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.