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AN ACT
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relating to promoting awareness and education about the purchase |
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and availability of health coverage. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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ARTICLE 1. TEXLINK |
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SECTION 1.01. Chapter 524, Insurance Code, is amended to |
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read as follows: |
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CHAPTER 524. TEXLINK TO HEALTH COVERAGE [AWARENESS AND
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EDUCATION] PROGRAM |
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SUBCHAPTER A. GENERAL PROVISIONS |
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Sec. 524.001. DEFINITIONS. In this chapter: |
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(1) "Division" means the division of the department |
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that administers the TexLink to Health Coverage Program. |
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(2) "Program" means the TexLink to Health Coverage |
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Program established in accordance with this chapter. |
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Sec. 524.002. DIVISION RESPONSIBILITIES. Under the |
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direction of the commissioner, the division implements this |
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chapter. |
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Sec. 524.003. TEXLINK TO HEALTH COVERAGE PROGRAM |
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ESTABLISHED. (a) The department shall develop and implement a |
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health coverage [public awareness and education] program that |
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complies with this chapter. The program must: |
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(1) educate the public about the importance and value |
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of health coverage; |
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(2) promote personal responsibility for health care |
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through the purchase of health coverage; |
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(3) assist small employers, individuals, and others |
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seeking to purchase health coverage with technical information |
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necessary to understand available health insurance coverage; |
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(4) promote and facilitate the development and |
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availability of new health coverage options; |
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(5) increase public awareness of health coverage |
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options available in this state; and |
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(6) [(2)
educate the public on the value of health
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coverage; and
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[(3)] provide information on health coverage options, |
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including health savings accounts and compatible high deductible |
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health benefit plans. |
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(b) The program must include a public awareness and |
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education component. |
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SUBCHAPTER B. PUBLIC AWARENESS AND EDUCATION |
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Sec. 524.051. INFORMATION ABOUT SPECIFIC HEALTH BENEFIT |
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PLAN ISSUERS. In materials produced for the program, the division |
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[department] may include information about specific health benefit |
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plan [coverage] issuers but may not favor or endorse one particular |
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issuer over another. |
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Sec. 524.052 [524.002]. PUBLIC SERVICE ANNOUNCEMENTS. The |
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division [department] shall develop and make public service |
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announcements to educate consumers and employers about the |
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availability of health coverage in this state. |
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Sec. 524.053 [524.003]. INTERNET WEBSITE; PRINTED |
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MATERIALS; NEWSLETTER [PUBLIC EDUCATION]. (a) The division |
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[department] shall develop an Internet website and printed |
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materials designed to educate small employers, individuals, and |
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others seeking to purchase health coverage [the public] about [the
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availability of] health coverage in accordance with Section |
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524.003(a) [this state], including information about health |
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savings accounts and compatible high deductible health benefit |
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plans. |
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(b) The division shall make the printed materials produced |
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under the program available to small employers, individuals, and |
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others seeking to purchase health coverage. The division may: |
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(1) distribute the printed materials through |
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facilities such as libraries, health care facilities, and schools |
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as well as other venues the division selects; and |
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(2) use other distribution methods the division |
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selects. |
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(c) The division may produce a newsletter to provide updated |
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information about health coverage to subscribers who elect to |
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receive the newsletter. The division may: |
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(1) produce a newsletter under this subsection for |
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small employers, for individuals, or for other purchasers of health |
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coverage; |
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(2) distribute the newsletter on a monthly, quarterly, |
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or other basis; and |
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(3) distribute the newsletter as a printed document or |
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electronically. |
