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A BILL TO BE ENTITLED
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AN ACT
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relating to regulation of health benefit plan issuers in this |
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state. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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ARTICLE 1. CREATION OF THE TEXAS HEALTH INSURANCE EXCHANGE |
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SECTION 1.01. Subtitle G, Title 8, Insurance Code, is |
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amended by adding Chapter 1509 to read as follows: |
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CHAPTER 1509. TEXAS HEALTH INSURANCE EXCHANGE |
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SUBCHAPTER A. GENERAL PROVISIONS |
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Sec. 1509.001. DEFINITIONS. In this chapter: |
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(1) "Board" means the board of directors of the |
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exchange. |
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(2) "Catastrophic plan" has the meaning assigned by |
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Section 1302(e), Patient Protection and Affordable Care Act (Pub. |
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L. No. 111-148). |
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(3) "Educated health care consumer" means an |
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individual who is knowledgeable about the health care system and |
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has background or experience in making informed decisions regarding |
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health, medical, and scientific matters. |
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(4) "Enrollee" means an individual who is enrolled in |
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a qualified health plan. |
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(5) "Exchange" means the Texas Health Insurance |
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Exchange. |
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(6) "Executive commissioner" means the executive |
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commissioner of the Health and Human Services Commission. |
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(7) "Qualified employer" means an employer that elects |
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to make all of its full-time employees eligible for one or more |
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qualified health plans offered through the exchange and, at the |
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option of the employer, some or all of its part-time employees and: |
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(A) has its principal place of business in this |
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state and elects to provide coverage through the exchange to all of |
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its eligible employees, wherever employed; or |
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(B) elects to provide coverage through the |
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exchange to all of its eligible employees who are principally |
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employed in this state and who are eligible to participate in a |
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qualified health plan. |
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(8) "Qualified health plan" means a health benefit |
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plan that has been certified by the board as meeting the criteria |
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specified by Section 1311(c), Patient Protection and Affordable |
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Care Act (Pub. L. No. 111-148). |
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(9) "Qualified individual" means an individual, |
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including a minor, who: |
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(A) seeks to enroll in a qualified health plan |
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offered to individuals through the exchange; |
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(B) resides in this state; |
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(C) at the time of enrollment, is not |
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incarcerated, other than incarceration pending the disposition of |
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charges; and |
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(D) is, and is reasonably expected to be, for the |
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entire period for which enrollment is sought, a citizen or national |
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of the United States or an alien lawfully present in the United |
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States. |
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(10) "Secretary" means the secretary of the United |
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States Department of Health and Human Services. |
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(11) "SHOP Exchange" means a Small Business Health |
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Options Program as defined by Section 1311(b)(1)(B), Patient |
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Protection and Affordable Care Act (Pub. L. No. 111-148). |
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Sec. 1509.002. DEFINITION OF HEALTH BENEFIT PLAN. (a) In |
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this chapter, "health benefit plan" means an insurance policy, |
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insurance agreement, evidence of coverage, or other similar |
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coverage document that provides coverage for medical or surgical |
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expenses incurred as a result of a health condition, accident, or |
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sickness that is issued by: |
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(1) an insurance company; |
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(2) a group hospital service corporation operating |
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under Chapter 842; |
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(3) a fraternal benefit society operating under |
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Chapter 885; |
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(4) a stipulated premium company operating under |
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Chapter 884; |
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(5) an exchange operating under Chapter 942; |
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(6) a health maintenance organization operating under |
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Chapter 843; |
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(7) a multiple employer welfare arrangement that holds |
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a certificate of authority under Chapter 846; or |
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(8) an approved nonprofit health corporation that |
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holds a certificate of authority under Chapter 844. |
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(b) In this chapter, "health benefit plan" does not include: |
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(1) a plan that provides coverage: |
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(A) for wages or payments in lieu of wages for a |
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period during which an employee is absent from work because of |
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sickness or injury; |
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(B) as a supplement to a liability insurance |
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policy; |
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(C) for credit insurance; |
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(D) only for vision care; |
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(E) only for hospital expenses; or |
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(F) only for indemnity for hospital confinement; |
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(2) a Medicare supplemental policy as defined by |
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Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss); |
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(3) a workers' compensation insurance policy; or |
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(4) medical payment insurance coverage provided under |
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a motor vehicle insurance policy. |
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Sec. 1509.003. DEFINITION OF SMALL EMPLOYER. (a) For |
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purposes of this chapter, "small employer" means a person who |
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employed at least two, and an average of not more than 50 employees |
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during the preceding calendar year. This subsection expires |
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December 31, 2013. |
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(b) All persons treated as a single employer under Section |
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414(b), (c), (m), or (o), Internal Revenue Code of 1986, are single |
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employers for purposes of this chapter. |
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(c) An employer and any predecessor employer are a single |
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employer for purposes of this chapter. |
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(d) In determining the number of employees of an employer |
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under this section, the number of employees: |
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(1) includes part-time employees and employees who are |
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not eligible for coverage through the employer; and |
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(2) for an employer that did not have employees during |
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the entire preceding calendar year, is the average number of |
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employees that the employer is reasonably expected to employ on |
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business days in the current calendar year. |
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(e) A small employer that makes enrollment in qualified |
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health benefit plans available to its employees through the |
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exchange and ceases to be a small employer by reason of an increase |
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in the number of its employees continues to be a small employer for |
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purposes of this chapter as long as it continuously makes |
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enrollment through the exchange available to its employees. |
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Sec. 1509.004. RULEMAKING AUTHORITY. The board may adopt |
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rules necessary and proper to implement this chapter. Rules adopted |
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under this section may not conflict with or prevent the application |
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of regulations promulgated by the secretary under the Patient |
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Protection and Affordable Care Act (Pub. L. No. 111-148). |
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Sec. 1509.005. AGENCY COOPERATION. (a) The exchange, the |
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department, and the Health and Human Services Commission shall |
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cooperate fully in performing their respective duties under this |
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code or another law of this state relating to the operation of the |
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exchange. |
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(b) The exchange and the Health and Human Services |
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Commission shall cooperate fully to: |
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(1) ensure that the development of eligibility and |
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enrollment systems for the exchange and its tax credits are fully |
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integrated with the planning and development of the Health and |
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Human Services Commission's eligibility systems modernization |
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efforts; |
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(2) ensure full and seamless interoperability and |
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minimize duplication of cost and effort; |
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(3) develop and administer transition procedures |
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that: |
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(A) address the needs of individuals and families |
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who experience a change in income that results in a change in the |
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source of coverage, with a particular emphasis on children and |
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adults with special health care needs and chronic illnesses, |
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conditions, and disabilities, as well as all individuals who are |
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also enrolled in Medicare; and |
