Commissioner’s Bulletin # Summary of Health Care Coverage/Life Related Legislation Enacted - 75th Legislative Session (House Bills Only)

NUMBER of BILL. (SECTION/ARTICLE) Statute and Title.

HOUSE BILL 239 (HB 239) relating to Prostate Specific Antigen Test (under the Texas Public School Employees Group Insurance Act) SECTION 1 adds Sec. 18D to Article 3.50-4, Texas Insurance Code

Effective Date of Statute 9/1/97

Requirements of Statute

Prostrate Specific Antigen Test - A health benefit plan offered under the Texas Public School Employees Group Insurance Act must provide coverage for each male (who is at least 50 years of age or at least 40 years of age with a family history of prostate cancer or other risk factor) for medically accepted prostate specified antigen test.

Responsibility of and/or Action Needed by Carriers

Inform staff (including agents). Revise or develop as applicable (a) A&H forms or amendments to bring previously submitted forms into compliance and submit in accordance with Article 3.42; (b) evidence of coverage and other applicable documents given to enrollees, quality assurance plans and submit in accordance with Article 20.A; and (c) any other internal documents.

Responsibility of and/or Action Needed by TDI

Inform staff. Revise checklists and/other educational materials/brochures. Take any other necessary action.

Applicable Date of Compliance

Applies to coverage delivered, issued for delivery or renewed on or after 1/1/98 - SECTION 2 of HB 239.

NUMBER of BILL. (SECTION/ARTICLE) Statute and Title.

HOUSE BILL 349 (HB 349) relating to Hospital Stays following a Mastectomy SECTION 1 adds Article 21.52G to Texas Insurance Code

Effective Date of Statute 9/1/97

Requirements of Statute

Scope of Article - This article applies 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/agreement, a group hospital service contract, or evidence of coverage that is offered by an insurance company, a group hospital service corporation, a fraternal benefit society, a stipulated premium insurance company, HMO (including an approved nonprofit health corporation under Article 21.52F), or to the extent permitted by the Employee Retirement Income Security Act of 1974, a multiple employer welfare arrangement or another analogous benefit arrangement - Article 21.52G, Sec. 2(a). This article applies to a plan that provides coverage only for a specific disease or condition or for hospitalization - Article 21.52G, Sec. 2(b).

Responsibility of and/or Action Needed by Carriers

Responsibility of and/or Action Needed by TDI

Applicable Date of Compliance

NUMBER of BILL. (SECTION/ARTICLE) Statute and Title.

HB 349 - Continued

Effective Date of Statute

Requirements of Statute

This article does NOT apply to a plan that provides coverage only for accidental death or dismemberment, disability income, as a supplement to liability insurance, a small employer plan written under Chapter 26, a Medicare supplemental policy, workers' compensation insurance coverage, medical payment insurance issued as part of a motor vehicle insurance policy, or a long-term care policy - Article 21.52G, Sec. 2(c).

Responsibility of and/or Action Needed by Carriers

Responsibility of and/or Action Needed by TDI

Applicable Date of Compliance

NUMBER of BILL. (SECTION/ARTICLE) Statute and Title.

HB 349 - Continued

Effective Date of Statute

Requirements of Statute

Required Coverage for Minimum Inpatient Stay Following Mastectomy - Issuers of health benefit plans that provide benefits for the treatment of breast cancer must include coverage for inpatient care for an enrollee for a minimum of (a) 48 hours following a mastectomy and (b) 24 hours following a lymph node dissection for the treatment of breast cancer. A plan is not required to provide the minimum hours of coverage of inpatient care required if the enrollee and the enrollee s attending physician determine that a shorter period of inpatient care is appropriate - Article 21.52G, Sec. 3.

Responsibility of and/or Action Needed by Carriers

Inform staff (including agents). Monitor development and adoption of rules. Revise or develop as applicable (a) A&H forms or amendments to bring previously submitted forms into compliance and submit in accordance with Article 3.42; (b) evidence of coverage and other applicable documents given to enrollees, quality assurance plans and submit in accordance with Articles 20A and 21.58A, (c) summary plan descriptions and submit in accordance with 28 TAC 7.1901-7.1910; and (d) any other internal documents.

Responsibility of and/or Action Needed by TDI

Inform staff. Develop and propose rules. Develop/revise checklists & other educational material/brochures. Review filings. Take any other necessary action.

Applicable Date of Compliance

Applies to any policy, contract, evidence of coverage issued, delivered or renewed on or after 1/1/98 - SECTION 2 of HB 349.

NUMBER of BILL. (SECTION/ARTICLE) Statute and Title.