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Sec. 524.054. TOLL-FREE TELEPHONE HOTLINE; ACCESS TO |
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INFORMATION. (a) The division may operate a toll-free telephone |
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hotline to respond to inquiries and provide information and |
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technical assistance concerning health insurance coverage. |
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(b) The Health and Human Services Commission, through its |
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2-1-1 telephone number for access to human services, may |
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disseminate information regarding health insurance coverage |
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provided to the commission by the department and may refer |
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inquiries regarding health insurance coverage to the toll-free |
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telephone hotline. The department may provide information to the |
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Health and Human Services Commission as necessary to implement this |
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subsection. |
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Sec. 524.055. EDUCATION FOR HIGH SCHOOL STUDENTS. (a) The |
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division may develop educational materials and a curriculum to be |
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used in high school classes that educate students about: |
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(1) the importance and value of health coverage; |
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(2) comparing health benefit plans; and |
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(3) understanding basic provisions contained in |
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health benefit plans. |
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(b) The division may consult with the Texas Education Agency |
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in developing educational materials and a curriculum under this |
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section. |
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Sec. 524.056. HEALTH COVERAGE FAIRS. (a) The division may |
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conduct health coverage fairs to provide small employers, |
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individuals, and others seeking to purchase health coverage the |
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opportunity to obtain information about health coverage from |
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division employees and from health benefit plan issuers and agents |
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that elect to participate. |
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(b) The division shall seek to obtain funding for health |
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coverage fairs conducted under this section through gifts and |
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grants obtained in accordance with Subchapter C. |
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Sec. 524.057. COMMUNITY EVENTS. The division may |
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participate in events held in this state to promote awareness of the |
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importance and value of health coverage and to educate small |
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employers, individuals, and others seeking to purchase health |
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coverage about health coverage in accordance with Section |
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524.003(a). |
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Sec. 524.058. HEALTH COVERAGE PROVIDED THROUGH COLLEGES AND |
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UNIVERSITIES. The division may cooperate with a public or private |
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college or university to promote enrollment in health coverage |
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programs sponsored by or through the college or university. |
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Sec. 524.059. SUPPORT FOR COMMUNITY-BASED PROJECTS. The |
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division may provide support and assistance to individuals and |
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organizations seeking to develop community-based health coverage |
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plans for uninsured individuals. |
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Sec. 524.060. OTHER EDUCATION. The division may [department
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shall] provide other appropriate education to the public regarding |
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health coverage and the importance and value of health coverage in |
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accordance with Section 524.003(a). |
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Sec. 524.061 [524.004]. TASK FORCE. (a) The commissioner |
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may [shall] appoint a task force to make recommendations regarding |
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the division's duties under this subchapter [health coverage public
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awareness and education program]. If appointed, the [The] task |
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force must be [is] composed of: |
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(1) one representative from each of the following |
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groups or entities: |
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(A) health [benefit] coverage consumers; |
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(B) small employers; |
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(C) employers generally; |
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(D) insurance agents; |
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(E) the office of public insurance counsel; |
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(F) the Texas Health Insurance Risk Pool; |
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(G) physicians; |
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(H) advanced practice nurses; |
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(I) hospital trade associations; and |
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(J) medical units of institutions of higher |
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education; |
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(2) a representative of the Health and Human Services |
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Commission responsible for programs under Medicaid and the |
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children's health insurance program; [and] |
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(3) one or more representatives of health benefit plan |
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issuers; and |
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(4) one or more representatives of a regional or local |
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health care program for employees of small employers under Chapter |
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75, Health and Safety Code. |
