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A BILL TO BE ENTITLED
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AN ACT
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relating to the deductible imposed by a health benefit plan issuer |
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for covered health care services or supplies. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Subtitle A, Title 8, Insurance Code, is amended |
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by adding Chapter 1219 to read as follows: |
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CHAPTER 1219. DEDUCTIBLE REQUIREMENTS |
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Sec. 1219.001. DEFINITIONS. In this chapter: |
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(1) "Covered health care service or supply" means a |
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health care service or supply, including a prescription drug, for |
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which the costs are payable, wholly or partly, under the terms of a |
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health benefit plan. |
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(2) "Enrollee" means an individual, including a |
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dependent, entitled to coverage under a health benefit plan. |
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(3) "Network provider" means any health care provider |
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of a health care service or supply with which a health benefit plan |
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issuer or administrator or a third party for the issuer or |
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administrator has a contract with the terms on which a relevant |
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health care service or supply is provided to an enrollee. |
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(4) "Out-of-network provider" means a health care |
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provider of any health care service or supply that does not have a |
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contract under an enrollee's health benefit plan. |
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Sec. 1219.002. 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 |
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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; |
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(13) county employee group health benefits provided |
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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. 1219.003. EXCEPTIONS. This chapter does not apply 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 1219.002. |
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Sec. 1219.004. CONFLICT WITH OTHER LAW. If this chapter |
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conflicts with another law relating to the imposition of a |
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deductible, this chapter controls. |
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Sec. 1219.005. SEPARATE DEDUCTIBLES PROHIBITED. A health |
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benefit plan issuer may not impose separate deductibles for covered |
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health care services and supplies provided by network providers and |
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out-of-network providers. |
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Sec. 1219.006. COVERED HEALTH CARE SERVICE OR SUPPLY FOR |
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PURPOSES OF DEDUCTIBLE. A health benefit plan issuer must include |
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as a covered health care service or supply for purposes of an |
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enrollee's deductible any amount the enrollee pays: |
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(1) for a health care service delivered as a |
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telemedicine medical service or telehealth service, as those terms |
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are defined by Section 111.001, Occupations Code; or |
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(2) under a direct primary care arrangement governed |
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by Subchapter F, Chapter 162, Occupations Code. |
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SECTION 2. The change in law made by this Act applies only |
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to a health benefit plan that is delivered, issued for delivery, or |
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renewed on or after January 1, 2022. A health benefit plan that is |
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delivered, issued for delivery, or renewed before January 1, 2022, |
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is governed by the law as it existed immediately before the |
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effective date of this Act, and that law is continued in effect for |
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that purpose. |
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SECTION 3. If before implementing any provision of this Act |
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a state agency determines that a waiver or authorization from a |
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federal agency is necessary for implementation of that provision, |
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the agency affected by the provision shall request the waiver or |
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authorization and may delay implementing that provision until the |
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waiver or authorization is granted. |
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SECTION 4. This Act takes effect September 1, 2021. |