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A BILL TO BE ENTITLED
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AN ACT
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relating to healthcare coverage in this state. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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ARTICLE 1. STATE MEDICAID PROGRAM |
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SECTION 1.01. Subtitle I, Title 4, Government Code, is |
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amended by adding Chapter 540 to read as follows: |
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SUBCHAPTER A. ACUTE CARE |
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Sec. 540.051. ELIGIBILITY FOR MEDICAID ACUTE CARE. (a) An |
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individual is eligible to receive acute care benefits under the |
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state Medicaid program if the individual: |
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(1) has a household income at or below 100 percent of |
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the federal poverty level; |
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(2) is under 19 years of age and: |
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(A) is receiving Supplemental Security Income |
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(SSI) under 42 U.S.C. Section 1381 et seq.; or |
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(B) is in foster care or resides in another |
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residential care setting under the conservatorship of the |
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Department of Family and Protective Services; or |
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(3) meets the eligibility requirements that were in |
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effect on September 1, 2013. |
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(b) The commission shall provide acute care benefits under |
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the state Medicaid program to each individual eligible under this |
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section through the most cost-effective means, as determined by the |
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commission. |
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(c) If an individual is not eligible for the state Medicaid |
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program under Subsection (a), the commission shall refer the |
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individual to the program established under Chapter 541 that helps |
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connect eligible residents with health benefit plan coverage |
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through private market solutions, a health benefit exchange, or any |
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other resource the commission determines appropriate. |
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Sec. 540.052. MEDICAID SLIDING SCALE SUBSIDIES. (a) An |
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individual who is eligible for the state Medicaid program under |
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Section 540.051 may receive a Medicaid sliding scale subsidy to |
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purchase a health benefit plan from an authorized health benefit |
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plan issuer. |
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(b) A sliding scale subsidy provided to an individual under |
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this section must: |
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(1) be based on: |
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(A) the average premium in the market; and |
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(B) a realistic assessment of the |
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individual's ability to pay a portion of the premium; and |
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(2) include an enhancement for individuals who choose |
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a high deductible health plan with a health savings account. |
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(c) The commission shall ensure that counselors are made |
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available to individuals receiving a subsidy to advise the |
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individuals on selecting a health benefit plan that meets the |
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individuals' needs. |
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(d) An individual receiving a subsidy under this section is |
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responsible for paying: |
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(1) any difference between the premium costs |
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associated with the purchase of a health benefit plan and the amount |
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of the individual's subsidy under this section; and |
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(2) any copayments associated with the health benefit |
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plan. |
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(e) If the amount of a subsidy received by an individual |
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under this section exceeds the premium costs associated with the |
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individual's purchase of a health benefit plan, the individual may |
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deposit the excess amount in a health savings account that may be |
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used only in the manner described by Section 540.054(b). |
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Sec. 540.053. ADDITIONAL COST-SHARING SUBSIDIES. In |
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addition to providing a subsidy to an individual under Section |
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540.052, the commission shall provide additional subsidies for |
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coinsurance payments, copayments, deductibles, and other |
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cost-sharing requirements associated with the individual's health |
