BG S.B. 163 75(R) BILL ANALYSIS PUBLIC HEALTH S.B. 163 By: Zaffirini (Berlanga) 4-17-97 Committee Report (Unamended) 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 is escalating rapidly, but can be avoided by preventing the disabling and devastating complications of the disease. Although studies confirm that 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. Other states, such as Florida, Maine, Minnesota, New Jersey, New York, Oklahoma, West Virginia, and Wisconsin, have successfully enacted legislation mandating diabetic preventative care reimbursements. Although, the 73rd Legislature adopted H.R. 209, which extended concern for those with diabetes; health benefit plans are not required to cover preventive care costs associated with this disease which ranks sixth among the 10 leading causes of death for Texans; affects almost seven percent of the adult population; and cost Texans roughly $4 billion in direct medical costs and lost productivity in 1992. PURPOSE S.B. 163 provides coverage under health benefit plans for certain 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 (Section 7, Article 21.53G, Insurance Code). SECTION BY SECTION ANALYSIS SECTION 1. Amends Chapter 21E, Insurance Code, by adding Article 21.53G, as follows: Art. 21.53G. COVERAGE FOR SUPPLIES AND SERVICES ASSOCIATED WITH TREATMENT OF DIABETES 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. SCOPE OF ARTICLE. Establishes applicability of this article in regards to a "health benefit plan." Subsection (a) lists the kinds of plans and benefits within its scope. 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. REQUIRED BENEFIT FOR SUPPLIES AND SERVICES ASSOCIATED WITH TREATMENT OF DIABETES. Requires a health benefit plan that provides benefits for the treatment of diabetes and associated conditions to provide coverage to each qualified insured for diabetes equipment, diabetes supplies, and diabetes self-management training programs. Sec. 4. DIABETES SELF-MANAGEMENT TRAINING. Requires diabetes selfmanagement training to be provided by a health care practitioner who is licensed, registered, or certified in this state to provide appropriate health care services. Sets forth the types of training included as self-management training. Sec. 5. EFFECT OF NEW TREATMENT MODALITIES. Requires each health benefit plan subject to this article to include coverage of new or improved equipment or supplies approved by the United States Food and Drug Administration, including improved insulin or other prescription drugs, if medically necessary and appropriate as determined by a physician or other health care practitioner. Sec. 6. LIMITATION. Allows benefits required under this article to be made subject to a deductible, copayment, or coinsurance requirement and prohibits the requirement from exceeding the deductible, copayment, or coinsurance required by the health benefit plan for treatment of other analogous chronic medical conditions. Sec. 7. RULES. Requires the commissioner of insurance to adopt rules as necessary for the implementation of this article. Allows the commissioner to consult with the commissioner of health and other appropriate entities in adopting rules under this section. SECTION 2. Effective date: September 1, 1997. Makes application of this Act prospective to January 1, 1998. SECTION 3. Emergency clause.