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A BILL TO BE ENTITLED
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AN ACT
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relating to coverage for childhood cranial remolding orthosis under |
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certain health benefit plans. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Chapter 1367, Insurance Code, is amended by |
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adding Subchapter G to read as follows: |
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SUBCHAPTER G. CHILDHOOD CRANIAL REMOLDING ORTHOSIS |
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Sec. 1367.301. DEFINITION. In this subchapter, "cranial |
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remolding orthosis" means a custom-fitted or custom-fabricated |
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medical device that is applied to the head to correct a deformity, |
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improve function, or relieve symptoms of a structural cranial |
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disease. |
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Sec. 1367.302. APPLICABILITY OF SUBCHAPTER. (a) This |
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subchapter applies only to a health benefit plan that provides |
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benefits for medical or surgical expenses incurred as a result of a |
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health condition, accident, or sickness, including an individual, |
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group, blanket, or franchise insurance policy or insurance |
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agreement, a group hospital service contract, or an individual or |
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group evidence of coverage or similar coverage document that is |
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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) an approved nonprofit health corporation that |
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holds a certificate of authority under Chapter 844; |
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(5) a multiple employer welfare arrangement that holds |
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a certificate of authority under Chapter 846; |
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(6) a stipulated premium company operating under |
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Chapter 884; |
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(7) a fraternal benefit society operating under |
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Chapter 885; |
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(8) a Lloyd's plan operating under Chapter 941; or |
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(9) an exchange operating under Chapter 942. |
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(b) This subchapter applies to coverage under a group health |
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benefit plan described by Subsection (a) provided to a resident of |
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this state, regardless of whether the group policy or contract is |
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delivered, issued for delivery, or renewed within or outside this |
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state. |
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(c) Notwithstanding any other law, this subchapter applies |
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to: |
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(1) a small employer health benefit plan subject to |
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Chapter 1501, including coverage provided through a health group |
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cooperative under Subchapter B of that chapter; |
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(2) a standard health benefit plan issued under |
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Chapter 1507; |
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(3) a basic coverage plan under Chapter 1551; |
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(4) a basic plan under Chapter 1575; |
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(5) a primary care coverage plan under Chapter 1579; |
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(6) a plan providing basic coverage under Chapter |
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1601; |
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(7) health benefits provided by or through a church |
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benefits board under Subchapter I, Chapter 22, Business |
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Organizations Code; |
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(8) group health coverage made available by a school |
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district in accordance with Section 22.004, Education Code; |
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(9) the state Medicaid program, including the Medicaid |
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managed care program operated under Chapter 533, Government Code; |
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(10) the child health plan program under Chapter 62, |
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Health and Safety Code; |
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(11) a regional or local health care program operated |
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under Section 75.104, Health and Safety Code; and |
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(12) a self-funded health benefit plan sponsored by a |
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professional employer organization under Chapter 91, Labor Code. |
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(d) This subchapter does not apply to a qualified health |
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plan defined by 45 C.F.R. Section 155.20 if a determination is made |
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under 45 C.F.R. Section 155.170 that: |
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(1) this subchapter requires the plan to offer |
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benefits in addition to the essential health benefits required |
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under 42 U.S.C. Section 18022(b); and |
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(2) this state must make payments to defray the cost of |
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the additional benefits mandated by this subchapter. |
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(e) This subchapter does not apply to an individual health |
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benefit plan issued on or before March 23, 2010, that has not had |
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any significant changes since that date that reduce benefits or |
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increase costs to the individual. |
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Sec. 1367.303. COVERAGE REQUIRED. (a) A health benefit |
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plan is required to cover in full the cost of a cranial remolding |
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orthosis for a child diagnosed with: |
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(1) craniostenosis; or |
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(2) plagiocephaly or brachycephaly if the child: |
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(A) is not less than three months of age and not |
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more than 18 months of age; |
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(B) has had documented failure to respond to |
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conservative therapy for at least two months; and |
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(C) has one of the following sets of measurements |
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or indications: |
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(i) asymmetrical appearance confirmed by a |
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right/left discrepancy of greater than six millimeters in a |
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craniofacial anthropometric measurement; or |
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(ii) brachycephalic or dolichocephalic |
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disproportion in the comparison of head length to head width |
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confirmed by a cephalic index of two standard deviations above or |
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below mean. |
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(b) Coverage required by this section: |
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(1) may not be less favorable than coverage for other |
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orthotics under the health benefit plan; and |
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(2) must be subject to the same dollar limits, |
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deductibles, and coinsurance as coverage for other orthotics under |
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the health benefit plan. |
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SECTION 2. If before implementing any provision of this Act |
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a state agency determines that a waiver or authorization from a |
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federal agency is necessary for implementation of that provision, |
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the agency affected by the provision shall request the waiver or |
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authorization and may delay implementing that provision until the |
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waiver or authorization is granted. |
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SECTION 3. The change in law made by this Act applies only |
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to a health benefit plan that is delivered, issued for delivery, or |
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renewed on or after January 1, 2022. |
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SECTION 4. This Act takes effect September 1, 2021. |