Bill Text: TX HB2165 | 2011-2012 | 82nd Legislature | Introduced
Bill Title: Relating to the establishment of a medical reinsurance system and to certain insurance reforms necessary to the efficient operation of that system; providing an administrative penalty.
Spectrum: Partisan Bill (Republican 9-0)
Status: (Introduced - Dead) 2011-04-12 - Left pending in committee [HB2165 Detail]
Download: Texas-2011-HB2165-Introduced.html
82R9143 KCR-D | ||
By: Perry | H.B. No. 2165 |
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relating to the establishment of a medical reinsurance system and | ||
to certain insurance reforms necessary to the efficient operation | ||
of that system; providing an administrative penalty. | ||
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: | ||
SECTION 1. The heading to Subtitle F, Title 4, Insurance | ||
Code, is amended to read as follows: | ||
SUBTITLE F. REINSURANCE; STOP-LOSS INSURANCE | ||
SECTION 2. Subtitle F, Title 4, Insurance Code, is amended | ||
by adding Chapter 495 to read as follows: | ||
CHAPTER 495. STOP-LOSS INSURANCE FOR CERTAIN SELF-FUNDED ENTITIES | ||
Sec. 495.001. DEFINITIONS. In this chapter: | ||
(1) "Aggregate stop-loss insurance" means stop-loss | ||
insurance in which the issuer responds after a self-funded health | ||
benefit plan has covered: | ||
(A) claims that total a specified dollar amount; | ||
or | ||
(B) a specified percentage of expected claims, | ||
which may be modified to account for any applicable individual | ||
stop-loss insurance coverage. | ||
(2) "Health benefit plan" means a plan that provides | ||
benefits for hospital, medical, surgical, or other treatment | ||
expenses incurred as a result of a health condition, an accident, or | ||
sickness, including a group health insurance policy, a group | ||
hospital service contract, a group evidence of coverage, or any | ||
other similar coverage document that: | ||
(A) is issued, entered into, or provided by: | ||
(i) an insurance company; | ||
(ii) a group hospital service corporation | ||
operating under Chapter 842; | ||
(iii) a health maintenance organization | ||
operating under Chapter 843; | ||
(iv) a multiple employer welfare | ||
arrangement that holds a certificate of authority under Chapter | ||
846; or | ||
(v) an employer, union, association, | ||
trustee, or other self-funded or self-insured welfare or benefit | ||
plan, program, or arrangement; and | ||
(B) is not limited in scope to only one or more of | ||
the following types of coverage: | ||
(i) accident-only or disability income | ||
insurance coverage or a combination of accident-only and disability | ||
income insurance coverage; | ||
(ii) credit-only insurance coverage; | ||
(iii) disability insurance coverage; | ||
(iv) coverage only for a specified disease | ||
or illness; | ||
(v) Medicare services under a federal | ||
contract; | ||
(vi) Medicare supplement and Medicare | ||
Select policies regulated in accordance with federal law; | ||
(vii) long-term care coverage or benefits, | ||
nursing home care coverage or benefits, home health care coverage | ||
or benefits, community-based care coverage or benefits, or any | ||
combination of those coverages or benefits; | ||
(viii) coverage that provides | ||
limited-scope dental or vision benefits; | ||
(ix) coverage for an on-site medical | ||
clinic; | ||
(x) liability insurance coverage, | ||
including general liability insurance coverage, automobile | ||
liability insurance coverage, and coverage issued as a supplement | ||
to liability insurance coverage; | ||
(xi) workers' compensation insurance | ||
coverage or similar insurance coverage; | ||
(xii) automobile medical payment insurance | ||
coverage, including coverage issued as a supplement to automobile | ||
medical payment insurance coverage; or | ||
(xiii) hospital indemnity or other fixed | ||
indemnity insurance coverage. | ||
(3) "Individual stop-loss deductible" means the | ||
dollar amount of claims that a self-funded health benefit plan must | ||
cover before the issuer of an individual stop-loss insurance policy | ||
begins to reimburse the health benefit plan for additional covered | ||
claims for the remainder of a policy period. | ||
(4) "Individual stop-loss insurance" means stop-loss | ||
insurance in which the issuer responds when the self-funded health | ||
benefit plan covered by the insurance has covered claims that | ||
exceed the applicable individual stop-loss deductible for one | ||
enrollee in the health benefit plan. | ||
(5) "Reinsurance" means a contractual arrangement | ||