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(B) to the extent practicable under the Patient |
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Protection and Affordable Care Act (Pub. L. No. 111-148), provide |
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for the coordination of payments to Medicaid managed care |
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organizations and qualified health plans that experience changes in |
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enrollment resulting from changes in eligibility for Medicaid |
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during an enrollment period; |
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(4) ensure consistent methods and standards, |
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including formulas and verification methods, for prompt |
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calculation of income based on individuals' modified adjusted gross |
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incomes in order to guard against lapses in coverage and |
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inconsistent eligibility determinations and procedures; |
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(5) ensure maximum access to federal data sources for |
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the purpose of verifying income eligibility for Medicaid, the state |
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child health plan program, premium tax credits, and cost-sharing |
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reductions; |
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(6) ensure the prompt processing of applications and |
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enrollment in the correct state subsidy program, regardless of |
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whether the program is Medicaid, the state child health plan |
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program, premium tax credits, or cost-sharing reductions; |
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(7) ensure procedures for transitioning individuals |
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between Medicaid and tax-credit-based subsidies that protect |
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individuals against delays in eligibility and plan enrollment; |
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(8) ensure rapid resolution of inconsistent |
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information affecting eligibility and dissemination of clear and |
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understandable information to applicants regarding the resolution |
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process and any interim assistance that may be available while |
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resolution is pending and procedures to assure that individuals are |
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meaningfully informed of: |
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(A) the potential existence of overpayments of |
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advance tax credits; |
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(B) procedures for reconciling enrollee |
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liability for repayment in the event that an advance tax credit is |
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subsequently proved to be an overpayment; |
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(C) procedures by which individuals can report a |
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change in income that may affect the subsequent level of advance tax |
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payment or the availability of a safe harbor; and |
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(D) information regarding safe harbors against |
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overpayment liability or recoupment that may exist under federal or |
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state law; and |
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(9) develop cross-market participation by: |
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(A) encouraging the development of common |
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provider networks, network performance standards for health |
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benefit plans that participate in the exchange, Medicaid, and the |
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state child health plan program, and developing coverage terms and |
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quality standards in order to ensure maximum continuity and quality |
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of care; |
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(B) promoting participation by health benefit |
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plans that satisfy both qualified health plan and Medicaid managed |
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care plan criteria, in order to minimize disruption in care as a |
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result of enrollment shifts between subsidy sources; |
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(C) developing incentives, including quality |
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ratings, default enrollment preferences, and other approaches, in |
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order to encourage health benefit plans to participate in both |
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Medicaid and the exchange; and |
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(D) coordinating health benefit plan payments |
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and timely adjustments in all markets that may result from |
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enrollment changes. |
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Sec. 1509.006. EXEMPTION FROM STATE TAXES AND FEES. The |
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exchange is not subject to any state tax, regulatory fee, or |
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surcharge, including a premium or maintenance tax or fee. |
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Sec. 1509.007. COMPLIANCE WITH FEDERAL LAW. The exchange |
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shall comply with all applicable federal law and regulations. |
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Sec. 1509.008. TEMPORARY EXEMPTION FROM STATE PURCHASING |
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PROCEDURES. (a) The exchange is not subject to state purchasing or |
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procurement requirements under Subtitle D, Title 10, Government |
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Code, or any other law. |
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(b) This section expires January 1, 2016. |
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[Sections 1509.009-1509.050 reserved for expansion] |
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SUBCHAPTER B. ESTABLISHMENT AND GOVERNANCE |
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Sec. 1509.051. ESTABLISHMENT. The Texas Health Insurance |
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Exchange is established as the American Health Benefit Exchange and |
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the Small Business Health Options Program (SHOP) Exchange |
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authorized and required by Section 1311, Patient Protection and |
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Affordable Care Act (Pub. L. No. 111-148). |
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Sec. 1509.052. GOVERNANCE OF EXCHANGE; BOARD MEMBERSHIP. |
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(a) The exchange is governed by a board of directors. |
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(b) The board consists of seven members as follows: |
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(1) five appointed members: |
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(A) one of whom is appointed by the governor; |
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(B) two of whom are appointed by the lieutenant |
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governor; and |
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(C) two of whom are appointed by the speaker of |
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the house of representatives; |
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(2) the commissioner as an ex officio voting member; |
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and |
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(3) the executive commissioner as an ex officio voting |
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member. |
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(c) Each of the five board members appointed under |
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Subsection (b)(1) must have demonstrated experience in at least two |
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of the following areas: |
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(1) individual health care coverage; |
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(2) small employer health care coverage; |
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(3) health benefit plan administration; |
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(4) health care finance or economics; |
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(5) actuarial science; |
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(6) administration of a public or private health care |
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delivery system; and |
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(7) purchasing health plan coverage. |
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(d) The board must include members who are health care |
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consumers or small business owners. |
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(e) In making appointments under this section, the |
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governor, lieutenant governor, and speaker of the house of |
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representatives shall attempt to make appointments that increase |
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the board's diversity of expertise. |
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Sec. 1509.053. PRESIDING OFFICER. The board shall annually |
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designate one member of the board to serve as presiding officer. |
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Sec. 1509.054. TERMS; VACANCY. (a) Appointed members of |
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the board serve two-year terms. |
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(b) The appropriate appointing authority shall fill a |
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vacancy on the board by appointing, for the unexpired term, an |
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individual who has the appropriate qualifications to fill that |
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position. |
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Sec. 1509.055. CONFLICT OF INTEREST. (a) Any board member |
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or a member of a committee formed by the board with a direct |
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interest in a matter, personally or through an employer, before the |
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board shall abstain from deliberations and actions on the matter in |
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which the conflict of interest arises and shall further abstain |
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from any vote on the matter, and may not otherwise participate in a |
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decision on the matter. |
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(b) Each board member shall file a conflict of interest |
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statement and a statement of ownership interests with the board to |
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ensure disclosure of all existing and potential personal interests |
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related to board business. |
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(c) A member of the board or of the staff of the exchange may |
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not be employed by, affiliated with, a consultant to, a member of |
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the board of directors of, or otherwise a representative of an |
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issuer or other insurer, an agent or broker, a health care provider, |
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or a health care facility or health clinic while serving on the |
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board or on the staff of the exchange. |
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(d) A member of the board or of the staff of the exchange may |
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not be a member, a board member, or an employee of a trade |
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association of issuers, health facilities, health clinics, or |
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health care providers while serving on the board or on the staff of |
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the exchange. |
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(e) A member of the board or of the staff of the exchange may |
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not be a health care provider unless the member receives no |
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compensation for rendering services as a health care provider and |
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does not have an ownership interest in a professional health care |
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practice. |
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Sec. 1509.056. GENERAL DUTIES OF BOARD MEMBERS. (a) Each |
