| |
| |
|
|
A BILL TO BE ENTITLED
|
|
|
AN ACT
|
|
|
relating to availability of and benefits provided under health |
|
|
benefit plan coverage. |
|
|
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
|
|
ARTICLE 1. HEALTH BENEFIT COVERAGE AVAILABILITY |
|
|
SECTION 1.01. Subtitle G, Title 8, Insurance Code, is |
|
|
amended by adding Chapter 1511 to read as follows: |
|
|
CHAPTER 1511. HEALTH BENEFIT COVERAGE AVAILABILITY |
|
|
SUBCHAPTER A. GENERAL PROVISIONS |
|
|
Sec. 1511.001. APPLICABILITY OF CHAPTER. (a) Except as |
|
|
otherwise provided by this chapter, 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; and |
|
|
(2) a standard health benefit plan issued under |
|
|
Chapter 1507. |
|
|
(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. 1511.002. EXCEPTIONS. (a) 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 a specified disease or for another |
|
|
limited benefit; or |
|
|
(F) only for accidental death or dismemberment; |
|
|
(2) a Medicare supplemental policy as defined by |
|
|
Section 1882(g)(1), Social Security Act (42 U.S.C. Section |
|
|
1395ss(g)(1)); |
|
|
(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 1511.001. |
|
|
(b) 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. 1511.003. CONFLICT WITH OTHER LAW. If there is a |
|
|
conflict between this chapter and other law, this chapter prevails. |
|
|
Sec. 1511.004. RULES. (a) Subject to Subsection (b), the |
|
|
commissioner may adopt rules as necessary to implement this |
|
|
chapter. |
|
|
(b) Rules adopted by the commissioner to implement this |
|
|
chapter must be consistent with the Patient Protection and |
|
|
Affordable Care Act (Pub. L. No. 111-148), as that Act existed on |
|
|
January 1, 2017. |
|
|
SUBCHAPTER B. GUARANTEED ISSUE AND RENEWABILITY |
|
|
Sec. 1511.051. GUARANTEED ISSUE. A health benefit plan |
|
|
issuer shall issue a group or individual health benefit plan chosen |
|
|
by a group plan sponsor or individual to each group plan sponsor or |
|
|
individual that elects to be covered under the plan and agrees to |
|
|
satisfy the requirements of the plan. |
|
|
Sec. 1511.052. RENEWABILITY AND CONTINUATION OF HEALTH |
|
|
BENEFIT PLANS. (a) Except as provided by Subsection (b), a health |
|
|
benefit plan issuer shall renew or continue a group or individual |
|
|
health benefit plan at the option of the group plan sponsor or |
|
|
individual, as applicable. |
|
|
(b) A health benefit plan issuer may decline to renew or |
|
|
continue a group or individual health benefit plan: |
|
|
(1) for failure to pay a premium or contribution in |
|
|
accordance with the terms of the plan; |
|
|
(2) for fraud or intentional misrepresentation; |
|
|
(3) because the issuer is ceasing to offer coverage in |
|
|
the relevant market in accordance with rules adopted by the |
|
|
commissioner; |
|
|
(4) with respect to an individual plan, because an |
|
|
individual no longer resides, lives, or works in an area in which |
|
|
the issuer is authorized to provide coverage, but only if all plans |
|
|
are not renewed or not continued under this subdivision uniformly |
|
|
without regard to any health status related factor of covered |
|
|
individuals; or |
|
|
(5) in accordance with federal law, including |
|
|
regulations. |
|
|
Sec. 1511.053. OPEN AND SPECIAL ENROLLMENT PERIODS. (a) A |
|
|
health benefit plan issuer issuing an individual health benefit |
|
|
plan may restrict enrollment in coverage to an annual open |
|
|
enrollment period and special enrollment periods. |
|
|
(b) An individual or an individual's dependent qualified to |
|
|
enroll in an individual health benefit plan may enroll anytime |
|
|
during the open enrollment period or during a special enrollment |
|
|
period designated by the commissioner. |
|
|
(c) A health benefit plan issuer issuing a group health |
|
|
benefit plan may not limit enrollment to an open or special |
|
|
enrollment period. |
|
|
(d) The commissioner shall adopt rules as necessary to |
|
|
administer this section, including rules designating enrollment |
|
|
periods. |
|
|
SUBCHAPTER C. PREEXISTING CONDITIONS AND HEALTH STATUS |