HB 349 - Continued

Effective Date of Statute

Requirements of Statute

Prohibitions. An issuer of a health benefit plan may not: (1) deny to an enrollee eligibility or continued eligibility to enroll or renew solely to avoid the requirements of this article; (2) provide money, payments or rebates to an enrollee to encourage the enrollee to accept less than the minimum coverage required; (3) reduce or limit the amount paid to an attending physician, or otherwise penalize the physician, because the physician provided care to an enrollee in accordance with this article; or (4) provide financial or other incentives to an attending physician to encourage the physician to provide care to an enrollee in a manner inconsistent with rules adopted by the commissioner - Article 21.52G, Sec. 4.

Responsibility of and/or Action Needed by Carriers

Inform staff. Review and revise any documents or procedures.

Responsibility of and/or Action Needed by TDI

Same as above.

Applicable Date of Compliance

NUMBER of BILL. (SECTION/ARTICLE) Statute and Title.

HB 349 - Continued

Effective Date of Statute

Requirements of Statute

Notice - In accordance with rules adopted by the commissioner, each health benefit plan must provide to each enrollee under the plan written notice regarding the coverage under this statute. - Article 21.52G, Sec. 5.

Responsibility of and/or Action Needed by Carriers

Monitor development and adoption of rules. Provide notice as required.

Responsibility of and/or Action Needed by TDI

Develop and propose rules.

Applicable Date of Compliance

NUMBER of BILL. (SECTION/ARTICLE) Statute and Title.

HB 349 - Continued

Effective Date of Statute

Requirements of Statute

Rules - If necessary, the commissioner may adopt rules to administer this article - Article 21.52G, Sec. 6.

Responsibility of and/or Action Needed by Carriers

Monitor development and adoption of rules.

Responsibility of and/or Action Needed by TDI

Same as above.

Applicable Date of Compliance

NUMBER of BILL. (SECTION/ARTICLE) Statute and Title.

HOUSE BILL 587 (HB 587) relating to Community Centers SECTION 1 amends Sec. 534.001 of the Health and Safety Code

Effective Date of Statute 9/1/97

Requirements of Statute

Definition - The definition of a community center (CC) was amended to include a local government and a political subdivision.

Responsibility of and/or Action Needed by Carriers

Inform staff (including agents).

Responsibility of and/or Action Needed by TDI

Inform staff. Take any other necessary action.

Applicable Date of Compliance

9/1/97 - SECTION 4 of HB 587.

NUMBER of BILL. (SECTION/ARTICLE) Statute and Title.

HB 587 - Continued SECTION 2 adds Subchapter C to Chapter 534, Health and Safety Code

Effective Date of Statute

Requirements of Statute

Health Maintenance Organizations Certificate of Authority (a) One or more CCs may create/operate a nonprofit corporation so that the CC may accept capitated or other at-risk payment arrangements for the provision of services designated in a TDI-approved plan under Subchapter A of the Health and Safety Code. (b) Before a nonprofit corporation accepts capitation or other at-risk payment, the nonprofit corporation must obtain a certificate of authority (C/A) from TDI to operate as an HMO. (c) Before submitting any bids, a nonprofit corporation must notify TDI (in writing) of the services to be provided by the CC through capitated /other at-risk payments. TDI must verify that the services provided under any capitated/ at-risk payment arrangement are within the scope of services approved by TDI in the CC s plan.

Responsibility of and/or Action Needed by Carriers

Inform staff (including agents). If proposed, monitor development and adoption of rules. Develop and submit to TDI C/A exhibits/filings as required by Article 20A.

Responsibility of and/or Action Needed by TDI

Inform staff. Evaluate and propose rules, if necessary. Develop/revise checklists and other educational materials/brochures. Review filings. Take any other necessary action.

Applicable Date of Compliance

NUMBER of BILL. (SECTION/ARTICLE) Statute and Title.

HB 587 - Continued

Effective Date of Statute

Requirements of Statute

(d) The non-profit corporation s board of directors shall provide public notice of its intent to submit a bid to provide capitated or at-risk services. This notice must be accomplished through placement of a board agenda item for the next regularly scheduled board meeting that allows at least 15 days public review of the plan. Additionally, the board must provide an opportunity for public comment on the services that the nonprofit corporation will provide, and for the consideration of local input into the plan.

Responsibility of and/or Action Needed by Carriers

Inform staff (including agents). Ensure compliance.

Responsibility of and/or Action Needed by TDI

Same as above.

Applicable Date of Compliance

NUMBER of BILL. (SECTION/ARTICLE) Statute and Title.