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board member has the responsibility and duty to meet the |
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requirements of this title and applicable state and federal laws |
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and regulations, to serve the public interest of the individuals |
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and small businesses seeking health care coverage through the |
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exchange, and to ensure the operational well-being and fiscal |
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solvency of the exchange. |
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(b) A member of the board may not make, participate in |
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making, or in any way attempt to use the board member's official |
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position to influence the making of any decision that the board |
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member knows or has reason to know will have a material financial |
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effect, distinguishable from its effect on the public generally, on |
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the board member or the board member's immediate family, or on: |
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(1) any source of income, other than gifts and loans by |
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a commercial lending institution in the regular course of business |
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on terms available to the public generally, aggregating $250 or |
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more in value, provided or promised to the member within the 12 |
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months immediately preceding the date the decision is made; or |
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(2) any business entity in which the member is a |
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director, officer, partner, trustee, or employee, or holds any |
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position of management. |
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Sec. 1509.057. REIMBURSEMENT. A member of the board is not |
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entitled to compensation but is entitled to reimbursement for |
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travel or other expenses incurred while performing duties as a |
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board member in the amount provided by the General Appropriations |
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Act for state officials. |
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Sec. 1509.058. MEMBER'S IMMUNITY. (a) A member of the |
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board is not liable for an act or omission made in good faith in the |
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performance of powers and duties under this chapter. |
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(b) A cause of action does not arise against a member of the |
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board for an act or omission described by Subsection (a). |
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Sec. 1509.059. OPEN RECORDS AND OPEN MEETINGS. The board is |
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subject to Chapters 551 and 552, Government Code. |
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Sec. 1509.060. RECORDS. The board shall keep records of the |
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board's proceedings for at least seven years. |
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[Sections 1509.061-1509.100 reserved for expansion] |
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SUBCHAPTER C. POWERS AND DUTIES OF EXCHANGE |
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Sec. 1509.101. EMPLOYEES; COMMITTEES. (a) The board may |
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employ an executive director, a chief fiscal officer, a chief |
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operations officer, a director of health plan contracting, a chief |
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technology and information officer, a general counsel, and any |
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other agents and employees that the board considers necessary to |
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assist the exchange in carrying out its responsibilities and |
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functions. |
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(b) The executive director shall organize, administer, and |
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manage the operations of the exchange. The executive director may |
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hire other employees as necessary to carry out the responsibilities |
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of the exchange. |
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(c) The exchange may appoint appropriate legal, actuarial, |
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and other committees necessary to provide technical assistance in |
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operating the exchange and performing any of the functions of the |
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exchange. |
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(d) The board shall set the salary for an agent or employee |
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position under this section in an amount reasonably necessary to |
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attract and retain individuals of superior qualifications. In |
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determining the compensation for these positions, the board shall |
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conduct, through the use of independent outside advisors, salary |
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surveys of both other state and federal health insurance exchanges |
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that are most comparable to the exchange and other relevant labor |
|
pools. |
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(e) The salaries established by the board under this section |
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may not exceed the highest comparable salary for a position of that |
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type, as determined by the salary surveys in Subsection (d). |
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(f) The board shall publish the salaries under this section |
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in the board's annual budget and post the budget on an Internet |
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website maintained by the exchange. |
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Sec. 1509.102. ADVISORY COMMITTEE. The board shall appoint |
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an advisory committee to allow for the involvement of the health |
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care and health insurance industries and other stakeholders in the |
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operation of the exchange. The advisory committee may provide |
|
expertise and recommendations to the board but may not adopt rules |
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or enter into contracts on behalf of the exchange. |
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Sec. 1509.103. CONTRACTS. (a) Except as provided by |
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Subsection (b), the exchange may enter into any contract that the |
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exchange considers necessary to implement or administer this |
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chapter, including a contract with the Health and Human Services |
|
Commission or an entity that has experience in individual and small |
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group health insurance, benefit administration, or other |
|
experience relevant to the responsibilities assumed by the entity, |
|
to perform functions or provide services in connection with the |
|
operation of the exchange. |
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(b) This exchange may not enter into a contract with a |
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health benefit plan issuer under this section. |
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Sec. 1509.104. INFORMATION SHARING AND CONFIDENTIALITY. |
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The exchange may enter into information-sharing agreements with |
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federal and state agencies to carry out the exchange's |
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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 |
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applicable state and federal law. |
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Sec. 1509.105. MEMORANDUM OF UNDERSTANDING. The exchange |
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shall enter into a memorandum of understanding with the department |
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and the Health and Human Services Commission regarding the exchange |
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of information and the division of regulatory functions among the |
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exchange, the department, and the commission. |
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Sec. 1509.106. LEGAL ACTION. (a) The exchange may sue or |
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be sued. |
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(b) The exchange may take any legal action necessary to |
|
recover or collect amounts due the exchange, including: |
|
(1) assessments due the exchange; |
|
(2) amounts erroneously or improperly paid by the |
|
exchange; and |
|
(3) amounts paid by the exchange as a mistake of fact |
|
or law. |
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Sec. 1509.107. FUNCTIONS. (a) The exchange shall make |
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qualified health plans available to qualified individuals and |
|
qualified employers. |
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(b) The exchange may not make available any health benefit |
|
plan that is not a qualified health plan. |
|
(c) The exchange may allow a health benefit plan issuer to |
|
offer a plan that provides limited scope dental benefits meeting |
|
the requirements of Section 9832(c)(2)(A), Internal Revenue Code of |
|
1986, through the exchange, either separately or in conjunction |
|
with a qualified health plan, if the plan provides pediatric dental |
|
benefits meeting the requirements of Section 1302(b)(1)(J), |
|
Patient Protection and Affordable Care Act (Pub. L. No. 111-148). |
|
(d) The exchange, or an issuer offering a health benefit |
|
plan through the exchange, may not charge an individual a fee or |
|
penalty for termination of coverage if the individual enrolls in |
|
another type of minimum essential coverage because the individual |
|
has become eligible for that coverage or because the individual's |
|
employer-sponsored coverage has become affordable under the |
|
standards of Section 36B(c)(2)(C), Internal Revenue Code of 1986. |
|
(e) In implementing the requirements of this section, the |
|
exchange 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, utilizing staff that |
|
is trained to provide assistance in a culturally and linguistically |
|
appropriate manner; |
|
(3) provide oral interpretation services in any |
|
language for individuals seeking coverage through the exchange and |
|
make available a toll-free telephone number for the hearing and |
|
speech impaired; |
|
(4) maintain an Internet website through which an |
|
enrollee or prospective enrollee may obtain standardized |
|
comparative information on a qualified health plan's premiums, |
|
coverage, cost-sharing, ratings, enrollee satisfaction, quality |
|
measures, and other relevant information; |
|
(5) use a standardized format for presenting health |
|
benefit options in the exchange, including the use of the uniform |
|
outline of coverage established under Section 2715, Public Health |
|
Service Act (42 U.S.C. Section 300gg-51); |
|
(6) assign a rating to each qualified health plan |
|
certified by the exchange based on criteria developed by the |
|
secretary; |
|
(7) ensure that written information made available by |
|
the exchange is presented in a plainly worded, easily |
|
understandable format and made available in prevalent languages; |
|
(8) determine each qualified health plan's level of |
|
coverage in accordance with regulations issued by the secretary |
|
under Section 1302(d)(2)(A), Patient Protection and Affordable |
|
Care Act (Pub. L. No. 111-148); and |
|
(9) in accordance with federal law and regulations, |
|
inform individuals of eligibility requirements for Medicaid, the |
|
state child health plan program, or any applicable state or local |
|
public program and if through screening of the application by the |
|
exchange, the exchange determines that an individual is eligible |
|
for such program, enroll the individual in the program. |
|
(f) In addition to performing the duties described by |
|
Subsection (e), and consistent with Section 1413, Patient |
|
Protection and Affordable Care Act (Pub. L. No. 111-148), the |
|
exchange shall: |
|
(1) enter into data-sharing agreements with relevant |
|
state and federal agencies to facilitate eligibility |
|
determinations and enrollment; |
|
(2) provide enrollment information and other relevant |
|
data, consistent with federal and state privacy rules, to the |
|
qualified health plan in which a qualified individual or qualified |
|
small employer is enrolled; |
|
(3) conduct redeterminations of eligibility for |
|
subsidies and assist in reenrollment as necessary, if an individual |
|
experiences changes in income or circumstances; |
|
(4) inform individuals of the potential for |
|
overpayments of advance premium tax credits and of procedures by |
|
which individuals can report a change of income that may affect the |
|
subsequent level of premium tax credits, including the availability |