|
|
Sec. 1511.101. DEFINITIONS. In this subchapter: |
|
|
(1) "Dependent" has the meaning assigned by Section |
|
|
1501.002. |
|
|
(2) "Health status related factor" has the meaning |
|
|
assigned by Section 1501.002. |
|
|
(3) "Preexisting condition" means a condition present |
|
|
before the effective date of an individual's coverage under a |
|
|
health benefit plan. |
|
|
Sec. 1511.102. APPLICABILITY OF SUBCHAPTER. |
|
|
Notwithstanding any other law, in addition to a health benefit plan |
|
|
to which this chapter applies under Subchapter A, this subchapter |
|
|
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; |
|
|
(4) a plan providing basic coverage under Chapter |
|
|
1601; |
|
|
(5) health benefits provided by or through a church |
|
|
benefits board under Subchapter I, Chapter 22, Business |
|
|
Organizations Code; |
|
|
(6) group health coverage made available by a school |
|
|
district in accordance with Section 22.004, Education Code; |
|
|
(7) the state Medicaid program, including the Medicaid |
|
|
managed care program operated under Chapter 533, Government Code; |
|
|
(8) the child health plan program under Chapter 62, |
|
|
Health and Safety Code; |
|
|
(9) a regional or local health care program operated |
|
|
under Section 75.104, Health and Safety Code; |
|
|
(10) a self-funded health benefit plan sponsored by a |
|
|
professional employer organization under Chapter 91, Labor Code; |
|
|
(11) county employee group health benefits provided |
|
|
under Chapter 157, Local Government Code; and |
|
|
(12) health and accident coverage provided by a risk |
|
|
pool created under Chapter 172, Local Government Code. |
|
|
Sec. 1511.103. PREEXISTING CONDITION AND HEALTH STATUS |
|
|
RESTRICTIONS PROHIBITED. Notwithstanding any other law, a health |
|
|
benefit plan issuer may not: |
|
|
(1) deny coverage to or refuse to enroll a group, an |
|
|
individual, or an individual's dependent in a health benefit plan |
|
|
on the basis of a preexisting condition or health status related |
|
|
factor; |
|
|
(2) limit or exclude, or require a waiting period for, |
|
|
coverage under the health benefit plan for treatment of a |
|
|
preexisting condition otherwise covered under the plan; or |
|
|
(3) charge a group, individual, or dependent more for |
|
|
coverage than the health benefit plan issuer charges a group, |
|
|
individual, or dependent who does not have a preexisting condition |
|
|
or health status related factor. |
|
|
SUBCHAPTER D. PROHIBITED DISCRIMINATION |
|
|
Sec. 1511.151. DISCRIMINATORY BENEFIT DESIGN PROHIBITED. |
|
|
(a) A health benefit plan issuer may not, through the plan's |
|
|
benefit design, discriminate against an enrollee on the basis of |
|
|
race, color, national origin, age, sex, expected length of life, |
|
|
present or predicted disability, degree of medical dependency, |
|
|
quality of life, or other health condition. |
|
|
(b) A health benefit plan issuer may not use a health |
|
|
benefit design that will have the effect of discouraging the |
|
|
enrollment of individuals with significant health needs in the |
|
|
health benefit plan. |
|
|
(c) This section may not be construed to prevent a health |
|
|
benefit plan issuer from appropriately utilizing reasonable |
|
|
medical management techniques. |
|
|
Sec. 1511.152. DISCRIMINATORY MARKETING PROHIBITED. A |
|
|
health benefit plan issuer may not use a marketing practice that |
|
|
will have the effect of discouraging the enrollment of individuals |
|
|
with significant health needs in the health benefit plan or that |
|
|
discriminates on the basis of race, color, national origin, age, |
|
|
sex, expected length of life, present or predicted disability, |
|
|
degree of medical dependency, quality of life, or other health |
|
|
condition. |
|
|
ARTICLE 2. COVERAGE OF ESSENTIAL HEALTH BENEFITS |
|
|
SECTION 2.01. 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) In this section: |
|
|
(1) "Individual health benefit plan" means: |
|
|
(A) an individual accident and health insurance |
|
|
policy to which Chapter 1201 applies; or |
|
|
