KMS S.B. 217 75(R) BILL ANALYSIS INSURANCE S.B. 217 By: Zaffirini (Van de Putte) 4-29-97 Committee Report (Unamended) BACKGROUND Currently, the Insurance Code does not require a health benefit plan to provide coverage for a breast reconstruction operation following a mastectomy surgery. Breast cancer, which affects approximately 11,500 Texas women annually, can be one of the most traumatic experiences a women ever endures due to a possible removal of a breast. Studies have shown that the fear of losing a breast is a leading reason why many women do not participate in early breast cancer detection programs. Medical technology has made it possible to reconstruct a woman's breast following a mastectomy surgery. This bill would require certain health benefit plans that provide coverage for a mastectomy to provide coverage for a breast reconstruction operation to restore or achieve breast symmetry after a mastectomy operation has been performed. PURPOSE As proposed, S.B. 217 requires certain health benefits plans that provide coverage for a mastectomy to provide coverage for a breast reconstruction operation incident to the mastectomy. RULEMAKING AUTHORITY Rulemaking authority is granted to the commissioner of the Texas Department of Insurance under SECTION 1 (Art. 21.53D(5), Insurance Code) of this bill. SECTION BY SECTION ANALYSIS SECTION 1. Amends Chapter 21E, Insurance Code, by adding Article 21.53D, as follows: Art. 21.53D. COVERAGE FOR RECONSTRUCTIVE SURGERY AFTER MASTECTOMY Sec. 1. DEFINITIONS. Defines "health benefit plan" and "breast reconstruction." Sec. 2. SCOPE OF ARTICLE. Provides that this article applies to a health benefit plan that provides benefits for medical or surgical expenses incurred as a result of a health condition, accident, or sickness; a plan that is offered by a multiple employer welfare arrangement as defined by Section 3, Employee Retirement Income Security Act of 1974 (29 U.S.C. Section 1002), or another analogous benefit arrangement; or a plan that is offered by an approved nonprofit health corporation that is certified under Section 5.01(a), Medical Practice Act (Article 4495b, V.T.C.S.), and that holds a certificate of authority issued by the commissioner of insurance (commissioner) under Article 21.52F of this code. Provides that this article does not apply to a plan that provides coverage for certain items; a small employer plan written under Chapter 26 of this code; a Medicare supplemental policy as defined by Section 1882(g)(1), Social Security Act (42 U.S.C. 1395ss); workers' compensation coverage; medical payment insurance issued as part of a motor vehicle insurance policy; or a long-term care policy, unless the commissioner determines that the policy provides benefit coverage so comprehensive that the policy is a health benefit plan as described in this section. Sec. 3. COVERAGE REQUIRED. Requires a health benefits plan that provides coverage for a mastectomy to provide coverage for breast reconstruction. Authorizes the coverage to be subject to the same deductible or copayment applicable to the mastectomy. Sec. 4. PROHIBITION. Prohibits a health benefit plan from offering a financial incentive for a patient to forego breast reconstruction or to waive the coverage required by Section 3 of this article. Sec. 5. RULES. Authorizes the commissioner to adopt rules to implement this article. SECTION 2. Effective date: September 1, 1997. Makes application of this Act prospective to January 1, 1998. SECTION 3. Emergency clause.