SRC-JFA C.S.S.B. 217 75(R)BILL ANALYSIS Senate Research CenterC.S.S.B. 217 By: Zaffirini Economic Development 3-20-97 Committee Report (Substituted) DIGEST 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, C.S.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. SUMMARY OF COMMITTEE CHANGES SECTION 1. Amends proposed Article 21.53D, Insurance Code, to set forth the definition of "health benefit plan" in Section 2 of the article. Removes original proposed definition set forth in Section 1. Adds the proposed scope of the article in Section 2. Sets forth the proposed required coverage in Section 3, rather than Section 2. Adds proposed prohibition to certain activities in Section 4. Sets forth the proposed rulemaking authority in Section 5, rather than Section 3.