(B) individual health maintenance organization |
|
|
coverage. |
|
|
(2) "Small employer health benefit plan" has the |
|
|
meaning assigned by Section 1501.002. |
|
|
(b) An individual or small employer 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, |
|
|
2017, and other benefits identified by the United States secretary |
|
|
of health and human services as essential health benefits as of that |
|
|
date. |
|
|
Sec. 1380.004. CERTAIN ANNUAL AND LIFETIME LIMITS |
|
|
PROHIBITED. A health benefit plan issuer may not establish an |
|
|
annual or lifetime benefit amount for an enrollee in relation to |
|
|
essential health benefits listed in 42 U.S.C. Section 18022(b)(1), |
|
|
as that section existed on January 1, 2017, and other benefits |
|
|
identified by the United States secretary of health and human |
|
|
services as essential health benefits as of that date. |
|
|
Sec. 1380.005. LIMITATIONS ON COST-SHARING. A health |
|
|
benefit plan issuer may not impose cost-sharing requirements that |
|
|
exceed the limits established in 42 U.S.C. Section 18022(c)(1) in |
|
|
relation to essential health benefits listed in 42 U.S.C. Section |
|
|
18022(b)(1), as those sections existed on January 1, 2017, and |
|
|
other benefits identified by the United States secretary of health |
|
|
and human services as essential health benefits as of that date. |
|
|
Sec. 1380.006. RULES. (a) Subject to Subsection (b), the |
|
|
commissioner may adopt rules as necessary to implement this |
|
|
chapter. |
|
|
(b) Rules adopted by the commissioner to implement this |
|
|
chapter must be consistent with the Patient Protection and |
|
|
Affordable Care Act (Pub. L. No. 111-148), as that Act existed on |
|
|
January 1, 2017. |
|
|
ARTICLE 3. CONFORMING AMENDMENTS; REPEALER |
|
|
SECTION 3.01. Section 841.002, Insurance Code, is amended |
|
|
to read as follows: |
|
|
Sec. 841.002. APPLICABILITY OF CHAPTER AND OTHER |
|
|
LAW. Except as otherwise expressly provided by this code, each |
|
|
insurance company incorporated or engaging in business in this |
|
|
state as a life insurance company, an accident insurance company, a |
|
|
life and accident insurance company, a health and accident |
|
|
insurance company, or a life, health, and accident insurance |
|
|
company is subject to: |
|
|
(1) this chapter; |
|
|
(2) Chapter 3; |
|
|
(3) Chapters 425 and 493; |
|
|
(4) Title 7; |
|
|
(5) Sections [1202.051,] 1204.151, 1204.153, and |
|
|
1204.154; |
|
|
(6) Subchapter A, Chapter 1202, Subchapters A and F, |
|
|
Chapter 1204, Subchapter A, Chapter 1273, Subchapters A, B, and D, |
|
|
Chapter 1355, and Subchapter A, Chapter 1366; |
|
|
(7) Subchapter A, Chapter 1507; |
|
|
(8) Chapters 1203, 1210, 1251-1254, 1301, 1351, 1354, |
|
|
1359, 1364, 1368, 1505, 1651, 1652, and 1701; and |
|
|
(9) Chapter 177, Local Government Code. |
|
|
SECTION 3.02. Section 1201.005, Insurance Code, is amended |
|
|
to read as follows: |
|
|
Sec. 1201.005. REFERENCES TO CHAPTER. In this chapter, a |
|
|
reference to this chapter includes a reference to: |
|
|
(1) [Section 1202.052; |
|
|
[(2)] Section 1271.005(a), to the extent that the |
|
|
subsection relates to the applicability of Section 1201.105, and |
|
|
Sections 1271.005(d) and (e); |
|
|
(2) [(3)] Chapter 1351; |
|
|
(3) [(4)] Subchapters C and E, Chapter 1355; |
|
|
(4) [(5)] Chapter 1356; |
|
|
(5) [(6)] Chapter 1365; |
|
|
(6) [(7)] Subchapter A, Chapter 1367; |
|
|
(7) Subchapter B, Chapter 1511; and |
|
|
(8) Subchapters A, B, and G, Chapter 1451. |
|
|
SECTION 3.03. Section 1507.003(b), Insurance Code, is |
|
|
amended to read as follows: |
|
|
(b) For purposes of this subchapter, "state-mandated health |
|
|
benefits" does not include benefits that are mandated by federal |
|
|
law or standard provisions or rights required under this code or |
|
|
other laws of this state to be provided in an individual, blanket, |
|
|
or group policy for accident and health insurance that are |
|
|
unrelated to a specific health illness, injury, or condition of an |
|
|
insured, including provisions related to: |
|
|
(1) continuation of coverage under: |