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(b) In addition to the individuals listed in Subsection (a), |
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the commissioner may select to serve on any task force one or more |
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individuals with experience in public relations, marketing, or |
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another related field of professional services. |
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(c) The division may [department shall] consult the task |
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force regarding the content for the public service announcements, |
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Internet website, printed materials, and other educational |
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materials required or authorized by this subchapter [chapter]. The |
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commissioner has authority to make final decisions as to what the |
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program's materials will contain. |
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Sec. 524.062. FEDERAL TAX "TOOL KIT" FOR CERTAIN |
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BUSINESSES. The department may: |
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(1) produce materials that: |
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(A) provide step-by-step instructions for a |
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small employer or single-employee business that is obtaining health |
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coverage for the benefit of the employer or business and the |
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employees of the business; and |
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(B) are designed to allow the employer or |
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business to obtain the coverage in a manner that qualifies for |
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favorable treatment under federal tax laws; and |
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(2) make department staff available to assist small |
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employers and single-employee businesses that are obtaining health |
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coverage as described by Subdivision (1). |
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Sec. 524.063. ASSISTANCE FOR SMALL EMPLOYERS AND |
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SINGLE-EMPLOYEE BUSINESSES. The department may train staff |
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concerning available health coverage options for small employers |
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and single-employee businesses to: |
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(1) respond to telephone inquiries from small |
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employers and single-employee businesses; and |
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(2) speak at events to provide information about |
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health coverage options for small employers and single-employee |
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businesses and about the importance and value of health coverage. |
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Sec. 524.064. ACCOUNTANT. The department may employ an |
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accountant with experience in federal tax law and the purchase of |
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group health coverage as necessary to implement this chapter. |
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SUBCHAPTER C. FUNDING |
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Sec. 524.101 [524.005]. FUNDING. The department may accept |
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gifts and grants from any party, including a health benefit plan |
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issuer or a foundation associated with a health benefit plan |
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issuer, to assist with funding the program. The department shall |
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adopt rules governing acceptance of donations that are consistent |
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with Chapter 575, Government Code. Before adopting rules under |
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this section [subsection], the department shall: |
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(1) submit the proposed rules to the Texas Ethics |
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Commission for review; and |
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(2) consider the commission's recommendations |
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regarding the regulations. |
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ARTICLE 2. HEALTHY TEXAS PROGRAM |
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SECTION 2.01. Subtitle G, Title 8, Insurance Code, is |
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amended by adding Chapter 1508 to read as follows: |
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CHAPTER 1508. HEALTHY TEXAS PROGRAM |
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SUBCHAPTER A. GENERAL PROVISIONS |
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Sec. 1508.001. PURPOSE. (a) The purposes of the Healthy |
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Texas Program are to: |
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(1) provide access to quality small employer health |
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benefit plans at an affordable price; |
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(2) encourage small employers to offer health benefit |
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plan coverage to employees and the dependents of employees; and |
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(3) maximize reliance on proven managed care |
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strategies and procedures. |
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(b) The Healthy Texas Program is not intended to diminish |
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the availability of traditional small employer health benefit plan |
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coverage under Chapter 1501. |
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Sec. 1508.002. DEFINITIONS. In this chapter: |
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(1) "Dependent" has the meaning assigned by Section |
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1501.002(2). |
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(2) "Eligible employee" has the meaning assigned by |
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Section 1501.002(3). |
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(3) "Fund" means the healthy Texas small employer |
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premium stabilization fund established under Subchapter F. |
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(4) "Health benefit plan" and "health benefit plan |
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issuer" have the meanings assigned by Sections 1501.002(5) and |
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1501.002(6), respectively. |
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(5) "Program" means the Healthy Texas Program |
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established under this chapter. |
