Bill Text: TX HB565 | 2019-2020 | 86th Legislature | Introduced
Bill Title: Relating to healthcare coverage in this state.
Spectrum: Partisan Bill (Democrat 2-0)
Status: (Introduced - Dead) 2019-03-05 - Left pending in committee [HB565 Detail]
Download: Texas-2019-HB565-Introduced.html
By: Coleman | H.B. No. 565 |
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relating to healthcare coverage in this state. | ||
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: | ||
ARTICLE 1. STATE MEDICAID PROGRAM | ||
SECTION 1.01. Subtitle I, Title 4, Government Code, is | ||
amended by adding Chapter 540 to read as follows: | ||
SUBCHAPTER A. ACUTE CARE | ||
Sec. 540.051. ELIGIBILITY FOR MEDICAID ACUTE CARE. (a) An | ||
individual is eligible to receive acute care benefits under the | ||
state Medicaid program if the individual: | ||
(1) has a household income at or below 100 percent of | ||
the federal poverty level; | ||
(2) is under 19 years of age and: | ||
(A) is receiving Supplemental Security Income | ||
(SSI) under 42 U.S.C. Section 1381 et seq.; or | ||
(B) is in foster care or resides in another | ||
residential care setting under the conservatorship of the | ||
Department of Family and Protective Services; or | ||
(3) meets the eligibility requirements that were in | ||
effect on September 1, 2013. | ||
(b) The commission shall provide acute care benefits under | ||
the state Medicaid program to each individual eligible under this | ||
section through the most cost-effective means, as determined by the | ||
commission. | ||
(c) If an individual is not eligible for the state Medicaid | ||
program under Subsection (a), the commission shall refer the | ||
individual to the program established under Chapter 541 that helps | ||
connect eligible residents with health benefit plan coverage | ||
through private market solutions, a health benefit exchange, or any | ||
other resource the commission determines appropriate. | ||
Sec. 540.052. MEDICAID SLIDING SCALE SUBSIDIES. (a) An | ||
individual who is eligible for the state Medicaid program under | ||
Section 540.051 may receive a Medicaid sliding scale subsidy to | ||
purchase a health benefit plan from an authorized health benefit | ||
plan issuer. | ||
(b) A sliding scale subsidy provided to an individual under | ||
this section must: | ||
(1) be based on: | ||
(A) the average premium in the market; and | ||
(B) a realistic assessment of the | ||
individual's ability to pay a portion of the premium; and | ||
(2) include an enhancement for individuals who choose | ||
a high deductible health plan with a health savings account. | ||
(c) The commission shall ensure that counselors are made | ||
available to individuals receiving a subsidy to advise the | ||
individuals on selecting a health benefit plan that meets the | ||
individuals' needs. | ||
(d) An individual receiving a subsidy under this section is | ||
responsible for paying: | ||
(1) any difference between the premium costs | ||
associated with the purchase of a health benefit plan and the amount | ||
of the individual's subsidy under this section; and | ||
(2) any copayments associated with the health benefit | ||
plan. | ||
(e) If the amount of a subsidy received by an individual | ||
under this section exceeds the premium costs associated with the | ||
individual's purchase of a health benefit plan, the individual may | ||
deposit the excess amount in a health savings account that may be | ||
used only in the manner described by Section 540.054(b). | ||
Sec. 540.053. ADDITIONAL COST-SHARING SUBSIDIES. In | ||
addition to providing a subsidy to an individual under Section | ||
540.052, the commission shall provide additional subsidies for | ||
coinsurance payments, copayments, deductibles, and other | ||
cost-sharing requirements associated with the individual's health | ||
benefit plan. The commission shall provide the additional | ||
subsidies on a sliding scale based on income. | ||
Sec. 540.054. DELIVERY OF SUBSIDIES; HEALTH SAVINGS | ||
ACCOUNTS. (a) The commission shall determine the most appropriate | ||
manner for delivering and administering subsidies provided under | ||
Sections 540.052 and 540.053. In determining the most appropriate | ||
manner, the commission shall consider depositing subsidy amounts | ||
for an individual in a health savings account established for that | ||
individual. | ||
(b) A health savings account established under this section | ||
may be used only to: | ||
(1) pay health benefit plan premiums and cost-sharing | ||
amounts; and | ||
(2) if appropriate, purchase health care-related | ||
goods and services. | ||
Sec. 540.055. MEDICAID HEALTH BENEFIT PLAN ISSUERS AND | ||
MINIMUM COVERAGE. The commission shall allow any health benefit | ||