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benefit plan. The commission shall provide the additional |
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subsidies on a sliding scale based on income. |
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Sec. 540.054. DELIVERY OF SUBSIDIES; HEALTH SAVINGS |
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ACCOUNTS. (a) The commission shall determine the most appropriate |
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manner for delivering and administering subsidies provided under |
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Sections 540.052 and 540.053. In determining the most appropriate |
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manner, the commission shall consider depositing subsidy amounts |
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for an individual in a health savings account established for that |
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individual. |
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(b) A health savings account established under this section |
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may be used only to: |
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(1) pay health benefit plan premiums and cost-sharing |
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amounts; and |
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(2) if appropriate, purchase health care-related |
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goods and services. |
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Sec. 540.055. MEDICAID HEALTH BENEFIT PLAN ISSUERS AND |
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MINIMUM COVERAGE. The commission shall allow any health benefit |
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plan issuer authorized to write health benefit plans in this state |
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to participate in the state Medicaid program. The commission in |
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consultation with the commissioner of insurance shall establish |
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minimum coverage requirements for a health benefit plan to be |
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eligible for purchase under the state Medicaid program, subject to |
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the requirements specified by this chapter. |
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Sec. 540.056. REINSURANCE FOR PARTICIPATING HEALTH BENEFIT |
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PLAN ISSUERS. (a) The commission in consultation with the |
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commissioner of insurance shall study a reinsurance program to |
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reinsure participating health benefit plan issuers. |
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(b) In examining options for a reinsurance program, the |
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commission and commissioner of insurance shall consider a plan |
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design under which: |
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(1) a participating health benefit plan is not charged |
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a premium for the reinsurance; and |
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(2) the health benefit plan issuer retains risk on a |
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sliding scale. |
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SUBCHAPTER B. LONG-TERM SERVICES AND SUPPORTS |
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Sec. 540.101. PLAN TO REFORM DELIVERY OF LONG-TERM SERVICES |
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AND SUPPORTS. The commission shall develop a comprehensive plan to |
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reform the delivery of long-term services and supports that is |
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designed to achieve the following objectives under the state |
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Medicaid program or any other program created as an alternative to |
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the state Medicaid program: |
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(1) encourage consumer direction; |
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(2) simplify and streamline the provision of services; |
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(3) provide flexibility to design benefits packages |
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that meet the needs of individuals receiving long-term services and |
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supports under the program; |
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(4) improve the cost-effectiveness and sustainability |
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of the provision of long-term services and supports; |
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(5) reduce reliance on institutional settings; and |
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(6) encourage cost sharing by family members when |
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appropriate. |
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ARTICLE 2. IMMEDIATE REFORM: PROGRAM TO ENSURE HEALTH BENEFIT |
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COVERAGE FOR CERTAIN INDIVIDUALS THROUGH PRIVATE MARKETPLACE |
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SECTION 2.01. Subtitle I, Title 4, Government Code, is |
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amended by adding Chapter 541 to read as follows: |
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CHAPTER 541. PROGRAM TO ENSURE HEALTH BENEFIT PLAN COVERAGE FOR |
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CERTAIN INDIVIDUALS THROUGH PRIVATE MARKET SOLUTIONS |
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SUBCHAPTER A. GENERAL PROVISIONS |
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Sec. 541.001. DEFINITION. In this chapter, "medical |
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assistance program" means the program established under Chapter 32, |
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Human Resources Code. |
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Sec. 541.002. CONFLICT WITH OTHER LAW. (a) Except as |
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provided by Subsection (b), to the extent of a conflict between a |