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(6) "Qualifying health benefit plan" means a health |
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benefit plan that provides benefits for health care services in the |
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manner described by this chapter. |
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(7) "Small employer" has the meaning assigned by |
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Section 1501.002(14). |
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Sec. 1508.003. RULES. The commissioner may adopt rules as |
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necessary to implement this chapter. |
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[Sections 1508.004-1508.050 reserved for expansion] |
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SUBCHAPTER B. EMPLOYER ELIGIBILITY; CONTRIBUTIONS |
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Sec. 1508.051. EMPLOYER ELIGIBILITY TO PARTICIPATE. (a) A |
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small employer may participate in the program if: |
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(1) during the 12-month period immediately preceding |
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the date of application for a qualifying health benefit plan, the |
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small employer does not offer employees group health benefits on an |
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expense-reimbursed or prepaid basis; and |
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(2) at least 30 percent of the small employer's |
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eligible employees receive annual wages from the employer in an |
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amount that is equal to or less than 300 percent of the poverty |
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guidelines for an individual, as defined and updated annually by |
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the United States Department of Health and Human Services. |
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(b) A small employer ceases to be eligible to participate in |
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the program if any health benefit plan that provides employee |
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benefits on an expense-reimbursed or prepaid basis, other than |
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another qualifying health benefit plan, is purchased or otherwise |
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takes effect after the purchase of a qualifying health benefit |
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plan. |
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Sec. 1508.052. COMMISSIONER ADJUSTMENTS AUTHORIZED. |
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(a) The commissioner by rule may adjust the 12-month period |
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described by Section 1508.051(a)(1) to an 18-month period if the |
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commissioner determines that the 12-month period is insufficient to |
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prevent inappropriate substitution of other health benefit plans |
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for qualifying health benefit plan coverage under this chapter. |
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(b) The commissioner by rule may adjust the percentage of |
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the poverty guidelines described by Section 1508.051(a)(2) to a |
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higher or lower percentage if the commissioner determines that the |
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adjustment is necessary to fulfill the purposes of this chapter. An |
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adjustment made by the commissioner under this subsection takes |
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effect on the first July 1 following the adjustment. |
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Sec. 1508.053. MINIMUM EMPLOYER PARTICIPATION |
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REQUIREMENTS. A small employer that meets the eligibility |
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requirements described by Section 1508.051(a) may apply to purchase |
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a qualifying health benefit plan if 60 percent or more of the |
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employer's eligible employees elect to participate in the plan. |
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Sec. 1508.054. EMPLOYER CONTRIBUTION REQUIREMENTS. (a) A |
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small employer that purchases a qualifying health benefit plan |
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must: |
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(1) pay 50 percent or more of the premium for each |
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employee covered under the qualifying health benefit plan; |
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(2) offer coverage to all eligible employees receiving |
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annual wages from the employer in an amount described by Section |
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1508.051(a)(2) or 1508.052(b), as applicable; and |
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(3) contribute the same percentage of premium for each |
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covered employee. |
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(b) A small employer that purchases a qualifying health |
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benefit plan under the program may elect to pay, but is not required |
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to pay, all or any portion of the premium paid for dependent |
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coverage under the qualifying health benefit plan. |
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[Sections 1508.055-1508.100 reserved for expansion] |
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SUBCHAPTER C. PROGRAM PARTICIPATION; REQUIRED COVERAGE AND |
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BENEFITS |
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Sec. 1508.101. PARTICIPATING PLAN ISSUERS. (a) Subject to |
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Subsection (b), any health benefit plan issuer may participate in |
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the program. |
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(b) The commissioner by rule may limit which health benefit |
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plan issuers may participate in the program if the commissioner |
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determines that the limitation is necessary to achieve the purposes |
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of this chapter. |
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(c) If the commissioner limits participation in the program |
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under Subsection (b), the commissioner shall contract on a |
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competitive procurement basis with one or more health benefit plan |
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issuers to provide qualifying health benefit plan coverage under |
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the program. |