HB 587 - Continued

Effective Date of Statute

Requirements of Statute

(e) The nonprofit corporation shall provide public notice of the services that the CC will provide before verification and disclosure occurs; opportunity for public comment on the services; published summaries of all relevant documentation concerning CC services that the nonprofit corporation provides (including descriptions of any relevant contracts that the nonprofit corporation has entered into); and public access and review of all relevant documentation.

Responsibility of and/or Action Needed by Carriers

Same as above. Ensure production of public notice, incorporation of public comment, creation of summaries, and public access to documents.

Responsibility of and/or Action Needed by TDI

Same as above.

Applicable Date of Compliance

NUMBER of BILL. (SECTION/ARTICLE) Statute and Title.

HB 587 - Continued

Effective Date of Statute

Requirements of Statute

A nonprofit corporation is subject to requirements under Chapters 551 and 552, Gov. Code; solicitation of public input on their operations and allow public access to information on their operations/ services/administration/governance/ revenues/expenses unless disclosure of these items is specifically prohibited by law or is confidential; publish an annual report which details the services/ administration/governance/revenues/ expenses of the nonprofit corporation, including the disposition of any excess revenues - Sec. 534.101, Health and Safety Code.

Responsibility of and/or Action Needed by Carriers

Inform staff (including agents). Ensure compliance with applicable statutes.

Responsibility of and/or Action Needed by TDI

Same as above.

Applicable Date of Compliance

NUMBER of BILL. (SECTION/ARTICLE) Statute and Title.

HB 587 - Continued

Effective Date of Statute

Requirements of Statute

Laws and Rules - A nonprofit corporation created/operating under this law that obtains and holds a valid C/A as an HMO may exercise the powers and authority of an HMO and is subject to the conditions and limitations provided by Chapter 20A, the Texas Non-Profit Corp. Act and TDI rules - Sec. 534.102, Health and Safety Code.

Responsibility of and/or Action Needed by Carriers

Same as above.

Responsibility of and/or Action Needed by TDI

Same as above.

Applicable Date of Compliance

NUMBER of BILL. (SECTION/ARTICLE) Statute and Title.

HB 587 - Continued

Effective Date of Statute

Requirements of Statute

Application of Laws and Rules - An HMO created under this law is governed by all of the applicable rules which apply to HMOs of this type as set forth in the laws and rules of the TDI. The commissioner may adopt rules as necessary to accept funding sources other than the sources specified by Article 20A.13 from a nonprofit HMO created and operating under this law, so that the HMO meets the minimum surplus requirements - Sec. 534.103, Health and Safety Code.

Responsibility of and/or Action Needed by Carriers

Inform staff (including agents). If proposed, monitor adoption of rules. Submit information as requested or required.

Responsibility of and/or Action Needed by TDI

Inform staff. Evaluate and propose rules, if necessary. Develop/revise checklists and other educational materials/brochures. Review filings. Take any other necessary action.

Applicable Date of Compliance

NUMBER of BILL. (SECTION/ARTICLE) Statute and Title.

HB 587 - Continued

Effective Date of Statute

Requirements of Statute

Application of Specific Laws - A nonprofit HMO created under this law is a healthcare provider that is a nonprofit HMO created and operated by a CC for purposes of Section 84.007(e), Civil Practices and Remedies Code; it is not a governmental unit or a unit of local government for purposes of Chapters 101 and 102, Civil Practice and Remedies Code; nor a local government for purposes of Chapter 791, Government Code.

Responsibility of and/or Action Needed by Carriers

Inform staff (including agents).

Responsibility of and/or Action Needed by TDI

Applicable Date of Compliance

NUMBER of BILL. (SECTION/ARTICLE) Statute and Title.

HB 587 - Continued

Effective Date of Statute

Requirements of Statute

Nothing in this law precludes one or more CCs from forming a nonprofit corporation under Sec. 5.01, Medical Practice Act, to provide services for risk-sharing or on a capitated basis as permitted under Article 21.52F - Sec. 534.104, Health and Safety Code.

Responsibility of and/or Action Needed by Carriers

Inform staff (including agents).

Responsibility of and/or Action Needed by TDI

Same as above.

Applicable Date of Compliance

NUMBER of BILL. (SECTION/ARTICLE) Statute and Title.

HB 587 - Continued

Effective Date of Statute

Requirements of Statute

Consideration of Bids - The Department of Human Services is required to give equal consideration to all bids submitted by any entity, whether public/for-profit/nonprofit, if the department accepts bids to provide services through a capitated or at-risk payment arrangement and if the entities meet all other criteria as required - Sec. 534.105, Health and Safety Code.

