By Gray, Greenberg, Van de Putte, McCall, H.B. No. 102
75R8032 PB-D
A BILL TO BE ENTITLED
1-1 AN ACT
1-2 relating to minimum coverage under certain health benefit plans for
1-3 inpatient stays and postdelivery care following the birth of a
1-4 child.
1-5 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-6 SECTION 1. Subchapter E, Chapter 21, Insurance Code, is
1-7 amended by adding Article 21.53F to read as follows:
1-8 Art. 21.53F. COVERAGE FOR MINIMUM INPATIENT STAY IN HEALTH
1-9 CARE FACILITY AND POSTDELIVERY CARE FOLLOWING BIRTH OF CHILD
1-10 Sec. 1. SHORT TITLE. This article may be cited as the Lee
1-11 Alexandria Hanley Act.
1-12 Sec. 2. DEFINITIONS. In this article:
1-13 (1) "Attending physician" means an obstetrician,
1-14 pediatrician, or other physician who attends a woman who has given
1-15 birth or who attends the newborn child.
1-16 (2) "Enrollee" means an individual enrolled in a
1-17 health benefit plan.
1-18 (3) "Health benefit plan" means a plan described by
1-19 Section 3 of this article.
1-20 Sec. 3. SCOPE OF ARTICLE. (a) This article applies to a
1-21 health benefit plan that:
1-22 (1) provides benefits for medical or surgical expenses
1-23 incurred as a result of a health condition, accident, or sickness,
1-24 including:
1-25 (A) an individual, group, blanket, or franchise
2-1 insurance policy or insurance agreement, a group hospital service
2-2 contract, or an individual or group evidence of coverage that is
2-3 offered by:
2-4 (i) an insurance company;
2-5 (ii) a group hospital service corporation
2-6 operating under Chapter 20 of this code;
2-7 (iii) a fraternal benefit society
2-8 operating under Chapter 10 of this code;
2-9 (iv) a stipulated premium insurance
2-10 company operating under Chapter 22 of this code; or
2-11 (v) a health maintenance organization
2-12 operating under the Texas Health Maintenance Organization Act
2-13 (Chapter 20A, Vernon's Texas Insurance Code); or
2-14 (B) to the extent permitted by the Employee
2-15 Retirement Income Security Act of 1974 (29 U.S.C. Section 1001 et
2-16 seq.), a health benefit plan that is offered by:
2-17 (i) a multiple employer welfare
2-18 arrangement as defined by Section 3, Employee Retirement Income
2-19 Security Act of 1974 (29 U.S.C. Section 1002);
2-20 (ii) any other entity not licensed under
2-21 this code or another insurance law of this state that contracts
2-22 directly for health care services on a risk-sharing basis,
2-23 including an entity that contracts for health care services on a
2-24 capitation basis; or
2-25 (iii) another analogous benefit
2-26 arrangement; or
2-27 (2) is offered by an approved nonprofit health
3-1 corporation that is certified under Section 5.01(a), Medical
3-2 Practice Act (Article 4495b, Vernon's Texas Civil Statutes), and
3-3 that holds a certificate of authority issued by the commissioner
3-4 under Article 21.52F of this code.
3-5 (b) This article does not apply to:
3-6 (1) a plan that provides coverage:
3-7 (A) only for a specified disease or other
3-8 limited benefit;
3-9 (B) only for accidental death or dismemberment;
3-10 (C) for wages or payments in lieu of wages for a
3-11 period during which an employee is absent from work because of
3-12 sickness or injury;
3-13 (D) as a supplement to liability insurance;
3-14 (E) for credit insurance;
3-15 (F) only for dental or vision care; or
3-16 (G) only for indemnity for hospital confinement;
3-17 (2) a small employer health benefit plan written under
3-18 Chapter 26 of this code;
3-19 (3) a Medicare supplemental policy as defined by
3-20 Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss);
3-21 (4) workers' compensation insurance coverage;
3-22 (5) medical payment insurance issued as part of a
3-23 motor vehicle insurance policy; or
3-24 (6) a long-term care policy, including a nursing home
3-25 fixed indemnity policy, unless the commissioner determines that the
3-26 policy provides benefit coverage so comprehensive that the policy
3-27 is a health benefit plan as described by Subsection (a) of this
4-1 section.
4-2 Sec. 4. REQUIRED COVERAGE FOR MINIMUM INPATIENT STAY
4-3 FOLLOWING BIRTH; EXCEPTIONS. (a) A health benefit plan that
4-4 provides maternity benefits, including benefits for childbirth,
4-5 must include coverage for inpatient care for a mother and her
4-6 newborn child in a health care facility for a minimum of:
4-7 (1) 48 hours following an uncomplicated vaginal
4-8 delivery; and
4-9 (2) 96 hours following an uncomplicated delivery by
4-10 caesarean section.
