By: Turner, Bob H.B. No. 645
73R2117 DLF-D
A BILL TO BE ENTITLED
1-1 AN ACT
1-2 relating to review of laws and proposed laws mandating certain
1-3 health benefit coverages.
1-4 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-5 SECTION 1. Subchapter E, Chapter 21, Insurance Code, is
1-6 amended by adding Article 21.52C to read as follows:
1-7 Art. 21.52C. REVIEW OF MANDATED COVERAGE IN HEALTH BENEFIT
1-8 PLANS
1-9 Sec. 1. DEFINITIONS. In this article:
1-10 (1) "Commissioner" means the commissioner of health.
1-11 (2) "Health benefit plan" means:
1-12 (A) an individual, group, blanket, or franchise
1-13 insurance policy, insurance agreement, or group hospital service
1-14 contract that provides benefits for medical or surgical expenses
1-15 incurred as a result of an accident or sickness; or
1-16 (B) an evidence of coverage or group subscriber
1-17 contract issued by a health maintenance organization.
1-18 (3) "Mandated benefit provision" means a provision of
1-19 law that requires a health benefit plan to:
1-20 (A) cover a particular health care service or
1-21 provide a particular benefit;
1-22 (B) cover a particular class of persons; or
1-23 (C) provide for the reimbursement, use, or
1-24 consideration of a particular category of health care
2-1 practitioners.
2-2 (4) "Panel" means the mandated benefit review panel
2-3 appointed under this article.
2-4 (5) "Sponsor's report" means the report filed with the
2-5 panel under Section 4 of this article.
2-6 Sec. 2. MANDATED BENEFIT REVIEW PANEL. (a) The mandated
2-7 benefit review panel is composed of three senior researchers
2-8 appointed by the commissioner. Two members of the panel must be
2-9 experts in health research or biostatistics and must serve on the
2-10 faculty of a university located in this state.
2-11 (b) Members of the panel serve staggered six-year terms,
2-12 with the term of one member expiring February 1 of each
2-13 odd-numbered year. If there is a vacancy during a term, the
2-14 commissioner shall appoint a replacement who meets the
2-15 qualifications of the vacated office to fill the unexpired term.
2-16 (c) A member of the panel is not entitled to compensation
2-17 but is entitled to reimbursement for actual and necessary expenses
2-18 incurred in performing duties as a member of the panel at the rate
2-19 provided for that reimbursement by the General Appropriations Act.
2-20 (d) The Texas Department of Health shall provide staff for
2-21 the panel in accordance with legislative appropriation.
2-22 Sec. 3. REFERRAL OF BILL. The presiding officer of either
2-23 house of the legislature shall refer a bill proposing a mandated
2-24 benefit provision or an amendment to a mandated benefit provision
2-25 to the panel for a review and report in accordance with this
2-26 article.
2-27 Sec. 4. SPONSOR'S REPORT. Not later than the fifth day
3-1 after the date a bill is referred to the panel, the sponsor of the
3-2 bill or a person designated by the sponsor shall submit to the
3-3 panel a report that meets the requirements of Section 5 of this
3-4 article.
3-5 Sec. 5. CONTENTS OF SPONSOR'S REPORT. (a) The sponsor's
3-6 report must address:
3-7 (1) the extent to which a health care service for
3-8 which coverage would be mandated is needed by, available to, and
3-9 used by the population of this state;
3-10 (2) whether coverage for the health care service is
3-11 usually provided and, if not, the extent to which the lack of
3-12 coverage results in inadequate health care or major financial
3-13 hardship;
3-14 (3) whether there is a demand for the coverage for the
3-15 health care service from members of the public or in collective
3-16 bargaining agreements;
3-17 (4) the extent to which the bill would increase or
3-18 decrease the cost of treatment;
3-19 (5) the manner in which similar mandated benefit
3-20 provisions enacted in other states have affected health care and
3-21 health insurance costs in those states;
3-22 (6) the extent to which the bill would increase the
3-23 appropriate use of a health care service or practitioner;
3-24 (7) the extent to which a service for which coverage
3-25 would be required is a substitute for any more expensive service
3-26 and for any less expensive service;
3-27 (8) the extent to which the bill would increase or
4-1 decrease the administrative expenses of companies that issue health
4-2 benefit plans and the premiums and administrative expenses charged
4-3 to persons covered under health benefit plans;
4-4 (9) the comparative value of any mandated benefit
4-5 provision that is in effect at the time the sponsor's report is
4-6 made and that provides for:
4-7 (A) coverage for a health care service that
4-8 serves a function similar to the service that would be covered
4-9 under the bill; or
4-10 (B) the reimbursement, use, or consideration of
4-11 a particular category of health care practitioners authorized to
4-12 provide services that would be provided by the category of health
4-13 care practitioners required to be reimbursed, used, or considered
4-14 under the bill;
4-15 (10) the financial impact of the bill on small-,
4-16 medium-, and large-sized employers; and
4-17 (11) the impact of the bill on the total cost of
4-18 health care.
