RS C.S.H.B. 349 75(R)BILL ANALYSIS INSURANCE C.S.H.B. 349 By: Hamric 4-19-97 Committee Report (Substituted) BACKGROUND Approximately 184,300 women will be diagnosed with invasive breast cancer this year in the United States. That is one in every eight women. An additional 44,300 women will die from the disease. There are currently no laws that require a health benefit plan to cover a minimum length of in-hospital stay for a patient following a mastectomy or lymph node dissection for the treatment of breast cancer in the State of Texas. A mastectomy is major surgery which in most cases requires a great deal of time to recover, both physically and mentally. Doctors who perform mastectomies and lymph node dissections are under constant pressure from managed care organizations to reduce costs, which generally means shorter and shorter hospital stays. Over the last ten years, the length of hospitalization for patients undergoing mastectomies has decreased significantly, from 4-6 days to 2-3. While few if any health plans mandate that mastectomies be done without an overnight hospital stay, some doctors have felt pressured to do so. It is estimated that 7.6 percent of mastectomies were done on an out-patient basis in 1995 five times as many as in 1991. This trend towards shorter and shorter hospital stays contradicts accepted medical practice which has shown that breast cancer patients should remain in the hospital for at least 48 hours following a mastectomy and 24 hours after a lymph node dissection. PURPOSE This bill would require that health benefit plans that provide benefits for the treatment of breast cancer include coverage for inpatient care for an enrollee for a minimum of 48 hours following a mastectomy and 24 hours following a lymph node dissection for the treatment of breast cancer. Should both the patient and the attending physician agree that a shorter period of inpatient care is appropriate, the patient may be released and the health plan is not required to provide the minimum hours of coverage of inpatient care. RULEMAKING AUTHORITY It is the opinion of the committee that this bill does grant additional rulemaking authority to the Commissioner of Insurance in SECTION 1 of the bill (Section 5, and Section 6, Article 21.52G, Insurance Code). SECTION BY SECTION ANALYSIS SECTION 1. Amends Subchapter E, Chapter 21, Insurance Code, by adding Article 21.52G. Article 21.52G. COVERAGE FOR HOSPITAL STAYS FOLLOWING PERFORMANCE OF A MASTECTOMY AND CERTAIN RELATED PROCEDURES. Sec. 1. - DEFINITIONS. Defines "Enrollee" and "Health benefit plan." Sec. 2. - SCOPE OF ARTICLE (a) This article applies to benefit plans that provide benefits for medical or surgical expenses incurred due to a health condition, accident, or sickness, is offered by an approved nonprofit health corporation, or a plan that is offered by any other entity not licensed under this code that contracts directly for health care services on a risk sharing basis, including one that contracts on a capitation basis. (b) Article applies to plan that provides coverage for specific disease or condition or hospitalization. (c) Article does not apply to plan that covers only accidental death or dismemberment; payments in lieu of wages lost for period worker is absent for sickness or injury; or acts as a supplement to liability insurance; small employer health benefit plan; Medicare supplemental policy, workers compensation, payment issued in conjunction with motor vehicle insurance policy, or long term health policy, including nursing home policy. Sec. 3. - REQUIRED COVERAGE FOR MINIMUM INPATIENT STAY FOLLOWING MASTECTOMY OR RELATED PROCEDURE; EXCEPTION. (a) 48 hour stay after mastectomy; and 24 hour stay after lymph node dissection for treatment of breast cancer. (b) Minimum stay is not required if enrollee and attending physician determine that a shorter period of care is appropriate. Sec. 4. - PROHIBITIONS. Prohibits health benefit plans from: (1) denying eligibility, enrollment, or renewal to avoid the requirements of this article; (2) providing payments or rebates to patients; (3) penalizing the physician for providing care in accordance with this article; or (4) providing financial incentives to the attending physician for acting in a method inconsistent with this article. Sec. 5. - NOTICE. (a) Each health benefit plan shall provide written notice to each enrollee under the plan regarding the coverage required under this article. (b) Such notice must be prominently positioned in any literature or correspondence made available or distributed by the health benefit plan. Sec. 6. - RULES. Commissioner shall adopt rules necessary to administer this article. SECTION 2. - Effective Date. September 1, 1997, and applies to a plan issued or renewed on or after January 1, 1998. SECTION 3. - Emergency Clause. COMPARISON OF ORIGINAL TO SUBSTITUTE SECTION 1 Changes Sec. 2 of article non-substantively by dropping language to new subsection 1 and renumbers other subsections accordingly. Adds new subsection (2) which adds nonprofit health corporations under this article and a new subsection (3) to include entities not licensed under this code, but that contract directly for health care services on a risk-sharing or capitation basis. Amends Sec. 4 to specify prohibitions on health benefit plan issuers.