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(d) Nothing in this chapter prohibits a regional or local |
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health care program described by Chapter 75, Health and Safety |
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Code, from participating in the program. The commissioner by rule |
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shall establish participation requirements applicable to regional |
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and local health care programs that consider the unique plan |
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designs, benefit levels, and participation criteria of each |
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program. |
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Sec. 1508.102. PREEXISTING CONDITION PROVISION REQUIRED. A |
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health benefit plan offered under the program must include a |
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preexisting condition provision that meets the requirements |
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described by Section 1501.102. |
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Sec. 1508.103. EXCEPTION FROM MANDATED BENEFIT |
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REQUIREMENTS. Except as expressly provided by this chapter, a |
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small employer health benefit plan issued under the program is not |
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subject to a law of this state that requires coverage or the offer |
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of coverage of a health care service or benefit. |
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Sec. 1508.104. CERTAIN COVERAGE PROHIBITED OR REQUIRED. |
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(a) A qualifying health benefit plan may only provide coverage for |
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in-plan services and benefits, except for: |
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(1) emergency care; or |
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(2) other services not available through a plan |
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provider. |
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(b) In-plan services and benefits provided under a |
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qualifying health benefit plan must include the following: |
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(1) inpatient hospital services; |
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(2) outpatient hospital services; |
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(3) physician services; and |
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(4) prescription drug benefits. |
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(c) The commissioner may approve in-plan benefits other |
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than those required under Subsection (b) or emergency care or other |
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services not available through a plan provider if the commissioner |
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determines the inclusion to be essential to achieve the purposes of |
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this chapter. |
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(d) The commissioner may, with respect to the categories of |
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services and benefits described by Subsections (b) and (c): |
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(1) prepare specifications for a coverage provided |
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under this chapter; |
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(2) determine the methods and procedures of claims |
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administration; |
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(3) establish procedures to decide contested cases |
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arising from coverage provided under this chapter; |
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(4) study, on an ongoing basis, the operation of all |
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coverages provided under this chapter, including gross and net |
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costs, administration costs, benefits, utilization of benefits, |
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and claims administration; |
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(5) administer the healthy Texas small employer |
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premium stabilization fund established under Subchapter F; |
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(6) provide the beginning and ending dates of |
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coverages for enrollees in a qualifying health benefit plan; |
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(7) develop basic group coverage plans applicable to |
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all individuals eligible to participate in the program; |
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(8) provide for optional group coverage plans in |
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addition to the basic group coverage plans described by Subdivision |
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(7); |
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(9) provide, as determined to be appropriate by the |
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commissioner, additional statewide optional coverage plans; |
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(10) develop specific health benefit plans that permit |
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access to high-quality, cost-effective health care; |
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(11) design, implement, and monitor health benefit |
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plan features intended to discourage excessive utilization, |
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promote efficiency, and contain costs for qualifying health benefit |
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plans; |
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(12) develop and refine, on an ongoing basis, a health |
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benefit strategy for the program that is consistent with evolving |
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benefits delivery systems; |
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(13) develop a funding strategy that efficiently uses |
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employer contributions to achieve the purposes of this chapter; and |
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(14) modify the copayment and deductible amounts for |
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prescription drug benefits under a qualifying health benefit plan, |
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if the commissioner determines that the modification is necessary |
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to achieve the purposes of this chapter. |
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[Sections 1508.105-1508.150 reserved for expansion] |
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SUBCHAPTER D. PROGRAM ADMINISTRATION |
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Sec. 1508.151. EMPLOYER CERTIFICATION. (a) At the time of |
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initial application, a health benefit plan issuer shall obtain from |