plan issuer authorized to write health benefit plans in this state | ||
to participate in the state Medicaid program. The commission in | ||
consultation with the commissioner of insurance shall establish | ||
minimum coverage requirements for a health benefit plan to be | ||
eligible for purchase under the state Medicaid program, subject to | ||
the requirements specified by this chapter. | ||
Sec. 540.056. REINSURANCE FOR PARTICIPATING HEALTH BENEFIT | ||
PLAN ISSUERS. (a) The commission in consultation with the | ||
commissioner of insurance shall study a reinsurance program to | ||
reinsure participating health benefit plan issuers. | ||
(b) In examining options for a reinsurance program, the | ||
commission and commissioner of insurance shall consider a plan | ||
design under which: | ||
(1) a participating health benefit plan is not charged | ||
a premium for the reinsurance; and | ||
(2) the health benefit plan issuer retains risk on a | ||
sliding scale. | ||
SUBCHAPTER B. LONG-TERM SERVICES AND SUPPORTS | ||
Sec. 540.101. PLAN TO REFORM DELIVERY OF LONG-TERM SERVICES | ||
AND SUPPORTS. The commission shall develop a comprehensive plan to | ||
reform the delivery of long-term services and supports that is | ||
designed to achieve the following objectives under the state | ||
Medicaid program or any other program created as an alternative to | ||
the state Medicaid program: | ||
(1) encourage consumer direction; | ||
(2) simplify and streamline the provision of services; | ||
(3) provide flexibility to design benefits packages | ||
that meet the needs of individuals receiving long-term services and | ||
supports under the program; | ||
(4) improve the cost-effectiveness and sustainability | ||
of the provision of long-term services and supports; | ||
(5) reduce reliance on institutional settings; and | ||
(6) encourage cost sharing by family members when | ||
appropriate. | ||
ARTICLE 2. IMMEDIATE REFORM: PROGRAM TO ENSURE HEALTH BENEFIT | ||
COVERAGE FOR CERTAIN INDIVIDUALS THROUGH PRIVATE MARKETPLACE | ||
SECTION 2.01. Subtitle I, Title 4, Government Code, is | ||
amended by adding Chapter 541 to read as follows: | ||
CHAPTER 541. PROGRAM TO ENSURE HEALTH BENEFIT PLAN COVERAGE FOR | ||
CERTAIN INDIVIDUALS THROUGH PRIVATE MARKET SOLUTIONS | ||
SUBCHAPTER A. GENERAL PROVISIONS | ||
Sec. 541.001. DEFINITION. In this chapter, "medical | ||
assistance program" means the program established under Chapter 32, | ||
Human Resources Code. | ||
Sec. 541.002. CONFLICT WITH OTHER LAW. (a) Except as | ||
provided by Subsection (b), to the extent of a conflict between a | ||
provision of this chapter and: | ||
(1) another provision of state law, the provision of | ||
this chapter controls; and | ||
(2) a provision of federal law or any authorization | ||
described under Subchapter B, the federal law or authorization | ||
controls. | ||
(b) The program operated under this chapter is in addition | ||
to any medical assistance program operated under a block grant | ||
funding system under Chapter 540. | ||
Sec. 541.003. PROGRAM FOR HEALTH BENEFIT PLAN COVERAGE | ||
THROUGH PRIVATE MARKET SOLUTIONS. Subject to the requirements of | ||
this chapter, the commission in consultation with the Texas | ||
Department of Insurance shall develop and implement a program that | ||
helps connect certain low-income residents of this state with | ||
health benefit plan coverage through private market solutions. | ||
Sec. 541.004. NOT AN ENTITLEMENT. This chapter does not | ||
establish an entitlement to assistance in obtaining health benefit | ||
plan coverage. | ||
Sec. 541.005. RULES. The executive commissioner shall | ||
adopt rules necessary to implement this chapter. | ||
SUBCHAPTER B. FEDERAL AUTHORIZATION | ||
Sec. 541.051. FEDERAL AUTHORIZATION FOR FLEXIBILITY TO | ||
ESTABLISH PROGRAM. (a) The commission in consultation with the | ||
Texas Department of Insurance shall negotiate with the United | ||
States secretary of health and human services, the federal Centers | ||
for Medicare and Medicaid Services, and other appropriate persons | ||
for purposes of seeking a waiver or other authorization necessary | ||
to obtain the flexibility to use federal matching funds to help | ||
provide, in accordance with Subchapter C, health benefit plan | ||
coverage to certain low-income individuals through private market | ||
solutions. | ||
(b) Any agreement reached under this section must: | ||
(1) create a program that is made cost neutral to this | ||
state by: | ||
(A) leveraging premium tax revenues; and | ||
(B) achieving cost savings through offsets to | ||
general revenue health care costs or the implementation of other | ||
cost savings mechanisms; | ||
(2) create more efficient health benefit plan coverage | ||
options for eligible individuals through: | ||