|
of any safe harbor from recoupment of any overpayment, to the extent |
|
permitted by that Act or any federal regulations promulgated under |
|
that Act; |
|
(5) establish, and make available electronically, a |
|
calculator designed to: |
|
(A) enable consumers to determine the actual cost |
|
of coverage after the application of any premium tax credit or |
|
cost-sharing subsidy available under federal law; and |
|
(B) provide consumers with information on |
|
out-of-pocket costs for in-network and, if feasible, |
|
out-of-network services, taking into account any cost-sharing |
|
reductions; |
|
(6) establish capability through which qualified |
|
employers may access coverage for their employees, and which shall |
|
enable any qualified employer to specify a level of coverage so that |
|
any of its employees may enroll in any qualified health plan offered |
|
through the exchange at the specified level of coverage; |
|
(7) subject to Section 1411, Patient Protection and |
|
Affordable Care Act (Pub. L. No. 111-148), grant a certification |
|
attesting that, for purposes of the individual responsibility |
|
penalty under Section 5000A, Internal Revenue Code of 1986, an |
|
individual is exempt from the individual responsibility |
|
requirement or from the penalty imposed by that section because: |
|
(A) there is no affordable qualified health plan |
|
available through the exchange, or the individual's employer, |
|
covering the individual; or |
|
(B) the individual meets the requirements for any |
|
other such exemption from the individual responsibility |
|
requirement or penalty; |
|
(8) transfer to the United States secretary of the |
|
treasury the following: |
|
(A) a list of the individuals who are issued a |
|
certification under Subdivision (7), including the name and |
|
taxpayer identification number of each individual; |
|
(B) the name and taxpayer identification number |
|
of each individual who was an employee of an employer but who was |
|
determined to be eligible for the premium tax credit under Section |
|
36B, Internal Revenue Code of 1986, because the employer did not |
|
provide minimum essential coverage, or the employer provided the |
|
minimum essential coverage, but it was determined under Section |
|
36B(c)(2)(C) of that code to be either unaffordable to the employee |
|
or not provide the required minimum actuarial value; and |
|
(C) the name and taxpayer identification number |
|
of each individual who notifies the exchange under Section |
|
1411(b)(4), Patient Protection and Affordable Care Act (Pub. L. No. |
|
111-148), that he or she has changed employers and each individual |
|
who ceases coverage under a qualified health plan during a plan |
|
year, and the effective date of that cessation; |
|
(9) provide to each employer the name of each employee |
|
of the employer described above who ceases coverage under a |
|
qualified health plan during a plan year and the effective date of |
|
the cessation; |
|
(10) perform duties required of the exchange by the |
|
secretary or the United States secretary of the treasury related to |
|
determining eligibility for premium tax credits, reduced |
|
cost-sharing, or individual responsibility requirement exemptions; |
|
(11) select entities qualified to serve as Navigators |
|
in accordance with Section 1311(i), Patient Protection and |
|
Affordable Care Act (Pub. L. No. 111-148), and standards developed |
|
by the secretary; and |
|
(12) award grants to enable Navigators to: |
|
(A) conduct public education activities to raise |
|
awareness of the availability of qualified health plans; |
|
(B) distribute fair and impartial information |
|
concerning enrollment in qualified health plans, and the |
|
availability of premium tax credits under Section 36B, Internal |
|
Revenue Code of 1986, and cost-sharing reductions under Section |
|
1402, Patient Protection and Affordable Care Act (Pub. L. No. |
|
111-148); |
|
(C) facilitate enrollment in qualified health |
|
plans; |
|
(D) provide referrals to any applicable office of |
|
health insurance consumer assistance or health insurance ombudsman |
|
established under Section 2793, Public Health Service Act (42 |
|
U.S.C. Section 300gg-93), or any other appropriate state agency or |
|
agencies, for any enrollee with a grievance, complaint, or question |
|
regarding the enrollee's health benefit plan or coverage or a |
|
determination under that plan or coverage; |
|
(E) provide information in a manner that is |
|
culturally and linguistically appropriate to the needs of the |
|
population being served by the exchange; and |
|
(F) counsel exchange participants about the |
|
exchange, Medicaid, and the state child health plan program |
|
markets, including selection of plans and transition procedures for |
|
transitioning among Medicaid, the state child health plan program, |
|
exchange plans, and other coverage; |
|
(13) ensure that there is a sufficient number of |
|
Navigators that possess the experience and capacity to serve |
|
disadvantaged, hard-to-reach, and culturally or linguistically |
|
isolated populations; |
|
(14) certify Navigators as able to carry out the |
|
duties required by Section 1311(i)(3), Patient Protection and |
|
Affordable Care Act (Pub. L. No. 111-148); |
|
(15) review the rate of premium growth within the |
|
exchange and outside the exchange and consider the information in |
|
developing recommendations on whether to continue limiting |
|
qualified employer status to small employers; |
|
(16) credit the amount of any free choice voucher to |
|
the monthly premium of the plan in which a qualified employee is |
|
enrolled, in accordance with Section 10108, Patient Protection and |
|
Affordable Care Act (Pub. L. No. 111-148), and collect the amount |
|
credited from the offering employer; |
|
(17) consult with stakeholders relevant to carrying |
|
out the activities required under this chapter, including: |
|
(A) educated health care consumers who are |
|
enrollees in qualified health plans; |
|
(B) individuals and entities with experience in |
|
facilitating enrollment in qualified health plans; |
|
(C) representatives of small businesses and |
|
self-employed individuals; |
|
(D) the Health and Human Services Commission; and |
|
(E) advocates for enrolling hard-to-reach |
|
populations; |
|
(18) meet the following financial integrity |
|
requirements: |
|
(A) keep an accurate accounting of all |
|
activities, receipts, and expenditures and annually submit to the |
|
secretary, the governor, the commissioner, and the legislature a |
|
report concerning such accountings; and |
|
(B) fully cooperate with any investigation |
|
conducted by the secretary pursuant to the secretary's authority |
|
under the Patient Protection and Affordable Care Act (Pub. L. No. |
|
111-148) and allow the secretary, in coordination with the |
|
inspector general of the United States Department of Health and |
|
Human Services, to investigate the affairs of the exchange, examine |
|
the books and records of the exchange, and require periodic reports |
|
in relation to the activities undertaken by the exchange; |
|
(19) use a single application for enrollment in |
|
Medicaid, the state child health plan program, and health benefit |
|
plans offered in the exchange, including establishing eligibility |
|
for premium tax credits and cost-sharing reductions, that may be: |
|
(A) the single application form developed by the |
|
secretary under Section 1413(b), Patient Protection and Affordable |
|
Care Act (Pub. L. No. 111-148); or |
|
(B) an application form developed in cooperation |
|
with the Health and Human Services Commission for that purpose; |
|
(20) undertake activities necessary to market and |
|
publicize the availability of health care coverage and federal |
|
subsidies through the exchange; |
|
(21) undertake outreach and enrollment activities |
|
that seek to assist enrollees and potential enrollees with |
|
enrolling and reenrolling in the exchange in the least burdensome |
|
manner, including populations that may experience barriers to |
|
enrollment, such as the disabled and those with limited English |
|
language proficiency; |
|
(22) provide for: |
|
(A) the processing of applications for coverage |
|
under a qualified health plan; |
|
(B) the enrollment of persons in qualified health |
|
plans; |
|
(C) the disenrollment of enrollees from |
|
qualified health plans; and |
|
(D) for individual coverage, the collection of |
|
premiums and assistance in the administration of subsidies, as the |
|
board considers appropriate; and |
|
(23) for small employers, collect and aggregate |
|
premiums and administer all other necessary and related tasks, |
|
including enrollment and plan payment, in order to make the |
|
offering of employee plan choice as simple as possible for |
|
qualified small employers. |
|
Sec. 1509.108. CERTIFICATION OF PLAN. The exchange shall |
|
certify a health benefit plan as a qualified health plan if: |
|
(1) the plan provides the essential health benefits |
|
package described by Section 1302(a), Patient Protection and |
|
Affordable Care Act (Pub. L. No. 111-148), except that the plan is |
|
not required to provide essential benefits that duplicate the |
|
minimum benefits of qualified dental plans, if: |
|
(A) the exchange has determined that at least one |
|
qualified dental plan is available to supplement the plan's |
|
coverage; and |
|
(B) the issuer makes prominent disclosure at the |
|
time it offers the plan, in a form approved by the exchange, that |
|
the plan does not provide the full range of essential pediatric |
|
benefits and that qualified dental plans providing those benefits |
|
and other dental benefits not covered by the plan are offered |
|
through the exchange; |
|
(2) the premium rates and contract language have been |
|
approved by the commissioner; |
|
(3) the plan provides at least a bronze level of |
|
coverage, as described by Section 1302(d), Patient Protection and |
|
Affordable Care Act (Pub. L. No. 111-148), unless the plan is a |
|
catastrophic plan and is offered only to individuals eligible for |
|
catastrophic coverage; |
|
(4) the plan's cost-sharing requirements do not exceed |
|
the limits established under Section 1302(c)(1), Patient |
|
Protection and Affordable Care Act (Pub. L. No. 111-148), and if the |
|
plan is offered to small employers, the plan's deductible does not |
|
exceed the limits established under Section 1302(c)(2) of that Act; |
|
(5) the health benefit plan issuer offering the plan: |
|
(A) is licensed and in good standing to offer |
|
health insurance coverage in this state; |
|
(B) offers at least one qualified health plan in |
|
the silver level and at least one plan in the gold level as |
|
described by Section 1302(d), Patient Protection and Affordable |
|
Care Act (Pub L. No. 111-148); |
|
(C) charges the same premium rate for each |
|
qualified health plan without regard to whether the plan is offered |
|
through the exchange and without regard to whether the plan is |
|
offered directly from the issuer or through an insurance producer; |
|
and |
|
(D) complies with the regulations developed by |
|
the secretary under Section 1311(d), Patient Protection and |
|
Affordable Care Act (Pub. L. No. 111-148), and other requirements |
|
the exchange establishes; |
|
(6) the plan meets the requirements of certification |
|
under this chapter and any rules promulgated by the secretary under |
|
Section 1311(c), Patient Protection and Affordable Care Act (Pub. |
|
L. No. 111-148), including minimum standards in the areas of |
|
marketing practices, network adequacy, essential community |
|
providers in underserved areas, accreditation, quality |
|
improvement, uniform enrollment forms and descriptions of |
|
coverage, and information on quality measures for health benefit |
|
plan performance; and |
|
(7) the exchange determines that making the plan |
|
available through the exchange is in the interest of qualified |
|
individuals and qualified employers in this state. |
|
Sec. 1509.109. PROHIBITED BASES FOR DENIAL OF |
|
CERTIFICATION. The exchange may not deny certification to a health |
|
benefit plan on the ground that the plan: |
|
(1) is a fee-for-service plan; or |
|
(2) provides treatments necessary to prevent patients' |
|
deaths in circumstances the exchange determines are inappropriate |
|
or too costly. |
|
Sec. 1509.110. PREREQUISITES TO CERTIFICATION. (a) The |
|
exchange shall require each health benefit plan issuer seeking |
|
certification of a plan as a qualified health plan to: |
|
(1) submit a justification for any premium increase |
|
before implementation of that increase; |
|
(2) prominently display the justification for any |
|
premium increase on the health benefit plan issuer's Internet |
|
website; |
|
(3) make available to the public, in plain language as |
|
that term is defined in Section 1311(e)(3)(B), Patient Protection |
|
and Affordable Care Act (Pub. L. No. 111-148), and submit to the |
|
exchange, the secretary, and the commissioner, accurate and timely |
|
disclosure of: |
|
(A) claims payment policies and practices; |
|
(B) periodic financial disclosures; |
|
(C) data on enrollment; |
|
(D) data on disenrollment; |
|
(E) data on the number of claims that are denied; |
|
(F) data on rating practices; |
|
(G) information on cost-sharing and payments |
|
with respect to any out-of-network coverage; |
|
(H) information on enrollee and participant |
|
rights under Title I, Patient Protection and Affordable Care Act |
|
(Pub. L. No. 111-148); and |
|
(I) other information as determined appropriate |
|
by the secretary; |
|
(4) on request, inform an individual of the amount of |
|
cost-sharing, including deductibles, copayments, and coinsurance, |
|
under the individual's plan or coverage that the individual would |
|
be responsible for paying with respect to the furnishing of a |
|
specific item or service by a participating provider; |
|
(5) make the information required to be disclosed |
|
under Subdivision (4) made available to the individual on an |
|
Internet website and by other means for individuals without access |
|
to the Internet; |
|
(6) promptly notify affected individuals of price and |
|
benefit changes or other changes in circumstance that could |
|
materially impact enrollment or coverage; |
|
(7) make available to the exchange and regularly |
|
update an electronic directory of contracting health care providers |
|
so that individuals seeking coverage through the exchange can |
|
search by health care provider name to determine which health plans |
|
in the exchange include that health care provider in their network; |
|
and |
|