4-11 (b) Notwithstanding Subsection (a) of this section, a health
4-12 benefit plan that provides coverage for in-home postdelivery care
4-13 to a mother and her newborn child is not required to provide the
4-14 minimum hours of coverage of inpatient care required under
4-15 Subsection (a) of this section unless that inpatient care is
4-16 determined to be medically necessary by an attending physician or
4-17 is requested by the mother.
4-18 (c) For purposes of Subsection (a) of this section, the
4-19 determination as to whether a delivery is complicated shall be made
4-20 by the attending physician.
4-21 (d) This article does not require a mother who is eligible
4-22 for coverage under a health benefit plan to:
4-23 (1) give birth in a hospital or other health care
4-24 facility; or
4-25 (2) remain under inpatient care in a hospital or other
4-26 health care facility for any fixed term following the birth of a
4-27 child.
5-1 Sec. 5. POSTDELIVERY CARE. (a) If a decision is made to
5-2 discharge a mother or newborn child from inpatient care before the
5-3 expiration of the minimum hours of coverage of inpatient care
5-4 required under Section 4(a) of this article, the health benefit
5-5 plan must provide coverage for timely postdelivery care. That care
5-6 may be provided to the mother and child by a physician, registered
5-7 nurse, or other appropriate licensed health care provider and may
5-8 be provided at:
5-9 (1) the mother's home, a health care provider's
5-10 office, or a health care facility; or
5-11 (2) another location determined to be appropriate
5-12 under rules adopted by the commissioner.
5-13 (b) The coverage required under Subsection (a) of this
5-14 section must allow the mother the option to have the care provided
5-15 in the mother's home.
5-16 (c) For purposes of this section, "postdelivery care" means
5-17 postpartum health care services provided in accordance with
5-18 accepted maternal and neonatal physical assessments. The term
5-19 includes parent education, assistance and training in
5-20 breast-feeding and bottle-feeding, and the performance of any
5-21 necessary and appropriate clinical tests. The timeliness of the
5-22 care shall be determined in accordance with recognized medical
5-23 standards for that care.
5-24 Sec. 6. PROHIBITIONS. A health benefit plan may not:
5-25 (1) modify the terms and conditions of coverage based
5-26 on the determination by a person enrolled in the health benefit
5-27 plan to request less than the minimum coverage required under
6-1 Section 4(a) of this article;
6-2 (2) offer to the mother of a newborn child financial
6-3 incentives or other compensation the receipt of which is contingent
6-4 on the waiver by the mother of the minimum hours of coverage of
6-5 inpatient care required under Section 4(a) of this article;
6-6 (3) refuse to accept a physician's recommendation for
6-7 a specified period of inpatient care made in consultation with the
6-8 mother of the newborn child if the period recommended by the
6-9 physician does not exceed the minimum periods recommended in
6-10 guidelines for perinatal care developed by the American College of
6-11 Obstetricians and Gynecologists, the American Academy of
6-12 Pediatrics, or another nationally recognized professional
6-13 association of obstetricians and gynecologists or of pediatricians;
6-14 (4) reduce payments or other forms of reimbursement
6-15 for inpatient care below the usual and customary rate of
6-16 reimbursement for that care; or
6-17 (5) penalize a physician for recommending inpatient
6-18 care for a mother or her newborn child by:
6-19 (A) refusing to allow the physician to
6-20 participate as a provider within the health benefit plan;
6-21 (B) reducing payments made to the physician;
6-22 (C) requiring the physician to provide
6-23 additional documentation or undergo additional utilization review;
6-24 or
6-25 (D) imposing other analogous sanctions or
6-26 disincentives.
6-27 Sec. 7. NOTICE. In accordance with rules adopted by the
7-1 commissioner, each health benefit plan must provide to each
7-2 enrollee under the plan written notice regarding the coverage
7-3 required by this article.
7-4 Sec. 8. RULES. The commissioner shall adopt rules as
7-5 necessary to administer this article.
7-6 SECTION 2. This Act takes effect September 1, 1997, and
7-7 applies only to a health benefit plan that is delivered, issued for
7-8 delivery, or renewed on or after January 1, 1998. A health benefit
7-9 plan that is delivered, issued for delivery, or renewed before
7-10 January 1, 1998, is governed by the law as it existed immediately
7-11 before the effective date of this Act, and that law is continued in
7-12 effect for that purpose.
7-13 SECTION 3. The importance of this legislation and the
7-14 crowded condition of the calendars in both houses create an
7-15 emergency and an imperative public necessity that the
7-16 constitutional rule requiring bills to be read on three several
7-17 days in each house be suspended, and this rule is hereby suspended.