(A) program changes that may be made without the | ||
need for additional federal approval; and | ||
(B) program changes that require additional | ||
federal approval; | ||
(3) require the commission to achieve efficiency and | ||
reduce unnecessary utilization, including duplication, of health | ||
care services; | ||
(4) be designed with the goals of: | ||
(A) relieving local tax burdens; | ||
(B) reducing general revenue reliance so as to | ||
make general revenue available for other state priorities; and | ||
(C) minimizing the impact of any federal health | ||
care laws on Texas-based businesses; and | ||
(5) afford this state the opportunity to develop a | ||
state-specific way with benefits that specifically meet the unique | ||
needs of this state's population. | ||
(c) An agreement reached under this section may be: | ||
(1) limited in duration; and | ||
(2) contingent on continued funding by the federal | ||
government. | ||
SUBCHAPTER C. PROGRAM REQUIREMENTS | ||
Sec. 541.101. ENROLLMENT ELIGIBILITY. (a) Subject to | ||
Subsection (b), an individual may be eligible to enroll in a program | ||
designed and established under this chapter if the person: | ||
(1) is younger than 65; | ||
(2) has a household income at or below 133 percent of | ||
the federal poverty level; and | ||
(3) is not otherwise eligible to receive benefits | ||
under the medical assistance program, including through a program | ||
operated under Chapter 540 through a block grant funding system or a | ||
waiver, other than one granted under this chapter, to the program. | ||
(b) The executive commissioner may amend or further define | ||
the eligibility requirements of this section if the commission | ||
determines it necessary to reach an agreement under Subchapter B. | ||
Sec. 541.102. MINIMUM PROGRAM REQUIREMENTS. A program | ||
designed and established under this chapter must: | ||
(1) if cost-effective for this state, provide premium | ||
assistance to purchase health benefit plan coverage in the private | ||
market, including health benefit plan coverage offered through a | ||
managed care delivery model; | ||
(2) provide enrollees with access to health benefits, | ||
including benefits provided through a managed care delivery model, | ||
that: | ||
(A) are tailored to the enrollees; | ||
(B) provide levels of coverage that are | ||
customized to meet health care needs of individuals within defined | ||
categories of the enrolled population; and | ||
(C) emphasize personal responsibility and | ||
accountability through flexible and meaningful cost-sharing | ||
requirements and wellness initiatives, including through | ||
incentives for compliance with health, wellness, and treatment | ||
strategies and disincentives for noncompliance; | ||
(3) include pay-for-performance initiatives for | ||
private health benefit plan issuers that participate in the | ||
program; | ||
(4) use technology to maximize the efficiency with | ||
which the commission and any health benefit plan issuer, health | ||
care provider, or managed care organization participating in the | ||
program manages enrollee participation; | ||
(5) allow recipients under the medical assistance | ||
program to enroll in the program to receive premium assistance as an | ||
alternative to the medical assistance program; | ||
(6) encourage eligible individuals to enroll in other | ||
private or employer-sponsored health benefit plan coverage, if | ||
available and appropriate; | ||
(7) encourage the utilization of health care services | ||
in the most appropriate low-cost settings; and | ||
(8) establish health savings accounts for enrollees, | ||
as appropriate. | ||
SECTION 2.02. The Health and Human Services Commission in | ||
consultation with the Texas Department of Insurance and the | ||
Medicaid Reform Task Force shall actively develop a proposal for | ||
the authorization from the appropriate federal entity as required | ||
by Subchapter B, Chapter 541, Government Code, as added by this | ||
article. As soon as possible after the effective date of this Act, | ||
the Health and Human Services Commission shall request and actively | ||
pursue obtaining the authorization from the appropriate federal | ||
entity. | ||
ARTICLE 3. FEDERAL AUTHORIZATION | ||
SECTION 3.01. Subject to Section 2.02 of this Act, 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. | ||
ARTICLE 4. HEALTH BENEFIT AFFORDABILITY AND ACCESSIBILITY | ||
SECTION 4.01. Subtitle A, Title 8, Insurance Code, is | ||
amended by adding Chapter 1218 to read as follows: | ||
CHAPTER 1218. HEALTH BENEFIT AFFORDABILITY AND ACCESSIBILITY | ||
SUBCHAPTER A. GENERAL PROVISIONS | ||
Sec. 1218.001. 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. 1218.002. 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 hospital expenses; or | ||