between a ceding insurer and an assuming insurer in accordance with | ||
Chapter 492. | ||
(6) "Self-funded health benefit plan" means a health | ||
benefit plan that: | ||
(A) is established as an employee welfare benefit | ||
plan under the Employee Retirement Income Security Act of 1974 (29 | ||
U.S.C. Section 1001 et seq.) or offered by an entity, agency, or | ||
political subdivision of this state under Subtitle H, Title 8; | ||
(B) holds the initial obligation to pay claims | ||
under the plan; and | ||
(C) is exempt under state or federal law from the | ||
licensing requirements of this code. | ||
(7) "Stop-loss insurance" means an insurance policy | ||
covering a self-funded health benefit plan. The term includes | ||
aggregate stop-loss insurance and individual stop-loss insurance. | ||
Sec. 495.002. REINSURANCE PROHIBITED; STOP-LOSS INSURANCE | ||
REQUIRED. (a) An insurer authorized to write reinsurance in this | ||
state may not issue a reinsurance policy covering a self-funded | ||
health benefit plan. | ||
(b) Subject to Section 495.003, an insurer authorized to | ||
write stop-loss insurance in this state may issue a stop-loss | ||
insurance policy covering a self-funded health benefit plan. | ||
Sec. 495.003. PRIOR APPROVAL OF POLICIES. (a) An insurer | ||
authorized to write stop-loss insurance in this state may not issue | ||
or issue for delivery a stop-loss insurance policy in this state | ||
until the policy has been filed with the department and approved by | ||
the commissioner. The commissioner may not approve an individual | ||
stop-loss insurance policy filed under this section if the | ||
individual stop-loss deductible is less than $5,000 or exceeds | ||
$100,000. | ||
(b) The commissioner shall adopt rules under Section 37.001 | ||
to govern the approval of policies filed under this section. | ||
(c) If the commissioner disapproves a policy filed under | ||
this section, the disapproval is subject to judicial review under | ||
Subchapter D, Chapter 36. | ||
(d) In the commissioner's order approving or disapproving a | ||
policy filed under this section, the commissioner shall state | ||
whether the stop-loss policy is subject to Chapters 1675 and 1676. | ||
Sec. 495.004. REPORTS CONCERNING INDIVIDUAL STOP-LOSS | ||
INSURANCE. An insurer that issues individual stop-loss insurance | ||
in this state shall annually file with the department a report that | ||
contains the annualized gross premium and annual individual | ||
stop-loss deductible for each individual stop-loss insurance | ||
policy issued in this state. | ||
SECTION 3. Title 8, Insurance Code, is amended by adding | ||
Subtitle K to read as follows: | ||
SUBTITLE K. TEXAS MEDICAL REINSURANCE SYSTEM | ||
CHAPTER 1675. TEXAS MEDICAL REINSURANCE SYSTEM | ||
Sec. 1675.001. DEFINITIONS. In this chapter: | ||
(1) "Affiliate" means a person or entity classified as | ||
an affiliate under Section 823.003. | ||
(2) "Aggregate stop-loss insurance" has the meaning | ||
assigned by Section 495.001. | ||
(3) "Board" means the board of directors of the Texas | ||
Medical Reinsurance System. | ||
(4) "Health benefit plan" has the meaning assigned by | ||
Section 495.001. | ||
(5) "Health benefit plan issuer" means an entity that | ||
issues a health benefit plan. | ||
(6) "Independent auditor" means the auditor with whom | ||
the board contracts under Section 1675.006 to audit the | ||
administration, management, and operation of the system. | ||
(7) "Individual stop-loss insurance" has the meaning | ||
assigned by Section 495.001. | ||
(8) "Management company" means the entity with whom | ||
the board contracts under Section 1675.006 to administer, manage, | ||
and operate the system. | ||
(9) "Plan of operation" means the plan of operation of | ||
the system established under Section 1675.007. | ||
(10) "Self-funded health benefit plan" has the meaning | ||
assigned by Section 495.001. | ||
(11) "Stop-loss insurance" has the meaning assigned by | ||
Section 495.001. | ||
(12) "Subsidiary" means a person classified as a | ||
subsidiary under Section 823.003. | ||
(13) "System" means the Texas Medical Reinsurance | ||
System established under this chapter. | ||
Sec. 1675.002. TEXAS MEDICAL REINSURANCE SYSTEM. The Texas | ||
Medical Reinsurance System is an entity that is: | ||
(1) administered by a board of directors and | ||
management company in accordance with this chapter; and | ||
(2) subject to the supervision and control of the | ||
commissioner. | ||
Sec. 1675.003. SYSTEM BOARD OF DIRECTORS. (a) The board of | ||
directors of the system is composed of the following nine members: | ||