Responsibility of and/or Action Needed by Carriers

Inform staff (including agents). Develop request for proposal, bid specifications and other procedures, as necessary.

Responsibility of and/or Action Needed by TDI

Inform staff. Take any other necessary action.

Applicable Date of Compliance

NUMBER of BILL. (SECTION/ARTICLE) Statute and Title.

HB 587 - Continued SECTION 3 amends Section 84.007(e), Civil Practice and Remedies Code

Effective Date of Statute

Requirements of Statute

This law was updated to (a) remove the applicability of 84.005 and 84.006, Health and Safety Code, to a health care provider that is a nonprofit HMO created and operated by a CC under Sec. 534.101, Health and Safety Code and (b) relieve HMOs from the applicability of 84.005 and 84.006, Health and Safety Code if the HMO is created and operated under the Texas HMO Act.

Responsibility of and/or Action Needed by Carriers

Same as above.

Responsibility of and/or Action Needed by TDI

Same as above.

Applicable Date of Compliance

NUMBER of BILL. (SECTION/ARTICLE) Statute and Title.

HB 587 - Continued SECTION 4

Effective Date of Statute

Requirements of Statute

TDI shall adopt rules that describe procedures an entity must follow and the standards the entity must meet to obtain a C/A as a single health care service plan providing behavioral health care services.

Responsibility of and/or Action Needed by Carriers

Monitor development and adoption of rules

Responsibility of and/or Action Needed by TDI

Develop and propose rules.

Applicable Date of Compliance

Rules to be adopted by 9/1/97 - SECTION 4 of HB 587.

NUMBER of BILL. (SECTION/ARTICLE) Statute and Title.

HOUSE BILL 710 (HB 710) relating to Implementation of Federal Reforms and the Texas Health Insurance Risk Pool (pool) PART 1 relating to the Pool amends Article 3.77, Texas Insurance Code SECTION 1.01 - amends Article 3.77, Sec. 3, Texas Insurance Code

Effective Date of Statute 7/1/97

Requirements of Statute

Definitions - The following terms are defined: benefit plan, board, commissioner, department, dependent, family member, health insurance, health maintenance organization, hospital, insured, insurer, insurance arrangement, Medicare, physician, plan of operation, pool, and resident - Article 3.77, Sec. 2.

Responsibility of and/or Action Needed by Carriers

Inform staff (including agents).

Responsibility of and/or Action Needed by TDI

Inform staff. Take any other necessary action.

Applicable Date of Compliance

NUMBER of BILL. (SECTION/ARTICLE) Statute and Title.

HB 710 - The Pool Continued SECTION 1.02 amends Article 3.77, Sec. 4, Texas Insurance Code

Effective Date of Statute

Requirements of Statute

Board of Directors - The Commissioner of Insurance is to appoint members of the board and designate one member to be chairman. Board members are not liable for an action or omission performed in good faith - Article 3.77, Sec. 4.

Responsibility of and/or Action Needed by Carriers

Same as above.

Responsibility of and/or Action Needed by TDI

Inform staff. Commissioner to appoint members.

Applicable Date of Compliance

Members appointed 8/20/97.

NUMBER of BILL. (SECTION/ARTICLE) Statute and Title.

HB 710 - The Pool Continued SECTION 1.03 amends Article 3.77, Section 5, Texas Insurance Code

Effective Date of Statute

Requirements of Statute

Plan Of Operation - The pool s initial board shall submit to the commissioner (for approval) a plan of operation. The plan must include procedures for (a) operation of the pool; (b) selecting an administrator; (c) creating a fund for administrative expenses; (d) handling, accounting, and auditing of money and other assets of the pool; (e) publicizing the existence of the pool and fostering public awareness of the pool; (f) creating a grievance committee; and (g) other necessary and proper procedures for execution of board powers, duties and obligations. Any amendments made to the plan of operation must be submitted to the commissioner for approval - Article 3.77, Sec. 5.

Responsibility of and/or Action Needed by Carriers

Inform staff (including agents). Monitor development and adoption of plan of operation. Monitor development/adoption of any amendments.

Responsibility of and/or Action Needed by TDI

After notice and hearing, the commissioner is to approve the plan of operation if it is determined to be suitable, fair, reasonable and equitable. If plan of operation is not submitted within 180 days of 8/20/97, the commissioner, after notice and hearing, may adopt rules to provide a plan for the pool. These rules continue in effect until the board submits and the commissioner approves a plan of operation. Commissioner to review and approve amendments to plan of operation.

Applicable Date of Compliance

Plan of operation to be approved within 180 days of 8/20/97.