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a small employer that seeks to purchase a qualifying health benefit |
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plan a written certification that the employer meets the |
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eligibility requirements described by Section 1508.051 and the |
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minimum employer participation requirements described by Section |
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1508.053. |
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(b) Not later than the 90th day before the renewal date of a |
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qualifying health benefit plan, a health benefit plan issuer shall |
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obtain from the small employer that purchased the qualifying health |
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benefit plan a written certification that the employer continues to |
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meet the eligibility requirements described by Section 1508.051 and |
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the minimum employer participation requirements described by |
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Section 1508.053. |
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(c) A participating health benefit plan issuer may require a |
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small employer to submit appropriate documentation in support of a |
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certification described by Subsection (a) or (b). |
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Sec. 1508.152. APPLICATION PROCESS. (a) Subject to |
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Subsection (b), a health benefit plan issuer shall accept |
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applications for qualifying health benefit plan coverage from small |
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employers at all times throughout the calendar year. |
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(b) The commissioner may limit the dates on which a health |
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benefit plan issuer must accept applications for qualifying health |
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benefit plan coverage if the commissioner determines the limitation |
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to be necessary to achieve the purposes of this chapter. |
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Sec. 1508.153. EMPLOYEE ENROLLMENT; WAITING PERIOD. (a) A |
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qualifying health benefit plan must provide employees with an |
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initial enrollment period that is 31 days or longer, and annually at |
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least one open enrollment period that is 31 days or longer. The |
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commissioner by rule may require an additional open enrollment |
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period if the commissioner determines that the additional open |
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enrollment period is necessary to achieve the purposes of this |
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chapter. |
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(b) A small employer may establish a waiting period for |
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employees during which an employee is not eligible for coverage |
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under a qualifying health benefit plan. The last day of a waiting |
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period established under this subsection may not be later than the |
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90th day after the date on which the employee begins employment with |
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the small employer. |
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(c) A health benefit plan issuer may not deny coverage under |
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a qualifying health benefit plan to a new employee of a small |
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employer that purchased the qualifying health benefit plan if the |
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health benefit plan issuer receives an application for coverage |
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from the employee not later than the 31st day after the latter of: |
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(1) the first day of the employee's employment; or |
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(2) the first day after the expiration of a waiting |
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period established under Subsection (b). |
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(d) Subject to Subsection (e), a health benefit plan issuer |
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may deny coverage under a qualifying health benefit plan to an |
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employee of a small employer who applies for coverage after the |
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period described by Subsection (c). |
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(e) A health benefit plan issuer that denies an employee |
|
coverage under Subsection (d): |
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(1) may only deny the employee coverage until the next |
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open enrollment period; and |
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(2) may subject the enrollee to a one-year preexisting |
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condition provision, as described by Section 1508.102, if the |
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period during which the preexisting condition provision applies |
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does not exceed 18 months from the date of the initial application |
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for coverage under the qualifying health benefit plan. |
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Sec. 1508.154. REPORTS. A health benefit plan issuer that |
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participates in the program shall submit reports to the department |
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in the form and at the time the commissioner prescribes. |
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[Sections 1508.155-1508.200 reserved for expansion] |
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SUBCHAPTER E. RATING OF QUALIFIED HEALTH BENEFIT PLANS |
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Sec. 1508.201. RATING; PREMIUM PRACTICES IN GENERAL. |
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(a) A health benefit plan issuer participating in the program |
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must: |
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(1) use rating practices for qualifying health benefit |
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plans that are consistent with the purposes of this chapter; and |
|
(2) in setting premiums for qualifying health benefit |
|
plans, consider the availability of reimbursement from the fund. |
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(b) A health benefit plan issuer participating in the |
|
program shall apply rating factors consistently with respect to all |