(1) one member appointed by the governor, selected | ||
from a list of candidates prepared by the lieutenant governor; | ||
(2) one member appointed by the governor, selected | ||
from a list of candidates prepared by the speaker of the house of | ||
representatives; | ||
(3) one member appointed by the governor who is a small | ||
employer, as defined by Section 1501.002; | ||
(4) one member appointed by the governor who is a large | ||
employer, as defined by Section 1501.002; | ||
(5) one member appointed by the governor who | ||
represents the interests of political subdivisions of this state; | ||
(6) one member appointed by the governor who | ||
represents the interests of physicians in this state; | ||
(7) one member appointed by the governor who | ||
represents the interests of hospitals in this state; | ||
(8) one member who is the executive director of the | ||
Employees Retirement System of Texas or that executive director's | ||
designee; and | ||
(9) one member who is the executive director of the | ||
Teacher Retirement System of Texas or that executive director's | ||
designee. | ||
(b) A board member may not: | ||
(1) be an officer, director, or employee of a health | ||
benefit plan issuer or an affiliate or subsidiary of a health | ||
benefit plan issuer; | ||
(2) be a person required to register under Chapter | ||
305, Government Code; or | ||
(3) be related to a person described by Subdivision | ||
(1) or (2) within the second degree by affinity or consanguinity. | ||
(c) Members of the board appointed by the governor serve | ||
two-year terms expiring December 31 of each odd-numbered year. A | ||
member's term continues until a successor is appointed. | ||
(d) A member of the board may not be compensated for serving | ||
on the board but is entitled to reimbursement for actual expenses | ||
incurred in performing functions as a member of the board as | ||
provided by the General Appropriations Act. | ||
Sec. 1675.004. OPEN MEETINGS; PUBLIC INFORMATION. The | ||
board is subject to: | ||
(1) the open meetings law, Chapter 551, Government | ||
Code; and | ||
(2) the public information law, Chapter 552, | ||
Government Code. | ||
Sec. 1675.005. BOARD MEMBER IMMUNITY. (a) A member of the | ||
board is not liable for an act performed, or omission made, in good | ||
faith in the performance of powers and duties under this chapter. | ||
(b) A cause of action does not arise against a member of the | ||
board for an act or omission described by Subsection (a). | ||
Sec. 1675.006. SELECTION OF MANAGEMENT COMPANY AND | ||
INDEPENDENT AUDITOR. (a) The board shall contract with: | ||
(1) an entity that is qualified to administer, manage, | ||
and operate the system; and | ||
(2) an entity that is qualified to audit the manner in | ||
which the entity described by Subdivision (1) performs its duties. | ||
(b) An entity with whom the board contracts under Subsection | ||
(a) may not be a health benefit plan issuer or an affiliate or | ||
subsidiary of a health benefit plan issuer. | ||
(c) A management company with whom the board contracts under | ||
Subsection (a)(1) must have the capability to gather, compile, and | ||
securely store information received from health benefit plan | ||
issuers and health care providers with whom health benefit plan | ||
issuers contract in a manner that allows the management company to | ||
prepare reports as requested by the board. | ||
Sec. 1675.007. SYSTEM PLAN OF OPERATION. (a) The | ||
management company shall submit to the commissioner a plan of | ||
operation and any amendments to that plan necessary or suitable to | ||
ensure the fair, reasonable, and equitable administration of the | ||
system. | ||
(b) The commissioner, after notice and hearing, may approve | ||
the plan of operation if the commissioner determines the plan: | ||
(1) is suitable to ensure the fair, reasonable, and | ||
equitable administration of the system; and | ||
(2) provides for the sharing of system gains or losses | ||
on an equitable and proportionate basis in accordance with this | ||
chapter. | ||
(c) The plan of operation is effective on the written | ||
approval of the commissioner. | ||
Sec. 1675.008. SYSTEM POWERS AND DUTIES. (a) The system, | ||
through the board and the management company, has the general | ||
powers and authority granted under state law to an insurer or a | ||
health maintenance organization authorized to engage in business, | ||
except that the system may not directly issue a health benefit plan. | ||
(b) The system may: | ||
(1) enter into contracts necessary or proper to | ||