4-19 (b) The sponsor's report must include research evidencing
4-20 the medical efficacy of the health care service.
4-21 (c) If the bill would require coverage for a particular
4-22 therapy, the research reported under Subsection (b) of this section
4-23 must include:
4-24 (1) the results of at least one professionally
4-25 acceptable controlled trial demonstrating the medical consequences
4-26 of that therapy compared to not applying any therapy and to
4-27 alternative therapies; and
5-1 (2) the results of any other relevant research.
5-2 (d) If the bill would require the reimbursement, use, or
5-3 consideration of a particular category of health care
5-4 practitioners, the research reported under Subsection (b) of this
5-5 section must include:
5-6 (1) the results of at least one professionally
5-7 acceptable controlled trial demonstrating the medical results
5-8 achieved by that category of practitioners in relation to
5-9 practitioners who already are reimbursed under health benefit
5-10 plans; and
5-11 (2) the results of any other relevant research.
5-12 Sec. 6. PANEL'S REPORT. (a) Not later than the 30th day
5-13 after the date the bill is referred to the panel, the panel shall
5-14 issue a report on the sponsor's report in accordance with
5-15 Subsection (c) of this section.
5-16 (b) The panel shall provide a copy of the panel's report to
5-17 the presiding officer of each house of the legislature and to the
5-18 commissioner of insurance.
5-19 (c) The panel's report must state whether:
5-20 (1) the sponsor's report is complete and addresses
5-21 each item required under Section 5 of this article;
5-22 (2) research cited in the sponsor's report meets
5-23 professional standards;
5-24 (3) the sponsor's report cites all relevant research;
5-25 and
5-26 (4) the conclusions and interpretations drawn in the
5-27 sponsor's report are consistent with the information presented in
6-1 the sponsor's report.
6-2 (d) If the panel finds the sponsor's report is deficient,
6-3 the panel's report must identify the deficiencies.
6-4 (e) The panel's report may not comment on the merits or
6-5 desirability of the bill.
6-6 Sec. 7. REPORT ON EXISTING MANDATED BENEFIT PROVISIONS. (a)
6-7 Not later than February 1 of each odd-numbered year, the panel
6-8 shall issue a report in accordance with Subsection (c) of this
6-9 section on each mandated benefit provision that is expressly
6-10 subject to this article and that is in effect on the date the
6-11 report is issued.
6-12 (b) The panel shall provide a copy of the panel's report to
6-13 the presiding officer of each house of the legislature and to the
6-14 commissioner of insurance.
6-15 (c) The panel's report issued under this section must
6-16 address:
6-17 (1) the extent to which the health care service for
6-18 which coverage is mandated is needed by, available to, and used by
6-19 the population of this state;
6-20 (2) the extent to which the mandated benefit provision
6-21 increases or decreases the cost of treatment;
6-22 (3) the extent to which the mandated benefit provision
6-23 increases the appropriate use of a health care service or
6-24 practitioner;
6-25 (4) the extent to which a service for which coverage
6-26 is required is a substitute for any more expensive service and for
6-27 any less expensive service;
7-1 (5) the extent to which the mandated benefit provision
7-2 increases or decreases the administrative expenses of companies
7-3 that issue health benefit plans and the premiums and administrative
7-4 expenses charged to persons covered under health benefit plans;
7-5 (6) the comparative value of any other mandated
7-6 benefit provision that is in effect at the time the panel's report
7-7 is made and that provides for:
7-8 (A) coverage for a health care service that
7-9 serves a function similar to the service that is covered under the
7-10 mandated benefit provision; or
7-11 (B) the reimbursement, use, or consideration of
7-12 a particular category of health care practitioners authorized to
7-13 provide services that would be provided by the category of health
7-14 care practitioners required to be reimbursed, used, or considered
7-15 under the mandated benefit provision;
7-16 (7) the financial impact of the mandated benefit
7-17 provision on small-, medium-, and large-sized employers; and
7-18 (8) the impact of the mandated benefit provision on
7-19 the total cost of health care.
