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A BILL TO BE ENTITLED
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AN ACT
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relating to coordination of vision and eye care benefits under |
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certain health benefit plans and vision benefit plans. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Chapter 1203, Insurance Code, is amended by |
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adding Subchapter C to read as follows: |
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SUBCHAPTER C. VISION AND EYE CARE BENEFITS |
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Sec. 1203.101. DEFINITIONS. In this subchapter: |
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(1) "Eye care expenses" means expenses related to |
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vision or medical eye care services, procedures, or products. |
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(2) "Health benefit plan" means a policy, agreement, |
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contract, or evidence of coverage that provides comprehensive |
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medical coverage. |
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(3) "Vision benefit plan" means a limited-scope |
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policy, agreement, contract, or evidence of coverage that provides |
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coverage for eye care expenses but does not provide comprehensive |
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medical coverage. |
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Sec. 1203.102. APPLICABILITY OF SUBCHAPTER. This |
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subchapter applies only to a health benefit plan or vision benefit |
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plan that provides or arranges for benefits for vision or medical |
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eye care services, procedures, or products, including an |
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individual, group, blanket, or franchise insurance policy or |
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insurance agreement, a group hospital service contract, an evidence |
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of coverage, or a vision benefit plan offered by: |
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(1) an insurance company; |
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(2) a group hospital service corporation operating |
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under Chapter 842; |
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(3) a health maintenance organization operating under |
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Chapter 843; |
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(4) a stipulated premium company operating under |
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Chapter 884; |
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(5) a fraternal benefit society operating under |
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Chapter 885; |
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(6) a Lloyd's plan operating under Chapter 941; |
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(7) an exchange operating under Chapter 942; or |
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(8) a person or entity that provides a vision benefit |
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plan. |
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Sec. 1203.103. EXCEPTION. This subchapter does not apply |
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to a supplemental insurance policy that only pays benefits directly |
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to the policyholder. |
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Sec. 1203.104. COORDINATION OF BENEFITS BETWEEN PRIMARY AND |
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SECONDARY PLAN ISSUERS. (a) This section applies if: |
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(1) an enrollee is covered by at least two different |
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health benefit plans or vision benefit plans; and |
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(2) each plan provides the enrollee coverage for the |
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same vision or medical eye care services, procedures, or products. |
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(b) The issuer of the primary health benefit plan or vision |
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benefit plan, as determined under a coordination of benefits |
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provision applicable to the plan, is responsible for eye care |
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expenses covered under the plan up to the full amount of any plan |
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coverage limit applicable to the covered eye care expenses. |
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(c) Before the plan coverage limit described by Subsection |
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(b) is reached, the issuer of a secondary health benefit plan or |
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vision benefit plan, as determined under a coordination of benefits |
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provision applicable to the plan, is responsible only for eye care |
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expenses covered under the plan that are not covered under the |
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health benefit plan or vision benefit plan issued by the primary |
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plan issuer. |
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(d) After the plan coverage limit described by Subsection |
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(b) has been reached, the secondary plan issuer, in addition to the |
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responsibilities described by Subsection (c), is responsible for |
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any eye care expenses covered by both plans that exceed the plan |
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coverage limit described by Subsection (b) up to the coverage limit |
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of the secondary plan. |
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(e) When an enrollee is covered by more than one health |
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benefit plan or vision benefit plan that provides benefits for eye |
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care expenses, the enrollee may use each plan on the same date of |
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service up to the coverage limit of each plan. |
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(f) A vision benefit plan issuer shall coordinate benefits |
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with a health benefit plan issuer if both provide benefits for eye |
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care expenses. |
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(g) A vision benefit plan issuer may not require a claim |
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denial before adjudicating a claim up to the coverage limit of the |
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plan. |
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(h) Nothing in this section prevents a secondary plan issuer |
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from requiring proof that a related claim has been submitted to a |
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primary plan issuer for purposes of determining the remaining |
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balance up to the secondary plan's coverage limits. |
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(i) If a secondary plan issuer requires proof that a related |
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claim has been submitted to a primary plan issuer as described by |
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Subsection (h), the mechanism of providing proof must be through an |
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online submission. |
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Sec. 1203.105. CERTAIN COORDINATION OF BENEFITS PROVISIONS |
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PROHIBITED. (a) A health benefit plan or vision benefit plan |
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subject to this subchapter may not be delivered, issued for |
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delivery, or renewed in this state if: |
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(1) a provision of the plan excludes or reduces the |
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payment of benefits for eye care expenses to or on behalf of an |
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enrollee; |
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(2) the reason for the exclusion or reduction is that |
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eye care benefits are payable or have been paid to or on behalf of |
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the enrollee under another plan; and |
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(3) the exclusion or reduction would apply before the |
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full amount of the eye care expenses incurred by the enrollee and |
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covered by both plans have been paid or reimbursed or the full |
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amount of the applicable coverage limit of the plan containing the |
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exclusion or reduction is reached. |
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(b) Nothing in this section requires a secondary plan issuer |
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to pay an amount that, when added to a payment amount made by a |
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primary plan issuer, would exceed the usual and customary billed |
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charges of the health care provider. |
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Sec. 1203.106. CERTAIN COORDINATION OF BENEFITS PROVISIONS |
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VOID. A provision of a health benefit plan or vision benefit plan |
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that violates this subchapter is void. |
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Sec. 1203.107. RULES. The commissioner may adopt rules |
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necessary to implement this subchapter. |
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SECTION 2. The change in law made by this Act applies only |
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to a health benefit plan or vision benefit plan that is delivered, |
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issued for delivery, or renewed on or after January 1, 2024. A plan |
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delivered, issued for delivery, or renewed before January 1, 2024, |
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is governed by the law as it existed immediately before the |
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effective date of this Act, and that law is continued in effect for |
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that purpose. |
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SECTION 3. This Act takes effect September 1, 2023. |