NUMBER of BILL. (SECTION/ARTICLE) Statute and Title.

HB 710 - The Pool Continued SECTION 1.04 amends Article 3.77, Section 6, Texas Insurance Code.

Effective Date of Statute

Requirements of Statute

Authority Of The Pool - The pool may exercise any of the authority that an insurance company authorized to write health insurance in this state may exercise under the law. Sixteen specific items are listed as part of the board s authority including, but not limited to: provide health coverage to eligible persons; enter into contracts; sue or be sued; institute legal action regarding claims; establish rates; expense allowances; referral fees; adopt and issue policy forms; contract for stop-loss coverage; collect/recover assessments imposed under Article 3.77, Sec. 13; provide for and employ cost containment measurers; and provide for reinsurance. The board shall promulgate a list of medical/health conditions for which a person shall be eligible for pool coverage without applying for health insurance. The board shall make an annual report summarizing the activities of the pool (including net written and earned premiums; enrollment; administrative expenses; and paid/incurred losses) to the governor, lieutenant governor, speaker of the house of representatives and the commissioner - Article 3.77, Sec. 6.

Responsibility of and/or Action Needed by Carriers

Inform staff (including agents). Monitor development of the list of medical/health conditions.

Responsibility of and/or Action Needed by TDI

Inform staff. Develop/revise educational material/brochures. Review report.

Applicable Date of Compliance

List to be effective on first day of the pool s operation. Report due annually on June 1.

NUMBER of BILL. (SECTION/ARTICLE) Statute and Title.

HB 710 - The Pool Continued SECTION 1.05 amends Article 3.77, Section 7, Texas Insurance Code

Effective Date of Statute

Requirements of Statute

Administrator - A competitive bidding process shall be utilized to select an administrator (an insurer/ third party administrator). Criteria for evaluating the bids is listed in the statute including, but not limited to: ability to handle individual A&H insurance, efficiency of claim paying procedures; and financial condition/stability of the entity. Functions of the pool are also included in the statute - Article 3.77, Sec. 7.

Responsibility of and/or Action Needed by Carriers

Inform staff (including agents). Monitor bidding process. If desired, submit application to be administrator.

Responsibility of and/or Action Needed by TDI

Inform staff. Notify board if entity bidding to be administrator is licensed and provide other information as necessary.

Applicable Date of Compliance

NUMBER of BILL. (SECTION/ARTICLE) Statute and Title.

HB 710 - The Pool Continued SECTION 1.06 amends Article 3.77, Section 8, Texas Insurance Code

Effective Date of Statute

Requirements of Statute

Rules - The commissioner may by rule (a) establish additional powers/duties of the board; and (b) adopt other rules as necessary to implement Article 3.77. The commissioner shall by rule provide procedures, criteria, and forms necessary to implement, collect, and deposit assessments made and collected under Article 3.77, Sec. 13 - Article 3.77, Sec. 8.

Responsibility of and/or Action Needed by Carriers

Inform staff (including agents). If proposed, monitor development and adoption of rules. Monitor development and adoption of rules.

Responsibility of and/or Action Needed by TDI

Inform staff. Evaluate and propose rules, if necessary. Develop/propose and adopt rules.

Applicable Date of Compliance

NUMBER of BILL. (SECTION/ARTICLE) Statute and Title.

HB 710 - The Pool Continued SECTION 1.07 amends Article 3.77, Section 9, Texas Insurance Code

Effective Date of Statute

Requirements of Statute

Rates - The pool shall determine the standard risk rate by considering the premium rates charged by other insurers offering health insurance coverage to individuals. The standard risk rate shall be established using reasonable actuarial techniques and reflect anticipated experience/expenses for coverage. Initial rates may not be less than 125% and may not exceed 150% of rates established as applicable for individual standard rates. Subsequent rates may not exceed 200% of rates applicable to individual standard risks. Rates are to be submitted to the commissioner for approval - Article 3.77, Sec. 9.

Responsibility of and/or Action Needed by Carriers

Inform staff (including agents). To assist in development of rates, respond to any data call by board or commissioner.

Responsibility of and/or Action Needed by TDI

Inform staff. Provide information/assistance to board as necessary. Develop/revise educational materials/brochures. Take any other necessary action. Review and approve rates.

Applicable Date of Compliance

NUMBER of BILL. (SECTION/ARTICLE) Statute and Title.