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provision of this chapter and: |
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(1) another provision of state law, the provision of |
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this chapter controls; and |
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(2) a provision of federal law or any authorization |
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described under Subchapter B, the federal law or authorization |
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controls. |
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(b) The program operated under this chapter is in addition |
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to any medical assistance program operated under a block grant |
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funding system under Chapter 540. |
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Sec. 541.003. PROGRAM FOR HEALTH BENEFIT PLAN COVERAGE |
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THROUGH PRIVATE MARKET SOLUTIONS. Subject to the requirements of |
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this chapter, the commission in consultation with the Texas |
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Department of Insurance shall develop and implement a program that |
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helps connect certain low-income residents of this state with |
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health benefit plan coverage through private market solutions. |
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Sec. 541.004. NOT AN ENTITLEMENT. This chapter does not |
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establish an entitlement to assistance in obtaining health benefit |
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plan coverage. |
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Sec. 541.005. RULES. The executive commissioner shall |
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adopt rules necessary to implement this chapter. |
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SUBCHAPTER B. FEDERAL AUTHORIZATION |
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Sec. 541.051. FEDERAL AUTHORIZATION FOR FLEXIBILITY TO |
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ESTABLISH PROGRAM. (a) The commission in consultation with the |
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Texas Department of Insurance shall negotiate with the United |
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States secretary of health and human services, the federal Centers |
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for Medicare and Medicaid Services, and other appropriate persons |
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for purposes of seeking a waiver or other authorization necessary |
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to obtain the flexibility to use federal matching funds to help |
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provide, in accordance with Subchapter C, health benefit plan |
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coverage to certain low-income individuals through private market |
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solutions. |
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(b) Any agreement reached under this section must: |
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(1) create a program that is made cost neutral to this |
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state by: |
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(A) leveraging premium tax revenues; and |
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(B) achieving cost savings through offsets to |
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general revenue health care costs or the implementation of other |
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cost savings mechanisms; |
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(2) create more efficient health benefit plan coverage |
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options for eligible individuals through: |
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(A) program changes that may be made without the |
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need for additional federal approval; and |
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(B) program changes that require additional |
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federal approval; |
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(3) require the commission to achieve efficiency and |
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reduce unnecessary utilization, including duplication, of health |
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care services; |
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(4) be designed with the goals of: |
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(A) relieving local tax burdens; |
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(B) reducing general revenue reliance so as to |
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make general revenue available for other state priorities; and |
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(C) minimizing the impact of any federal health |
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care laws on Texas-based businesses; and |
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(5) afford this state the opportunity to develop a |
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state-specific way with benefits that specifically meet the unique |
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needs of this state's population. |
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(c) An agreement reached under this section may be: |
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(1) limited in duration; and |
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(2) contingent on continued funding by the federal |
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government. |
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SUBCHAPTER C. PROGRAM REQUIREMENTS |
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Sec. 541.101. ENROLLMENT ELIGIBILITY. (a) Subject to |
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Subsection (b), an individual may be eligible to enroll in a program |
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designed and established under this chapter if the person: |
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(1) is younger than 65; |
