84R13564 PMO-D
	By: Herrero	H.B. No. 4016

	A BILL TO BE ENTITLED
	AN ACT
	relating to coordination of health benefits under certain insurance
	policies.
	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
	SECTION 1.  Chapter 1203, Insurance Code, is amended by
	adding Subchapter B to read as follows:
	SUBCHAPTER B. MANDATED COORDINATION OF HEALTH BENEFITS
	Sec. 1203.051.  APPLICABILITY OF SUBCHAPTER. (a)  This
	subchapter applies only to a health benefit plan that provides
	benefits for medical, surgical, or dental expenses incurred as a
	result of a health condition, accident, or sickness, including an
	individual, group, blanket, or franchise insurance policy or
	insurance agreement, or a group hospital service contract, or an
	individual or group evidence of coverage or similar coverage
	document that is offered by:
	(1)  an insurance company;
	(2)  a group hospital service corporation operating
	under Chapter 842;
	(3)  a fraternal benefit society operating under
	Chapter 885;
	(4)  a stipulated premium company operating under
	Chapter 884;
	(5)  a reciprocal exchange operating under Chapter 942;
	(6)  a Lloyd's plan operating under Chapter 941; or
	(7)  a health maintenance organization operating under
	Chapter 843.
	(b)  This subchapter applies to group insurance contracts,
	individual insurance contracts, and subscriber contracts that pay
	or reimburse for the cost of dental care.
	(c)  This subchapter applies to the medical care components
	of individual and group long-term care contracts.
	(d)  This subchapter does not apply to:
	(1)  workers' compensation insurance coverage;
	(2)  hospital indemnity coverage benefits or other
	fixed indemnity coverage;
	(3)  accident-only coverage;
	(4)  specified disease or specified accident coverage;
	(5)  school accident-type coverages that cover
	students for accidents only, including athletic injuries, either on
	a "24-hour" or a "to and from school" basis;
	(6)  benefits provided in long-term care insurance
	policies for nonmedical services, including personal care, adult
	day care, homemaker services, assistance with activities of daily
	living, respite care, custodial care, or payment of a fixed daily
	benefit without regard to expenses incurred or the receipt of
	services;
	(7)  Medicare supplement policies;
	(8)  a state plan under Medicaid;
	(9)  a governmental plan that by law provides benefits
	that are in excess of those of any private insurance plan or other
	nongovernmental plan; or
	(10)  an individual accident and health insurance
	policy that is designed to fully integrate with other policies
	through a variable deductible.
	Sec. 1203.052.  MANDATED COORDINATION OF BENEFITS. (a)
	This subchapter applies if:
	(1)  an insured or enrollee is covered by two or more
	insurance policies or other coverage documents; and
	(2)  each policy or other coverage document provides
	the insured or enrollee benefits for medical, surgical, or dental
	expenses.
	(b)  The primary health benefit plan issuer, as determined
	under Section 1203.053, is responsible for expenses covered under
	the insurance policy or other coverage document issued by the
	primary health benefit plan issuer up to the full amount of the
	applicable policy or document limit.
	(c)  Before the limit described by Subsection (b) is reached,
	the secondary health benefit plan issuer, as determined under
	Section 1203.053, is responsible only for the expenses covered
	under the insurance policy or other coverage document issued by the
	secondary health benefit plan issuer that are not covered under the
	policy or document issued by the primary health benefit plan
	issuer.
	(d)  After the limit described by Subsection (b) has been
	reached, the secondary health benefit plan issuer, in addition to
	the responsibility described by Subsection (c), is responsible for
	any expenses covered by both policies or documents that exceed the
	limit described by Subsection (b), up to the full amount of the
	applicable limit of the insurance policy or other coverage document
	issued by the secondary health benefit plan issuer.
	Sec. 1203.053.  DETERMINATION OF ORDER OF BENEFITS. (a)
	Except as provided by Subsections (b) and (c), if the person
	receiving benefits under an insurance policy or other coverage
	document:
	(1)  is named as insured or enrollee, the policy or
	coverage document is primary; or
	(2)  is not named as insured or enrollee, the policy or
	coverage document is secondary to a primary policy or coverage
	document.
	(b)  If a dependent child is covered under two or more
	insurance policies or coverage documents:
	(1)  the primary policy or coverage document is the
	policy or coverage document of the insured or enrollee whose
	birthday is earlier in the calendar year than the insured or
	enrollee of other policies or coverage documents that provide
	coverage to the child; or
	(2)  if the insureds or enrollees under the policies or
	coverage documents have the same birthday, the policy or coverage
	document that has been in effect longest is primary.
	(c)  A determination of the order of benefits made under
	Subsection (a) or (b) may be superseded by a court order under
	Section 154.182, Family Code.
	Sec. 1203.054.  CERTAIN COORDINATION OF BENEFITS PROVISIONS
	PROHIBITED. An insurance policy or other coverage document subject
	to this subchapter may not be delivered, issued for delivery, or
	renewed in this state if:
	(1)  a provision of the policy or document excludes or
	reduces the payment of benefits for medical, surgical, or dental
	expenses to or on behalf of an insured or enrollee;
	(2)  the reason for the exclusion or reduction is that
	benefits are payable or have been paid to or on behalf of the
	insured or enrollee under another insurance policy or coverage
	document; and
	(3)  the exclusion or reduction applies before the full
	amount of the expenses incurred by the insured or enrollee and
	covered by both policies has been paid or reimbursed or the full
	amount of the applicable limit of the policy or document containing
	the exclusion or reduction is reached.
	Sec. 1203.055.  RESTRICTION ON COORDINATION OF BENEFITS
	VOID. A provision of an insurance policy or other coverage document
	that violates this subchapter is void.
	SECTION 2.  Chapter 1203, Insurance Code, is amended by
	designating Sections 1203.001 through 1203.003 as Subchapter A and
	adding a subchapter heading to read as follows:
	SUBCHAPTER A. SUPPLEMENTAL INSURANCE POLICIES
	SECTION 3.  Section 1203.001, Insurance Code, is amended to
	read as follows:
	Sec. 1203.001.  APPLICABILITY OF SUBCHAPTER [CHAPTER]. (a)
	This subchapter [chapter] applies only to:
	(1)  a policy of group accident and health insurance as
	described by Chapter 1251;
	(2)  a policy of blanket accident and health insurance
	as described by Chapter 1251;
	(3)  a policy of individual accident and health
	insurance as defined by Section 1201.001; or
	(4)  an evidence of coverage as defined by Section
	843.002.
	(b)  This subchapter [chapter] does not apply to an
	individual accident and health insurance policy that is designed to
	fully integrate with other policies through a variable deductible.
	SECTION 4.  The change in law made by this Act applies only
	to an insurance policy or other coverage document that is
	delivered, issued for delivery, or renewed on or after January 1,
	2016.  A policy or document delivered, issued for delivery, or
	renewed before January 1, 2016, 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 5.  This Act takes effect September 1, 2015.