HB 710 - The Pool Continued SECTION 1.08 amends Article 3.77, Section 10, Texas Insurance Code

Effective Date of Statute

Requirements of Statute

Eligibility For Coverage - A person is eligible for coverage from the pool if the individual is and continues to be a resident of Texas and provides evidence of (a) rejection by two insurers offering substantially similar insurance; (b) an offer to issue insurance only with conditional riders; (c) coverage at rates that are higher than the pool s rate; (d) the individual s maintenance of health insurance coverage for the previous 18 months with no gap in coverage greater than 63 days of which the most recent coverage was through an employer sponsored plan; or (e) one of the medical/health conditions listed by the board under Article 3.77, Section 6. Dependents of an eligible insured are also eligible. If a child is the eligible person, resident family members are also eligible. Pool coverage may be maintained by a person who is satisfying a preexisting waiting period under another policy or arrangement intended to replace the pool coverage - Article 3.77, Sec. 10.

Responsibility of and/or Action Needed by Carriers

Inform staff (including agents).

Responsibility of and/or Action Needed by TDI

Inform staff. Review and approve coverage submitted. Develop/revise educational materials/brochures. Take any other necessary action.

Applicable Date of Compliance

NUMBER of BILL. (SECTION/ARTICLE) Statute and Title.

HB 710 - The Pool Continued

Effective Date of Statute

Requirements of Statute

A person is NOT eligible for coverage from the pool if the person (a) has health insurance coverage from an insurer or an insurance arrangement in effect at the time pool coverage takes effect; (b) is eligible for other health care benefits, including COBRA continuation (see statute for exceptions); (c) has terminated coverage in the pool within 12 months of the date that application is made to the pool (unless the person demonstrates a good faith reason for the termination); (d) is confined in a county jail or imprisoned in a state prison; (e) premiums are paid or reimbursed under any government sponsored program; or (f) termination of pool coverage due to non-payment of premiums or fraud. Coverage ceases (a) upon the date a person is no longer a resident of the state (exceptions are listed in statute); (b) the date coverage is requested to end; (c) upon the death of the covered person; (d) on the date state law mandates; (e) at the option of the pool, 30 days after the pool sends any inquiry concerning the person s eligibility; (f) on the 31st day after the day on which a premium payment for pool coverage becomes due and is not paid; or (g) when the person no longer meets the eligibility requirements - Article 3.77, Sec. 10.

Responsibility of and/or Action Needed by Carriers

Same as above.

Responsibility of and/or Action Needed by TDI

Same as above.

Applicable Date of Compliance

NUMBER of BILL. (SECTION/ARTICLE) Statute and Title.

HB 710 - The Pool Continued SECTION 1.09 amends Article 3.77, Section 11, Texas Insurance Code

Effective Date of Statute

Requirements of Statute

Minimum Pool Benefits - Coverage offered by the pool shall be consistent with major medical expense coverage available. The board, with the approval of the commissioner, shall establish: (a) coverages to be provided; (b) schedules of benefits; and (c) exclusions to coverage and other limitations. Benefits provisions of the pool s coverage s must include: (a) all required or applicable definitions; (b) a list of any exclusions or limitations to coverage; (c) descriptions of covered services; and (d) deductibles, coinsurance options, and copayment options. Adjustments to deductibles, the amounts of stop-loss coverage, and the time periods governing preexisting conditions under Article 3.77, Section 12 may be made to preserve the financial integrity of the pool. All adjustments must be reported in writing to the commissioner not later than the 30th day after the date the adjustment is made. Benefits provided by the pool shall be reduced by amounts paid or payable through any other coverage - Article 3.77, Sec. 11.

Responsibility of and/or Action Needed by Carriers

Inform staff. Respond to any data calls by board or commissioner. Monitor development/adoption of coverage. Monitor adjustments.

Responsibility of and/or Action Needed by TDI

Inform staff. Provide information/assistance to board. Review and approve coverage submitted. Develop/revise educational materials/brochures. Take any other necessary action. Review adjustments submitted. Develop/revise educational materials/brochures. Review and approve coverage submitted. Take any other necessary action.

Applicable Date of Compliance

Coverage must be made available no later than 1/1/98 - SECTION 5.02 of HB 710.

NUMBER of BILL. (SECTION/ARTICLE) Statute and Title.

HB 710 - The Pool Continued SECTION 1.10 amends Article 3.77, Sections 12 and 13, Texas Insurance Code

Effective Date of Statute

Requirements of Statute

Preexisting Conditions - Pool coverage shall exclude charges incurred during the first 12 months following the effective date of coverage with regard to any condition for which medical advice, care, or treatment was recommended or received during the six-month period preceding the effective date of coverage. A preexisting condition provision shall not apply to an individual who was continuously covered for an aggregate period of 12 months by health insurance that was in effect up to a date not more than 63 days before the effective date of coverage under the pool (excluding any waiting period provided application for pool coverage is made no later than 63 days following the termination of coverage). In determining whether a preexisting condition applies, the pool shall credit the time the individual was previously covered under health insurance if the previous coverage was in effect at any time during the 12 months preceding the effective date of coverage under the pool. Any waiting period that applied before that coverage became effective also shall be credited against the preexisting condition provision period - Article 3.77, Sec. 12.