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(2) has a household income at or below 133 percent of |
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the federal poverty level; and |
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(3) is not otherwise eligible to receive benefits |
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under the medical assistance program, including through a program |
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operated under Chapter 540 through a block grant funding system or a |
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waiver, other than one granted under this chapter, to the program. |
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(b) The executive commissioner may amend or further define |
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the eligibility requirements of this section if the commission |
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determines it necessary to reach an agreement under Subchapter B. |
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Sec. 541.102. MINIMUM PROGRAM REQUIREMENTS. A program |
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designed and established under this chapter must: |
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(1) if cost-effective for this state, provide premium |
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assistance to purchase health benefit plan coverage in the private |
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market, including health benefit plan coverage offered through a |
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managed care delivery model; |
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(2) provide enrollees with access to health benefits, |
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including benefits provided through a managed care delivery model, |
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that: |
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(A) are tailored to the enrollees; |
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(B) provide levels of coverage that are |
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customized to meet health care needs of individuals within defined |
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categories of the enrolled population; and |
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(C) emphasize personal responsibility and |
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accountability through flexible and meaningful cost-sharing |
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requirements and wellness initiatives, including through |
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incentives for compliance with health, wellness, and treatment |
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strategies and disincentives for noncompliance; |
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(3) include pay-for-performance initiatives for |
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private health benefit plan issuers that participate in the |
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program; |
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(4) use technology to maximize the efficiency with |
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which the commission and any health benefit plan issuer, health |
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care provider, or managed care organization participating in the |
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program manages enrollee participation; |
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(5) allow recipients under the medical assistance |
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program to enroll in the program to receive premium assistance as an |
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alternative to the medical assistance program; |
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(6) encourage eligible individuals to enroll in other |
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private or employer-sponsored health benefit plan coverage, if |
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available and appropriate; |
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(7) encourage the utilization of health care services |
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in the most appropriate low-cost settings; and |
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(8) establish health savings accounts for enrollees, |
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as appropriate. |
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SECTION 2.02. The Health and Human Services Commission in |
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consultation with the Texas Department of Insurance and the |
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Medicaid Reform Task Force shall actively develop a proposal for |
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the authorization from the appropriate federal entity as required |
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by Subchapter B, Chapter 541, Government Code, as added by this |
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article. As soon as possible after the effective date of this Act, |
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the Health and Human Services Commission shall request and actively |
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pursue obtaining the authorization from the appropriate federal |
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entity. |
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ARTICLE 3. FEDERAL AUTHORIZATION |
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SECTION 3.01. Subject to Section 2.02 of this Act, if before |
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implementing any provision of this Act a state agency determines |
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that a waiver or authorization from a federal agency is necessary |
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for implementation of that provision, the agency affected by the |
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provision shall request the waiver or authorization and may delay |
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implementing that provision until the waiver or authorization is |
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granted. |
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ARTICLE 4. HEALTH BENEFIT AFFORDABILITY AND ACCESSIBILITY |
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SECTION 4.01. Subtitle A, Title 8, Insurance Code, is |
