By: Hughes, LaMantia S.B. No. 861
 
 
A BILL TO BE ENTITLED
 
AN ACT
  relating to coordination of vision and eye care benefits under
  certain health benefit plans and vision benefit plans.
         BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
         SECTION 1.  Chapter 1203, Insurance Code, is amended by
  adding Subchapter C to read as follows:
  SUBCHAPTER C.  VISION AND EYE CARE BENEFITS
         Sec. 1203.101.  DEFINITIONS. In this subchapter:
               (1)  "Eye care expenses" means expenses related to
  vision or medical eye care services, procedures, or products.
               (2)  "Health benefit plan" means a policy, agreement,
  contract, or evidence of coverage that provides comprehensive
  medical coverage.
               (3)  "Vision benefit plan" means a limited-scope
  policy, agreement, contract, or evidence of coverage that provides
  coverage for eye care expenses but does not provide comprehensive
  medical coverage.
         Sec. 1203.102.  APPLICABILITY OF SUBCHAPTER. This
  subchapter applies only to a health benefit plan or vision benefit
  plan that provides or arranges for benefits for vision or medical
  eye care services, procedures, or products, including an
  individual, group, blanket, or franchise insurance policy or
  insurance agreement, a group hospital service contract, an evidence
  of coverage, or a vision benefit plan offered 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)  a stipulated premium company operating under
  Chapter 884;
               (5)  a fraternal benefit society operating under
  Chapter 885;
               (6)  a Lloyd's plan operating under Chapter 941;
               (7)  an exchange operating under Chapter 942; or
               (8)  a person or entity that provides a vision benefit
  plan.
         Sec. 1203.103.  EXCEPTION.  This subchapter does not apply
  to a supplemental insurance policy that only pays benefits directly
  to the policyholder.
         Sec. 1203.104.  COORDINATION OF BENEFITS BETWEEN PRIMARY AND
  SECONDARY PLAN ISSUERS. (a) This section applies if:
               (1)  an enrollee is covered by at least two different
  health benefit plans or vision benefit plans; and
               (2)  each plan provides the enrollee coverage for the
  same vision or medical eye care services, procedures, or products.
         (b)  The issuer of the primary health benefit plan or vision
  benefit plan, as determined under a coordination of benefits
  provision applicable to the plan, is responsible for eye care
  expenses covered under the plan up to the full amount of any plan
  coverage limit applicable to the covered eye care expenses.
         (c)  Before the plan coverage limit described by Subsection
  (b) is reached, the issuer of a secondary health benefit plan or
  vision benefit plan, as determined under a coordination of benefits
  provision applicable to the plan, is responsible only for eye care
  expenses covered under the plan that are not covered under the
  health benefit plan or vision benefit plan issued by the primary
  plan issuer.
         (d)  After the plan coverage limit described by Subsection
  (b) has been reached, the secondary plan issuer, in addition to the
  responsibilities described by Subsection (c), is responsible for
  any eye care expenses covered by both plans that exceed the plan
  coverage limit described by Subsection (b) up to the coverage limit
  of the secondary plan.
         (e)  When an enrollee is covered by more than one health
  benefit plan or vision benefit plan that provides benefits for eye
  care expenses, the enrollee may use each plan on the same date of
  service up to the coverage limit of each plan.
         (f)  A vision benefit plan issuer shall coordinate benefits
  with a health benefit plan issuer if both provide benefits for eye
  care expenses.
         (g)  A vision benefit plan issuer may not require a claim
  denial before adjudicating a claim up to the coverage limit of the
  plan.
         (h)  Nothing in this section prevents a secondary plan issuer
  from requiring proof that a related claim has been submitted to a
  primary plan issuer for purposes of determining the remaining
  balance up to the secondary plan's coverage limits.
         (i)  If a secondary plan issuer requires proof that a related
  claim has been submitted to a primary plan issuer as described by
  Subsection (h), the mechanism of providing proof must be through an
  online submission.
         Sec. 1203.105.  CERTAIN COORDINATION OF BENEFITS PROVISIONS
  PROHIBITED.  (a)  A health benefit plan or vision benefit plan
  subject to this subchapter may not be delivered, issued for
  delivery, or renewed in this state if:
               (1)  a provision of the plan excludes or reduces the
  payment of benefits for eye care expenses to or on behalf of an
  enrollee;
               (2)  the reason for the exclusion or reduction is that
  eye care benefits are payable or have been paid to or on behalf of
  the enrollee under another plan; and
               (3)  the exclusion or reduction would apply before the
  full amount of the eye care expenses incurred by the enrollee and
  covered by both plans have been paid or reimbursed or the full
  amount of the applicable coverage limit of the plan containing the
  exclusion or reduction is reached.
         (b)  Nothing in this section requires a secondary plan issuer
  to pay an amount that, when added to a payment amount made by a
  primary plan issuer, would exceed the usual and customary billed
  charges of the health care provider.
         Sec. 1203.106.  CERTAIN COORDINATION OF BENEFITS PROVISIONS
  VOID. A provision of a health benefit plan or vision benefit plan
  that violates this subchapter is void.
         Sec. 1203.107.  RULES.  The commissioner may adopt rules
  necessary to implement this subchapter.
         SECTION 2.  The change in law made by this Act applies only
  to a health benefit plan or vision benefit plan that is delivered,
  issued for delivery, or renewed on or after January 1, 2024.  A plan
  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 3.  This Act takes effect September 1, 2023.