implement this chapter, including, with the commissioner's | ||
approval, contracts with similar programs of other states for the | ||
joint performance of common functions or with persons or other | ||
organizations for the performance of administrative functions; | ||
(2) sue or be sued, including taking legal action | ||
necessary or proper to recover assessments and penalties for, on | ||
behalf of, or against the system or a reinsured health benefit plan | ||
issuer; | ||
(3) take legal action necessary to avoid the payment | ||
of improper claims against the system; | ||
(4) issue reinsurance contracts in accordance with | ||
this chapter; | ||
(5) establish guidelines, conditions, and procedures | ||
for reinsuring risks under the plan of operation; | ||
(6) establish actuarial and underwriting functions as | ||
appropriate for the operation of the system; | ||
(7) appoint appropriate legal, actuarial, and other | ||
committees necessary to provide technical assistance in: | ||
(A) the operation of the system; | ||
(B) policy and other contract design; and | ||
(C) any other function within the authority of | ||
the system; and | ||
(8) assess health benefit plan issuers and stop-loss | ||
insurers in accordance with Section 1675.012. | ||
Sec. 1675.009. SYSTEM AUDIT; INDEPENDENT AUDIT AND STATE | ||
AUDIT. (a) The transactions of the system are subject to audit by | ||
the state auditor in accordance with Chapter 321, Government Code. | ||
The state auditor shall report the cost of each audit conducted | ||
under this subsection to the board, the management company, and the | ||
comptroller, and the board shall remit that amount to the | ||
comptroller. | ||
(b) The independent auditor shall annually audit the | ||
transactions of the system and the manner in which the management | ||
company is performing the management company's duties. The | ||
independent auditor shall deliver to the board the results of an | ||
audit conducted under this subsection. An independent audit | ||
conducted under this subsection must include a budgetary and | ||
accounting analysis of the system's operation. | ||
Sec. 1675.010. REINSURANCE REQUIRED; AMOUNT REQUIRED FOR | ||
STOP-LOSS INSURANCE. (a) The following entities shall purchase | ||
from the system reinsurance for the following types of health | ||
benefit plans: | ||
(1) a health benefit plan issuer, for each health | ||
benefit plan issued; and | ||
(2) an insurer that is authorized to write stop-loss | ||
insurance in this state, for each individual stop-loss policy | ||
covering a self-funded health benefit plan. | ||
(b) A health benefit plan issuer required to purchase | ||
reinsurance under Subsection (a)(1) is not required to and may not | ||
purchase reinsurance for a health benefit plan issued that covers | ||
exclusively Medicare services or is a Medicare supplement policy, | ||
as applicable and as determined by federal law. | ||
(c) An insurer required to purchase reinsurance under | ||
Subsection (a)(2) must purchase reinsurance on each health benefit | ||
plan and each individual stop-loss insurance policy in a manner and | ||
amount consistent with Section 1676.002. | ||
Sec. 1675.011. PREMIUM RATES FOR REINSURANCE. (a) As part | ||
of the plan of operation, the management company shall adopt a | ||
method to determine premium rates to be charged by the system for | ||
reinsurance contracts issued under this chapter. | ||
(b) The method adopted must: | ||
(1) allow premium rate variations based on: | ||
(A) demographic and geographic factors; and | ||
(B) the level of benefits provided under a | ||
reinsured health benefit plan; | ||
(2) be actuarially justifiable and approved by the | ||
commissioner under Section 1675.007 as part of the system plan of | ||
operation; and | ||
(3) provide for the sharing, on an equitable and | ||
proportionate basis, of system gains or losses among health benefit | ||
plan issuers and stop-loss insurers required to purchase | ||
reinsurance from the system under Section 1675.010. | ||
Sec. 1675.012. ASSESSMENTS; DEFERMENT OF ASSESSMENTS. (a) | ||
The board shall recover any net loss of the system by assessing each | ||
reinsured health benefit plan issuer or stop-loss insurer required | ||
to purchase reinsurance through the system under Section 1675.010 | ||
an amount determined annually by the board based on information in | ||
annual statements and other reports required by and filed with the | ||
board. | ||
(b) The board shall establish, as part of the plan of | ||
operation, a formula by which to make assessments that are made | ||