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amended by adding Chapter 1218 to read as follows: |
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CHAPTER 1218. HEALTH BENEFIT AFFORDABILITY AND ACCESSIBILITY |
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SUBCHAPTER A. GENERAL PROVISIONS |
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Sec. 1218.001. APPLICABILITY OF CHAPTER. (a) This chapter |
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applies only to a health benefit plan that provides benefits for |
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medical or surgical expenses incurred as a result of a health |
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condition, accident, or sickness, including an individual, group, |
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blanket, or franchise insurance policy or insurance agreement, a |
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group hospital service contract, or an individual or group evidence |
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of coverage or similar coverage document 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 health maintenance organization operating under |
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Chapter 843; |
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(4) an approved nonprofit health corporation that |
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holds a certificate of authority under Chapter 844; |
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(5) a multiple employer welfare arrangement that holds |
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a certificate of authority under Chapter 846; |
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(6) a stipulated premium company operating under |
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Chapter 884; |
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(7) a fraternal benefit society operating under |
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Chapter 885; |
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(8) a Lloyd's plan operating under Chapter 941; or |
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(9) an exchange operating under Chapter 942. |
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(b) Notwithstanding any other law, this chapter applies to: |
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(1) a small employer health benefit plan subject to |
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Chapter 1501, including coverage provided through a health group |
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cooperative under Subchapter B of that chapter; |
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(2) a standard health benefit plan issued under |
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Chapter 1507; |
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(3) a basic coverage plan under Chapter 1551; |
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(4) a basic plan under Chapter 1575; |
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(5) a primary care coverage plan under Chapter 1579; |
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(6) a plan providing basic coverage under Chapter |
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1601; |
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(7) health benefits provided by or through a church |
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benefits board under Subchapter I, Chapter 22, Business |
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Organizations Code; |
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(8) group health coverage made available by a school |
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district in accordance with Section 22.004, Education Code; |
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(9) the state Medicaid program, including the Medicaid |
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managed care program operated under Chapter 533, Government Code; |
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(10) the child health plan program under Chapter 62, |
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Health and Safety Code; |
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(11) a regional or local health care program operated |
|
under Section 75.104, Health and Safety Code; |
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(12) a self-funded health benefit plan sponsored by a |
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professional employer organization under Chapter 91, Labor Code; |
|
(13) county employee group health benefits provided |
|
under Chapter 157, Local Government Code; and |
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(14) health and accident coverage provided by a risk |
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pool created under Chapter 172, Local Government Code. |
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(c) This chapter applies to coverage under a group health |
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benefit plan provided to a resident of this state regardless of |
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whether the group policy, agreement, or contract is delivered, |
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issued for delivery, or renewed in this state. |
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Sec. 1218.002. EXCEPTIONS. (a) This chapter does not apply |
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to: |
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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 dental or 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 |
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1395ss(g)(1)); |
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(3) a workers' compensation insurance policy; |
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(4) medical payment insurance coverage provided under |
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a motor vehicle insurance policy; or |
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(5) a long-term care policy, including a nursing home |
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fixed indemnity policy, unless the commissioner determines that the |
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policy provides benefit coverage so comprehensive that the policy |
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is a health benefit plan as described by Section 1218.001. |
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(b) This chapter does not apply to an individual health |