Responsibility of and/or Action Needed by Carriers

Inform staff (including agents).

Responsibility of and/or Action Needed by TDI

Inform staff. Review and approve coverage submitted. Develop/revise educational materials/brochures Take any other necessary action.

Applicable Date of Compliance

NUMBER of BILL. (SECTION/ARTICLE) Statute and Title.

HB 710 - The Pool Continued

Effective Date of Statute

Requirements of Statute

Assessments - The pool may assess insurers and make advance interim assessments as necessary for the plan s organizational and interim operating expenses. Interim assessments shall be credited as offsets against regular assessments due following the close of the fiscal year. If assessment exceed actual losses and administrative expenses, the excess shall be placed in an interest bearing account to be used for future losses or to reduce future assessments. The board shall report net losses (including administrative and incurred losses) to the commissioner after each fiscal year. Losses shall be recouped by assessments on insurers. Each insurer s assessments shall be determined by the board based on annual statements and other reports required by the board. (Medicare supplement and small employer group premiums are excluded from assessment calculation.) An insurer may petition the commissioner for an abatement or deferment of all or part of an assessment. The total of all assessments may not exceed 1/2 of one percent of the insurer s health insurance premiums collected in this state - Article 3.77, Sec. 13.

Responsibility of and/or Action Needed by Carriers

Inform staff. Pay assessments. Monitor assessments collected and losses/expenses of pool. Monitor and pay assessments. Provide annual statements and reports as required. Petition commissioner as necessary.

Responsibility of and/or Action Needed by TDI

Inform staff. Develop/revise educational materials/brochures. Take any other necessary action. Review report. Provide information/assistance to board as necessary. Commissioner to review any petition submitted and may defer or abate (in part or in whole) the assessment.

Applicable Date of Compliance

NUMBER of BILL. (SECTION/ARTICLE) Statute and Title.

HB 710 - The Pool Continued SECTION 1.11 adds Sections 14 and 15 to Article 3.77, Texas Insurance Code

Effective Date of Statute

Requirements of Statute

Complaint Procedures - An applicant/participant in the pool is entitled to have complaints against the pool reviewed by a grievance committee. All complaints shall be held by the pool for three years - Article 3.77, Sec. 14.

Responsibility of and/or Action Needed by Carriers

Inform staff ( including agents).

Responsibility of and/or Action Needed by TDI

Inform staff. Develop/revise educational materials/brochures. Take any other necessary action.

Applicable Date of Compliance

NUMBER of BILL. (SECTION/ARTICLE) Statute and Title.

HB 710 - The Pool Continued

Effective Date of Statute

Requirements of Statute

Audits -The state auditor shall audit the pool annually. The auditor s report shall contain a financial, economy, and efficiency audit. The cost of the audit shall be reported to the board and the comptroller. The board shall remit cost of the audit to the comptroller - Article 3.77, Sec. 15.

Responsibility of and/or Action Needed by Carriers

Same as above.

Responsibility of and/or Action Needed by TDI

Inform staff. Provide information/assistance to auditor. Take any other necessary action.

Applicable Date of Compliance

NUMBER of BILL. (SECTION/ARTICLE) Statute and Title.

HB 710 - Continuation/ Conversion PART 2 relating to Continuation/ Conversion of Group Insurance SECTION 2.01 amends Article 3.51-6, Sec. 1(d)(3), Texas Insurance Code

Effective Date of Statute

Requirements of Statute

Continuation - Insurers providing group insurance coverage shall provide 6 months of continuation of group coverage to employees/members/ dependents whose coverage has been terminated. Eligibility requirements remain the same including, but not limited to, request for continuation must be made within 31 days of termination, the premium must be paid in advance, etc. - Article 3.51-6, Sec. 1(d)(3)(A).

Responsibility of and/or Action Needed by Carriers

Inform staff (including agents). Monitor development and adoption of rules. Revise or develop (a) A&H forms or amendments to bring previously submitted forms into compliance and submit in accordance with Article 3.42 and (b) any other internal documents.

Responsibility of and/or Action Needed by TDI

Inform staff. Develop and propose rules. Review form filings. Develop/revise checklists and other educational materials/brochures. Take any other necessary action.