(8) as the board considers necessary, provide |
|
regularly updated information to the exchange as to whether a |
|
health care provider is accepting new patients for a particular |
|
health plan. |
|
(b) In determining whether to certify an issuer, the |
|
exchange shall consider premium increase justification information |
|
obtained under Subsection (a), together with information and |
|
recommendations provided by the commissioner under Section |
|
2794(b), Public Health Service Act (42 U.S.C. Section 300gg-94(b)). |
|
Sec. 1509.111. ADDITIONAL REQUIREMENTS RELATING TO |
|
RULEMAKING BY BOARD. In adopting rules under this chapter, the |
|
board shall: |
|
(1) standardize benefits and cost-sharing within |
|
tiers for products to be offered through the exchange; |
|
(2) establish and use a competitive process, which is |
|
not required to comply with Chapter 2151, Government Code, to |
|
select participating health benefit plan issuers; |
|
(3) determine the minimum requirements an issuer must |
|
meet to be considered for participation in the exchange and the |
|
standards and criteria for selecting qualified health plans to be |
|
offered through the exchange that are in the best interests of |
|
qualified individuals and qualified small employers; |
|
(4) consistently and uniformly apply any |
|
requirements, standards, and criteria under this chapter to all |
|
issuers; |
|
(5) in the course of selectively contracting for |
|
health care coverage offered to qualified individuals and qualified |
|
small employers through the exchange, seek to contract with issuers |
|
to provide health care coverage choices that offer the optimal |
|
combination of choice, value, quality, and service; |
|
(6) ensure, in each region of the state, a choice of |
|
qualified health plans at each of the five tiers of coverage |
|
contained in Sections 1302(d) and (e), Patient Protection and |
|
Affordable Care Act (Pub. L. No. 111-148); |
|
(7) require issuers, as a condition of participation |
|
in the exchange, to fairly and affirmatively offer, market, and |
|
sell in the exchange at least one product within each of the five |
|
levels of coverage described by Sections 1302(d) and (e), Patient |
|
Protection and Affordable Care Act (Pub. L. No. 111-148), and, as |
|
the board considers necessary, to offer additional products within |
|
each of the five levels of coverage described by Section 1302(d) of |
|
that Act; and |
|
(8) require, as a condition of participation in the |
|
exchange, issuers that sell any products outside the exchange to |
|
fairly and affirmatively offer, market, and sell: |
|
(A) all products made available to individuals in |
|
the exchange to individuals purchasing coverage outside the |
|
exchange; or |
|
(B) all products made available to small |
|
employers in the exchange to small employers purchasing coverage |
|
outside the exchange. |
|
Sec. 1509.112. EXEMPTION FROM STANDARDS PROHIBITED. (a) |
|
The exchange may not exempt any health benefit plan issuer seeking |
|
certification of a qualified health plan, regardless of the type or |
|
size of the issuer, from state licensing or solvency requirements. |
|
(b) The exchange shall apply the criteria of this section in |
|
a manner that assures a fair competitive market between or among |
|
health benefit plan issuers participating in the exchange. |
|
Sec. 1509.113. DENTAL PLANS. (a) This chapter applies to |
|
dental plans as provided in this section. |
|
(b) A health benefit plan issuer may be certified to offer |
|
dental coverage, without being certified to offer other health |
|
coverages. |
|
(c) A plan may be limited to dental and oral health benefits |
|
without substantially duplicating the benefits typically offered |
|
by health benefit plans that do not offer dental coverage. |
|
(d) To be certified under this chapter, a dental plan must |
|
include, at a minimum, the essential pediatric dental benefits |
|
prescribed by the secretary pursuant to Section 1302(b)(1)(J), |
|
Patient Protection and Affordable Care Act (Pub. L. No. 111-148), |
|
and any other dental benefits the exchange or the secretary |
|
specifies by regulation. |
|
(e) An issuer may offer jointly with another issuer a |
|
comprehensive plan through the exchange in which dental benefits |
|
are provided by an issuer through a qualified dental plan and the |
|
other benefits are provided by an issuer through a qualified health |
|
plan. Plans offered under this subsection must be priced |
|
separately and made available for purchase separately at the same |
|
price at which they are offered together. |
|
Sec. 1509.114. (a) The exchange may provide an integrated |
|
and uniform consumer directory of health care providers indicating |
|
which health benefit plan issuers the providers contract with and |
|
whether the providers are currently accepting new patients. |
|
(b) The exchange may establish methods by which health care |
|
providers may transmit relevant information directly to the |
|
exchange, rather than through an issuer. |
|
[Sections 1509.115-1509.150 reserved for expansion] |
|
SUBCHAPTER D. ASSESSMENTS FOR OPERATION OF EXCHANGE |
|
Sec. 1509.151. ASSESSMENTS; PENALTY FOR NONPAYMENT. (a) |
|
The exchange may charge the issuers of health benefit plans in this |
|
state, including qualified health plans, an assessment as |
|
reasonable and necessary for the exchange's organizational and |
|
operating expenses. Assessments must be determined annually. The |
|
exchange may charge interest for late assessments. |
|
(b) The exchange 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. |
|
(c) The commissioner shall adopt rules to implement and |
|
enforce the assessment of health benefit plan issuers under this |
|
section. |
|
Sec. 1509.152. GRANTS AND FEDERAL FUNDS. (a) The exchange |
|
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 exchange may accept federal funds and shall use |
|
those funds in compliance with applicable federal law, regulations, |
|
and guidelines. |
|
Sec. 1509.153. USE OF EXCHANGE ASSETS; ANNUAL REPORT. (a) |
|
The assets of the exchange may be used only to pay the costs of the |
|
administration and operation of the exchange. |
|
(b) The exchange shall prepare annually a complete and |
|
detailed written report accounting for all funds received and |
|
disbursed by the exchange during the preceding fiscal year. The |
|
report must meet any reporting requirements provided in the General |
|
Appropriations Act, regardless of whether the exchange receives any |
|
funds under that Act. The exchange shall submit the report to the |
|
governor, the legislature, the commissioner, and the executive |
|
commissioner not later than January 31 of each year. |
|
(c) General revenue may not be appropriated for the |
|
exchange. |
|
Sec. 1509.154. PUBLICATION OF FINANCIAL INFORMATION. The |
|
exchange shall publish the average costs of licensing, regulatory |
|
fees, and any other payments required by the exchange, and the |
|
administrative costs of the exchange, on an Internet website to |
|
educate consumers on those costs. This information must include |
|
information on losses due to waste, fraud, and abuse. |
|
[Sections 1509.155-1509.200 reserved for expansion] |
|
SUBCHAPTER E. TRUST FUND |
|
Sec. 1509.201. TRUST FUND. (a) The exchange 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 exchange may deposit assessments, gifts or |
|
donations, and any federal funding obtained by the exchange in the |
|
exchange 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. |
|
[Sections 1509.202-1509.250 reserved for expansion] |
|
SUBCHAPTER F. LEVEL PLAYING FIELD |
|
Sec. 1509.251. LEVEL PLAYING FIELD. (a) The commissioner |
|
shall adopt rules to ensure a level playing field and a fair |
|
competitive market environment among issuers that offer qualified |
|
health plans through the exchange and issuers that offer health |
|
benefit plans or other health insurance coverage outside of the |
|
exchange. Notwithstanding any other law, the rules shall, to the |
|
extent practicable, ensure against adverse selection either in |
|
favor of or against exchange-participating issuers. |
|
(b) To discourage adverse selection or steering of |
|
enrollees to or from the exchange, if the board opts to pay agents |
|
helping people enroll in exchange-participating, qualified plans a |
|
fee, instead of using existing compensation structures directly |
|
from issuers, the exchange shall survey the market outside of the |
|
exchange to determine prevailing agent commission rates and set |
|
exchange fees in a manner that is consistent with prevailing rates |
|
in the market outside of the exchange. This section does not |
|
prohibit the exchange from paying a per member per month fee or |
|
using another fee structure if: |
|
(1) prevailing rates in the market outside of the |
|
exchange are paid a percentage of premiums; and |
|
(2) the total fee amounts earned are reasonably |
|
expected to be similar. |
|
(c) The department shall coordinate with the exchange as |
|
necessary to survey the market on commission rates and identify |
|
prevailing practices. Agent fees paid inside or outside of the |
|
exchange must be fully transparent and clearly disclosed to the |
|
purchaser. |
|
SECTION 1.02. Effective January 1, 2014, Section 1509.004, |
|
Insurance Code, as added by this Act, is amended by adding |
|
Subsection (a-1) to read as follows: |
|
(a-1) For purposes of this chapter, "small employer" means a |
|
person who employed an average of not more than 100 employees during |
|
the preceding calendar year. |
|
SECTION 1.03. (a) As soon as practicable after the |
|
effective date of this Act, but not later than October 31, 2011, the |
|
governor, lieutenant governor, and speaker of the house of |
|
representatives shall appoint the initial members of the board of |
|
directors of the Texas Health Insurance Exchange. |
|
(b) As soon as practicable 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 Exchange 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 practicable after the effective date of this |
|
Act, but not later than January 31, 2012, the board of directors of |
|
the Texas Health Insurance Exchange shall adopt rules and |
|
procedures necessary to implement Chapter 1509, Insurance Code, as |
|
added by this Act. |
|
(d) Not later than January 1, 2017, the board shall issue a |
|
report to the 85th Legislature recommending whether to adopt the |
|
option in Section 1312(c), Patient Protection and Affordable Care |
|
Act (Pub. L. No. 111-148), to merge the individual and small |
|
employer markets. In the report, the board shall provide |
|
information, based on at least two years of data from the exchange, |
|
on the potential impact on rates paid by individuals and by small |
|
employers in a merged individual and small employer market, as |
|
compared to the rates paid by individuals and small employers if a |
|
separate individual and small employer market is maintained. |
|
(e) If, after the effective date of this Act but before the |
|
initial members of the board of directors of the Texas Health |
|
Insurance Exchange have been appointed as required by Subsection |
|
(a), the Texas Department of Insurance becomes aware of any |
|
planning and establishment grants as described by Section 1311, |
|
Patient Protection and Affordable Care Act (Pub. L. No. 111-148), |
|
or any other public or private funding source, the department may |
|
apply for funding from that source. |
|
(f) The exchange may not begin operations without adequate |
|
funding. |
|
(g) The board of directors of the Texas Health Insurance |
|
Exchange may adopt rules on an emergency basis in accordance with |
|
Section 2001.034, Government Code. Notwithstanding Section |
|
2001.034(c), Government Code, a rule adopted under this subsection |
|
may remain in effect until January 1, 2015. Rules adopted under |
|
this subsection shall be deemed necessary for the immediate |
|
preservation of the public peace, health, safety, and general |
|
welfare and an additional finding under Sections 2001.034(a)(1) and |
|
(2), Government Code, is not required. The authority to adopt rules |
|
under this subsection expires January 1, 2015. |
|
ARTICLE 2. EMERGENCY COVERAGE UNDER CERTAIN MANAGED CARE PLANS |
|
SECTION 2.01. Section 843.107, Insurance Code, is amended |
|
to read as follows: |
|
Sec. 843.107. INDEMNITY BENEFITS; POINT-OF-SERVICE |
|
PROVISIONS. (a) A health maintenance organization may offer: |
|
(1) indemnity benefits covering out-of-area emergency |
|
care; |
|
(2) indemnity benefits, in addition to those relating |
|
to out-of-area and emergency care, provided through an insurer or |
|
group hospital service corporation; |
|
(3) a point-of-service plan under Subchapter A, |
|
Chapter 1273; or |
|
(4) a point-of-service rider under Section 843.108. |
|
(b) A health maintenance organization that offers indemnity |
|
benefits covering out-of-area emergency care under this section |
|
shall apply the same cost-sharing requirement to the emergency care |
|
as it applies to emergency care provided in-area. |
|
SECTION 2.02. Section 843.348, Insurance Code, is amended |
|
by adding Subsection (k) to read as follows: |
|
(k) A health maintenance organization may not require |
|
preauthorization for emergency care. |
|
SECTION 2.03. Sections 1271.155(a) and (b), Insurance Code, |
|
are amended to read as follows: |
|
(a) A health maintenance organization shall pay for |
|
emergency care performed by non-network physicians or providers at |
|
the same rate the health maintenance organization pays for |
|
emergency care performed by network physicians or providers [at the
|
|
usual and customary rate or at an agreed rate]. |
|
(b) A health care plan of a health maintenance organization |
|
must provide the following coverage of emergency care: |
|
(1) a medical screening examination or other |
|
evaluation required by state or federal law necessary to determine |
|
whether an emergency medical condition exists shall be provided to |
|
covered enrollees in a hospital emergency facility or comparable |
|
facility; |
|
(2) necessary emergency care shall be provided to |
|
covered enrollees, including the treatment and stabilization of an |
|
emergency medical condition; [and] |
|
(3) services originated in a hospital emergency |
|
facility, freestanding emergency medical care facility, or |
|
comparable emergency facility following treatment or stabilization |
|
of an emergency medical condition shall be provided to covered |
|
enrollees as approved by the health maintenance organization, |
|
subject to Subsections (c) and (d); and |
|
(4) as required by Section 1867, Social Security Act |
|