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benefit plan issued on or before March 23, 2010, that has not had |
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any significant changes since that date that reduce benefits or |
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increase costs to the individual. |
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Sec. 1218.003. CONFLICT WITH OTHER LAW. If this chapter |
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conflicts with another law relating to lifetime or annual benefit |
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limits or the imposition of a premium, deductible, copayment, |
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coinsurance, or other cost-sharing provision, this chapter |
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controls. |
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SUBCHAPTER B. CERTAIN COST-SHARING AND COVERAGE AMOUNT LIMITS |
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PROHIBITED |
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Sec. 1218.051. CERTAIN COST-SHARING PROVISIONS FOR |
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PREVENTIVE SERVICES PROHIBITED. A health benefit plan issuer may |
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not impose a deductible, copayment, coinsurance, or other |
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cost-sharing provision applicable to benefits for: |
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(1) a preventive item or service that has in effect a |
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rating of "A" or "B" in the most recent recommendations of the |
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United States Preventive Services Task Force; |
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(2) an immunization recommended for routine use in the |
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most recent immunization schedules published by the United States |
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Centers for Disease Control and Prevention of the United States |
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Public Health Service; or |
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(3) preventive care and screenings supported by the |
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most recent comprehensive guidelines adopted by the United States |
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Health Resources and Services Administration. |
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Sec. 1218.052. CERTAIN ANNUAL AND LIFETIME LIMITS |
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PROHIBITED. A health benefit plan issuer may not establish an |
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annual or lifetime benefit amount for an enrollee in relation to |
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essential health benefits listed in 42 U.S.C. Section 18022(b)(1), |
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as that section existed on January 1, 2019, and other benefits |
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identified by the United States secretary of health and human |
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services as essential health benefits as of that date. |
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Sec. 1218.053. LIMITATIONS ON COST-SHARING. A health |
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benefit plan issuer may not impose cost-sharing requirements that |
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exceed the limits established in 42 U.S.C. Section 18022(c)(1) in |
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relation to essential health benefits listed in 42 U.S.C. Section |
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18022(b)(1), as those sections existed on January 1, 2019, and |
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other benefits identified by the United States secretary of health |
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and human services as essential health benefits as of that date. |
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Sec. 1218.054. DISCRIMINATION BASED ON GENDER PROHIBITED. A |
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health benefit plan issuer may not charge an individual a higher |
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premium rate based on the individual's gender. |
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SUBCHAPTER C. COVERAGE OF PREEXISTING CONDITIONS |
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Sec. 1218.101. DEFINITION. In this subchapter, |
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"preexisting condition" means a condition present before the |
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effective date of an individual's coverage under a health benefit |
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plan. |
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Sec. 1218.102. PREEXISTING CONDITION RESTRICTIONS |
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PROHIBITED. Notwithstanding any other law, a health benefit plan |
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issuer may not: |
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(1) deny an individual's application for coverage or |
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refuse to enroll an individual in a health benefit plan due to a |
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preexisting condition; |
|
(2) limit or exclude coverage under the health benefit |
|
plan for the treatment of a preexisting condition otherwise covered |
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under the plan; or |
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(3) charge the individual more for coverage than the |
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health benefit plan issuer charges an individual who does not have a |
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preexisting condition. |
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SUBCHAPTER D. EXTERNAL REVIEW PROCEDURE |
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Sec. 1218.151. EXTERNAL REVIEW MODEL ACT RULES. (a) The |
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department shall adopt rules as necessary to conform Texas law with |
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the requirements of the NAIC Uniform Health Carrier External Review |
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Model Act (April 2010). |