|
|
(A) Subchapters F and G, Chapter 1251; |
|
|
(B) Section 1201.059; and |
|
|
(C) Subchapter B, Chapter 1253; |
|
|
(2) termination of coverage under Sections [1202.051 |
|
|
and] 1501.108 and 1511.052; |
|
|
(3) preexisting conditions under Subchapter D, |
|
|
Chapter 1201, and Sections 1501.102-1501.105; |
|
|
(4) coverage of children, including newborn or adopted |
|
|
children, under: |
|
|
(A) Subchapter D, Chapter 1251; |
|
|
(B) Sections 1201.053, 1201.061, |
|
|
1201.063-1201.065, and Subchapter A, Chapter 1367; |
|
|
(C) Chapter 1504; |
|
|
(D) Chapter 1503; |
|
|
(E) Section 1501.157; |
|
|
(F) Section 1501.158; and |
|
|
(G) Sections 1501.607-1501.609; |
|
|
(5) services of practitioners under: |
|
|
(A) Subchapters A, B, and C, Chapter 1451; or |
|
|
(B) Section 1301.052; |
|
|
(6) supplies and services associated with the |
|
|
treatment of diabetes under Subchapter B, Chapter 1358; |
|
|
(7) coverage for serious mental illness under |
|
|
Subchapter A, Chapter 1355; |
|
|
(8) coverage for childhood immunizations and hearing |
|
|
screening as required by Subchapters B and C, Chapter 1367, other |
|
|
than Section 1367.053(c) and Chapter 1353; |
|
|
(9) coverage for reconstructive surgery for certain |
|
|
craniofacial abnormalities of children as required by Subchapter D, |
|
|
Chapter 1367; |
|
|
(10) coverage for the dietary treatment of |
|
|
phenylketonuria as required by Chapter 1359; |
|
|
(11) coverage for referral to a non-network physician |
|
|
or provider when medically necessary covered services are not |
|
|
available through network physicians or providers, as required by |
|
|
Section 1271.055; and |
|
|
(12) coverage for cancer screenings under: |
|
|
(A) Chapter 1356; |
|
|
(B) Chapter 1362; |
|
|
(C) Chapter 1363; and |
|
|
(D) Chapter 1370. |
|
|
SECTION 3.04. Section 1507.053(b), Insurance Code, is |
|
|
amended to read as follows: |
|
|
(b) For purposes of this subchapter, "state-mandated health |
|
|
benefits" does not include coverage that is mandated by federal law |
|
|
or standard provisions or rights required under this code or other |
|
|
laws of this state to be provided in an evidence of coverage that |
|
|
are unrelated to a specific health illness, injury, or condition of |
|
|
an enrollee, including provisions related to: |
|
|
(1) continuation of coverage under Subchapter G, |
|
|
Chapter 1251; |
|
|
(2) termination of coverage under Sections [1202.051 |
|
|
and] 1501.108 and 1511.052; |
|
|
(3) preexisting conditions under Subchapter D, |
|
|
Chapter 1201, and Sections 1501.102-1501.105; |
|
|
(4) coverage of children, including newborn or adopted |
|
|
children, under: |
|
|
(A) Chapter 1504; |
|
|
(B) Chapter 1503; |
|
|
(C) Section 1501.157; |
|
|
(D) Section 1501.158; and |
|
|
(E) Sections 1501.607-1501.609; |
|
|
(5) services of providers under Section 843.304; |
|
|
(6) coverage for serious mental health illness under |
|
|
Subchapter A, Chapter 1355; and |
|
|
(7) coverage for cancer screenings under: |
|
|
(A) Chapter 1356; |
|
|
(B) Chapter 1362; |
|
|
(C) Chapter 1363; and |
|
|
(D) Chapter 1370. |
|
|
SECTION 3.05. Section 1501.602(a), Insurance Code, is |
|
|
amended to read as follows: |
|
|
(a) A large employer health benefit plan issuer[: |
|
|
[(1) may refuse to provide coverage to a large |
|
|
employer in accordance with the issuer's underwriting standards and |
|
|
criteria; |
|
|
[(2) shall accept or reject the entire group of |
|
|
individuals who meet the participation criteria and choose |
|
|
coverage; and |
|
|
[(3)] may exclude only those employees or dependents |
|
|
who decline coverage. |
|
|
SECTION 3.06. Subchapter B, Chapter 1202, Insurance Code, |
|
|
is repealed. |
|
|
ARTICLE 4. IMPLEMENTATION; TRANSITION; EFFECTIVE DATE |
|
|
SECTION 4.01. 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 4.02. 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, 2024. A health benefit |
|
|
plan that is delivered, issued for delivery, or renewed before |
|
|
January 1, 2024, 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 4.03. This Act takes effect September 1, 2023. |