7-20 (d) The panel's report must include research evidencing the
7-21 medical efficacy of the health care service.
7-22 (e) If the mandated benefit provision requires coverage for
7-23 a particular therapy, the research reported under Subsection (d) of
7-24 this section must include:
7-25 (1) the results of at least one professionally
7-26 acceptable controlled trial demonstrating the medical consequences
7-27 of that therapy compared to not applying any therapy and to
8-1 alternative therapies; and
8-2 (2) the results of any other relevant research.
8-3 (f) If the mandated benefit provision requires the
8-4 reimbursement, use, or consideration of a particular category of
8-5 health care practitioners, the research reported under Subsection
8-6 (d) of this section must include:
8-7 (1) the results of at least one professionally
8-8 acceptable controlled trial demonstrating the medical results
8-9 achieved by that category of practitioners in relation to
8-10 practitioners who already are reimbursed under health benefit
8-11 plans; and
8-12 (2) the results of any other relevant research.
8-13 Sec. 8. EXPIRATION OF MANDATED BENEFIT PROVISION; EFFECT OF
8-14 EXPIRATION. (a) A mandated benefit provision that is expressly
8-15 subject to this article expires on September 1 of any odd-numbered
8-16 year in which the provision is in effect, unless extended under
8-17 Section 9 of this article.
8-18 (b) The expiration of a mandated benefit provision in
8-19 accordance with Subsection (a) of this section applies only to a
8-20 health benefit plan that is delivered, issued for delivery, or
8-21 renewed on or after January 1 of the year following the year in
8-22 which the mandated benefit provision expired. A plan that is
8-23 delivered, issued for delivery, or renewed before that date is
8-24 governed by the law as it existed immediately before the date on
8-25 which the provision expired, and that law is continued in effect
8-26 for that purpose.
8-27 Sec. 9. CONTINUATION BY LAW. During the regular legislative
9-1 session immediately before the expiration of a mandated benefit
9-2 provision that is expressly subject to this article, the
9-3 legislature may continue the provision for a period not to exceed
9-4 two years.
9-5 Sec. 10. MANDATED BENEFIT RULE. (a) The panel shall also
9-6 issue the report required by Section 7 of this article for each
9-7 mandated benefit rule.
9-8 (b) In this section, "mandated benefit rule" means a rule
9-9 adopted by the board or the commissioner that requires a health
9-10 benefit plan to:
9-11 (1) cover a particular health care service or to
9-12 provide a particular benefit;
9-13 (2) cover a particular class of persons; or
9-14 (3) provide for the reimbursement, use, or
9-15 consideration of a particular category of health care
9-16 practitioners.
9-17 SECTION 2. Article 3.42B, Insurance Code, is amended to read
9-18 as follows:
9-19 Art. 3.42B. BENEFITS PAYABLE TO CERTAIN HOSPITALS. (a)
9-20 After the effective date of this Act, no insurance policy issued or
9-21 delivered in this state providing hospital, nursing, medical, or
9-22 surgical coverage may include a provision which would prevent
9-23 payment of benefits for expenses of a person who is a non-indigent
9-24 patient incurred in a hospital facility owned or controlled by the
9-25 state government or by any unit of local government, provided
9-26 charges for such expenses are regularly and customarily charged to
9-27 and collected from non-indigent persons by such hospital facility.
10-1 (b) The provisions of this article shall not apply to
10-2 indigent care nor to chronic disease care, in an eleemosynary
10-3 institution, sanitarium, sanitorium, mental treatment facility of
10-4 every type, tuberculosis treatment facility of every type, and
10-5 cancer treatment facility of every type, where any such care is
10-6 provided in or by any such facility (regardless of the type or
10-7 name) owned or controlled by the state government or by any unit of
10-8 local government.
10-9 (c) Article 21.52C of this code applies to this article.
10-10 This article expires September 1, 1995, in accordance with Section
10-11 8, Article 21.52C of this code.
10-12 SECTION 3. Section 5, Texas Employees Uniform Group
10-13 Insurance Benefits Act (Article 3.50-2, Vernon's Texas Insurance
10-14 Code), is amended by adding Subsection (k) to read as follows:
10-15 (k) Article 21.52C, Insurance Code, applies to Subsection
10-16 (j) of this section. This subsection and Subsection (j) of this
10-17 section expire September 1, 1995, in accordance with Section 8,
10-18 Article 21.52C, Insurance Code.