Applicable Date of Compliance

Applies to group insurance policy that is delivered, issued for delivery or renewed on or after 1/1/98 - SECTION 5.02 of HB 710.

NUMBER of BILL. (SECTION/ARTICLE) Statute and Title.

HB 710 - Continuation/ Conversion Continued

Effective Date of Statute

Requirements of Statute

Not less than 30 days before the end of the 6 months continuation, the insurer shall notify the individual of the coverage available under pool - Article 3.51-6, Sec. 1(d)(3)(A)(vi). An insurer providing group insurance coverage may offer each employee/member/dependent a conversion policy. Conversion shall be issued without evidence of insurability if application and payment of premium are made no later than the 31st day after date of termination. The conversion policy must meet the minimum standards for benefits for conversion policies - Article 3.51-6, Sec. 1(d)(3)(B).

Responsibility of and/or Action Needed by Carriers

Provide notice as required. Inform staff (including agents). Monitor development and adoption of rules. Revise or develop (a) A&H forms or amendments to bring previously submitted forms into compliance and submit in accordance with Article 3.42 and (b) any other internal documents.

Responsibility of and/or Action Needed by TDI

Evaluate proposing promulgated language for the required notice. Inform staff. Develop and propose rules. Review form filings. Develop/revise checklists and other educational materials/brochures. Take any other necessary action.

Applicable Date of Compliance

Same as above.

NUMBER of BILL. (SECTION/ARTICLE) Statute and Title.

HB 710 - Continued PART 3 - INDIVIDUAL COVERAGES SECTION 3.01 relating to Preexisting Conditions in Certain Individual Health Insurance Policies amends Article 3.70, Texas Insurance Code

Effective Date of Statute

Requirements of Statute

Refer to Bulletin #B-0027-97 dated 7/9/97.

Responsibility of and/or Action Needed by Carriers

Same as above.

Responsibility of and/or Action Needed by TDI

Same as above. Proposed rules published in Texas Register on 8/29/97.

Applicable Date of Compliance

Applies to an insurance policy that is delivered, issued for delivery or renewed on or after 7/1/97 - SECTION 5.01 of HB 710.

NUMBER of BILL. (SECTION/ARTICLE) Statute and Title.

HB 710 - Individual Coverages Continued SECTION 3.01 relating to Guaranteed Renewability of Certain Individual Health Insurance Policies adds Article 3.70-1A to the Texas Insurance Code

Effective Date of Statute

Requirements of Statute

Refer to Bulletin #B-0027-97 dated 7/9/97.

Responsibility of and/or Action Needed by Carriers

Same as above.

Responsibility of and/or Action Needed by TDI

Same as above. Proposed rules published in Texas Register on 8/29/97.

Applicable Date of Compliance

Same as above.

NUMBER of BILL. (SECTION/ARTICLE) Statute and Title.

HB 710 - Continued PART 4 - COVERAGE THROUGH HEALTH MAINTENANCE ORGANIZATIONS SECTION 4.01 adds Subsection (k) to Article 20A, Sec. 9, Texas Insurance Code relating to Continuation/ Conversion of group HMO coverage

Effective Date of Statute

Requirements of Statute

Refer to Bulletin #B-0027-97 dated 7/9/97.

Responsibility of and/or Action Needed by Carriers

Inform staff (including agents). Monitor development and adoption of rules. Revise or develop as applicable (a) evidence of coverage and other applicable documents given to enrollees, quality assurance plans and submit in accordance with Article 20A; and (b) any other internal documents.

Responsibility of and/or Action Needed by TDI

Inform staff. Develop and propose rules. Develop/revise checklists and other educational materials/brochures. Review form filings. Take any other necessary action.

Applicable Date of Compliance

Applies to group evidence of coverage delivered, issued for delivery or renewed on or after 7/1/97 - SECTION 5.01 of HB 710.

NUMBER of BILL. (SECTION/ARTICLE) Statute and Title.

HB 710 - HMO Continued SECTION 4.01 adds Subsection (l) to Article 20A, Sec. 9, Texas Insurance Code relating to Health Maintenance Organizations providing Individual Health Care Plans

Effective Date of Statute

Requirements of Statute

Refer to Bulletin #B-0027-97 dated 7/9/97.

Responsibility of and/or Action Needed by Carriers

Same as above.

Responsibility of and/or Action Needed by TDI

Same as above.

Applicable Date of Compliance

Applies to an individual evidence of coverage delivered, issued for delivery or renewed on or after 7/1/97 - SECTION 5.01 of HB 710.