(F) only for indemnity for hospital confinement; | ||
(2) a Medicare supplemental policy as defined by | ||
Section 1882(g)(1), Social Security Act (42 U.S.C. Section | ||
1395ss(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 1218.001. | ||
(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. 1218.003. CONFLICT WITH OTHER LAW. If this chapter | ||
conflicts with another law relating to lifetime or annual benefit | ||
limits or the imposition of a premium, deductible, copayment, | ||
coinsurance, or other cost-sharing provision, this chapter | ||
controls. | ||
SUBCHAPTER B. CERTAIN COST-SHARING AND COVERAGE AMOUNT LIMITS | ||
PROHIBITED | ||
Sec. 1218.051. CERTAIN COST-SHARING PROVISIONS FOR | ||
PREVENTIVE SERVICES PROHIBITED. A health benefit plan issuer may | ||
not impose a deductible, copayment, coinsurance, or other | ||
cost-sharing provision applicable to benefits for: | ||
(1) a preventive item or service that has in effect a | ||
rating of "A" or "B" in the most recent recommendations of the | ||
United States Preventive Services Task Force; | ||
(2) an immunization recommended for routine use in the | ||
most recent immunization schedules published by the United States | ||
Centers for Disease Control and Prevention of the United States | ||
Public Health Service; or | ||
(3) preventive care and screenings supported by the | ||
most recent comprehensive guidelines adopted by the United States | ||
Health Resources and Services Administration. | ||
Sec. 1218.052. 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, 2019, and other benefits | ||
identified by the United States secretary of health and human | ||
services as essential health benefits as of that date. | ||
Sec. 1218.053. 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, 2019, and | ||
other benefits identified by the United States secretary of health | ||
and human services as essential health benefits as of that date. | ||
Sec. 1218.054. DISCRIMINATION BASED ON GENDER PROHIBITED. A | ||
health benefit plan issuer may not charge an individual a higher | ||
premium rate based on the individual's gender. | ||
SUBCHAPTER C. COVERAGE OF PREEXISTING CONDITIONS | ||
Sec. 1218.101. DEFINITION. In this subchapter, | ||
"preexisting condition" means a condition present before the | ||
effective date of an individual's coverage under a health benefit | ||
plan. | ||
Sec. 1218.102. PREEXISTING CONDITION RESTRICTIONS | ||
PROHIBITED. Notwithstanding any other law, a health benefit plan | ||
issuer may not: | ||
(1) deny an individual's application for coverage or | ||
refuse to enroll an individual in a health benefit plan due to a | ||
preexisting condition; | ||
(2) limit or exclude coverage under the health benefit | ||
plan for the treatment of a preexisting condition otherwise covered | ||
under the plan; or | ||
(3) charge the individual more for coverage than the | ||
health benefit plan issuer charges an individual who does not have a | ||
preexisting condition. | ||
SUBCHAPTER D. EXTERNAL REVIEW PROCEDURE | ||
Sec. 1218.151. EXTERNAL REVIEW MODEL ACT RULES. (a) The | ||
department shall adopt rules as necessary to conform Texas law with | ||
the requirements of the NAIC Uniform Health Carrier External Review | ||
Model Act (April 2010). | ||
(b) To the extent that the rules adopted under this section | ||
conflict with Chapter 843 or Title 14, the rules control. | ||
ARTICLE 5. HEALTH BENEFIT PLAN COVERAGE FOR MENTAL HEALTH | ||
CONDITIONS AND SUBSTANCE USE DISORDERS | ||
SECTION 5.01. Chapter 1355, Insurance Code, is amended by | ||
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 | ||
relating to a deductible, copayment, coinsurance, or other | ||
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 | ||
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 [ |
||
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 [ |
||
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 [ |
||
(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 [ |
||
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 [ |
||
(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 [ |
||
(2) a grandchild of an employee or member who is: | ||
(A) unmarried; | ||
(B) younger than 26 [ |
||
(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 [ |
||
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 [ |
||
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 [ |
||
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 [ |
||
enrolled at an educational institution. | ||
(b) A health benefit plan that requires as a condition of | ||
coverage for a child 26 [ |
||
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 | ||
[ |
||
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 [ |
||
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. |