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small employers in a class of business. |
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(c) Differences in premium rates charged for qualifying |
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health benefit plans must be reasonable and reflect objective |
|
differences in plan design. |
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Sec. 1508.202. PREMIUM RATE DEVELOPMENT AND CALCULATION. |
|
(a) Rating factors used to underwrite qualifying health benefit |
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plans must produce premium rates for identical groups that: |
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(1) differ only by the amounts attributable to health |
|
benefit plan design; and |
|
(2) do not reflect differences because of the nature |
|
of the groups assumed to select a particular health benefit plan. |
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(b) A health benefit plan issuer shall treat each qualifying |
|
health benefit plan that is issued or renewed in a calendar month as |
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having the same rating period. |
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(c) A health benefit plan issuer may use only age and gender |
|
as case characteristics, as defined by Section 1501.201(2), in |
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setting premium rates for a qualifying health benefit plan. |
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(d) The commissioner by rule may establish additional |
|
rating criteria and requirements for qualifying health benefit |
|
plans if the commissioner determines that the criteria and |
|
requirements are necessary to achieve the purposes of this chapter. |
|
Sec. 1508.203. FILING; APPROVAL. (a) A health benefit |
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plan issuer shall file with the department, for review and approval |
|
by the commissioner, premium rates to be charged for qualifying |
|
health benefit plans. |
|
(b) If the commissioner limits health benefit plan issuer |
|
participation in the program under Section 1508.101(b), premium |
|
rates proposed to be charged for each qualifying health benefit |
|
plan will be considered as an element in the contract procurement |
|
process required under that section. |
|
[Sections 1508.204-1508.250 reserved for expansion] |
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SUBCHAPTER F. HEALTHY TEXAS SMALL EMPLOYER PREMIUM STABILIZATION |
|
FUND |
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Sec. 1508.251. ESTABLISHMENT OF FUND. (a) To the extent |
|
that funds appropriated to the department are available for this |
|
purpose, the commissioner shall establish a fund from which health |
|
benefit plan issuers may receive reimbursement for claims paid by |
|
the health benefit plan issuers for individuals covered under |
|
qualifying group health plans. |
|
(b) The fund established under this section shall be known |
|
as the healthy Texas small employer premium stabilization fund. |
|
(c) The commissioner shall adopt rules necessary to |
|
implement and administer the fund, including rules that set out the |
|
procedures for operation of the fund and distribution of money from |
|
the fund. |
|
Sec. 1508.252. OPERATION OF FUND; CLAIM ELIGIBILITY. |
|
(a) A health benefit plan issuer is eligible to receive |
|
reimbursement in an amount that is equal to 80 percent of the dollar |
|
amount of claims paid between $5,000 and $75,000 in a calendar year |
|
for an enrollee in a qualifying health benefit plan. |
|
(b) A health benefit plan issuer is eligible for |
|
reimbursement from the fund only for the calendar year in which |
|
claims are paid. |
|
(c) Once the dollar amount of claims paid on behalf of a |
|
covered individual reaches or exceeds $75,000 in a given calendar |
|
year, a health benefit plan issuer may not receive reimbursement |
|
for any other claims paid on behalf of the individual in that |
|
calendar year. |
|
Sec. 1508.253. REIMBURSEMENT REQUEST SUBMISSION. (a) A |
|
health benefit plan issuer seeking reimbursement from the fund |
|
shall submit a request for reimbursement in the form prescribed by |
|
the commissioner by rule. |
|
(b) A health benefit plan issuer must request reimbursement |
|
from the fund annually, not later than the date determined by the |
|
commissioner, following the end of the calendar year for which the |
|
reimbursement requests are made. |
|
(c) The commissioner may require a health benefit plan |
|
issuer participating in the program to submit claims data in |
|
connection with reimbursement requests as the commissioner |
|
determines to be necessary to ensure appropriate distribution of |
|
reimbursement funds and oversee the operation of the fund. The |
|
commissioner may require that the data be submitted on a per covered |
|
individual, aggregate, or categorical basis. |
|
Sec. 1508.254. FUND AVAILABILITY. (a) The commissioner |
|
shall compute the total claims reimbursement amount for all health |
|
benefit plan issuers participating in the program for the calendar |
|
year for which claims are reported and reimbursement requested. |
|
(b) If the total amount requested by health benefit plan |
|
issuers participating in the program for reimbursement for a |
|
calendar year exceeds the amount of funds available for |
|
distribution for claims paid during that same calendar year, the |
|
commissioner shall provide for the pro rata distribution of any |
|
available funds. A health benefit plan issuer participating in the |
|
program is eligible to receive a proportional amount of any |
|
available funds that is equal to the proportion of total eligible |
|
claims paid by all participating health benefit plan issuers that |
|
the requesting health benefit plan issuer paid. |
|
(c) If the amount of funds available for distribution for |
|
claims paid by all health benefit plan issuers participating in the |
|
program during a calendar year exceeds the total amount requested |
|
for reimbursement by all participating health benefit plan issuers |
|
during that calendar year, the commissioner shall carry forward any |
|
excess funds and make those excess funds available for distribution |
|
in the next calendar year. Excess funds carried over under this |
|
section are added to the fund in addition to any other money |
|
appropriated for the fund for the calendar year into which the funds |
|
are carried forward. |
|
Sec. 1508.255. PROGRAM REPORTING. (a) Each health benefit |
|
plan issuer participating in the program shall provide the |
|
department, in the form prescribed by the commissioner, monthly |
|
reports of total enrollment under qualifying health benefit plans. |
|
(b) On the request of the commissioner, each health benefit |
|
plan issuer participating in the program shall furnish to the |
|
department, in the form prescribed by the commissioner, data other |
|
than data described by Subsection (a) that the commissioner |
|
determines necessary to oversee the operation of the fund. |
|
Sec. 1508.256. CLAIMS EXPERIENCE DATA. (a) Based on |
|
available data and appropriate actuarial assumptions, the |
|
commissioner shall separately estimate the per covered individual |
|
annual cost of total claims reimbursement from the fund for |
|
qualifying health benefit plans. |
|
(b) On request, a health benefit plan issuer participating |
|
in the program shall furnish to the department claims experience |
|
data for use in the estimates described by Subsection (a). |
|
Sec. 1508.257. TOTAL ELIGIBLE ENROLLMENT DETERMINATION. |
|
(a) The commissioner shall determine total eligible enrollment |
|
under qualifying health benefit plans by dividing the total funds |