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(b) To the extent that the rules adopted under this section |
|
conflict with Chapter 843 or Title 14, the rules control. |
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ARTICLE 5. HEALTH BENEFIT PLAN COVERAGE FOR MENTAL HEALTH |
|
CONDITIONS AND SUBSTANCE USE DISORDERS |
|
SECTION 5.01. Chapter 1355, Insurance Code, is amended by |
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adding Subchapter F to read as follows: |
|
SUBCHAPTER F. COVERAGE FOR MENTAL HEALTH CONDITIONS AND SUBSTANCE |
|
USE DISORDERS |
|
Sec. 1355.251. DEFINITIONS. In this subchapter: |
|
(1) "Financial requirement" includes a requirement |
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relating to a deductible, copayment, coinsurance, or other |
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out-of-pocket expense or an annual or lifetime limit. |
|
(2) "Mental health benefit" means a benefit relating |
|
to an item or service for a mental health condition, as defined |
|
under the terms of a health benefit plan and in accordance with |
|
applicable federal and state law. |
|
(3) "Nonquantitative treatment limitation" includes: |
|
(A) a medical management standard limiting or |
|
excluding benefits based on medical necessity or medical |
|
appropriateness or based on whether a treatment is experimental or |
|
investigational; |
|
(B) formulary design for prescription drugs; |
|
(C) network tier design; |
|
(D) a standard for provider participation in a |
|
network, including reimbursement rates; |
|
(E) a method used by a health benefit plan to |
|
determine usual, customary, and reasonable charges; |
|
(F) a step therapy protocol; |
|
(G) an exclusion based on failure to complete a |
|
course of treatment; and |
|
(H) a restriction based on geographic location, |
|
facility type, provider specialty, and other criteria that limit |
|
the scope or duration of a benefit. |
|
(4) "Substance use disorder benefit" means a benefit |
|
relating to an item or service for a substance use disorder, as |
|
defined under the terms of a health benefit plan and in accordance |
|
with applicable federal and state law. |
|
(5) "Treatment limitation" includes a limit on the |
|
frequency of treatment, number of visits, days of coverage, or |
|
other similar limit on the scope or duration of treatment. The term |
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includes a nonquantitative treatment limitation. |
|
Sec. 1355.252. APPLICABILITY OF SUBCHAPTER. (a) This |
|
subchapter 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 |
|
issued by: |
|
(1) an insurance company; |
|
(2) a group hospital service corporation operating |
|
under Chapter 842; |
|
(3) a health maintenance organization operating under |
|
Chapter 843; |
|
(4) an approved nonprofit health corporation that |
|
holds a certificate of authority under Chapter 844; |
|
(5) a multiple employer welfare arrangement that holds |
|
a certificate of authority under Chapter 846; |
|
(6) a stipulated premium company operating under |
|
Chapter 884; |
|
(7) a fraternal benefit society operating under |
|
Chapter 885; |
|
(8) a Lloyd's plan operating under Chapter 941; or |
|
(9) an exchange operating under Chapter 942. |
|
(b) Notwithstanding any other law, this subchapter applies |
|
to: |
|
(1) a small employer health benefit plan subject to |
|
Chapter 1501, including coverage provided through a health group |
|
cooperative under Subchapter B of that chapter; |
|
(2) a standard health benefit plan issued under |
|
Chapter 1507; |
|
(3) a basic coverage plan under Chapter 1551; |
|
(4) a basic plan under Chapter 1575; |
|
(5) a primary care coverage plan under Chapter 1579; |
|
(6) a plan providing basic coverage under Chapter |
|
1601; |
|
(7) health benefits provided by or through a church |
|
benefits board under Subchapter I, Chapter 22, Business |
|
Organizations Code; |
|
(8) group health coverage made available by a school |
|
district in accordance with Section 22.004, Education Code; |
|
(9) the state Medicaid program, including the Medicaid |
|
managed care program operated under Chapter 533, Government Code; |
|
(10) the child health plan program under Chapter 62, |
|
Health and Safety Code; |
|
(11) a regional or local health care program operated |
|
under Section 75.104, Health and Safety Code; |
|
(12) a self-funded health benefit plan sponsored by a |
|
professional employer organization under Chapter 91, Labor Code; |
|
(13) county employee group health benefits provided |
|
under Chapter 157, Local Government Code; and |
|
(14) health and accident coverage provided by a risk |
|
pool created under Chapter 172, Local Government Code. |
|
(c) This subchapter applies to coverage under a group health |
|
benefit plan provided to a resident of this state regardless of |
|
whether the group policy, agreement, or contract is delivered, |
|
issued for delivery, or renewed in this state. |
|
Sec. 1355.253. EXCEPTION. This subchapter does not apply |
|
to an individual health benefit plan issued on or before March 23, |
|
2010, that has not had any significant changes since that date that |
|
reduce benefits or increase costs to the individual. |
|
Sec. 1355.254. REQUIRED COVERAGE FOR MENTAL HEALTH |
|
CONDITIONS AND SUBSTANCE USE DISORDERS. (a) A health benefit plan |
|
must provide benefits for mental health conditions and substance |
|
use disorders under the same terms and conditions applicable to |
|
benefits for medical or surgical expenses. |
|
(b) Coverage under Subsection (a) may not impose treatment |
|
limitations or financial requirements on benefits for a mental |
|
health condition or substance use disorder that are generally more |
|
restrictive than treatment limitations or financial requirements |
|
imposed on coverage of benefits for medical or surgical expenses. |
|
Sec. 1355.255. DEFINITIONS UNDER PLAN. (a) A health |
|
benefit plan must define a condition to be a mental health condition |
|
or not a mental health condition in a manner consistent with |
|
generally recognized independent standards of medical practice. |
|
(b) A health benefit plan must define a condition to be a |
|
substance use disorder or not a substance use disorder in a manner |
|
consistent with generally recognized independent standards of |
|
medical practice. |
|
Sec. 1355.256. COORDINATION WITH OTHER LAW; INTENT OF |
|
LEGISLATURE. This subchapter supplements Subchapters A and B of |
|
this chapter and Chapter 1368 and the department rules adopted |
|
under those statutes. It is the intent of the legislature that |
|