under Subsection (a). With the approval of the commissioner, the | ||
board may periodically change the assessment formula as | ||
appropriate. The board shall base the assessment formula on each | ||
reinsured health benefit plan issuer's or stop-loss insurer's share | ||
of the total premiums earned in the preceding calendar year from | ||
health benefit plans and policies of individual stop-loss insurance | ||
described by Section 1675.010. | ||
(c) A reinsured health benefit plan issuer or stop-loss | ||
insurer may petition the commissioner for a deferment in whole or in | ||
part of an assessment imposed by the board. | ||
(d) The commissioner may defer all or part of the assessment | ||
if the commissioner determines that payment of the assessment would | ||
endanger the ability of the reinsured health benefit plan issuer or | ||
stop-loss insurer to fulfill its contractual obligations. | ||
(e) The board shall assess the amount of any deferred | ||
assessment against other reinsured health benefit plan issuers and | ||
stop-loss insurers in a manner consistent with the basis for | ||
assessment established by this chapter. | ||
Sec. 1675.013. EFFECT OF DEFERRAL. A reinsured health | ||
benefit plan issuer or stop-loss insurer that receives a deferral | ||
under Section 1675.012(d): | ||
(1) remains liable to the system for the amount | ||
deferred; and | ||
(2) until the deferred assessment is paid, may not | ||
advertise, market, deliver, or issue for delivery: | ||
(A) a health benefit plan or insurance policy of | ||
the type for which the deferral is received; or | ||
(B) any other health benefit plan or insurance | ||
policy subject to this chapter. | ||
Sec. 1675.014. RULES. The commissioner may adopt rules | ||
necessary to implement this chapter. | ||
CHAPTER 1676. CERTAIN HEALTH SERVICES AND SUPPLIES PROVIDED UNDER | ||
REINSURED PLANS AND POLICIES | ||
Sec. 1676.001. DEFINITIONS. (a) In this chapter: | ||
(1) "Health benefit plan claim" means a claim | ||
reimbursable under a reinsured plan or policy. | ||
(2) "Health care provider" means a practitioner, | ||
institutional provider, or other person or organization that | ||
furnishes health care services or supplies and that is licensed or | ||
otherwise authorized to practice in this state. The term includes a | ||
physician. | ||
(3) "Hospital" means a licensed public or private | ||
institution as defined by Chapter 241, Health and Safety Code, or | ||
Subtitle C, Title 7, Health and Safety Code. | ||
(4) "Institutional provider" means a hospital, | ||
nursing home, or other medical or health-related service facility | ||
that provides care for the sick or injured or other care that may be | ||
covered in a reinsured plan or policy. | ||
(5) "Plan claim administrator" means the individual or | ||
entity responsible for paying claims under a reinsured plan or | ||
policy. | ||
(6) "Policy period" means the period during which a | ||
reinsured plan or policy provides coverage. | ||
(7) "Practitioner" means an individual who practices a | ||
healing art. The term includes a practitioner described by Section | ||
1451.001 or 1451.101. | ||
(8) "Qualified health benefit plan claim" means a | ||
health benefit plan claim that has been repriced and adjusted by the | ||
plan claim administrator under Section 1676.003(b). | ||
(9) "Reinsurance attachment point" means the point at | ||
which the system begins to reimburse a reinsured plan or policy | ||
under Section 1676.002. | ||
(10) "Reinsurance extension period" means the | ||
applicable period in which the system provides reinsurance coverage | ||
for a reinsured plan or policy under Section 1676.006. | ||
(11) "Reinsured entity" means: | ||
(A) for a health benefit plan claim under a plan | ||
that is insured, the health benefit plan issuer; or | ||
(B) for a health benefit plan claim under a | ||
self-funded health benefit plan that is self-insured, the insurer | ||
issuing the stop-loss insurance covering the plan. | ||
(12) "Reinsured plan or policy" means a health benefit | ||
plan or individual stop-loss insurance policy that is reinsured | ||
under the system as provided by Section 1675.010. | ||
(13) "Repricing schedule" means the schedule | ||
established by the system under Section 1676.004 for the purpose of | ||
determining whether a health benefit plan claim is a qualified | ||
health benefit plan claim and, if applicable, the amount of | ||
reimbursement to which a reinsured entity may be entitled. | ||
(b) In this chapter, "board," "management company," and | ||
