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
 
 
 
A BILL TO BE ENTITLED
 
AN ACT
  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 [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.
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