10-19 SECTION 4. Section 4C, Texas State College and University
10-20 Employees Uniform Insurance Benefits Act (Article 3.50-3, Vernon's
10-21 Texas Insurance Code), is amended to read as follows:
10-22 Sec. 4C. EXCLUDING OR LIMITING CERTAIN COVERAGES PROHIBITED.
10-23 (a) An institution, in contracting for group insurance or health
10-24 maintenance organization coverage or in self-insuring its own
10-25 coverage, may not contract for or provide in that coverage:
10-26 (1) an exclusion or limitation on coverage or services
10-27 for acquired immune deficiency syndrome, as defined by the Centers
11-1 for Disease Control of the United States Public Health Service, or
11-2 human immunodeficiency virus infection; or
11-3 (2) <provides> coverage for serious mental illness
11-4 that is less extensive than the coverage provided for any other
11-5 physical illness.
11-6 (b) Article 21.52C, Insurance Code, applies to this section.
11-7 This section expires September 1, 1995, in accordance with Section
11-8 8, Article 21.52C, Insurance Code.
11-9 SECTION 5. Article 3.51-5A, Insurance Code, is amended by
11-10 adding Subsection (c) to read as follows:
11-11 (c) Article 21.52C of this code applies to this article.
11-12 This article expires September 1, 1995, in accordance with Section
11-13 8, Article 21.52C, of this code.
11-14 SECTION 6. Article 3.51-6, Insurance Code, is amended by
11-15 redesignating Section 3C, as added by Section 10, Chapter 1041,
11-16 Acts of the 71st Legislature, Regular Session, 1989, as Section 3F
11-17 and by adding Section 6 to read as follows:
11-18 Sec. 3F <3C>. (a) An employer that provides to its
11-19 employees group accident and health insurance coverage that
11-20 includes a conversion or group continuation privilege on
11-21 termination of coverage shall give written notice to each employee,
11-22 member, or dependent insured under the group and affected by the
11-23 termination of this conversion or group continuation privileges
11-24 under the policy.
11-25 (b) The State Board of Insurance by rule shall establish
11-26 minimum standards for the notice required by this section.
11-27 Sec. 6. Article 21.52C of this code applies to Sections
12-1 1(d)(3), 3A, 3B, 3C, 3D, and 3E of this article. This section and
12-2 Sections 1(d)(3), 3A, 3B, 3C, 3D, and 3E of this article expire
12-3 September 1, 1995, in accordance with Section 8, Article 21.52C, of
12-4 this code.
12-5 SECTION 7. Article 3.51-6A, Insurance Code, is amended by
12-6 adding Section 7 to read as follows:
12-7 Sec. 7. EXPIRATION OF CERTAIN SECTIONS. Article 21.52C of
12-8 this code applies to Sections 5 and 6 of this article. This
12-9 section and Sections 5 and 6 of this article expire September 1,
12-10 1995, in accordance with Section 8, Article 21.52C, of this code.
12-11 SECTION 8. Article 3.51-8, Insurance Code, is amended by
12-12 adding Subdivision (j) to read as follows:
12-13 (j) Article 21.52C of this code applies to this
12-14 article. This article expires September 1, 1995, in accordance
12-15 with Section 8, Article 21.52C, of this code.
12-16 SECTION 9. Article 3.51-9, Insurance Code, is amended by
12-17 adding Section 4 to read as follows:
12-18 Sec. 4. EXPIRATION. Article 21.52C of this code applies to
12-19 this article. This article expires September 1, 1995, in
12-20 accordance with Section 8, Article 21.52C, of this code.
12-21 SECTION 10. Article 3.51-14, Insurance Code, is amended by
12-22 adding Section 4 to read as follows:
12-23 Sec. 4. EXPIRATION. Article 21.52C of this code applies to
12-24 this article. This article expires September 1, 1995, in
12-25 accordance with Section 8, Article 21.52C, of this code.
12-26 SECTION 11. Section 2, Chapter 397, Acts of the 54th
12-27 Legislature, Regular Session, 1955 (Article 3.70-2, Vernon's Texas
13-1 Insurance Code), is amended by redesignating Subsection (H), as
13-2 amended by Chapter 1091, Acts of the 70th Legislature, Regular
13-3 Session, 1987, as Subsection (J) and by adding Subsection (N) to
13-4 read as follows:
13-5 (J) <(H)> In this section, "low-dose mammography" means the
13-6 X-ray examination of the breast using equipment dedicated
13-7 specifically for mammography, including the X-ray tube, filter,
13-8 compression device, screens, films, and cassettes, with an average
13-9 radiation exposure delivery of less than one rad mid-breast, with
13-10 two views for each breast. Each individual policy or group policy
13-11 of accident and sickness insurance that covers a female 35 years
13-12 old or older and that is delivered, issued for delivery, or renewed
13-13 in this state, except for policies that provide coverage for
13-14 specified disease or other limited benefit coverage but including
13-15 policies issued by companies subject to Chapter 20, Insurance Code,
13-16 must include coverage for an annual screening by low-dose
13-17 mammography for the presence of occult breast cancer within the
13-18 provisions of the policy that is not less favorable than for other
13-19 radiological examinations and subject to the same dollar limits,
13-20 deductibles, and co-insurance factors.
