
coverage for an abortion, as defined by Section 171.002, Health and |
|
Safety Code. |
|
[Sections 1509.152-1509.200 reserved for expansion] |
|
SUBCHAPTER E. ASSESSMENTS FOR OPERATION OF CONNECTOR |
|
Sec. 1509.201. ASSESSMENTS; PENALTY FOR NONPAYMENT. (a) |
|
The connector may charge the issuers of qualified health plans and |
|
health benefit plans applying for certification as qualified health |
|
plans an assessment as reasonable and necessary for the connector's |
|
organizational and operating expenses. |
|
(b) The connector may refuse to recertify or may decertify a |
|
health benefit plan as a qualified health plan if the issuer of the |
|
plan fails or refuses to pay an assessment under this section. |
|
Sec. 1509.202. GRANTS AND FEDERAL FUNDS. (a) The connector |
|
may accept a grant from a public or private organization and may |
|
spend those funds to pay the costs of program administration and |
|
operations. |
|
(b) The connector may accept federal funds and shall use |
|
those funds in compliance with applicable federal law, regulations, |
|
and guidelines. |
|
Sec. 1509.203. USE OF CONNECTOR ASSETS; ANNUAL REPORT. (a) |
|
The assets of the connector may be used only to pay the costs of the |
|
administration and operation of the connector. |
|
(b) The connector shall prepare annually a complete and |
|
detailed written report accounting for all funds received and |
|
disbursed by the connector during the preceding fiscal year. The |
|
report must meet any reporting requirements provided in the General |
|
Appropriations Act, regardless of whether the connector receives |
|
any funds under that Act. The connector shall submit the report to |
|
the governor, the legislature, the commissioner, and the executive |
|
commissioner not later than January 31 of each year. |
|
[Sections 1509.204-1509.250 reserved for expansion] |
|
SUBCHAPTER F. TRUST FUND |
|
Sec. 1509.251. TRUST FUND. (a) The connector fund is |
|
established as a special trust fund outside of the state treasury in |
|
the custody of the comptroller separate and apart from all public |
|
money or funds of this state. |
|
(b) The connector may deposit assessments, gifts or |
|
donations, and any federal funding obtained by the connector into |
|
the connector fund in accordance with procedures established by the |
|
comptroller. |
|
(c) Interest or other income from the investment of the fund |
|
shall be deposited to the credit of the fund. |
|
SECTION 3. (a) As soon as possible after the effective date |
|
of this Act, but not later than October 31, 2011, the governor shall |
|
appoint the initial members of the board of directors of the Texas |
|
Health Insurance Connector. In making the appointments, the |
|
governor shall designate two persons to terms expiring February 1, |
|
2013, two persons to terms expiring February 1, 2015, and one person |
|
to a term expiring February 1, 2017. |
|
(b) As soon as possible after the appointments required by |
|
Subsection (a) of this section are made, but not later than November |
|
30, 2011, the board of directors of the Texas Health Insurance |
|
Connector shall hold a special meeting to discuss the adoption of |
|
rules and procedures necessary to implement Chapter 1509, Insurance |
|
Code, as added by this Act. |
|
(c) As soon as possible after the effective date of this |
|
Act, but not later than January 31, 2012, the board of directors of |
|
the Texas Health Insurance Connector shall adopt rules and |
|
procedures necessary to implement Chapter 1509, Insurance Code, as |
|
added by this Act. |
|
SECTION 4. 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, 2011. |