"system" have the meanings assigned by Section 1675.001. | ||
Sec. 1676.002. REINSURANCE ATTACHMENT POINT. (a) The | ||
board of the system, after consulting with the management company, | ||
shall annually establish the aggregated dollar amount of qualified | ||
health benefit claims at which the system begins to reimburse a | ||
reinsured entity. | ||
(b) The system shall submit the reinsurance attachment | ||
point to the commissioner as an amendment to the system plan of | ||
operation for approval under Section 1675.007. | ||
(c) The reinsurance attachment point may not be less than: | ||
(1) $50,000 per enrollee in a policy period, if the | ||
reinsured plan or policy is not described by Subdivision (2); and | ||
(2) $50,000 above the individual stop-loss deductible | ||
of an individual stop-loss insurance policy in a policy period. | ||
Sec. 1676.003. DETERMINATION THAT CLAIM IS REINSURED; | ||
NOTICE TO SYSTEM. (a) A plan claim administrator shall determine, | ||
at the time of receipt of a claim under a reinsured plan or policy, | ||
whether the claim is potentially a reinsured claim. | ||
(b) On receipt of a potentially reinsured claim, the plan | ||
claim administrator shall adjust the amount of the claim to the | ||
lesser of: | ||
(1) the amount charged for the service by the health | ||
care provider; | ||
(2) the amount payable for the claim, without regard | ||
to whether it is a reinsured claim, under the reinsured plan or | ||
policy in accordance with any contract entered into by the health | ||
care provider; or | ||
(3) the amount payable for the claim under the | ||
repricing schedule established under Section 1676.004. | ||
(c) At the end of a policy period during which a health | ||
benefit plan claim occurs, the plan claim administrator shall | ||
calculate the total dollar amount of qualified health benefit plan | ||
claims for an individual. | ||
(d) If a plan claim administrator determines that the total | ||
dollar amount of qualified health benefit plan claims for an | ||
individual exceeds the applicable reinsurance attachment point, | ||
the plan claim administrator, not later than the 30th day after the | ||
last day of the policy period, shall notify the system in writing of | ||
that determination and submit the claim to the system. | ||
Sec. 1676.004. REPRICING SCHEDULE. (a) The system shall | ||
establish and maintain a repricing schedule for reinsured claims in | ||
accordance with the plan of operation and this section. | ||
(b) The repricing schedule established under Subsection (a) | ||
must provide for certain reimbursement rates as follows: | ||
(1) for a practitioner, a rate that is not less than | ||
110 percent of Medicare reimbursement rates for the practitioner; | ||
and | ||
(2) for an institutional provider, a rate that is not | ||
less than 140 percent of Medicare reimbursement rates for the | ||
institutional provider. | ||
Sec. 1676.005. AMOUNT OF REINSURANCE; REINSURANCE | ||
REIMBURSEMENT. The system must provide for the reimbursement of | ||
aggregated qualified health benefit plan claims that exceed the | ||
reinsurance attachment point and that are originally submitted to | ||
the system under Section 1676.003(d), or during any applicable | ||
reinsurance extension period, as follows: | ||
(1) for a reinsured health benefit plan, an amount | ||
that is equal to the lesser of: | ||
(A) 95 percent of the aggregated dollar amount of | ||
health benefit plan claims that exceed the reinsurance attachment | ||
point for the respective period, before those claims have been | ||
repriced and adjusted under Section 1676.003(b); or | ||
(B) the aggregated dollar amount of qualified | ||
health benefit plan claims that were submitted to the system under | ||
Section 1676.003(d) that exceed the reinsurance attachment point | ||
for the respective period; and | ||
(2) for a reinsured stop-loss insurance policy, an | ||
amount that is equal to the lesser of: | ||
(A) 95 percent of the aggregated dollar amount of | ||
health benefit plan claims that exceed the applicable reinsurance | ||
attachment point for the respective period and for which the | ||
reinsured entity is responsible under the individual stop-loss | ||
insurance policy, before those claims have been repriced and | ||
adjusted under Section 1676.003(b); or | ||
(B) the aggregated dollar amount of qualified | ||
health benefit plan claims that were submitted to the system under | ||
Section 1676.003(d) for the respective period and for which the | ||
insurer issuing the individual stop-loss insurance is responsible. | ||