13-21 (N) Article 21.52C of this code applies to Subsections (B),
13-22 (C), (D), (E), (F), (G), (H), (J), and (L) of this article. This
13-23 subsection and Subsections (B), (C), (D), (E), (F), (G), (H), (J),
13-24 and (L) of this article expire September 1, 1995, in accordance
13-25 with Section 8, Article 21.52C, of this code.
13-26 SECTION 12. Article 3.70-3B, Insurance Code, is amended by
13-27 adding Section 4 to read as follows:
14-1 Sec. 4. Article 21.52C of this code applies to this article.
14-2 This article expires September 1, 1995, in accordance with Section
14-3 8, Article 21.52C, of this code.
14-4 SECTION 13. Article 3.72, Insurance Code, is amended by
14-5 adding Subsection (h) to read as follows:
14-6 (h) Article 21.52C of this code applies to this article.
14-7 This article expires September 1, 1995, in accordance with Section
14-8 8, Article 21.52C, of this code.
14-9 SECTION 14. Section 3A, Article 3.74, Insurance Code, is
14-10 amended by adding Subsection (c) to read as follows:
14-11 (c) Article 21.52C of this code applies to this section.
14-12 This section expires September 1, 1995, in accordance with Section
14-13 8, Article 21.52C, of this code.
14-14 SECTION 15. Article 3.79, Insurance Code, is amended by
14-15 adding Section 3 to read as follows:
14-16 Sec. 3. EXPIRATION. Article 21.52C of this code applies to
14-17 this article. This article expires September 1, 1995, in
14-18 accordance with Section 8, Article 21.52C, of this code.
14-19 SECTION 16. Article 21.52, Insurance Code, is amended by
14-20 adding Section 4 to read as follows:
14-21 Sec. 4. EXPIRATION. Article 21.52C of this code applies to
14-22 this article. This article expires September 1, 1995, in
14-23 accordance with Section 8, Article 21.52C, of this code.
14-24 SECTION 17. Article 21.52A, Insurance Code, is amended to
14-25 read as follows:
14-26 Art. 21.52A. CERTIFICATION BY PODIATRIST. (a) An insurance
14-27 policy that is delivered, issued for delivery, or renewed in this
15-1 state and that provides benefits covering loss of income based on
15-2 an acute and temporary disability caused by sickness or injury may
15-3 not deny payment of those benefits on the ground that the acute and
15-4 temporary disability is certified or attested to by a podiatrist
15-5 licensed by the Texas State Board of Podiatry Examiners if the
15-6 acute and temporary disability is caused by a sickness or injury
15-7 that may be treated by acts performed by a licensed podiatrist
15-8 under the scope of that license.
15-9 (b) Article 21.52C of this code applies to this article.
15-10 This article expires September 1, 1995, in accordance with Section
15-11 8, Article 21.52C, of this code.
15-12 SECTION 18. Section 21.53A, Insurance Code, is amended by
15-13 adding Subsection (f) to read as follows:
15-14 (f) Article 21.52C of this code applies to this article.
15-15 This article expires September 1, 1995, in accordance with Section
15-16 8, Article 21.52C, of this code.
15-17 SECTION 19. In making the initial appointments to the
15-18 mandated benefit review panel created under Article 21.52C,
15-19 Insurance Code, as added by this Act, the commissioner of health
15-20 shall appoint one member for a term expiring February 1, 1995, one
15-21 member for a term expiring February 1, 1997, and one member for a
15-22 term expiring February 1, 1999.
15-23 SECTION 20. This Act takes effect September 1, 1993.
15-24 SECTION 21. The importance of this legislation and the
15-25 crowded condition of the calendars in both houses create an
15-26 emergency and an imperative public necessity that the
15-27 constitutional rule requiring bills to be read on three several
16-1 days in each house be suspended, and this rule is hereby suspended.