(42 U.S.C. Section 1395dd), medical screening examinations that are |
|
within the capability of the emergency department of a hospital, |
|
including ancillary services routinely available to the emergency |
|
department to evaluate the patient's condition and any further |
|
medical examination and treatment necessary to stabilize the |
|
patient within the capabilities of the staff and facilities |
|
available at the hospital shall be provided to covered enrollees. |
|
SECTION 2.04. Section 1273.004, Insurance Code, is amended |
|
to read as follows: |
|
Sec. 1273.004. LIMITED BENEFITS AND SERVICES; COST-SHARING |
|
PROVISIONS. (a) Indemnity benefits and services provided under a |
|
point-of-service plan may be limited to those services described by |
|
the blended contract and may be subject to different cost-sharing |
|
provisions. The cost-sharing provisions for indemnity benefits may |
|
be higher than the cost-sharing provisions for in-network health |
|
maintenance organization coverage. For an enrollee in a limited |
|
provider network, higher cost-sharing may be imposed only when the |
|
enrollee obtains benefits or services outside the health |
|
maintenance organization delivery network. |
|
(b) Notwithstanding Subsection (a), indemnity benefits and |
|
services provided under a point-of-service plan that covers |
|
emergency care may not be subject to different cost-sharing |
|
provisions. The cost-sharing provisions for indemnity benefits |
|
related to emergency care may not be higher than the cost-sharing |
|
provisions for in-network health maintenance organization |
|
coverage. For an enrollee in a limited provider network, higher |
|
cost-sharing provisions may not be imposed when the enrollee |
|
obtains emergency care outside the health maintenance organization |
|
delivery network. |
|
SECTION 2.05. Section 1301.135, Insurance Code, is amended |
|
by adding Subsection (i) to read as follows: |
|
(i) An insurer that uses a preauthorization process for |
|
medical care and health care services may not require |
|
preauthorization for emergency care. |
|
SECTION 2.06. Section 1301.155(b), Insurance Code, is |
|
amended to read as follows: |
|
(b) If an insured cannot reasonably reach a preferred |
|
provider, an insurer shall provide reimbursement for the following |
|
emergency care services at the preferred level of benefits until |
|
the insured can reasonably be expected to transfer to a preferred |
|
provider: |
|
(1) a medical screening examination or other |
|
evaluation required by state or federal law to be provided in the |
|
emergency facility of a hospital that is necessary to determine |
|
whether a medical emergency condition exists; |
|
(2) necessary emergency care services, including the |
|
treatment and stabilization of an emergency medical condition; |
|
[and] |
|
(3) services originating in a hospital emergency |
|
facility or freestanding emergency medical care facility following |
|
treatment or stabilization of an emergency medical condition; and |
|
(4) as required by Section 1867, Social Security Act |
|
(42 U.S.C. Section 1395dd), medical screening examinations that are |
|
within the capability of the emergency department of a hospital, |
|
including ancillary services routinely available to the emergency |
|
department to evaluate the patient's condition and any further |
|
medical examination and treatment necessary to stabilize the |
|
patient within the capabilities of the staff and facilities |
|
available at the hospital. |
|
SECTION 2.07. The changes in law made by this article apply |
|
only to a health insurance policy or contract or health maintenance |
|
organization contract or agreement that is delivered, issued for |
|
delivery, or renewed on or after January 1, 2012. A health |
|
insurance policy or contract or health maintenance organization |
|
contract or agreement that is delivered, issued for delivery, or |
|
renewed before January 1, 2012, is covered by the law in effect |
|
immediately before the effective date of this Act, and that law is |
|
continued in effect for that purpose. |
|
ARTICLE 3. SELECTION OF PRIMARY CARE PHYSICIANS AND PROVIDERS |
|
UNDER PREFERRED PROVIDER BENEFIT PLANS AND HEALTH MAINTENANCE |
|
ORGANIZATIONS |
|
SECTION 3.01. Section 843.203, Insurance Code, is amended |
|
by amending Subsection (b) and adding Subsections (d) and (e) to |
|
read as follows: |
|
(b) An enrollee shall at all times have the right to select |
|
or change a primary care physician or primary care provider within |
|
the health maintenance organization network of available primary |
|
care physicians and primary care providers[, except that a health
|
|
maintenance organization may limit an enrollee's request to change
|
|
physicians or providers to not more than four changes in a 12-month
|
|
period]. An enrollee may designate any participating primary care |
|
physician or primary care provider who is available to accept the |
|
individual. |
|
(d) For an enrollee who is a child, the health maintenance |
|
organization must allow the child's parent or guardian to designate |
|
as the child's primary care physician or primary care provider a |
|
participating physician who specializes in pediatrics. |
|
(e) A health maintenance organization shall notify each |
|
enrollee of the enrollee's rights under Subsections (b) and (d). |
|
SECTION 3.02. Subchapter D, Chapter 1301, Insurance Code, |
|
is amended by adding Section 1301.164 to read as follows: |
|
Sec. 1301.164. SELECTION OF PRIMARY CARE PHYSICIAN OR |
|
PROVIDER. (a) If a preferred provider benefit plan requires or |
|
provides for designation by an insured of a participating primary |
|
care physician or primary care provider, the insurer shall allow an |
|
insured to designate any participating primary care physician or |
|
primary care provider who is available to accept the individual. |
|
(b) For an enrollee who is a child, the insurer must allow |
|
the child's parent or guardian to designate as the child's primary |
|
care physician or primary care provider a participating physician |
|
who specializes in pediatrics. |
|
(c) An insurer shall notify each insured of the insured's |
|
rights under this section. |
|
SECTION 3.03. The change in law made by this article applies |
|
only to a health insurance policy or contract or health maintenance |
|
organization contract or agreement that is delivered or issued for |
|
delivery on or after January 1, 2012. An insurance policy or |
|
contract or health maintenance organization contract or agreement |
|
that is delivered or issued for delivery before January 1, 2012, is |
|
governed by the law as it existed immediately before the effective |
|
date of this Act, and that law is continued in effect for that |
|
purpose. |
|
ARTICLE 4. HEALTH BENEFIT PLAN COVERAGE OF CERTAIN DEPENDENTS |
|
SECTION 4.01. Section 846.260, Insurance Code, is amended |
|
to read as follows: |
|
Sec. 846.260. LIMITING AGE APPLICABLE TO UNMARRIED CHILD. |
|
If children are eligible for coverage under the terms of a multiple |
|
employer welfare arrangement's plan document, any limiting age |
|
applicable to an unmarried child of an enrollee is 26 [25] years of |
|
age. |
|
SECTION 4.02. Section 1201.053(b), Insurance Code, is |
|
amended to read as follows: |
|
(b) On the application of an adult member of a family, an |
|
individual accident and health insurance policy may, at the time of |
|
original issuance or by subsequent amendment, insure two or more |
|
eligible members of the adult's family, including a spouse, |
|
unmarried children younger than 26 [25] years of age, including a |
|
grandchild of the adult as described by Section 1201.062(a)(1), a |
|
child the adult is required to insure under a medical support order |
|
issued under Chapter 154, Family Code, or enforceable by a court in |
|
this state, a foster child, a stepchild, a child of a domestic |
|
partner if the domestic partner is eligible to be insured and is |
|
insured under the policy, and any other individual dependent on the |
|
adult. |
|
SECTION 4.03. Section 1201.062(a), Insurance Code, is |
|
amended to read as follows: |
|
(a) An individual or group accident and health insurance |
|
policy that is delivered, issued for delivery, or renewed in this |
|
state, including a policy issued by a corporation operating under |
|
Chapter 842, or a self-funded or self-insured welfare or benefit |
|
plan or program, to the extent that regulation of the plan or |
|
program is not preempted by federal law, that provides coverage for |
|
a child of an insured or group member, on payment of a premium, must |
|
provide coverage for: |
|
(1) each grandchild of the insured or group member if |
|
the grandchild is: |
|
(A) unmarried; |
|
(B) younger than 26 [25] years of age; and |
|
(C) a dependent of the insured or group member |
|
for federal income tax purposes at the time application for |
|
coverage of the grandchild is made; and |
|
(2) each child for whom the insured or group member |
|
must provide medical support under an order issued under Chapter |
|
154, Family Code, or enforceable by a court in this state. |
|
SECTION 4.04. Section 1201.065(a), Insurance Code, is |
|
amended to read as follows: |
|
(a) An individual or group accident and health insurance |
|
policy may contain criteria relating to a maximum age or enrollment |
|
in school to establish continued eligibility for coverage of a |
|
child 26 [25] years of age or older. |
|
SECTION 4.05. Section 1251.151(a), Insurance Code, is |
|
amended to read as follows: |
|
(a) A group policy or contract of insurance for hospital, |
|
surgical, or medical expenses incurred as a result of accident or |
|
sickness, including a group contract issued by a group hospital |
|
service corporation, that provides coverage under the policy or |
|
contract for a child of an insured must, on payment of a premium, |
|
provide coverage for any grandchild of the insured if the |
|
grandchild is: |
|
(1) unmarried; |
|
(2) younger than 26 [25] years of age; and |
|
(3) a dependent of the insured for federal income tax |
|
purposes at the time the application for coverage of the grandchild |
|
is made. |
|
SECTION 4.06. Section 1251.152(a), Insurance Code, is |
|
amended to read as follows: |
|
(a) For purposes of this section: |
|
(1) "Child," with respect to an individual, includes |
|
the individual's stepchild or foster child or a child of the |
|
individual's domestic partner if the domestic partner is eligible |
|
for coverage and is covered under the group policy or contract. |
|
(2) "Dependent" [, "dependent"] includes: |
|
(A) [(1)] a child of an employee or member who |
|
is: |
|
(i) [(A)] unmarried; and |
|
(ii) [(B)] younger than 26 [25] years of |
|
age; and |
|
(B) [(2)] a grandchild of an employee or member |
|
who is: |
|
(i) [(A)] unmarried; |
|
(ii) [(B)] younger than 26 [25] years of |
|
age; and |
|
(iii) [(C)] a dependent of the insured for |
|
federal income tax purposes at the time the application for |
|
coverage of the grandchild is made. |
|
SECTION 4.07. Section 1271.006(a), Insurance Code, is |
|
amended to read as follows: |
|
(a) If children are eligible for coverage under the terms of |
|
an evidence of coverage, any limiting age applicable to an |
|
unmarried child of an enrollee, including an unmarried grandchild |
|
of an enrollee, a stepchild of an enrollee, a child of an enrollee's |
|
domestic partner if the domestic partner is eligible to be enrolled |
|
and is enrolled, an adopted child of an enrollee, and a foster child |
|
of an enrollee, is 26 [25] years of age. The limiting age |
|
applicable to a child must be stated in the evidence of coverage. |
|
SECTION 4.08. Section 1501.002(2), Insurance Code, is |
|
amended to read as follows: |
|
(2) "Dependent" means: |
|
(A) a spouse; |
|
(B) a child younger than 26 [25] years of age, |
|
including a newborn child; |
|
(C) a child of any age who is: |
|
(i) medically certified as disabled; and |
|
(ii) dependent on the parent; |
|
(D) an individual who must be covered under: |
|
(i) Section 1251.154; or |
|
(ii) Section 1201.062; and |
|
(E) any other child eligible under an employer's |
|
health benefit plan, including a child described by Section |
|
1503.003, a stepchild, a child of an employee's domestic partner if |
|
the domestic partner is eligible to receive and does receive |
|
coverage under the plan, or a foster child. |
|
SECTION 4.09. Section 1501.609(b), Insurance Code, is |
|
amended to read as follows: |
|
(b) Any limiting age applicable under a large employer |
|
health benefit plan to an unmarried child of an enrollee is 26 [25] |
|
years of age. |
|
SECTION 4.10. Sections 1503.003(a) and (b), Insurance Code, |
|
are amended to read as follows: |
|
(a) A health benefit plan may not condition coverage for a |
|
child younger than 26 [25] years of age on the child's being |
|
enrolled at an educational institution. |
|
(b) A health benefit plan that requires as a condition of |
|
coverage for a child 26 [25] years of age or older that the child be |
|
a full-time student at an educational institution must provide the |
|
coverage: |
|
(1) for the entire academic term during which the |
|
child begins as a full-time student and remains enrolled, |
|
regardless of whether the number of hours of instruction for which |
|
the child is enrolled is reduced to a level that changes the child's |
|
academic status to less than that of a full-time student; and |
|
(2) continuously until the 10th day of instruction of |
|
the subsequent academic term, on which date the health benefit plan |
|
may terminate coverage for the child if the child does not return to |
|
full-time student status before that date. |
|
SECTION 4.11. Section 1506.003, Insurance Code, is amended |
|
to read as follows: |
|
Sec. 1506.003. DEFINITION OF DEPENDENT. In this chapter: |
|
(1) "Child," with respect to an individual, includes |
|
the individual's stepchild or foster child. |
|
(2) "Dependent" [, "dependent"] means: |
|
(A) [(1)] a resident spouse or unmarried child |
|
younger than 26 [25] years of age; or |
|
(B) [(2)] a child who is: |
|
(i) [(A)] a full-time student younger than |
|
26 [25] years of age who is financially dependent on the parent; |
|
(ii) [(B)] 18 years of age or older and is |
|
an individual for whom a person may be obligated to pay child |
|
support; or |
|
(iii) [(C)] disabled and dependent on the |
|
parent regardless of the age of the child. |
|
SECTION 4.12. Section 1506.158(a), Insurance Code, is |
|
amended to read as follows: |
|
(a) An individual's pool coverage ends: |
|
(1) on the date the individual ceases to be a legally |
|
domiciled resident of this state, unless the individual: |
|
