BILL ANALYSIS

C.S.H.B. 2134

By: Bernal

Insurance

Committee Report (Substituted)

BACKGROUND AND PURPOSE

There are three major medical conditions for which a cranial remolding orthosis, or remolding helmet, may be prescribed by a pediatrician. Two conditions, brachycephaly and plagiocephaly, often called flat or misshaped heads, are not considered by state health insurance plans to qualify a child for coverage because orthoses are purely cosmetic. The third condition, craniosynostosis, is potentially life-threatening and requires surgery followed by two separate cranial orthoses to correct. In this situation, the surgery and first remolding orthosis are covered by insurance, but the second molding device is deemed purely cosmetic by some insurance plans. C.S.H.B. 2134 seeks to require a health benefit plan to provide coverage of the full cost of a cranial remolding orthosis for a child diagnosed with craniostenosis or for a child diagnosed with plagiocephaly or brachycephaly under certain additional conditions.

CRIMINAL JUSTICE IMPACT

It is the committee's opinion that this bill does not expressly create a criminal offense, increase the punishment for an existing criminal offense or category of offenses, or change the eligibility of a person for community supervision, parole, or mandatory supervision.

RULEMAKING AUTHORITY

It is the committee's opinion that this bill does not expressly grant any additional rulemaking authority to a state officer, department, agency, or institution.

ANALYSIS

C.S.H.B. 2134 amends the Insurance Code to require a health benefit plan to provide coverage of the full cost of a cranial remolding orthosis for a child diagnosed with the following:

· craniostenosis; or

· plagiocephaly or brachycephaly, if the child is not less than three months of age and not more than 18 months of age, has had documented failure to respond to conservative therapy for at least two months, and has one of the following sets of measurements or indications:

o asymmetrical appearance confirmed by a right/left discrepancy of greater than six millimeters in a craniofacial anthropometric measurement; or

o brachycephalic or dolichocephalic disproportion in the comparison of head length to head width confirmed by a cephalic index of two standard deviations above or below mean.

The bill prohibits the coverage from being less favorable than coverage for other orthotics under the plan and requires the coverage to be subject to the same dollar limits, deductibles, and coinsurance factors as coverage for other orthotics under the plan. The bill defines "cranial remolding orthosis" as a custom-fitted or custom-fabricated medical device that is applied to the head to correct a deformity, improve function, or relieve symptoms of a structural cranial disease.

C.S.H.B. 2134 establishes, and provides certain exceptions to, the applicability of its provisions. The bill applies only to a health benefit plan that is delivered, issued for delivery, or renewed on or after January 1, 2022.

EFFECTIVE DATE

September 1, 2021.

COMPARISON OF ORIGINAL AND SUBSTITUTE

While C.S.H.B. 2134 may differ from the original in minor or nonsubstantive ways, the following summarizes the substantial differences between the introduced and committee substitute versions of the bill.

The substitute requires a health benefit plan to cover the full cost of a cranial remolding orthosis for a child diagnosed with craniostenosis or for a child diagnosed with plagiocephaly or brachycephaly who meets certain additional criteria, including specified measurements or indications, whereas the original based the coverage requirement on a determination of medical necessity and a physician's determination regarding improved quality of life without specifying the nature of the cranial deformity to be treated by the orthosis.

The substitute includes the following provisions relating to applicability that were absent from the original:

· a provision establishing that the bill's provisions apply to the children's health insurance program (CHIP);

· a provision excluding from the applicability of the bill's provisions certain individual health benefit plans issued on or before March 23, 2010; and

· an exception from the bill's coverage requirements for a qualified health plan under the federal Patient Protection and Affordable Care Act of 2010 if the following determination is made under related federal regulations:

o that the bill requires the plan to offer benefits in addition to the essential health benefits required by federal law; and

o that the state must make payments to defray the cost of those additional benefits.

The substitute does not include a provision of the original making the bill's provisions inapplicable to a plan that provides coverage only for a specified disease or for another limited benefit.

The substitute revises and reorganizes provisions from the original relating to the applicability of the bill's provisions. The substitute differs from the original in other minor or nonsubstantive ways by conforming to certain bill drafting conventions.