By: Coleman H.B. No. 4218       A BILL TO BE ENTITLED   AN ACT   relating to health benefit plan coverage in this state.          BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:   ARTICLE 1.  HEALTH BENEFIT AFFORDABILITY AND ACCESSIBILITY          SECTION 1.01.  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, 2017, 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, 2017, 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 2.  HEALTH BENEFIT PLAN COVERAGE FOR MENTAL HEALTH   CONDITIONS AND SUBSTANCE USE DISORDERS          SECTION 2.01.  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 3.  COVERAGE OF ESSENTIAL HEALTH BENEFITS          SECTION 3.01.  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, 2017, and other benefits   identified by the United States secretary of health and human   services as essential health benefits as of that date.   ARTICLE 4. HEALTH BENEFIT PLAN COVERAGE FOR CERTAIN YOUNG ADULTS          SECTION 4.01.  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 4.02.  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 4.03.  Section 1201.053(b), Insurance Code, as   effective until September 1, 2018, 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   issued under Chapter 154, Family Code, or enforceable by a court in   this state, and any other individual dependent on the adult.          SECTION 4.04.  Section 1201.053(b), Insurance Code, as   effective September 1, 2018, 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 4.05.  Section 1201.062(a), Insurance Code, as   effective until September 1, 2018, 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 under an order issued under Chapter   154, Family Code, or enforceable by a court in this state.          SECTION 4.06.  Section 1201.062(a), Insurance Code, as   effective September 1, 2018, 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 4.07.  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 4.08.  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 4.09.  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 4.10.  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 4.11.  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 4.12.  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 4.13.  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 4.14.  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 5.  TRANSITION; EFFECTIVE DATE          SECTION 5.01.  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, 2018.  A health benefit   plan that is delivered, issued for delivery, or renewed before   January 1, 2018, 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 5.02.  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 5.03.  This Act takes effect September 1, 2017.