(A) is a student younger than 26 [25] years of age |
|
and is financially dependent on a parent covered by the pool; |
|
(B) is a child for whom an individual covered by |
|
the pool may be obligated to pay child support; or |
|
(C) is a child who is disabled and dependent on a |
|
parent covered by the pool, regardless of the age of the child; |
|
(2) on the first day of the month following the date |
|
the individual requests coverage to end; |
|
(3) on the date the individual covered by the pool |
|
dies; |
|
(4) on the date state law requires cancellation of the |
|
coverage; |
|
(5) at the option of the pool, on the 31st day after |
|
the date the pool sends to the individual any inquiry concerning the |
|
individual's eligibility, including an inquiry concerning the |
|
individual's residence, to which the individual does not reply; |
|
(6) on the 31st day after the date a premium payment |
|
for pool coverage becomes due if the payment is not made before that |
|
day; |
|
(7) on the date the individual is 65 years of age and |
|
eligible for coverage under Medicare, unless the coverage received |
|
from the pool is Medicare supplement coverage issued by the pool; or |
|
(8) at the time the individual ceases to meet the |
|
eligibility requirements for coverage. |
|
SECTION 4.13. Section 1551.004(a), Insurance Code, is |
|
amended to read as follows: |
|
(a) In this chapter, "dependent" with respect to an |
|
individual eligible to participate in the group benefits program |
|
under Section 1551.101 or 1551.102 means the individual's: |
|
(1) spouse; |
|
(2) unmarried child younger than 26 [25] years of age; |
|
(3) child of any age who the board of trustees |
|
determines lives with or has the child's care provided by the |
|
individual on a regular basis if: |
|
(A) the child is mentally retarded or physically |
|
incapacitated to the extent that the child is dependent on the |
|
individual for care or support, as determined by the board of |
|
trustees; |
|
(B) the child's coverage under this chapter has |
|
not lapsed; and |
|
(C) the child is at least 26 [25] years old and |
|
was enrolled as a participant in the health benefits coverage under |
|
the group benefits program on the date of the child's 26th [25th] |
|
birthday; |
|
(4) child of any age who is unmarried, for purposes of |
|
health benefit coverage under this chapter, on expiration of the |
|
child's continuation coverage under the Consolidated Omnibus |
|
Budget Reconciliation Act of 1985 (Pub. L. No. 99-272) and its |
|
subsequent amendments; and |
|
(5) ward, as that term is defined by Section 601, Texas |
|
Probate Code. |
|
SECTION 4.14. Section 1551.158(a), Insurance Code, is |
|
amended to read as follows: |
|
(a) A dependent child who is unmarried and whose coverage |
|
under this chapter ends when the child becomes 26 [25] years of age |
|
may, on expiration of continuation coverage under the Consolidated |
|
Omnibus Budget Reconciliation Act of 1985 (Pub. L. No. 99-272), |
|
reinstate health benefit plan coverage under this chapter if the |
|
child, or the child's participating parent or guardian, pays the |
|
full cost of the health benefit plan coverage. |
|
SECTION 4.15. Section 1575.003(1), Insurance Code, is |
|
amended to read as follows: |
|
(1) "Dependent" means: |
|
(A) the spouse of a retiree; |
|
(B) an unmarried child of a retiree or deceased |
|
active member if the child is younger than 26 [25] years of age, |
|
including: |
|
(i) an adopted child; |
|
(ii) a foster child, stepchild, or other |
|
child who is in a regular parent-child relationship; or |
|
(iii) a recognized natural child; |
|
(C) a retiree's recognized natural child, |
|
adopted child, foster child, stepchild, or other child who is in a |
|
regular parent-child relationship and who lives with or has his or |
|
her care provided by the retiree or surviving spouse on a regular |
|
basis regardless of the child's age, if the child is mentally |
|
retarded or physically incapacitated to an extent that the child is |
|
dependent on the retiree or surviving spouse for care or support, as |
|
determined by the trustee; or |
|
(D) a deceased active member's recognized |
|
natural child, adopted child, foster child, stepchild, or other |
|
child who is in a regular parent-child relationship, without regard |
|
to the age of the child, if, while the active member was alive, the |
|
child: |
|
(i) lived with or had the child's care |
|
provided by the active member on a regular basis; and |
|
(ii) was mentally retarded or physically |
|
incapacitated to an extent that the child was dependent on the |
|
active member or surviving spouse for care or support, as |
|
determined by the trustee. |
|
SECTION 4.16. Section 1579.004, Insurance Code, is amended |
|
to read as follows: |
|
Sec. 1579.004. DEFINITION OF DEPENDENT. In this chapter, |
|
"dependent" means: |
|
(1) a spouse of a full-time employee or part-time |
|
employee; |
|
(2) an unmarried child of a full-time or part-time |
|
employee if the child is younger than 26 [25] years of age, |
|
including: |
|
(A) an adopted child; |
|
(B) a foster child, stepchild, or other child who |
|
is in a regular parent-child relationship; and |
|
(C) a recognized natural child; |
|
(3) a full-time or part-time employee's recognized |
|
natural child, adopted child, foster child, stepchild, or other |
|
child who is in a regular parent-child relationship and who lives |
|
with or has his or her care provided by the employee or the |
|
surviving spouse on a regular basis, regardless of the child's age, |
|
if the child is mentally retarded or physically incapacitated to an |
|
extent that the child is dependent on the employee or surviving |
|
spouse for care or support, as determined by the board of trustees; |
|
and |
|
(4) notwithstanding any other provision of this code, |
|
any other dependent of a full-time or part-time employee specified |
|
by rules adopted by the board of trustees. |
|
SECTION 4.17. Section 1601.004(a), Insurance Code, is |
|
amended to read as follows: |
|
(a) In this chapter, "dependent," with respect to an |
|
individual eligible to participate in the uniform program under |
|
Section 1601.101 or 1601.102, means the individual's: |
|
(1) spouse; |
|
(2) unmarried child younger than 26 [25] years of age; |
|
and |
|
(3) child of any age who lives with or has the child's |
|
care provided by the individual on a regular basis if the child is |
|
mentally retarded or physically incapacitated to the extent that |
|
the child is dependent on the individual for care or support, as |
|
determined by the system. |
|
SECTION 4.18. The changes in law made by this article apply |
|
only to a health benefit plan that is delivered, issued for |
|
delivery, or renewed on or after January 1, 2012. A health benefit |
|
plan that is delivered, issued for delivery, or renewed before |
|
January 1, 2012, is covered by the law in effect immediately before |
|
the effective date of this Act, and that law is continued in effect |
|
for that purpose. |
|
ARTICLE 5. RESCISSION OF HEALTH BENEFIT PLAN |
|
SECTION 5.01. Chapter 1202, Insurance Code, is amended by |
|
adding Subchapter C to read as follows: |
|
SUBCHAPTER C. RESCISSION OF HEALTH BENEFIT PLAN |
|
Sec. 1202.101. DEFINITION. In this subchapter, |
|
"rescission" means the termination of an insurance agreement, |
|
contract, evidence of coverage, insurance policy, or other similar |
|
coverage document in which the health benefit plan issuer, as |
|
applicable, refunds premium payments or demands the recoupment of |
|
any benefit already paid under the plan. |
|
Sec. 1202.102. APPLICABILITY. (a) This subchapter applies |
|
only to a health benefit plan, including a small or large employer |
|
health benefit plan written under Chapter 1501, that provides |
|
benefits for medical or surgical expenses incurred as a result of a |
|
health condition, accident, or sickness, including an individual, |
|
group, blanket, or franchise insurance policy or insurance |
|
agreement, a group hospital service contract, or an individual or |
|
group evidence of coverage or similar coverage document that is |
|
offered 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) a reciprocal exchange operating under Chapter 942; |
|
(6) a Lloyd's plan operating under Chapter 941; |
|
(7) a health maintenance organization operating under |
|
Chapter 843; |
|
(8) a multiple employer welfare arrangement that holds |
|
a certificate of authority under Chapter 846; or |
|
(9) an approved nonprofit health corporation that |
|
holds a certificate of authority under Chapter 844. |
|
(b) This subchapter does not apply to: |
|
(1) a health benefit plan that provides coverage: |
|
(A) only for a specified disease or for another |
|
limited benefit other than an accident policy; |
|
(B) only for accidental death or dismemberment; |
|
(C) for wages or payments in lieu of wages for a |
|
period during which an employee is absent from work because of |
|
sickness or injury; |
|
(D) as a supplement to a liability insurance |
|
policy; |
|
(E) for credit insurance; |
|
(F) only for dental or vision care; |
|
(G) only for hospital expenses; or |
|
(H) 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), |
|
as amended; |
|
(3) a workers' compensation insurance policy; |
|
(4) medical payment insurance coverage provided under |
|
a motor vehicle insurance policy; |
|
(5) a long-term care insurance policy, including a |
|
nursing home fixed indemnity policy, unless the commissioner |
|
determines that the policy provides benefit coverage so |
|
comprehensive that the policy is a health benefit plan described by |
|
Subsection (a); |
|
(6) a Medicaid managed care plan offered under Chapter |
|
533, Government Code; |
|
(7) any policy or contract of insurance with a state |
|
agency, department, or board providing health services to eligible |
|
individuals under Chapter 32, Human Resources Code; or |
|
(8) a child health plan offered under Chapter 62, |
|
Health and Safety Code, or a health benefits plan offered under |
|
Chapter 63, Health and Safety Code. |
|
Sec. 1202.103. RESCISSION PROHIBITED; EXCEPTION. (a) |
|
Notwithstanding any other law, except as provided by Subsection |
|
(b), a health benefit plan issuer may not rescind coverage under a |
|
health benefit plan with respect to an enrollee in the plan. |
|
(b) A health benefit plan issuer may rescind coverage under |
|
a health benefit plan with respect to an enrollee if the enrollee |
|
engages in conduct that constitutes fraud or makes an intentional |
|
misrepresentation of a material fact. |
|
Sec. 1202.104. NOTICE OF INTENT TO RESCIND. (a) A health |
|
benefit plan issuer may not rescind a health benefit plan on the |
|
basis of a material misrepresentation without first notifying the |
|
affected enrollee in writing of the issuer's intent to rescind the |
|
health benefit plan. |
|
(b) The notice required under Subsection (a) must include, |
|
as applicable: |
|
(1) the principal reasons for the decision to rescind |
|
the health benefit plan; |
|
(2) the date on which the rescission is effective and |
|
the prior date to which the rescission retroactively reaches; |
|
(3) an itemized list of any pending or paid claims the |
|
health benefit plan issuer intends to recoup following the |
|
rescission; |
|
(4) an explanation of how the enrollee may obtain any |
|
documentation used by the health benefit plan issuer to justify the |
|
rescission; |
|
(5) a statement that the enrollee is entitled to |
|
appeal a rescission decision to an independent review organization |
|
and that the health benefit plan issuer bears the burden of proof on |
|
appeal; |
|
(6) an explanation of any time limit with which the |
|
enrollee must comply to appeal the rescission decision to an |
|
independent review organization, and a description of the |
|
consequences of failure to appeal within that time limit; and |
|
(7) a statement that there is no cost to the individual |
|
to appeal the rescission decision to an independent review |
|
organization. |
|
Sec. 1202.105. INDEPENDENT REVIEW PROCESS; PAYMENT OF |
|
CLAIMS. (a) An enrollee may appeal a health benefit plan issuer's |
|
rescission decision to an independent review organization in the |
|
manner prescribed by the commissioner by rule. |
|
(b) A health benefit plan issuer shall comply with all |
|
requests for information made by the independent review |
|
organization and with the independent review organization's |
|
determination regarding the appropriateness of the issuer's |
|
decision to rescind. |
|
(c) A health benefit plan issuer shall pay all otherwise |
|
valid medical claims under an individual's plan until the later of: |
|
(1) the date on which an independent review |
|
organization determines that the decision to rescind is |
|
appropriate; or |
|
(2) the time to appeal to an independent review |
|
organization has expired without an affected individual initiating |
|
an appeal. |
|
(d) The commissioner shall adopt rules necessary to |
|
implement and enforce this section, including rules establishing |
|
certification standards for independent review organizations for |
|
purposes of this chapter. |
|
Sec. 1202.106. BURDEN OF PROOF. In an appeal to an |
|
independent review organization under Section 1202.105 or an |
|
enforcement action or cause of action based on a violation of this |
|
subchapter by a health benefit plan issuer, the health benefit plan |
|
issuer must prove that the issuer did not violate this subchapter. |
|
SECTION 5.02. The change in law made by this article applies |
|
only to a health benefit plan that is delivered, issued for |
|
delivery, or renewed on or after January 1, 2012. A health benefit |
|
plan that is delivered, issued for delivery, or renewed before |
|
January 1, 2012, is governed by the law as it existed immediately |
|
before the effective date of this Act, and that law is continued in |
|
effect for that purpose. |
|
ARTICLE 6. HEALTH BENEFIT PLAN COVERAGE FOR CERTAIN CHILDREN |
|
SECTION 6.01. Subtitle G, Title 8, Insurance Code, is |
|
amended by adding Chapter 1521 to read as follows: |
|
CHAPTER 1521. COVERAGE FOR CHILDREN; PREEXISTING CONDITIONS; |
|
ENROLLMENT IN PLANS |
|
Sec. 1521.001. DEFINITION. In this chapter, "preexisting |
|
condition" means a condition present before the effective date of |
|
an individual's coverage under a health benefit plan. |
|
Sec. 1521.002. APPLICABILITY OF CHAPTER. (a) This chapter |
|
applies only to a health benefit plan that provides benefits for |
|
medical or surgical expenses incurred as a result of a health |
|
condition, accident, or sickness, including an individual, group, |
|
blanket, or franchise insurance policy or insurance agreement, a |