Subchapter A or B of this chapter or Chapter 1368 or the department |
|
rules adopted under those statutes controls in any circumstance in |
|
which that other law requires: |
|
(1) a benefit that is not required by this subchapter; |
|
or |
|
(2) a more extensive benefit than is required by this |
|
subchapter. |
|
Sec. 1355.257. RULES. The commissioner shall adopt rules |
|
necessary to implement this subchapter. |
|
ARTICLE 6. COVERAGE OF ESSENTIAL HEALTH BENEFITS |
|
SECTION 6.01. Subtitle E, Title 8, Insurance Code, is |
|
amended by adding Chapter 1380 to read as follows: |
|
CHAPTER 1380. COVERAGE OF ESSENTIAL HEALTH BENEFITS |
|
Sec. 1380.001. 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 issued by: |
|
(1) an insurance company; |
|
(2) a group hospital service corporation operating |
|
under Chapter 842; |
|
(3) a health maintenance organization operating under |
|
Chapter 843; |
|
(4) an approved nonprofit health corporation that |
|
holds a certificate of authority under Chapter 844; |
|
(5) a multiple employer welfare arrangement that holds |
|
a certificate of authority under Chapter 846; |
|
(6) a stipulated premium company operating under |
|
Chapter 884; |
|
(7) a fraternal benefit society operating under |
|
Chapter 885; |
|
(8) a Lloyd's plan operating under Chapter 941; or |
|
(9) an exchange operating under Chapter 942. |
|
(b) Notwithstanding any other law, this chapter applies to: |
|
(1) a small employer health benefit plan subject to |
|
Chapter 1501, including coverage provided through a health group |
|
cooperative under Subchapter B of that chapter; |
|
(2) a standard health benefit plan issued under |
|
Chapter 1507; |
|
(3) a basic coverage plan under Chapter 1551; |
|
(4) a basic plan under Chapter 1575; |
|
(5) a primary care coverage plan under Chapter 1579; |
|
(6) a plan providing basic coverage under Chapter |
|
1601; |
|
(7) health benefits provided by or through a church |
|
benefits board under Subchapter I, Chapter 22, Business |
|
Organizations Code; |
|
(8) group health coverage made available by a school |
|
district in accordance with Section 22.004, Education Code; |
|
(9) the state Medicaid program, including the Medicaid |
|
managed care program operated under Chapter 533, Government Code; |
|
(10) the child health plan program under Chapter 62, |
|
Health and Safety Code; |
|
(11) a regional or local health care program operated |
|
under Section 75.104, Health and Safety Code; |
|
(12) a self-funded health benefit plan sponsored by a |
|
professional employer organization under Chapter 91, Labor Code; |
|
(13) county employee group health benefits provided |
|
under Chapter 157, Local Government Code; and |
|
(14) health and accident coverage provided by a risk |
|
pool created under Chapter 172, Local Government Code. |
|
(c) This chapter applies to coverage under a group health |
|
benefit plan provided to a resident of this state regardless of |
|
whether the group policy, agreement, or contract is delivered, |
|
issued for delivery, or renewed in this state. |
|
Sec. 1380.002. EXCEPTION. This chapter does not apply to an |
|
individual health benefit plan issued on or before March 23, 2010, |
|
that has not had any significant changes since that date that reduce |
|
benefits or increase costs to the individual. |
|
Sec. 1380.003. REQUIRED COVERAGE FOR ESSENTIAL HEALTH |
|
BENEFITS. A health benefit plan must provide coverage for the |
|
essential health benefits listed in 42 U.S.C. Section 18022(b)(1), |
|
as that section existed on January 1, 2019, and other benefits |
|
identified by the United States secretary of health and human |
|
services as essential health benefits as of that date. |
|
ARTICLE 7. HEALTH BENEFIT PLAN COVERAGE FOR CERTAIN YOUNG ADULTS |
|
SECTION 7.01. Subchapter A, Chapter 533, Government Code, |
|
is amended by adding Section 533.0054 to read as follows: |
|
Sec. 533.0054. ELIGIBILITY AGE FOR STAR HEALTH COVERAGE. A |
|
child enrolled in the STAR Health Medicaid managed care program is |
|
eligible to receive health care services under the program until |
|
the child is 26 years of age. |
|
SECTION 7.02. 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 7.03. 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 |
|
or dental support order, if the policy provides dental coverage, |
|
issued under Chapter 154, Family Code, or enforceable by a court in |
|
this state, and any other individual dependent on the adult. |
|
SECTION 7.04. 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 or dental support, if the policy |
|
provides dental coverage, under an order issued under Chapter 154, |
|
Family Code, or enforceable by a court in this state. |
|
SECTION 7.05. 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 7.06. 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 7.07. Section 1251.152(a), Insurance Code, is |
|
amended to read as follows: |
|
(a) For purposes of this section, "dependent" includes: |
|
(1) a child of an employee or member who is: |
|
(A) unmarried; and |
|
(B) younger than 26 [25] years of age; and |
|
(2) a grandchild of an employee or member who is: |
|
(A) unmarried; |
|
(B) younger than 26 [25] years of age; and |
|
(C) a dependent of the insured for federal income |
|
tax purposes at the time the application for coverage of the |
|
grandchild is made. |
|
SECTION 7.08. 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, is 26 [25] years of age. The limiting age |
|
applicable to a child must be stated in the evidence of coverage. |
|
SECTION 7.09. 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. |
|
SECTION 7.10. 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 7.11. 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 7.12. 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 has |
|
a mental disability or 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. |
|
ARTICLE 8. TRANSITION; EFFECTIVE DATE |
|
SECTION 8.01. The change in law made by this Act applies |
|
only to a health benefit plan that is delivered, issued for |
|
delivery, or renewed on or after January 1, 2020. A health benefit |
|
plan that is delivered, issued for delivery, or renewed before |
|
January 1, 2020, 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. |
|
SECTION 8.02. If before implementing any provision of this |
|
Act a state agency determines that a waiver or authorization from a |
|
federal agency is necessary for implementation of that provision, |
|
the agency affected by the provision shall request the waiver or |
|
authorization and may delay implementing that provision until the |
|
waiver or authorization is granted. |
|
SECTION 8.03. This Act takes effect September 1, 2019. |