Sec. 1676.006. PERIOD OF REINSURANCE COVERAGE; CLAIMS | ||
BASIS. (a) The reinsurance policy issued by the system shall cover | ||
a reinsured plan or policy for: | ||
(1) subject to Subsection (b), a period that is | ||
concomitant with the policy period of the reinsured plan or policy; | ||
and | ||
(2) a claims basis that is consistent with the claims | ||
basis of the reinsured plan or policy, regardless of whether the | ||
reinsured plan or policy is an insured plan or a self-funded plan. | ||
(b) A reinsurance policy issued by the system may not | ||
provide coverage for an initial period that exceeds 12 months. | ||
Sec. 1676.007. REINSURANCE EXTENSION PERIOD. (a) The | ||
policy period that immediately follows the initial policy period | ||
during which the aggregated dollar amount of qualified reinsurance | ||
claims exceeds the reinsurance attachment point is the first | ||
reinsurance extension period. A reinsurance extension period under | ||
this subsection is automatic and applies regardless of whether a | ||
different health benefit plan issuer is responsible for the | ||
reinsured claims or a different stop-loss insurance carrier is | ||
responsible for the stop-loss insurance policy. | ||
(b) If, during the first reinsurance extension period | ||
described by Subsection (a), the system reimburses a reinsured | ||
entity for qualified health benefit claims that, if submitted | ||
during the initial policy period would have exceeded the | ||
reinsurance attachment point, the system shall extend reinsurance | ||
coverage from the first dollar of claims to the reinsured entity for | ||
a second reinsurance extension period. | ||
(c) A reinsured entity may not receive a third or subsequent | ||
reinsurance extension period, and the period following the first | ||
reinsurance extension period is considered a new initial policy | ||
period. | ||
Sec. 1676.008. DATA CALL FOR REIMBURSEMENT SCHEDULE. (a) | ||
The commissioner shall provide the system the information required | ||
by the system to establish and maintain the repricing schedule | ||
under Section 1676.004. | ||
(b) The commissioner may request information necessary to | ||
comply with this section from any individual or entity that holds a | ||
license or certificate of authority under this code. | ||
(c) An individual or entity that fails to comply with a | ||
request for information under this section violates this code and | ||
is subject to sanctions under Chapters 82, 83, and 84. | ||
(d) Information that is obtained by the commissioner under | ||
this section and that is exempt from disclosure under Chapter 552, | ||
Government Code, including information exempt from disclosure | ||
under Section 552.104 or 552.110, Government Code: | ||
(1) may be disclosed by the commissioner only to the | ||
system for the purposes of the reimbursement schedule; and | ||
(2) may not be disclosed by the commissioner or the | ||
system to any other individual or entity. | ||
SECTION 4. Effective September 1, 2014, Subchapter G, | ||
Chapter 1501, Insurance Code, is repealed. | ||
SECTION 5. As soon as practicable after the effective date | ||
of this Act, the commissioner of insurance by rule shall develop a | ||
transition plan for implementation of Chapters 1675 and 1676, | ||
Insurance Code, as added by this Act, and for the orderly | ||
termination of the Texas Health Reinsurance System established | ||
under Subchapter G, Chapter 1501, Insurance Code. The transition | ||
plan must include a timetable with specific steps and deadlines | ||
needed to fully implement Chapters 1675 and 1676, Insurance Code. | ||
The transition plan must ensure that Chapters 1675 and 1676, | ||
Insurance Code, are fully implemented not later than September 1, | ||
2012. | ||
SECTION 6. (a) The governor shall make the appointments | ||
described by Section 1675.003, Insurance Code, as added by this | ||
Act, as soon as possible after the effective date of this Act, and | ||
in no event later than April 1, 2012. | ||
(b) The lieutenant governor and the speaker of the house of | ||
representatives shall submit the lists of candidates described by | ||
Sections 1675.003(a)(1) and (2), Insurance Code, as added by this | ||
Act, to the governor not later than January 1, 2012. | ||
SECTION 7. This Act takes effect immediately if it receives | ||
a vote of two-thirds of all the members elected to each house, as | ||
provided by Section 39, Article III, Texas Constitution. If this | ||
Act does not receive the vote necessary for immediate effect, this | ||
Act takes effect September 1, 2011. |