|
group hospital service contract, or an individual or group evidence |
|
of coverage or similar coverage document that is offered 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) This chapter applies to group health coverage made |
|
available by a school district in accordance with Section 22.004, |
|
Education Code. |
|
(c) Notwithstanding Section 172.014, Local Government Code, |
|
or any other law, this chapter applies to health and accident |
|
coverage provided by a risk pool created under Chapter 172, Local |
|
Government Code. |
|
(d) Notwithstanding any provision in Chapter 1551, 1575, |
|
1579, or 1601 or any other law, this chapter applies to: |
|
(1) a basic coverage plan under Chapter 1551; |
|
(2) a basic plan under Chapter 1575; |
|
(3) a primary care coverage plan under Chapter 1579; |
|
and |
|
(4) basic coverage under Chapter 1601. |
|
(e) Notwithstanding Section 1501.251 or any other law, this |
|
chapter applies to coverage under a small or large employer health |
|
benefit plan subject to Chapter 1501. |
|
(f) Notwithstanding Section 1507.003 or 1507.053, this |
|
chapter applies to a standard health benefit plan provided under |
|
Chapter 1507. |
|
Sec. 1521.003. EXCEPTION. This chapter does not apply to: |
|
(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 dental or 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; |
|
(4) medical payment insurance coverage provided under |
|
a motor vehicle insurance policy; or |
|
(5) a long-term care policy, including a nursing home |
|
fixed indemnity policy, unless the commissioner determines that the |
|
policy provides benefit coverage so comprehensive that the policy |
|
is a health benefit plan as described by Section 1521.002. |
|
Sec. 1521.004. PREEXISTING CONDITION PROVISION PROHIBITED. |
|
A health benefit plan issuer may not, with respect to an individual |
|
younger than 19 years of age: |
|
(1) deny the individual's application for coverage due |
|
to a preexisting condition; |
|
(2) limit or deny coverage under the health benefit |
|
plan to the individual on the basis that the benefits requested are |
|
required to treat a preexisting condition; or |
|
(3) charge the individual a premium in an amount that |
|
is more than two times the premium charged by the health benefit |
|
plan issuer to an individual younger than 19 years of age who does |
|
not have a preexisting condition, if the individual enrolls in a |
|
health benefit plan described by Section 1521.006 during an |
|
enrollment period described by Section 1521.006. |
|
Sec. 1521.005. COVERAGE FOR CERTAIN DEPENDENTS REQUIRED. |
|
If a health benefit plan includes dependent coverage, the health |
|
benefit plan issuer shall approve the enrollment of an individual |
|
who is the minor child of an enrollee in the health benefit plan. |
|
Sec. 1521.006. CHILD-ONLY PLANS REQUIRED; PENALTY. (a) A |
|
health benefit plan issuer shall offer, market, and sell health |
|
benefit plans in this state that exclusively cover individuals |
|
younger than 19 years of age. |
|
(b) A health benefit plan issuer that does not comply with |
|
Subsection (a) may not issue new individual health benefit plans of |
|
any nature in this state. |
|
(c) The department by rule shall require a health benefit |
|
plan issuer to have, and shall adopt rules concerning, enrollment |
|
periods for applicants described by Subsection (a). A health |
|
benefit plan issuer must have at least two enrollment periods per |
|
year of at least 60 days each. |
|
(d) During a required enrollment period, a health benefit |
|
plan issuer must issue individual health benefit plan coverage on a |
|
guaranteed issue basis to an applicant younger than 19 years of age |
|
and may not issue a health benefit plan with a preexisting condition |
|
exclusion rider or endorsement described by Section 1521.004. |
|
(e) The department by rule shall adopt standard special |
|
enrollment procedures in which an applicant described by Subsection |
|
(a) may enroll in an individual health benefit plan under this |
|
section on a guaranteed issue basis during a period other than an |
|
enrollment period under Subsection (c) if the applicant or a |
|
parent, managing conservator, or legal guardian of the applicant |
|
experiences a qualifying event under the Health Insurance |
|
Portability and Accountability Act of 1996 (42 U.S.C. Section 1320d |
|
et seq.). |
|
Sec. 1521.007. CONFLICT WITH OTHER LAW. If this chapter |
|
conflicts with another law relating to coverage provided by a |
|
health benefit plan to an individual who is younger than 19 years of |
|
age, including a provision of Chapter 846, 1201, 1251, 1252, 1501, |
|
1504, 1507, 1508, 1575, 1579, 1625, 1651, or 1652, this chapter |
|
controls. |
|
SECTION 6.02. Each health benefit plan issuer required to |
|
issue individual health benefit plan coverage under Section |
|
1521.005, Insurance Code, as added by this article, shall offer an |
|
initial enrollment period satisfying the requirements of Section |
|
1521.006(d), Insurance Code, as added by this article, beginning |
|
not later than March 1, 2012. Notwithstanding Section 1521.005, |
|
Insurance Code, as added by this article, the initial enrollment |
|
period required by this section must be at least 90 days. |
|
SECTION 6.03. This article applies only to a health benefit |
|
plan that is delivered, issued for delivery, or renewed on or after |
|
January 1, 2012. A health benefit plan that is delivered, issued |
|
for delivery, or renewed before January 1, 2012, is governed by the |
|
law as it existed immediately before the effective date of this Act, |
|
and that law is continued in effect for that purpose. |
|
ARTICLE 7. HEALTH BENEFIT PLAN COVERAGE FOR CERTAIN PREVENTIVE |
|
CARE SERVICES |
|
SECTION 7.01. Subtitle G, Title 8, Insurance Code, is |
|
amended by adding Chapter 1522 to read as follows: |
|
CHAPTER 1522. PREVENTIVE CARE SERVICES |
|
Sec. 1522.001. APPLICABILITY OF CHAPTER. (a) This chapter |
|
applies only to a health benefit plan that provides benefits for |
|
medical or surgical expenses incurred as a result of a health |
|
condition, accident, or sickness, including an individual, group, |
|
blanket, or franchise insurance policy or insurance agreement, a |
|
group hospital service contract, or an individual or group evidence |
|
of coverage or similar coverage document that is offered 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) This chapter applies to group health coverage made |
|
available by a school district in accordance with Section 22.004, |
|
Education Code. |
|
(c) Notwithstanding Section 172.014, Local Government Code, |
|
or any other law, this chapter applies to health and accident |
|
coverage provided by a risk pool created under Chapter 172, Local |
|
Government Code. |
|
(d) Notwithstanding any provision in Chapter 1551, 1575, |
|
1579, or 1601 or any other law, this chapter applies to: |
|
(1) a basic coverage plan under Chapter 1551; |
|
(2) a basic plan under Chapter 1575; |
|
(3) a primary care coverage plan under Chapter 1579; |
|
and |
|
(4) basic coverage under Chapter 1601. |
|
(e) Notwithstanding Section 1501.251 or any other law, this |
|
chapter applies to coverage under a small or large employer health |
|
benefit plan subject to Chapter 1501. |
|
(f) Notwithstanding Section 1507.003 or 1507.053, this |
|
chapter applies to a standard health benefit plan provided under |
|
Chapter 1507. |
|
Sec. 1522.002. EXCEPTION. This chapter does not apply to: |
|
(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 dental or 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; |
|
(4) medical payment insurance coverage provided under |
|
a motor vehicle insurance policy; or |
|
(5) a long-term care policy, including a nursing home |
|
fixed indemnity policy, unless the commissioner determines that the |
|
policy provides benefit coverage so comprehensive that the policy |
|
is a health benefit plan as described by Section 1522.001. |
|
Sec. 1522.003. CERTAIN COST-SHARING PROVISIONS PROHIBITED. |
|
A health benefit plan issuer may not impose a deductible, |
|
copayment, coinsurance, or other cost-sharing provision applicable |
|
to benefits for: |
|
(1) a preventive item or service that has in effect a |
|
rating of "A" or "B" in the most recent recommendations of the |
|
United States Preventive Services Task Force; |
|
(2) an immunization recommended for routine use in the |
|
most recent immunization schedules published by the United States |
|
Centers for Disease Control and Prevention of the United States |
|
Public Health Service; or |
|
(3) preventive care and screenings supported by the |
|
most recent comprehensive guidelines adopted by the United States |
|
Health Resources and Services Administration. |
|
Sec. 1522.004. CONFLICT WITH OTHER LAW. If this chapter |
|
conflicts with another law relating to the imposition of a |
|
deductible, copayment, coinsurance, or other cost-sharing |
|
provision, this chapter controls. |
|
SECTION 7.02. This article applies only to a health benefit |
|
plan that is delivered or issued for delivery on or after January 1, |
|
2012. A health benefit plan that is delivered or issued for |
|
delivery before January 1, 2012, is governed by the law as it |
|
existed immediately before the effective date of this Act, and that |
|
law is continued in effect for that purpose. |
|
ARTICLE 8. CERTAIN LIFETIME AND ANNUAL LIMITATIONS ON HEALTH |
|
BENEFIT PLAN COVERAGE |
|
SECTION 8.01. Subtitle G, Title 8, Insurance Code, is |
|
amended by adding Chapter 1523 to read as follows: |
|
CHAPTER 1523. CERTAIN LIFETIME AND ANNUAL LIMITATIONS ON COVERAGE |
|
PROHIBITED |
|
Sec. 1523.001. APPLICABILITY OF CHAPTER. (a) This chapter |
|
applies only to a health benefit plan that provides benefits for |
|
medical or surgical expenses incurred as a result of a health |
|
condition, accident, or sickness, including an individual, group, |
|
blanket, or franchise insurance policy or insurance agreement, a |
|
group hospital service contract, or an individual or group evidence |
|
of coverage or similar coverage document that is offered 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) This chapter applies to group health coverage made |
|
available by a school district in accordance with Section 22.004, |
|
Education Code. |
|
(c) Notwithstanding Section 172.014, Local Government Code, |
|
or any other law, this chapter applies to health and accident |
|
coverage provided by a risk pool created under Chapter 172, Local |
|
Government Code. |
|
(d) Notwithstanding any provision in Chapter 1551, 1575, |
|
1579, or 1601 or any other law, this chapter applies to: |
|
(1) a basic coverage plan under Chapter 1551; |
|
(2) a basic plan under Chapter 1575; |
|
(3) a primary care coverage plan under Chapter 1579; |
|
and |
|
(4) basic coverage under Chapter 1601. |
|
(e) Notwithstanding Section 1501.251 or any other law, this |
|
chapter applies to coverage under a small or large employer health |
|
benefit plan subject to Chapter 1501. |
|
(f) Notwithstanding Section 1507.003 or 1507.053, this |
|
chapter applies to a standard health benefit plan provided under |
|
Chapter 1507. |
|
Sec. 1523.002. EXCEPTION. This chapter does not apply to: |
|
(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 dental or 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; |
|
(4) medical payment insurance coverage provided under |
|
a motor vehicle insurance policy; or |
|
(5) a long-term care policy, including a nursing home |
|
fixed indemnity policy, unless the commissioner determines that the |
|
policy provides benefit coverage so comprehensive that the policy |
|
is a health benefit plan as described by Section 1523.001. |
|
Sec. 1523.003. CERTAIN ANNUAL AND LIFETIME LIMITS |
|
PROHIBITED; REENROLLMENT REQUIRED. A health benefit plan issuer |
|
may not establish: |
|
(1) a lifetime or annual benefit amount for an |
|
enrollee in relation to essential health benefits listed in 42 |
|
U.S.C. Section 18022(b)(1) and other benefits identified by the |
|
United States secretary of health and human services as essential |
|
health benefits; or |
|
(2) an annual limit on the services for which the |
|
health benefit plan will provide coverage, including an annual |
|
limit on an enrollee's number of: |
|
(A) visits to a physician; |
|
(B) days of inpatient or outpatient treatment; or |
|
(C) prescription refills. |
|
Sec. 1523.004. REINSTATEMENT OF COVERAGE. (a) A health |
|
benefit plan issuer, with relation to a former enrollee whose |
|
participation in or benefits under a health benefit plan terminated |
|
by reason of the enrollee exceeding a lifetime maximum benefit, |
|
shall: |
|
(1) notify the former enrollee: |
|
(A) that the lifetime maximum benefit no longer |
|
applies to the former enrollee; and |
|
(B) that the former enrollee is eligible to |
|
reenroll in a health benefit plan issued by the health benefit plan |
|
issuer; and |
|
(2) on request of the former enrollee, enroll the |
|
former enrollee in a health benefit plan that is identical or |
|
substantially similar to the enrollee's former health benefit plan. |
|
(b) The notice required by Subsection (a) must be mailed to |
|
the former enrollee at the enrollee's last known address as shown in |
|
the records of the health benefit plan issuer. |
|
Sec. 1523.005. CONFLICT WITH OTHER LAW. If this chapter |
|
conflicts with another law relating to lifetime or annual benefit |
|
limits or annual limits for specified services under a health |
|
benefit plan, this chapter controls. |
|
SECTION 8.02. Each health benefit plan issuer required to |
|
offer to former enrollees reenrollment in a health benefit plan |
|
under Section 1523.004, Insurance Code, as added by this article, |
|
shall send to each former enrollee entitled to a notice under that |
|
section the notice required by that section not later than December |
|
1, 2011. |
|
SECTION 8.03. (a) Except as provided by Subsection (b) of |
|
this section, this article applies only to a health benefit plan |
|
that is delivered, issued for delivery, or renewed on or after |
|
January 1, 2012. A health benefit plan that is delivered, issued |
|
for delivery, or renewed before January 1, 2012, is governed by the |
|
law as it existed immediately before the effective date of this Act, |
|
and that law is continued in effect for that purpose. |
|
(b) The change in law made by Section 1523.004, Insurance |
|
Code, as added by this article, applies to a health benefit plan |
|
that is delivered, issued for delivery, or renewed before, on, or |
|
after January 1, 2012. |
|
ARTICLE 9. EFFECTIVE DATE |
|
SECTION 9.01. 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. |