LSL C.S.H.B. 750 75(R) BILL ANALYSIS PUBLIC HEALTH C.S.H.B. 750 By: Berlanga 3-12-97 Committee Report (Substituted) BACKGROUND Approximately 1.7 million Texans have diabetes. Complications of diabetes include blindness, kidney failure, amputations, heart disease, stroke and death. A study done by the Texas Diabetes Cost Project showed that diabetes costs for Texans totaled approximately 3.9 billion dollars in 1992. National studies continue to indicate that the costs of diabetes are escalating rapidly, but can be avoided by preventing the disabling and devastating complications of the disease. Although studies confirm that the training, supplies and equipment necessary for diabetic selfmanagement save money and human suffering by reducing hospital admissions and lowering the risk of developing complications, too often such items are not covered health insurance benefits. The American Diabetes Association found that lack of reimbursement is the most significant impediment to the development of diabetes outpatient education programs. The 73rd Legislature adopted H.R. 209, which extended concern for those with diabetes. The inclusion of diabetes self-management training, supplies, and equipment as standard health care coverage in the state of Texas was unanimously endorsed. Texas could join the ranks of other states, such as Florida, Maine, Minnesota, New Jersey, New York, Oklahoma, West Virginia, and Wisconsin, which have successfully enacted this legislation. PURPOSE CSHB 750 mandates that certain health benefit plans cover supplies and services associated with the treatment of diabetes. RULEMAKING AUTHORITY It is the committee's opinion that this bill expressly grants additional rulemaking authority to the Commissioner of the Texas Department of Insurance in SECTION 1 (Subchapter E, Chapter 21, Insurance Code, Article 21.53G, Sec. 7) of the bill. SECTION BY SECTION ANALYSIS SECTION 1. Amends Subchapter E, Chapter 21, Insurance Code, by adding Art. 21.53G, regarding coverage for supplies and services associated with the treatment of diabetes, as follows: Sec. 1. Definitions. Subsection (1) defines "diabetes equipment" to include glucose monitors, insulin pumps and infusion devices, and preventive podiatric appliances. Subsection (2) defines "diabetes supplies" as diabetic testing strips, lancets and lancet devices, insulin and insulin analogs, syringes and injection aids, oral agents used to control blood sugar, and glucagon emergency kits. Subsection (3) establishes that the meaning of "health benefit plan" is described by Section 2 of this article. Subsection (4) defines "qualified insured" as someone eligible for coverage and diagnosed with diabetes, pregnancy-induced elevated blood sugar, or high blood glucose levels associated with another medical condition. Sec. 2. Establishes applicability of this article in regards to a "health benefit plan." Subsection (a) lists the kinds of plans and benefits within the scope of this article. Subsection (b) specifies that plans that are only disease specific; for accidental death or dismemberment; disability or liability supplements; Medicare supplements; workers' compensation insurance; part of a motor vehicle insurance contract; or long-term care policy are not applicable under this article. Allows the commissioner to determine that a long-term care policy meets the definition of a health benefit plan as described by Subsection (a) due to its provision of comprehensive benefit coverage, and thus deemed to be within the scope of this article. Sec. 3. Mandates that a health benefit plan covering treatment of diabetes and associated conditions provide coverage of diabetic supplies, equipment, and self-management training programs. Sec. 4. Mandates that self-management training be provided by a state licensed, registered, or certified health care practitioner and include initial patient training about diabetic care, management, proper use of equipment and supplies, and nutritional counseling; additional training for significant changes in condition or symptoms; plus periodic or episodic continuing patient education and training as warranted and prescribed by an appropriate health care practitioner. Sec. 5. Mandates coverage of new or improved diabetic equipment or supplies, including improved insulin or other prescription drugs, upon United States Food and Drug Administration approval, if medically necessary and appropriate as determined by a health care practitioner. Sec. 6. Allows required benefits to be subject to a deductible, copay or coinsurance requirement. Limits amount of allowable deductible, copayment, or coinsurance for benefits required under this article to not exceed that associated with other analogous chronic medical conditions. Sec. 7. Requires that the Commissioner of Insurance adopt rules necessary for the implementation of this article. Allows consultation with Commissioner of Health and other appropriate entities. SECTION 2. Provides that this act takes effect on September 1, 1997 and applies only to health benefit plans issued or renewed by January 1, 1998. Plans issued or renewed prior to January 1, 1998 are governed by existing law which is continued in effect for this purpose. SECTION 3. Emergency Clause. COMPARISON OF ORIGINAL TO SUBSTITUTE SECTION 1. In amending Subchapter E, Chapter 21, Insurance Code, CSHB 750 makes the following changes to Article 21.53G from the original bill: Sec. 1. The substitute adds lancets, lancet devices and insulin analogs to the list of items to be covered within the meaning of "diabetic supplies" as defined in the new article. The definition of "health benefit plan" is revised and moved to Sec. 2. Sec. 2. The substitute adds this section to the language and definition of "health benefit plan" so that it is conformed with other legislation. The new definition of "health benefit plan" as used in CSHB 750 no longer makes any reference to Chapter 26 of the Insurance Code, and thus avoids the issue of any small business insurance exclusions. The remaining sections of the substitute are renumbered to reflect the addition of this section. Sec. 4. CSHB 750 clarifies that the required continuing education for diabetes self-management training must be done on a periodic or episodic basis as medically prescribed and warranted. The words "or episodic" were added to the substitute version. Sec. 5. CSHB 750 inserts the clause, "if medically necessary and appropriate as determined by physician or health care provider" to the requirement that new or improved diabetes equipment, supplies, once approved by the Food and Drug Administration, become covered benefits under this article.