|
available for distribution from the fund by the estimated per |
|
covered individual annual cost of total claims reimbursement from |
|
the fund. |
|
(b) At the end of the first year of enrollment and annually |
|
thereafter, the commissioner shall submit a report to the governor |
|
and the legislature regarding enrollment for the previous year and |
|
limitations on future enrollment that ensure that the program does |
|
not necessitate a substantial increase in funding to continue the |
|
program, as consistent with Section 1508.001. |
|
Sec. 1508.258. EVALUATION AND PROTECTION OF FUND; EMPLOYER |
|
ENROLLMENT SUSPENSION. (a) The commissioner shall suspend the |
|
enrollment of new employers in qualifying health benefit plans if |
|
the commissioner determines that the total enrollment reported by |
|
all health benefit plan issuers under qualifying health benefit |
|
plans exceeds the total eligible enrollment determined under |
|
Section 1508.257 and is likely to result in anticipated annual |
|
expenditures from the fund in excess of the total funds available |
|
for distribution from the fund. |
|
(b) The commissioner shall provide a health benefit plan |
|
issuer participating in the program with notification of any |
|
enrollment suspension under Subsection (a) as soon as practicable |
|
after: |
|
(1) receipt of all enrollment data; and |
|
(2) determination of the need to suspend enrollment. |
|
(c) A suspension of issuance of qualifying health benefit |
|
plans to employers under Subsection (a) does not preclude the |
|
addition of new employees of an employer already covered under a |
|
qualifying health benefit plan or new dependents of employees |
|
already covered under a qualifying health benefit plan. |
|
Sec. 1508.259. EMPLOYER ENROLLMENT REACTIVATION. If, at |
|
any point during a suspension of enrollment under Section 1508.258, |
|
the commissioner determines that funds are sufficient to provide |
|
for the addition of new enrollments, the commissioner: |
|
(1) may reactivate new enrollments; and |
|
(2) shall notify all participating group health |
|
benefit plan issuers that enrollment of new employers may be |
|
resumed. |
|
Sec. 1508.260. FUND ADMINISTRATOR. (a) The commissioner |
|
may obtain the services of an independent organization to |
|
administer the fund. |
|
(b) The commissioner shall establish guidelines for the |
|
submission of proposals by organizations for the purposes of |
|
administering the fund and may approve, disapprove, or recommend |
|
modification to the proposal of an applicant to administer the |
|
fund. |
|
(c) An organization approved to administer the fund shall |
|
submit reports to the commissioner, in the form and at the times |
|
required by the commissioner, as necessary to facilitate evaluation |
|
and ensure orderly operation of the fund, including an annual |
|
report of the affairs and operations of the fund. The annual report |
|
must also be delivered to the governor, the lieutenant governor, |
|
and the speaker of the house of representatives. |
|
(d) An organization approved to administer the fund shall |
|
maintain records in the form prescribed by the commissioner and |
|
make those records available for inspection by or at the request of |
|
the commissioner. |
|
(e) The commissioner shall determine the amount of |
|
compensation to be allocated to an approved organization as payment |
|
for fund administration. Compensation is payable only from the |
|
fund. |
|
(f) The commissioner may remove an organization approved to |
|
administer the fund from fund administration. An organization |
|
removed from fund administration under this subsection must |
|
cooperate in the orderly transition of services to another approved |
|
organization or to the commissioner. |
|
Sec. 1508.261. STOP-LOSS INSURANCE; REINSURANCE. (a) The |
|
administrator of the fund, on behalf of and with the prior approval |
|
of the commissioner, may purchase stop-loss insurance or |
|
reinsurance from an insurance company licensed to write that |
|
coverage in this state. |
|
(b) Stop-loss insurance or reinsurance may be purchased to |
|
the extent that the commissioner determines funds are available for |
|
the purchase of that insurance. |
|
Sec. 1508.262. PUBLIC EDUCATION AND OUTREACH. (a) The |
|
commissioner may use an amount of the fund, not to exceed eight |
|
percent of the annual amount of the fund, for purposes of developing |
|
and implementing public education, outreach, and facilitated |
|
enrollment strategies targeted to small employers who do not |
|
provide health insurance. |
|
(b) The commissioner shall solicit and accept |
|
recommendations concerning the development and implementation of |
|
education, outreach, and enrollment strategies under Subsection |
|
(a) from agents licensed under Title 13 to write health benefit |
|
plans in this state. |
|
(c) The commissioner may contract with marketing |
|
organizations to perform or provide assistance with education, |
|
outreach, and enrollment strategies described by Subsection (a). |
|
SECTION 2.02. The commissioner of insurance shall adopt any |
|
rules necessary to implement the change in law made by Chapter 1508, |
|
Insurance Code, as added by this article, not later than January 4, |
|
2010. |
|
SECTION 2.03. (a) The commissioner of insurance shall make |
|
an initial determination concerning limitation of health benefit |
|
plan issuer participation in the program established under Chapter |
|
1508, Insurance Code, as added by this article, not later than |
|
January 18, 2010. If the commissioner determines that limited |
|
participation is necessary to achieve the purposes of Chapter 1508, |
|
Insurance Code, as added by this article, the commissioner shall |
|
issue a request for proposal from health benefit plan issuers to |
|
participate in the program not later than May 1, 2010. |
|
(b) The commissioner of insurance shall ensure that the |
|
Healthy Texas Program is fully operational in a manner that allows |
|
health benefit plan issuers participating in the program to make |
|
the first annual request for reimbursement on January 1, 2011. |
|
SECTION 2.04. This Act does not make an appropriation. This |
|
Act takes effect only if a specific appropriation for the |
|
implementation of the Act is provided in a general appropriations |
|
act of the 81st Legislature. |
|
ARTICLE 3. EFFECTIVE DATE |
|
SECTION 3.01. This Act takes effect September 1, 2009. |
|
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|
______________________________ |
______________________________ |
|
President of the Senate |
Speaker of the House |
|
|
I hereby certify that S.B. No. 78 passed the Senate on |
|
April 9, 2009, by the following vote: Yeas 31, Nays 0; |
|
May 29, 2009, Senate refused to concur in House amendment and |
|
requested appointment of Conference Committee; May 30, 2009, House |
|
granted request of the Senate; June 1, 2009, Senate adopted |
|
Conference Committee Report by the following vote: Yeas 30, |
|
Nays 1. |
|
|
|
|
______________________________ |
|
Secretary of the Senate |
|
|
I hereby certify that S.B. No. 78 passed the House, with |
|
amendment, on May 19, 2009, by the following vote: Yeas 144, |
|
Nays 0, one present not voting; May 30, 2009, House granted request |
|
of the Senate for appointment of Conference Committee; |
|
May 31, 2009, House adopted Conference Committee Report by the |
|
following vote: Yeas 135, Nays 8, one present not voting. |
|
|
|
|
______________________________ |
|
Chief Clerk of the House |
|
|
|
|
|
Approved: |
|
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|
______________________________ |
|
Date |
|
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|
|
______________________________ |
|
Governor |