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A BILL TO BE ENTITLED
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AN ACT
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relating to health benefit plan coverage for hair prostheses for |
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breast cancer patients. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. The heading to Chapter 1371, Insurance Code, is |
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amended to read as follows: |
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CHAPTER 1371. COVERAGE FOR CERTAIN PROSTHETIC DEVICES AND OTHER |
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PROSTHESES, ORTHOTIC DEVICES, AND RELATED SERVICES |
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SECTION 2. Chapter 1371, Insurance Code, is amended by |
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designating Sections 1371.001 and 1371.002 as Subchapter A and |
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adding a subchapter heading to read as follows: |
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SUBCHAPTER A. GENERAL PROVISIONS |
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SECTION 3. Chapter 1371, Insurance Code, is amended by |
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designating Sections 1371.003 through 1371.005 as Subchapter B and |
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adding a subchapter heading to read as follows: |
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SUBCHAPTER B. PROSTHETIC DEVICES, ORTHOTIC DEVICES, AND RELATED |
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SERVICES |
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SECTION 4. Sections 1371.003(b), (c), and (e), Insurance |
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Code, are amended to read as follows: |
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(b) Covered benefits under this subchapter [chapter] are |
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limited to the most appropriate model of prosthetic device or |
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orthotic device that adequately meets the medical needs of the |
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enrollee as determined by the enrollee's treating physician or |
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podiatrist and prosthetist or orthotist, as applicable. |
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(c) Subject to applicable copayments and deductibles, the |
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repair and replacement of a prosthetic device or orthotic device is |
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a covered benefit under this subchapter [chapter] unless the repair |
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or replacement is necessitated by misuse or loss by the enrollee. |
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(e) Covered benefits under this subchapter [chapter] may be |
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provided by a pharmacy that has employees who are qualified under |
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the Medicare system and applicable Medicaid regulations to service |
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and bill for orthotic services. This subchapter [chapter] does not |
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preclude a pharmacy from being reimbursed by a health benefit plan |
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for the provision of orthotic services. |
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SECTION 5. Section 1371.005, Insurance Code, is amended to |
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read as follows: |
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Sec. 1371.005. MANAGED CARE PLAN. A health benefit plan |
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provider may require that, if coverage is provided through a |
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managed care plan, the benefits mandated under this subchapter |
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[chapter] are covered benefits only if the prosthetic devices or |
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orthotic devices are provided by a vendor or a provider, and related |
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services are rendered by a provider, that contracts with or is |
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designated by the health benefit plan provider. If the health |
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benefit plan provider provides in-network and out-of-network |
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services, the coverage for prosthetic devices or orthotic devices |
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provided through out-of-network services must be comparable to that |
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provided through in-network services. |
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SECTION 6. Chapter 1371, Insurance Code, is amended by |
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adding Subchapter C to read as follows: |
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SUBCHAPTER C. HAIR PROSTHESES FOR BREAST CANCER PATIENTS |
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Sec. 1371.051. APPLICABILITY OF SUBCHAPTER. (a) In |
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addition to a health benefit plan subject to this chapter under |
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Section 1371.002, this subchapter applies to a health benefit plan |
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that provides benefits for medical or surgical expenses incurred as |
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a result of a health condition, accident, or sickness, including an |
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individual or group evidence of coverage or similar coverage |
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document that is issued by an approved nonprofit health corporation |
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that holds a certificate of authority under Chapter 844. |
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(b) Notwithstanding any other law, this subchapter applies |
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to: |
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(1) a standard health benefit plan issued under |
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Chapter 1507; |
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(2) nonprofit agricultural organization health |
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benefits offered by a nonprofit agricultural organization under |
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Chapter 1682; |
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(3) alternative health benefit coverage offered by a |
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subsidiary of the Texas Mutual Insurance Company under Subchapter |
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M, Chapter 2054; |
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(4) 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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(5) the state Medicaid program, including the Medicaid |
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managed care program operated under Chapter 533, Government Code; |
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(6) the child health plan program under Chapter 62, |
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Health and Safety Code; |
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(7) 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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(8) 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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(c) This subchapter applies to coverage under a group health |
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benefit plan provided to a resident of this state regardless of |
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whether the group policy, agreement, or contract is delivered, |
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issued for delivery, or renewed in this state. |
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Sec. 1371.052. REQUIRED COVERAGE FOR HAIR PROSTHESES FOR |
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CERTAIN CANCER PATIENTS. (a) A health benefit plan must provide |
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coverage for: |
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(1) a hair prosthesis: |
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(A) for an enrollee who is undergoing or has |
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undergone medical treatment for breast cancer; and |
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(B) determined by the enrollee's treating |
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physician to be appropriate for the enrollee in connection with the |
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side effects of the treatment described by Paragraph (A); and |
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(2) repair or replacement of a hair prosthesis |
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described by Subdivision (1) unless the repair or replacement is |
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necessitated by misuse or loss by the enrollee. |
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(b) The benefit amount for the coverage required under |
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Subsection (a) must be not less than $100 for a hair prosthesis or |
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the repair or replacement of a hair prosthesis. |
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(c) An additional premium may not be charged for the |
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coverage required by Subsection (a). |
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(d) Coverage required under Subsection (a) may be subject to |
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the annual deductibles, copayments, and coinsurance that are |
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consistent with annual deductibles, copayments, and coinsurance |
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for other coverage under the health benefit plan. |
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SECTION 7. 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 8. Subchapter C, Chapter 1371, Insurance Code, as |
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added by this Act, applies only to a health benefit plan that is |
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delivered, issued for delivery, or renewed on or after January 1, |
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2024. A health benefit plan delivered, issued for delivery, or |
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renewed before January 1, 2024, is governed by the law as it existed |
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immediately before the effective date of this Act, and that law is |
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continued in effect for that purpose. |
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SECTION 9. This Act takes effect September 1, 2023. |